Universal Flu Immunization Now

A debate in the vaccine community currently revolves around the wisdom of recommending universal influenza vaccine administration, rather than continuing the current strategy of focusing on high-risk individuals. I come down solidly on the side of universal immunization.

The influenza-related death toll—36,000 annually in the United States—is greater than that from all other vaccine-preventable diseases combined. Influenza also results in an average of 150,000 hospitalizations and millions of physician visits each year. Among children aged less than 5 years, hospitalization rates are nearly 500/100,000 in children with high-risk medical conditions, but still are robust at 100/100,000 even in children without high-risk conditions (MMWR 2006;55[early release]:1–41).

Given those numbers, it seems to me that we're tying one hand behind our backs when trying to defend against influenza by not immunizing all our patients.

Even the current guidelines from the Centers for Disease Control and Prevention say that “physicians should administer influenza vaccine to any person who wishes to reduce the likelihood of becoming ill with influenza or transmitting influenza to others should they become infected.” To me, that makes everyone a potential candidate. The real sticking points at present in implementing universal influenza immunization are the limitations of our infrastructure for producing, distributing, and administering the vaccine.

I practiced primary care for 8 years in the 1970s and ′80s before specializing in infectious disease. Even then, I recommended influenza vaccine to everyone who came to the office in the time leading up to influenza season. It seemed illogical to protect only a select few of my patients.

The piecemeal approach we follow now is confusing and a headache for practitioners—things are never the same from year to year. For example, this year for the first time we'll need to order enough vaccine for 24- to 59-month-olds as well as 6- to 23-month-olds, plus our older patients with high-risk medical conditions and all of their household contacts. Wouldn't it be a lot simpler just to count how many children are in our practices and order that number?

If vaccine manufacturers could be assured that we would order a certain number of doses each year, they would gear up and make them. So far, they haven't been willing to do this because it's too much of a gamble—during some seasons, as much as two-thirds of their doses have gone unused. If there were a universal recommendation with consistent year-to-year utilization, it should remove their reticence.

Manufacturers also would be aided a great deal if there were a way to make influenza vaccine without having to grow the virus in thousands of fertilized chicken eggs. In June of this year, a Canadian company called Hepalife Technologies Inc. licensed technology from researchers at Michigan State University in East Lansing for the development of new cell culture-based influenza vaccines, including one for the potential pandemic-causing strain H5N1. If the cell line is able to grow influenza virus reliably—preliminary data indicate that it is—it would greatly facilitate the manufacturing process by enabling influenza vaccine to be grown more efficiently and less expensively. It also would eliminate the egg allergy problem. I don't own stock in the company, but I am excited about this product's potential.

Of course, immunizing all of our patients within a 6-week period during October and November would be a huge challenge. It wouldn't be practical for the primary care office to be the only avenue for distribution. Grocery and drugstore chains have become major influenza vaccine vendors for adults, but generally not for children because of liability concerns. I think the effort will need to utilize public health departments to extend the infrastructure, and perhaps coordinate with schools for the older children.

There has been precedent for this. During the influenza season 2 years ago that killed several children in Colorado and in this year's Midwest mumps outbreak, county health departments moved their mobile units to schools and managed to immunize large numbers of children. Documentation may be a bit of a problem, but this can be worked out. We just need the go-ahead of a universal recommendation to get the ball rolling.

A universal immunization recommendation for routine influenza seasons would also prepare us for a pandemic situation. We currently have incomplete logistical support for potential intervention involving the entire U.S. population. This would be excellent training for our health care system, and would provide templates upon which to build. If we had 2 or 3 years of practice in immunizing everyone prior to a pandemic, we'd all be much more expert when a pandemic arrived.

Obviously, a universal recommendation doesn't mean that everyone will be immunized. But, we would be far more likely to achieve herd immunity than with what we do now. We should see fewer hospitalizations in the very old and the very young, the two groups that utilize the greatest amount of health care resources.

We know that the severe complications of influenza—invasive bacterial infections such as empyemas, bacteremias, and meningococcemia—tend to peak during and just after each influenza season because bacterial pathogens more readily invade the mucosa of influenza-damaged respiratory tracts, which are still healing for weeks after the patient's influenza infection has resolved. In a bad influenza season, emergency departments are bombarded with influenza cases and patients with sequelae during January-April. Reducing that enormous utilization of medical resources should be worth every bit of effort we'd put into getting everyone immunized in the fall.

