The time may soon come when doctors recommend that every American man, woman and child be vaccinated every year for influenza — an idea offered Wednesday by a leading expert in vaccines and preventive medicine.
Dr. Gregory Poland, director of the Vaccine Research Group at the Mayo Clinic in Rochester, Minn., testified Wednesday at a meeting of the Advisory Committee on Immunization Practices (ACIP), the subcommittee at the Centers for Disease Control and Prevention that issues federal recommendations for the use of vaccines in the United States.
In his testimony, Poland recommended that the United States should move to a so-called "universal recommendation" for vaccination against influenza, the virus that causes the flu.
A universal recommendation would make official that Americans of all ages should receive an influenza vaccination every year. The testimony came at a time when the committee is considering a smaller step of recommending that all school-age children receive a yearly vaccine.
"I think it's a good idea to expand [vaccination] to all school-age children," Poland said. "But a better idea is to say, 'let's not just go age group by age group; let's just recommend that everybody get it.'"
Review of recent changes in the CDC recommendations shows that ACIP has been steadily increasing the indications for a flu vaccine for several years. Current estimates are that more than 70 percent of the U.S. population now meets one of the 15 published criteria for recommendation of a yearly flu vaccine.
"We've changed the recommendation every year or two since '97," Poland said. "It's sort of a creeping incrementalism."
Instead of marking out ever-increasing numbers of groups that should get the flu vaccine yearly, Poland espoused a universal recommendation that all Americans should be getting the shot, with particular emphasis on vulnerable groups.
"Let's just make a universal recommendation — that all Americans should get vaccinated. But then note that there are particular high-risk groups that should be particularly recommended to get the vaccine."
How Do You Deliver 300 Million Vaccines?
Such a move would not come without difficulty. Currently, less than 40 percent of America's 300 million people receive yearly flu shots — and many of those for whom it is recommended do not receive their immunizations.
Other vaccine experts pointed out that any effort to vaccinate all Americans would face many logistical hurdles. Concerns included the availability of enough flu vaccine for the entire American population and the lack of a public health infrastructure to deliver that many vaccines.
"If a universal flu vaccine is recommended, it would need a plan," said Ira M. Longini Jr., a professor in biostatistics and biomathematics at the University of Washington School of Public Health. "Right now, if you look at vaccine supply, we can't make 300 million dose of vaccine and get them to the right people. Even if we could make enough dose, we would need to put in place a program to reach everyone."
A move to vaccinate everyone could also face significant financial hurdles.
"Who is going to pay for all of this?" asked Dr. William Schaffner, chair of the department of preventive medicine at Vanderbilt University. "For example, we know that there are 40 million people who don't have medical insurance. Who is going to get the vaccine to those people?"
According to Poland, though, vaccine supplies have been increasing steadily since the widely publicized vaccine shortages from several years ago.
"This year, manufacturers are going to make 130 million doses in America. Last year … we threw away about 12 million doses," he said. "Every year this decade, we've leaned on the manufacturers to make more vaccine, and we've thrown away doses in the millions."
"Until this year, there were concerns that we'd even have enough vaccines to cover our indicated patients," said Schaffner. "However, that concern is receding. We are having more manufacturers coming into the U.S. market. This year we'll have 130 million doses or even more. This year, we are faced with the idea of, 'can we even use it all?'"
Preparing America for Pandemics and Bioterrorism
According to Poland, however, there could be a very important hidden benefit to addressing these issues now: Americans would learn how to be prepared in case of a bioterrorist attack or a pandemic infectious disease.
"Once you've made a recommendation and then implement the recommendations, you go a long way towards figuring out the ways to operationalize the ways to administer these things to all Americans," Poland said. "You can't make that happen in the middle of an emergency."
Schaffner agreed that the development of such public health infrastructure could be a critically important step for the future.
"If we undertook to vaccinate a very substantial proportion of the U.S. population each year, you'd have to organize everything from vaccine development to production to delivery," he said. "It'd be like a training session or a fire drill that we'd conduct each year.
"So if we had to do it in any kind of emergent situation — for example, anthrax, smallpox vaccine, delivering cipro [antibiotics] — we'd have a trained provider network and a trained public," he said. "Just as most of us know where to go to vote, we'd be trained on where to go to get vaccinated or get your antibiotics or whatever the public health intervention would be."
"It may be something that could lay the groundwork for something looming down the line in the form of an avian flu pandemic," said Dr. Peter Hotez, chair of the Department of Microbiology, Immunology and Tropical Medicine at The George Washington University. "By getting this infrastructure into place by vaccinating the whole population against [seasonal] flu, you lay the groundwork to combat deadly avian influenza.
"In effect, you would be killing two birds with one stone."
But according to Poland, this type of recommendation would likely need some advance warning to allow for the infrastructure to be built.
"I suggest we make the recommendation in advance," Poland said. "For example, something like 'starting next year, we'll be recommending all Americans get a flu vaccine.'"
Carla Williams and Dan Childs contributed to this report.