RIAFP Policy
Brief: 11/27/00
2000 Influenza Vaccine - A Vaccine
"Urgency"
The 2000 influenza
vaccine season has been marked by confusion and inconsistent communication
from the CDC and vaccine manufacturers. It may be remembered as a
time when the health care system worked together effectively in time
of stress to get supply to those who need it most. Or it may be remembered
as a time when we had a preventable epidemic.
We have included
a longer than usual description of the influenza vaccine situation
as we see it.
The Rhode Island
Academy of Family Physicians believes we are at a crossroads, and
that now is the time for the State of Rhode Island, and the Rhode
Island Department of Health, to become active in securing influenza
vaccine supply, and insuring its distribution to high-risk individuals.
We do not believe
that adequate vaccine is available to prevent more injury and death
from influenza than usual if influenza becomes widespread by the third
week in December.
We urge the Rhode
Island Department of Health to identify those individuals at highest
risk, and work closely with the physician, nursing, and hospital community
to insure that these individuals receive influenza vaccine soon.
In the coming
months, we urge the State of Rhode Island to centralize vaccine purchase
and supply for 2001-2002 and beyond. We have the best child immunization
program in the United States. Our adult immunization rates and process
should be the best in the United States as well.
Influenza
and Influenza Vaccine
Influenza is
a viral illness that causes fever, cough, and severe muscle aches.
In otherwise well young people, it usually causes five to ten days
of illness, and has the potential to lead to pneumonia. In older people
and people with chronic diseases like asthma, heart disease, emphysema,
kidney failure and diabetes, influenza can cause severe pneumonia
and death. In the pandemic of 1918, influenza caused over one million
deaths in the United States.
Influenza becomes
common in December, January and February.
Influenza is
a viral illness, caused by one of two related viruses that change
every year, so people need to be vaccinated yearly, with a vaccine
that must be redesigned every year to account for the evolution of
the viruses. About 80 percent of individuals who receive influenza
vaccine become immune to influenza. That immunity takes about two
weeks to develop, and lasts 3 to 4 months.
Sixty to sixty
five percent of all influenza vaccinations are provided by primary
care physicians in their offices. The rest of the influenza immunization
is provided by nursing homes for their patients, by Visiting Nurses
at senior centers and in senior housing projects and public clinics,
with the smallest number of vaccinations being provided by hospitals.
The physician
practices are the best place to immunize those at highest risk, as
physicians are trained at evaluating and mitigating risk, with mass
immunization campaigns in nursing homes, senior centers and elderly
high rises, providing the immunization of those in the next highest
risk tier.
Public immunization
clinics represent an effective strategy for the immunization of those
at risk for influenza, but not necessarily at high risk for the complications
of influenza.
The supply of
influenza vaccine is entirely market driven, with each physician practice
ordering its own supply from one of a plethora of suppliers, who urge
practices to "book" (or reserve) their vaccine order early.
Vaccine contracted for in January or March typically sells for a little
more than $2.00 a dose, and vaccine purchased in November often sells
for as much as $4.00 a dose. Reimbursement from health insurers and
Medicare is set before the season, and does not change with price
fluctuations. Hospitals, nursing homes, businesses, and Visiting Nurse
Associations also purchase vaccine from independent wholesalers. Vaccine
purchasers' market power is determined by size, the strength of their
relationships with their wholesalers, and the price they are willing
to pay. Vaccine purchasers' market power is not determined by the
relative risk of the patients they serve.
Rhode Island's
1998 Medicare influenza vaccination rate was 67.7 percent, ranking
us 20th in the nation - a significant concern given our large elderly
population.
In addition to
vaccination, there are four antiviral medications approved by the
FDA to treat influenza. Two older medications, have a number of side
effects, and are often not well tolerated by older people. Two newer
medications were introduced in 1999-2000 influenza season, but did
not sell well, as they were significantly more expensive than either
influenza vaccine or the older medications. One of those has been
reported to have significant side effects unrecognized before its
release.
Influenza
Vaccine Supply in Rhode Island
In early summer,
the Centers for Disease Control and Prevention announced there would
be significant delays in shipments of influenza vaccine for the 2000-2001
season, and notified the provider community that there might be shortages
of influenza vaccine. By early fall, however, physicians, patients
and health care providers were assured that, though there would be
delays in delivery, adequate supply would be available in time to
prevent illness and death from influenza. Although still recommending
that physicians and other vaccine providers immunize high risk people
first (those over 65, those with chronic disease, and health care
workers), CDC had decided against issuing restrictive modified recommendations,
which would have restricted available vaccine supply to the highest
risk groups. Instead, CDC recommended only postponing open community
vaccine clinics until at least November, but did not recommend a mechanism
to match the vaccine as it became available to people in order of
their relative risk.
In fact vaccine
supply has been spotty at best, filtering in dribs and drabs to hospitals,
nursing homes, Visiting Nurse Associations, and physician practices.
Some practices have had adequate supply, and have immunized their
high-risk patients in a timely manner. Some practices have had no
supply, and their highest risk patients have not been immunized at
all. Some nursing homes and senior centers have been immunized, and
some have not. Some health care workers have been immunized, and some
have not. Some Visiting Nurse Associations have been able to run community
clinics (which are not equipped to do risk stratification, and not
able to restrict vaccine to those at highest risk) but most community
clinics have been cancelled for lack of supply.
But many lower
risk patients have been immunized, and that was done before adequate
supply for the high-risk patients could be assured. Business and schools
lucky enough to receive vaccine supply have immunized their healthy
working population; and some visiting nurse associations have run
open community clinics, which risk immunizing those vigorous and strong
enough to be first in line, before those at greatest risk were immunized.
The number of
unimmunized high-risk patients is unknown. The number of immunized
high-risk patients is unknown. The number of vaccine doses Rhode Island
can expect to receive is unknown.
Recently, CDC
announced it had obtained 9 million "new doses" from a major
manufacturer which would be available in late December for $2.90 a
dose to public institutions, and $5.00 a dose to the private medical
community. At the same time of CDC's announcement, many physician
practices which had contracted for vaccine delivery at $2.30 a dose
were informed by their suppliers that they should only expect 40 percent
of their ordered number of doses because CDC had directed the bulk
to the supply "to public clinics"(a claim which is at best
a distortion of CDC's position), were told not to expect any delivery
until late December or early January (at which time it is often too
late to immunize), and were encouraged by vaccine suppliers to cancel
their vaccine orders. Unfortunately, a number of practices have cancelled
those orders, in the belief that there will be adequate supply in
the "public clinics" to immunize their high-risk patients.
But lacking any vaccine supply, many public clinics have been cancelled.
Subsequently,
the manufacturer who is CDC's supplier and is a major Rhode Island
supplier as well notified practices that they would receive 25 percent
of their orders by November 17, 2000. But that manufacturer's wholesaler's
then notified at least one practice that it could expect to receive
only 13 percent of its order by November 17, 2000, and as of November
27, 2000, that amount has not yet been received.
The current wholesale
price for influenza vaccine is $6.95 per dose.
This is one
in a series of reports designed to advance Family Practice and primary
care in Rhode Island's health care system, as well as to discuss public
health issues of importance to all Rhode Islanders.
We welcome
the opportunity to further discuss the issues presented here. We can
be reached by phone at 401-453-4176, or by email at info@riafp.org.
11/27/00