A debate in the vaccine community currently revolves around the wisdom of recommending universal influenza vaccine administration, rather than continuing the current strategy of focusing on high-risk individuals. I come down solidly on the side of universal immunization.

The influenza-related death toll—36,000 annually in the United States—is greater than that from all other vaccine-preventable diseases combined. Influenza also results in an average of 150,000 hospitalizations and millions of physician visits each year. Among children aged less than 5 years, hospitalization rates are nearly 500/100,000 in children with high-risk medical conditions, but still are robust at 100/100,000 even in children without high-risk conditions (MMWR 2006;55[early release]:1–41).

Given those numbers, it seems to me that we're tying one hand behind our backs when trying to defend against influenza by not immunizing all our patients.

Even the current guidelines from the Centers for Disease Control and Prevention say that “physicians should administer influenza vaccine to any person who wishes to reduce the likelihood of becoming ill with influenza or transmitting influenza to others should they become infected.” To me, that makes everyone a potential candidate. The real sticking points at present in implementing universal influenza immunization are the limitations of our infrastructure for producing, distributing, and administering the vaccine.

I practiced primary care for 8 years in the 1970s and ′80s before specializing in infectious disease. Even then, I recommended influenza vaccine to everyone who came to the office in the time leading up to influenza season. It seemed illogical to protect only a select few of my patients.

The piecemeal approach we follow now is confusing and a headache for practitioners—things are never the same from year to year. For example, this year for the first time we'll need to order enough vaccine for 24- to 59-month-olds as well as 6- to 23-month-olds, plus our older patients with high-risk medical conditions and all of their household contacts. Wouldn't it be a lot simpler just to count how many children are in our practices and order that number?

If vaccine manufacturers could be assured that we would order a certain number of doses each year, they would gear up and make them. So far, they haven't been willing to do this because it's too much of a gamble—during some seasons, as much as two-thirds of their doses have gone unused. If there were a universal recommendation with consistent year-to-year utilization, it should remove their reticence.

Manufacturers also would be aided a great deal if there were a way to make influenza vaccine without having to grow the virus in thousands of fertilized chicken eggs. In June of this year, a Canadian company called Hepalife Technologies Inc. licensed technology from researchers at Michigan State University in East Lansing for the development of new cell culture-based influenza vaccines, including one for the potential pandemic-causing strain H5N1. If the cell line is able to grow influenza virus reliably—preliminary data indicate that it is—it would greatly facilitate the manufacturing process by enabling influenza vaccine to be grown more efficiently and less expensively. It also would eliminate the egg allergy problem. I don't own stock in the company, but I am excited about this product's potential.

Of course, immunizing all of our patients within a 6-week period during October and November would be a huge challenge. It wouldn't be practical for the primary care office to be the only avenue for distribution. Grocery and drugstore chains have become major influenza vaccine vendors for adults, but generally not for children because of liability concerns. I think the effort will need to utilize public health departments to extend the infrastructure, and perhaps coordinate with schools for the older children.

There has been precedent for this. During the influenza season 2 years ago that killed several children in Colorado and in this year's Midwest mumps outbreak, county health departments moved their mobile units to schools and managed to immunize large numbers of children. Documentation may be a bit of a problem, but this can be worked out. We just need the go-ahead of a universal recommendation to get the ball rolling.

A universal immunization recommendation for routine influenza seasons would also prepare us for a pandemic situation. We currently have incomplete logistical support for potential intervention involving the entire U.S. population. This would be excellent training for our health care system, and would provide templates upon which to build. If we had 2 or 3 years of practice in immunizing everyone prior to a pandemic, we'd all be much more expert when a pandemic arrived.

Obviously, a universal recommendation doesn't mean that everyone will be immunized. But, we would be far more likely to achieve herd immunity than with what we do now. We should see fewer hospitalizations in the very old and the very young, the two groups that utilize the greatest amount of health care resources.

We know that the severe complications of influenza—invasive bacterial infections such as empyemas, bacteremias, and meningococcemia—tend to peak during and just after each influenza season because bacterial pathogens more readily invade the mucosa of influenza-damaged respiratory tracts, which are still healing for weeks after the patient's influenza infection has resolved. In a bad influenza season, emergency departments are bombarded with influenza cases and patients with sequelae during January-April. Reducing that enormous utilization of medical resources should be worth every bit of effort we'd put into getting everyone immunized in the fall.

