Flu blues: High-risk patients top priority
ICPs may have to prioritize due to vaccine delay
Immunizing high-risk patients and their family contacts probably should take precedence over vaccinating health care workers if influenza vaccine delays lead to prioritizing limited supplies this season, epidemiologists advise Hospital Infection Control.
"If we come to a situation where we really are in a vaccine ration, and we have more people who want the vaccine than we have doses to give, we’ll give it first to high-risk patients, second to their household contacts, and third to health care workers," says Patrick Joseph, MD, chief of epidemiology at Summit Medical Center in Oakland, CA. "We are hoping that the first shipment of vaccine is adequate to cover all three of those so that type of prioritization will not be necessary."
The Centers for Disease Control and Prevention has taken steps to prevent an outright vaccine shortage but is warning that delayed receipt of vaccine can be expected for many areas due to production problems. Most vaccine doses usually become available to providers by October, with 99% of distributed doses available before December. But this year, about 18 million doses are expected to be distributed in December. Despite the delays, total number of doses is similar to last year, when 3 million went unused. For the 2000-2001 season, distribution of about 75 million doses is anticipated. That includes a special supplement of 9 million doses the CDC contracted from Aventis Pasteur Inc. in Swiftwater, PA.
Extra doses available mid-December
"We have negotiated a contract to bring an additional 9 million doses on the market in the middle part of December, after their normal distribution is done," says Bob Snyder, MA, public advisor for the CDC’s national immunization program. "This would be supplied to providers who serve high-risk patients first, and then contacts, health care workers, and healthy others.’ It will be done through the manufacturer. They will be accepting orders in November, but they won’t actually be shipped until mid-December." (See editor’s note for more information.)
When influenza vaccine becomes available, vaccination efforts should be focused on those at high risk for complications associated with influenza disease and on health care workers who care for them, the CDC advises. In updating its guidance on the issue, the CDC Advisory Committee on Immunization Practices (ACIP) stated that "temporary shortages because of delayed or partial shipments may require decisions on how to prioritize use of vaccine available early in the season among high-risk persons and health care workers; such decisions are best made by those familiar with the local situation."1
William Schaffner, MD, chairman of the department of preventive medicine at Vanderbilt University School of Medicine in Nashville, concurred with the committee’s stance. "ACIP can issue general guidelines," he says. "It is impossible, however, for the committee to design specific local immunization programs. We’re asking providers to be sensible and encourage those folks who are at high risk to get to the head of the line, and that includes health care workers. The vaccine will be late. We’re asking for understanding, flexibility, and assertiveness. You are going to have to be a little more assertive about getting the vaccine and put a little more energy into it."
Indeed, the delay has raised the question of whether health care workers traditionally reluctant to be immunized might respond to the old "supply and demand" theory and seek out vaccination when it becomes available. "It may well be that health care workers will be a little more receptive than usual, thinking this is a scarce commodity and we are likely to see more flu patients this year," he says.
However, if the vaccine is delayed to the extent that a choice has to be made, the vaccine will first be offered to high-risk patients in the hospital clinics, Schaffner says.
"If we only have a limited amount, particularly in the early days, then I think we will be directing that principally to our patients," he says. "But we don’t expect to really have much of a shortage, so if we’re just patient, we will get enough vaccine so that in November and December we can carry out our institutional employee immunization program."
Continue to offer vaccine
The optimal time to administer influenza vaccine is October through mid-November to assure that vaccination occurs before there is substantial influenza activity. In any influenza season, vaccine should continue to be offered after November to persons at high risk for influenza complications. That will be particularly important in this season in which vaccine delivery is delayed, the CDC advises.
The effectiveness of this approach is supported by surveillance data from the past 18 years, indicating that seasonal activity peaked four times in December, four times in January, seven times in February, and three times in March.
"Those who are immunizing and those who are being immunized need to realize that the vaccine can be very effectively administered in December, which is not a conventional month that people think about getting immunized," Schaffner says.
(Editor’s note: As a bonus to Hospital Infection Control subscribers, a special report on influenza issues in emergency medicine has been posted on our Web site, HIConline.com. Look for "Influenza Year 2000 Update" under our Headline Watch section. Also, click on our subscriber poll on the site to weigh in your opinion on the flu vaccine situation in your area this year. Look for flu updates on our site as well as the CDC’s site, www.cdc.gov/nip.)
Reference
1. Centers for Disease Control and Prevention. Notice to readers: Updated recommendations from the advisory committee on immunization practices in response to delays in supply of influenza vaccine for the 2000-01 season. MMWR 2000; 49:888-892.
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