WMR WRITES:
Dr. S comments about "targeting males" as vaccine scofflaws support those that propose removing hospital privileges from those physicians who cannot provide proof of flu vaccine. This was passed by several Memphis hospitals in 2010. How many freedoms are you willing to trade for saving one life somewhere?
The vaccine police are alive and prospering in Tennessee. But why stop there?
There are so many opportunities for additional life saving regulation. Public Health officials should demand a BMI card for the right to eat fast food.
"Sorry we cannot serve you, your BMI is over 40".
WMR
Dr. Rodney:
Although I agree that H1N1 was a hysteria, there are plenty of articles and studies showing the benefit of influenza vaccine. It’s not just death from flu, it’s also CHF and MI. I don’t know that I buy into the wide spread vaccination of everyone, that seems like overkill, but then you have time out of work saved, time out of school, other indicators. Don’t forget, the last 2 years flu season has been incredibly mild and the pandemic H1N1 turned out to be a nothing flu virus. How many adults and adolescents are we vaccinating against pertussis to prevent a couple of infants from dying. But, it’s infants, right? Seems worth it.
Found this article that demonstrates the benefits:
Benefits of Influenza Vaccination for Low-, Intermediate-, and High-Risk Senior Citizens
Kristin L. Nichol, MD, MPH; J. Wuorenma, RN, BSN; T. von Sternberg, MD
Arch Intern Med. 1998;158:1769-1776.
Background Vaccination rates for healthy senior citizens are lower than those for senior citizens with underlying medical conditions such as chronic heart or lung disease. Uncertainty about the benefits of influenza vaccination for healthy senior citizens may contribute to lower rates of utilization in this group.
Objective To clarify the benefits of influenza vaccination among low-risk senior citizens while concurrently assessing the benefits for intermediate- and high-risk senior citizens.
Methods All elderly members of a large health maintenance organization were included in each of 6 consecutive study cohorts. Subjects were grouped according to risk status: high risk (having heart or lung disease), intermediate risk (having diabetes, renal disease, stroke and/or dementia, or rheumatologic disease), and low risk. Outcomes were compared between vaccinated and unvaccinated subjects after controlling for baseline demographic and health characteristics.
Results There were more than 20000 subjects in each of the 6 cohorts who provided 147,551 person-periods of observation. The pooled vaccination rate was 60%. There were 101619 person-periods of observation for low-risk subjects, 15482 for intermediate-risk, and 30450 for high-risk subjects. Vaccination over the 6 seasons was associated with an overall reduction of 39% for pneumonia hospitalizations (P<.001), a 32% decrease in hospitalizations for all respiratory conditions (P<.001), and a 27% decrease in hospitalizations for congestive heart failure (P<.001). Immunization was also associated with a 50% reduction in all-cause mortality (P<.001). Within the risk subgroups, vaccine effectiveness was 29%, 32%, and 49% for high-, intermediate-, and low-risk senior citizens for reducing hospitalizations for pneumonia and influenza (for high and low risk, P.002; for intermediate risk, P =.11). Effectiveness was 19%, 39%, and 33% (for each, P .008), respectively, for reducing hospitalizations for all respiratory conditions and 49%, 64%, and 55% for reducing deaths from all causes (for each, P<.001). Vaccination was also associated with direct medical care cost savings of $73 per individual vaccinated for all subjects combined (P=.002). Estimates of cost savings within each risk group suggest that vaccination would be cost saving for each subgroup (range of cost savings of $171 per individual vaccinated for high risk to $7 for low risk), although within the subgroups these findings did not reach statistical significance (for each, P.05).
Conclusions This study confirms that healthy senior citizens as well as senior citizens with underlying medical conditions are at risk for the serious complications of influenza and benefit from vaccination. All individuals 65 years or older should be immunized with this vaccine.
Another graph:
I’m not sure what happened in 1999. And I expected to see a rise in 2004 when we had the vaccine shortage. With widespread immunization there has been a decline in rates. How much is worth it? I don’t know. Based on this, looks like we should be vaccinating males or targeting males anyway. So $25 to prevent a few deaths, a few more hospitalizations, a lot of time out of work and out of school. I know, I would rather not spend a week sick with the flu if I can help it as it is really unpleasant to have.
Kathy Saradarian, MD
Dr Kimber writes:
The problem with this study is that it is an observational study. People who did and did not get vaccinated in the 3 risk groups self selected, and therefore were likely very different in many ways (measured &/or measurable and unmeasured &/or unmeasurable). These differences are the likely cause of most, if not all the differences in outcomes between the two groups, not the fact of having had influenza vaccination. This effect has been shown time and time again when the outcomes of RTCs did not show the purported benefits of therapies that seemed to be beneficial on the basis of these kinds of observational studies (not matter how well the authors tried to statistically adjust for confounding factors). The illusory benefits of post menopausal estrogens is an example that most immediately comes to mind.
The problem with the traditional approach to flu vaccination has been that those targeted (sick, elderly, and sick elderly) were least likely to mount an effective immune response to vaccination. The new strategy is an attempt to protect them by herd immunity in the community, by my understanding of the scientific rationale. That it fits with the economic interests of the public health-academic medical-vaccine industrial complex kind of clouds the picture.
The pertussis situation just returns us to the status quo ante prior to 1970s, as it is long known that pertussis immunity wanes, and absent a well vaccinated adult population and preponderance of breast feeding, the most vulnerable cannot be fully protected by vaccinating them, and yes there is a huge payoff in terms of years of life gained in that case.
As I think about it, moving vaccination from the (now almost completely socialized) health care system into the market place, is not a bad idea. Let people be educated or mis-educated, and let them make their own decision and spend their own money on flu shot.
