Influenza vaccines: why are we missing high-risk patients?

Between 1918 and 1919, 20 million people, including 549,000 Americans, died from Spanish influenza.1 Healthcare workers’ hands were tied, because no forms of prevention were available; this led to continued infection and death. Since this fateful outbreak, 3 other pandemics occurred in 1957, 1968, and 1977. Moreover, the Centers for Disease Control and Prevention estimates that 20,000 Americans die from influenza or its complications annually; 90% of these fatalities occur in the elderly.2 The infection continues to be associated with significant morbidity, resulting in a tremendous economic impact on society each year. The financial burden of the disease in the United States is an estimated $27.8 billion annually. These costs include direct costs to the health care system and indirect costs due to lost wages, lost revenues, and decreased productivity. Considering the toll influenza places on patients and the health care system, it is remarkable that health care providers struggle to give a simple, relatively risk-free vaccine to the elderly and to patients with underlying medical conditions. Because the attack rates are as high as 40%, prevention strategies are advocated to decrease the burden of the disease. Since influenza vaccine first became available in the 1940s, public health authorities and other experts have defined the aforementioned patients as those who can best benefit from the influenza immunization. The vaccine is well tolerated by all types of patients. In a randomized, double blind placebo-controlled trial, 25% of patients reported discomfort at the site of the vaccination.3 Systemic reactions such as malaise and myalgia are rare. Although some caveats apply to high-risk persons, influenza vaccine is generally extremely well tolerated. When administered in the Fall, the vaccine prevents infection and disease in 70% to 90% of recipients if the vaccine strain matches the strain circulating in the community.4 The vaccine's immunogenicity is higher in healthy adults. Studies show that vaccination reduces illness severity, decreases absenteeism from work and school, and is cost-effective.5,6 Among the elderly, the vaccine prevents approximately 50% of respiratory illnesses, decreases influenza and pneumonia-related hospitalizations, and reduces all-cause mortality.7 The question one must ask is: how do we identify these high-risk patients, whether the elderly or those with medical conditions? Many strategies have been proposed, but automated reminder systems are thought to be the most cost-effective.8 In this volume of the Journal, Davis et al. show that although physicians are giving the vaccine to many at-risk patients, physicians have limited ability to track and target “high-risk” patients, including the elderly, who most need the vaccine.9 Even among those providers who have computer systems in place, the systems have not been fully utilized to provide reminders. The one exception is managed care settings. It is easy to conclude that these organized settings have forced prevention into the forefront. We must ask ourselves what to do. Yes, we need to look at these data and modify our practice habits, and administrators need to make it simple. The vaccine should be administered in the early to mid Fall to allow time for the recipient to develop antibodies. However, influenza epidemics can last weeks, so administering vaccine during an outbreak among unvaccinated at-risk individuals is an adjuvant prevention strategy that is commonly used in the public health sector. Davis et al. share data reporting vaccination rates among the elderly that exceed 67%. They also show the dismal coverage rate of 30% among younger patients with underlying medical conditions. Although Federal officials are pleased with the 67% coverage rate, the study by Davis et al. highlights some challenges that educators and clinicians face. These investigators found that family physicians are more likely than internists to administer influenza vaccine in their practices. This may be of concern, because internists tend to follow patients with more-severe and complicated medical problems. If this is the case, then we must better target the physicians who care for these at-risk patients and impress upon them the importance of vaccinating not only before the influenza season but also during the time that influenza is endemic in the community. Again, this may be an opportunity to use automatic reminders to enhance prevention efforts among patients at risk of influenza infection. In this era of patient safety, influenza vaccination is an easy and cost-effective prevention strategy that is not being used effectively because of infrastructure barriers, lack of provider knowledge, and lack of incentives from health providers. As we embrace efforts to protect patients, should we not ask ourselves where we, or our system, have failed?