Dr. Buttery's Public Health BLOG

Shortly after a version of this question was sent to the Public Health Physicians listserve, this response came to the list from Phillip C. Gioia, MD, MPH:

"Public/Private Health needs a better data system to manage vaccine availability and allocation. Last year in NY State our health department threatened fine anyone giving vaccine to any low risk person. Many people who wanted and could have benefited from the vaccine failed to get it while high risk people who did not want the vaccine still did not get it. Information systems could have determined this problems in real time so we could target education at high risk people, ascertain they are refusing the vaccine or have already gotten it, then make it available to those who would benefit most before the flu season had started. As it was we had much left over vaccine at the end of the flu season and many people who wanted the vaccine but were of relatively low risk without the vaccine."

Shortly after others received Dr. Gioia's comments about data systems, I received this comment from Jonathan B. Weisbuch, MD, MPH, intended for the larger group:

"It is not that we need a data system to provide those who are at high risk with vaccine. What we need is federal policy to protect all citizens form disease, disability and death (35 to 45,000 deaths per year, hundreds of thousands of hospital bed days, millions of days lost from work, etc.). This policy would take the form of the government purchasing 250 to 300 million doses of vaccine from 4 or 5 vaccine manufacturers at one dollar over their manufacturing cost, (a total of about $5.00). The government would than have the vaccine sent to each state health department who could distribute it to every provider in the state no later than September 15. Since enough vaccine would be available for nearly everyone, each state could determine the most appropriate group to vaccinate (the Japanese have lowered the deaths from flu sharply by vaccinating teenagers, not elders). But that could be a state choice. The distribution would finally be made by private physicians, public health distribution centers, hospitals, etc.. but probably not pharmacies and private flu centers. Yes, some vaccine would be left over, but the rates of flu, hospitalization and death would all decline.

"And, the best benefit of the process would be that a system would be set in place that could be used for any other form of mass vaccination were some untoward event to occur in the future.

"But, unfortunately, the current administration does not see the protection of the population as one of its priorities if it has to spend money to do the job (at least money that is not spent with Halliburton).

"Maybe AAPHP should take this idea up for discussion."

Finally, my own comments:

When private systems work as designed, we have a good year. When they don’t, the private response to a shortage is not designed from a public health perspective at all. First distribution from any company usually goes to that company’s long-time customers, regardless of public health need. Last distribution goes to those who had previously ordered from the other company, regardless of public health need. Each health system distributes vaccine to, and redistributes vaccine among, its own operations without regard to overall need in any of the communities in which they operate. From my perspective as a Health Officer in Fall 2004, the whole system seemed pretty dysfunctional when stressed.

In line with Dr. Weisbuch's comments, I believe the federal government should recommend that EVERYONE get annual influenza vaccine, and should set up systems to assure that it happens. Payment systems should guarantee a modest profit, and predictable litigation environments, to a diverse group of vaccine manufacturers. Data systems should be structured around public health goals, rather than the other way around. Planning for vaccine shortages could start at a baseline of 100% population coverage, rather than the current baseline of "selected groups, haphazardly immunized" that we see in a GOOD year in the USA.

Universal influenza immunization wouldn't be a guaranteed solution forever. No biological intervention can achieve that. Ongoing research would be needed, to watch for unintended consequences of the new system. But universal influenza immunization appears to be well-justified by current data, which suggests short-term community benefits far exceeding community risks and costs. Absent any significant evidence of individual or community harm from universal influenza vaccine, it appears that this idea's time has come.

I believe that in the last few years, NACCHO has adopted policy that calls for universal influenza immunization in the USA. Perhaps the rest of us should help move this idea ahead.

Kim, David, the issue of universal influenza vaccination on an annual basis deserves consideration if we are to lower the number of deaths from the disease and prepare for the time when we may have to vaccinate everyone in the nation on a very rapid time schedule.

I would disagree with previous commentators who argue that a better individual risk data base is needed. What is needed is federal policy to protect all citizens form influenza disease, disability and death: 35 to 45,000 deaths per year, hundreds of thousands of hospital bed days, millions of days lost from work, etc. This policy would take the form of the government purchasing 250 to 300 million doses of vaccine from 4 or 5 vaccine manufacturers at one dollar over their manufacturing cost, (a total of about $5.00). The government would than have the vaccine sent to each state health department on the basis of population. The states would distribute it to every provider in the state no later than September 15. Since enough vaccine would be available for nearly everyone, each state could determine the most appropriate group to vaccinate (the Japanese have lowered the deaths from flu sharply by vaccinating teenagers, not elders). But that could be a state choice. The distribution would finally be made by private physicians, public health distribution centers, hospitals, etc.. but probably not pharmacies and private flu centers. Yes, some vaccine would be left over, but the rates of flu, hospitalization and death would all decline along with their attendent costs.

And, the best benefit of the process would be that a system would be set in place that could be used for any other form of mass vaccination or treatment were some untoward event to occur in the future.

Jonathan Weisbuch, MD