Roger Kimber
I agree, Dr. Rodney.
One of the unintended effects of the H1N1 hysteria was a clarification of the true burden of influenza. As you know for much of 2009 and 2010 patients who died after ILI (influenza-like illness) and patients admitted to ICU with ILI had virus specific typing of their viral illness. In many months the majority of ILI is not in fact influenza. The months where the ILI peaks incudes RSV, rhinovirus, picornavirus and so on. Also some of the influenza that was typeable did not match the antigen chosen for the year. I received the weekly NJ state department of health stats with all the state wide ICU admissions and deaths related to ILI and the weekly scatter plot of ILI and what percentage is influenza A, influenza B and untypeabe influenza.
The number of deaths in patients with lab confirmed influenza in NJ for year 2009-2010 : twenty four
The number of deaths in patients with lab confirmed influenza in NJ for year 2010-2011 : eight
We have heard the hype number 36,000 annual deaths for decades now. Instead of more detail and more testing bolstering that number we have the opposite. The last two seasons where there was an unprecedented effort to document as many cases of influenza as possible the case /fatality rate in NJ was 570 / 8. That means 570 positive samples for patients with ILI and 8 deaths among those patients. If you use the same rate for the positive sample number nationwide you get about 800 deaths. (54,226 influenza positive samples in the USA last flu season of the 250,000 total samples done by the CDC/WHO influenza surveillance system).
Are we to believe that 35,000+ influenza deaths are missed by the CDC? More likely there are around 1,000 influenza related deaths per year in the USA and several thousand other deaths after non influenza viral illnesses. I think if you use 1,000 annual US flu deaths (eight in NJ) you can make a better estimate of how much risk there is for your patients.
John L. Bucek, MD,
Somerset Medical Center
Paid off legislators using purchased science have inflated these miniscule statistical benefits for the purpose of profit. Why play? I know everybody has an anecdote,but do you really believe that you are saving lives with all of this? NNT?
wmr
I received my first shipment of flu vaccine Friday, Walgreens has had it (or at least the big roadside sign has been up) for six weeks already. Used to be we could fall back on the CDC recommendation to delay the vaccine till closer to flu season, but they have migrated to a policy of "Give it as soon as you've got it".
I'm considering just no longer ordering any, or only ordering enough to make sure my gravids get it. The medical industrial complex trumps the cottage industry of family medicine once again.
Arthur Freeland
Kirksville, Missouri
It’s a battle for us. Every pharmacy I call I have to listen to the message for 5 minutes about how they are offering flu vaccine. I am going to have to change my answering machine to include the message. I also by my vaccine from VaccineShoppe and they offer a free service where I just have to provide them with an Excel list of phone numbers and record a 30 second message to my patients to come in for their flu shot. So I am moving forward on that. It’s either stop doing it or advertise it to my own patients as much or more than the pharmacies.
I have even started reminding my patients this summer that I will get the vaccine and I have ordered it for them. Trying to guilt them a little if they go elsewhere for the vaccine.
Remember the pharmacies don’t have anything but the traditional vaccine. I am ordering doses of hi-dose for my oldest and sickest and I am trialing a few of the intradermal although it doesn’t sound better to me.
Kathy Saradarian, MD
Kathy S, sounds like you have the right approach. We have been giving them out for 2 weeks already, offering them to all that come in and all that will take them. Bill Vaccine and Bill the Administration Fee
Falball
Safeway sign: “10% off groceries purchased same day as flu shot”.
Earl J. Carstensen, MD, MHS
It's the same complaints and issues for the last 10 years. That's just the way it is. I'd say move on. We've all been upset and disturbed by this for years. It hasn't changed.
The AAFP hasn't come out and lobbied for us on this. It's ok to make me in CT have to have a Physician or an RN administer the vaccine. Can't allow or have my MAs even draw vaccines up, much less give them. That's stepping on the RNs turf and toes. So had to spend more money hiring a nurse for vaccines, even though MAs are experienced and trained for it. So my extra time doing them ourselves (the physicians) and paying extra $$$$ / hour for a nurse, didn't matter much to the AAFP ears and years ago. It isn't going to matter now. This is the way it is. Live with it. Move on.
Earl:
Tried that years ago. Took vitals, Asked about egg allergies. Billed 99211. Every insurance company denied payment. Had to write it all off. Have to do more than that.
Kathy Saradarian, MD
We give them out for a routine office visit. No one just comes in for Flu Vaccines any more
Falball
Even if there are acceptable studies showing a reduction of influenza burden in an immunized population, the benefit is always overstated by docs and public health officials. Many of the groups like pregnant patients and young children are not studied so requiring them to get the shot is just unscientific. Thankfully there has been no major safety disasters with influenza vaccine since the swine flu vaccine in the 1970s.
However there was a recent significant safety issue with the H1N1 shot marketed in Europe. Dozens of children in England and Australia and Sweden got the condition narcolepsy from their 2010 H1N1 vaccine. These countries will no longer give the vaccine to under 6 year olds as a result. If that level of side effect is possible then I want much better info on the NNT and NNH. Even if available these stats are not very helpful with influenza because the vaccine and the virus changes each year.
John Bucek
I agree with the general tenor of Dr. Rodney’s remarks. I was required to either get a varicella titer or varicella vaccine, even though I can remember having chicken pox as a child, and I was born in 1950!! (I took the shot to avoid the risk of having a false negative serology result,and have to get two procedures.
That said, I get my flu shot every year. Documented decreased sick time lost (Target employee RCT study a couple decades ago), and I get enough viral respiratory illnesses in the course of my work, and I would not like to be part of a chain of contagion.
Roger Kimber
Index--Vaccine Police, flu vaccine
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