A debate in the vaccine community currently revolves around the wisdom of recommending universal influenza vaccine administration, rather than continuing the current strategy of focusing on high-risk individuals. I come down solidly on the side of universal immunization.

The influenza-related death toll—36,000 annually in the United States—is greater than that from all other vaccine-preventable diseases combined. Influenza also results in an average of 150,000 hospitalizations and millions of physician visits each year. Among children aged less than 5 years, hospitalization rates are nearly 500/100,000 in children with high-risk medical conditions, but still are robust at 100/100,000 even in children without high-risk conditions (MMWR 2006;55[early release]:1–41).

Given those numbers, it seems to me that we're tying one hand behind our backs when trying to defend against influenza by not immunizing all our patients.

Even the current guidelines from the Centers for Disease Control and Prevention say that “physicians should administer influenza vaccine to any person who wishes to reduce the likelihood of becoming ill with influenza or transmitting influenza to others should they become infected.” To me, that makes everyone a potential candidate. The real sticking points at present in implementing universal influenza immunization are the limitations of our infrastructure for producing, distributing, and administering the vaccine.

I practiced primary care for 8 years in the 1970s and ′80s before specializing in infectious disease. Even then, I recommended influenza vaccine to everyone who came to the office in the time leading up to influenza season. It seemed illogical to protect only a select few of my patients.

The piecemeal approach we follow now is confusing and a headache for practitioners—things are never the same from year to year. For example, this year for the first time we'll need to order enough vaccine for 24- to 59-month-olds as well as 6- to 23-month-olds, plus our older patients with high-risk medical conditions and all of their household contacts. Wouldn't it be a lot simpler just to count how many children are in our practices and order that number?

If vaccine manufacturers could be assured that we would order a certain number of doses each year, they would gear up and make them. So far, they haven't been willing to do this because it's too much of a gamble—during some seasons, as much as two-thirds of their doses have gone unused. If there were a universal recommendation with consistent year-to-year utilization, it should remove their reticence.

Manufacturers also would be aided a great deal if there were a way to make influenza vaccine without having to grow the virus in thousands of fertilized chicken eggs. In June of this year, a Canadian company called Hepalife Technologies Inc. licensed technology from researchers at Michigan State University in East Lansing for the development of new cell culture-based influenza vaccines, including one for the potential pandemic-causing strain H5N1. If the cell line is able to grow influenza virus reliably—preliminary data indicate that it is—it would greatly facilitate the manufacturing process by enabling influenza vaccine to be grown more efficiently and less expensively. It also would eliminate the egg allergy problem. I don't own stock in the company, but I am excited about this product's potential.

Of course, immunizing all of our patients within a 6-week period during October and November would be a huge challenge. It wouldn't be practical for the primary care office to be the only avenue for distribution. Grocery and drugstore chains have become major influenza vaccine vendors for adults, but generally not for children because of liability concerns. I think the effort will need to utilize public health departments to extend the infrastructure, and perhaps coordinate with schools for the older children.

There has been precedent for this. During the influenza season 2 years ago that killed several children in Colorado and in this year's Midwest mumps outbreak, county health departments moved their mobile units to schools and managed to immunize large numbers of children. Documentation may be a bit of a problem, but this can be worked out. We just need the go-ahead of a universal recommendation to get the ball rolling.

A universal immunization recommendation for routine influenza seasons would also prepare us for a pandemic situation. We currently have incomplete logistical support for potential intervention involving the entire U.S. population. This would be excellent training for our health care system, and would provide templates upon which to build. If we had 2 or 3 years of practice in immunizing everyone prior to a pandemic, we'd all be much more expert when a pandemic arrived.

Obviously, a universal recommendation doesn't mean that everyone will be immunized. But, we would be far more likely to achieve herd immunity than with what we do now. We should see fewer hospitalizations in the very old and the very young, the two groups that utilize the greatest amount of health care resources.

We know that the severe complications of influenza—invasive bacterial infections such as empyemas, bacteremias, and meningococcemia—tend to peak during and just after each influenza season because bacterial pathogens more readily invade the mucosa of influenza-damaged respiratory tracts, which are still healing for weeks after the patient's influenza infection has resolved. In a bad influenza season, emergency departments are bombarded with influenza cases and patients with sequelae during January-April. Reducing that enormous utilization of medical resources should be worth every bit of effort we'd put into getting everyone immunized in the fall.