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Flu vaccination most successful in 3 years

But doctors and public health officials are concerned about vaccine coverage rates, one maker's exit from the market and rising costs.

By Victoria Stagg Elliott, amednews staff. Feb. 10, 2003.

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For physicians and public health officials, the 2002-03 winter has seemed like a dream come true.

After two bruising flu vaccine seasons, the glitches finally seem a thing of the past. This time, the flu shots were ordered and arrived on time, even though the price was generally higher. The September trickle of doses turned into an October and November flood. Patients lined up for shots, and there was lots of vaccine to go around -- 95 million doses total.

"It's just as exciting as can be," said Ronald Bangasser, MD, director of external affairs at Beaver Medical Group in Redlands, Calif.

Although this was one of the most successful vaccination seasons in recent memory, concerns persist about the long-term implications of the shortages and delays of the previous two seasons, when coverage rates dipped by as much as 13% for some target groups.

New data on coverage rates for the previous quarter are not available yet, but anecdotal evidence is mixed. Some physicians and other vaccine providers report record demand. Dr. Bangasser, who is also president-elect of the California Medical Assn., expects to provide nearly 30,000 vaccinations before he's done -- a 50% increase over last year.

Others, though, say the demand has softened -- that patients are now out of the habit. Workplace clinics have reached fewer people in part because in these trying economic times, companies have fewer workers and are picking up less of the tab. No shortage, combined with significant media attention on smallpox, also means that flu is making fewer appearances in the consumer media.

And there hasn't been a really bad flu season for quite some time.

"Human nature is that when the problem isn't staring you in the face, you procrastinate," said Kristy Bradley, DVM, MPH, assistant state epidemiologist for the Oklahoma State Dept. of Health.

For instance, so far this year, national flu activity has been low -- emerging in 25 states. It has hit in places such as Texas and Kentucky, where schools were closed, and brought patients to Maryland hospitals, according to local news reports. Thus, the medical community is braced for it to gain strength.

Meanwhile, even with the year's positive reviews, there have still been hiccups. Some physicians and other providers of flu vaccine say the priority approach by the government's Advisory Committee on Immunization Practices during the 2000-01 season does not work in seasons of plenty, such as this one. It has actually interfered with getting the vaccine out.

"It causes a lot of confusion out in the field," said William Schaffner, MD, chair of preventive medicine at Vanderbilt University School of Medicine in Nashville. "If we have abundant vaccine, we should go for it. Start vaccinating trees. Anybody."

The ACIP will reconsider the recommendations at its next meeting.

Some say the system also leaves too small a time window to provide most vaccinations. Those of low priority are supposed to be vaccinated after Nov. 1, but those providing vaccines say inoculating after Thanksgiving is a very hard sell.

"You can't immunize the whole country in three or four weeks," said Stephen Wright, national director of Maxim Health Systems, a Columbia, Md.-based company that provides 1.7 million flu shots annually in retail and workplace settings.

Many providing vaccinations say they will continue offering shots until they are out. There is anecdotal evidence that late-season vaccinations are getting easier and may become even more so in the future.

"Patients have now heard the message two or three times that December, January is not too late," Dr. Bangasser said. "They're getting used to it."

Emphasizing coverage rates

But reflecting on this year's season leads some to begin laying the groundwork for next year. A primary goal will be to increase coverage rates.

More and more, there are concerns about the stability of the vaccine supply. Supply has increased over the past few years, but this year has seen significant amounts of vaccine left over -- including at least 12 million doses unsold by the manufacturers and unknown numbers of doses still on the shelves of various suppliers, physician's offices and other vaccine providers. Those in the business say it's a situation that threatens the whole system.

Also, one of the three manufacturers, Wyeth Pharmaceuticals, left the injectable flu vaccine market, although the company is continuing to work toward a nasal version that may be approved for use in children and healthy adults younger than 50. The other two manufacturers -- Aventis Pasteur and Powderject Pharmaceuticals -- have promised to ramp up production. There is speculation, though, that fewer companies in the business means more instability.

"There are always uncertainties with vaccine production," said Dennis J. O'Mara, associate director for adult immunizations at the Centers for Disease Control and Prevention National Immunization Program. "Now that we have two manufacturers instead of three, that heightens the uncertainty."

There are also great concerns about how the significant price increases of the past few years will impact coverage rates. Another increase is expected for next season, and reimbursement rates haven't generally kept up. Increased prices in times of state budget shortfalls also mean that public health agencies are buying less vaccine. Oklahoma, for example, reduced its order from 210,000 in previous years to 180,000 for this year, in part due to the increase in cost.

"Next year, flu vaccine will be more expensive, and we're going to maximize the number of doses we will have based on the financial resources that are available. But it may not be enough," said Don Blose, chief of immunization services for the Oklahoma health department.

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