Universal influenza vaccination: an optimal goal--but how and when?

On June 29, 2010, the Advisory Committee on Immunization Practices approved detailed recommendations for the future use of influenza vaccines for preventing and controlling influenza. A significant change was the recommendation for ‘‘annual influenza vaccination to include all people aged 6 months and older.’’ Past recommendations had focused on priority vaccination for an ever-increasing number of groups of people with ‘‘risk factors for influenza-related complications or having close contact with a person at high risk for influenza-related complications.’’ By 2009, the ever-growing list of risk groups accounted for 85% of the total population. The only group for whom routine vaccination was not then recommended were healthy, nonpregnant adults aged 18 to 49 years who did not have an occupational risk for infection and who were not close contacts of people at special risk of experiencing complications. Thus, to recommend vaccination for everyone was a logical simplification of longstanding recommendations. There is no question but that there is a benefit from vaccine protection against possible influenza infection, while the risks of adverse reactions to the vaccine are negligible. The conclusion is obvious—but how does this recommendation rank among the long list of public health problems demanding attention? No guidance has been provided. The CDC has not yet made clear whether the recommended strategies for vaccination will be primarily the traditional approaches for seasonal influenza vaccination or whether additional funding will be sought to permit special programs to be undertaken. Until 2009, influenza vaccination had been a highly decentralized operation involving many participants. The role of health departments was to help disseminate information about the vaccine and vaccination to physicians, hospitals, public health clinics, occupational health programs, nursing homes, long-term care facilities, and others. Some vaccinations were provided at pharmacies and other locations, but two-thirds of all vaccinations were provided in a medical setting. The costs were borne in part by participating providers in the Vaccines for Children program and by insurance plans. Vaccine supplies were separately ordered and stocked by the dispensing organizations. National Immunization Surveys during each of the 3 years preceding 2010 revealed essentially unchanging coverage of 15% to 25% for school-age children and those up to 50 years of age. Coverage among preschoolers was somewhat higher (20% to 30%). Those over 65 years of age were the best vaccinated, with coverage of 60% to 65%. During the past year, special federal appropriations were made available for vaccine purchase and delivery because of the heightened threat posed by the new H1N1 pandemic influenza strain. More than $1.6 billion in federal funds was allocated for vaccine purchase, and $350 million was made available to support state and local initiatives in vaccination. Fear of a pandemic whose severity was unclear provided motivation for public acceptance of vaccination. However, apprehension and fear of the new virus waned as delays occurred in vaccine delivery and as it became apparent that the epidemic was less severe than many had expected. In all, fewer than 90 million people were vaccinated—less than 30% of the population. Only 37% of healthcare workers were themselves vaccinated. Some local health departments undertook special programs to vaccinate schoolchildren because it was thought that large numbers could readily be reached. But such programs proved to be far more complicated than imagined. The burden to teachers of an additional Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science Volume 8, Number 3, 2010 a Mary Ann Liebert, Inc. DOI: 10.1089=bsp.2010.0816