Letters to the Editor
Lowering the Age for Influenza Vaccination
TO THE EDITOR: This note is in support of the concept of immunizing healthy persons younger than 65 years, as recently recommended by the American Academy of Family Physicians (AAFP), seconded by Zimmerman1 and endorsed by the accompanying editorial.2 To support the case for immunizing the work force as reported by Nichol and colleagues,3 Clover2 reiterates the need for a close antigenic match between the vaccine and the attacking strain of influenza, and a high attack rate. However, Clover2 seems to minimize the impact of "avoiding lost wages" in contrast to "direct cost savings." In fact, the payroll costs themselves understate the impact of illness/absence in the workplace as we recently experienced in having to close facilities to new admissions when staffing became inadequate because of laboratory-diagnosed influenza. Most of the staff had chosen not to take the free but voluntary "flu shots." In production settings, illness-absence can have an even stronger ripple effect.4
Other studies have also shown the cost-effectiveness of prophylactic influenza vaccination of persons in the workplace. For example, a randomized, controlled, double-blind study5 of 2,079 petrochemical workers in Houston (presented so far only as an abstract) compared the impact of trivalent (influenza types AAB) versus monovalent immunization (influenza type B only) on short-term (one to three days) absence from work. During the moderate influenza A epidemic of 1993 to 1994, the type B-only influenza immunization served as a placebo, and those given the trivalent prophylactic immunization experienced 30 percent less illness/absence. Adverse reactions over two days postimmunization were the same in the two groups (0.5 percent), confirming the low risk of this type of immunization. The evidence of vaccine efficacy was demonstrated in a work force that typically has perfect annual attendance in nearly two thirds of its members; thus, absence may actually understate the impact of illness on productivity. Still others have also found significant (although smaller) benefits from influenza immunization of their workers.6
Costs not captured by such studies include the fortunately uncommon but catastrophic cases, in which influenza is complicated by pneumococcal sepsis with multiorgan failure or similar tragic illnesses. From an overall business perspective, the use of influenza immunization makes good sense.
Perhaps if we follow the new recommendation of AAFP's leaders in this regard, we'll raise our own awareness of the more pressing need to protect those of our patients who are at greater risk from influenza and its complications, and come closer to batting a thousand in that department than we currently do. At the same time, we can try to get most of our own health care staff on board, too!
LAWRENCE W. RAYMOND, M.D., SC.M.
Department of Family Practice
Carolinas Medical Group/Myers Park
Charlotte, NC 28207REFERENCES
- Zimmerman RK. Lowering the age for routine influenza to 50 years: AAFP leads the nation in influenza vaccine policy. Am Fam Physician 1999; 60:2061-6.
- Clover R. Influenza vaccine for adults 50 to 64 years of age [Editorial]. Am Fam Physician 1999;60:1921,1924.
- Nichol KL, Lind A, Margolis KL, Murdoch M, McFadden R, Hauge M, et al. The effectiveness of vaccination against influenza in healthy, working adults. N Engl J Med 1995;333:889-93.
- Mets JT, LaDou J. Diagnosis of absenteeism. In: Zenz C, ed-in-chief; Dickerson OB, Horvath EP, eds. Occupational medicine. 3rd ed. St. Louis: Mosby-Yearbook, 1994:989-96.
- Montgomery CH, Batey DM, Couch RC, Glezen GP. American Occupational Health Conference. Abstract of scientific presentations. The effect of influenza vaccination on occupational absenteeism. American Occupational Health Conference, April 15-21, 1994, Chicago, IL.
- Olsen GW, Burris JM, Burlew MM, Steinberg ME, Patz NV, Stoltzfus JA, et al. Absenteeism among employees who participated in a workplace immunization program. J Occup Environ Med 1998; 40:311-6.
IN REPLY: Dr. Raymond makes excellent points regarding the costs of influenza disease. I agree that some previous studies may have underestimated the costs because of lost productivity and turning away business because of the number of staff who are ill. One possible explanation for the limited number of studies on this topic is that manufacturers in a competitive market might not tell other companies about the benefit of work force vaccination against influenza, thereby maintaining their competitive advantage. The data Dr. Raymond mentions further supports the American Academy of Family Physicians (AAFP) policy, which many other organizations will follow for the fall of 2000--AAFP led the nation on this.
After having lowered the recommended age for annual influenza vaccination to 50 years, what is the next step in reducing influenza morbidity? Data show higher morbidity from influenza in preschool-aged children, particularly within the first two years of life. One possibility is to vaccinate this age group. One technologic advance that might make this feasible is licensure of live attenuated intranasal influenza vaccine that is expected to be available within a few years. Another option is to vaccinate school children because they are among the major transmission routes for influenza within a community.
Experts are beginning to ponder whether to lower the age for pneumococcal polysaccharide vaccination from 65 to 50 years. Smokers and passive smokers appear to be at higher risk for pneumococcal infection. After many years of little to no change in the vaccination schedule for adults, exciting developments are occurring that can lead to reduced morbidity and, for certain vaccines, even reduced costs to society.
RICHARD KENT ZIMMERMAN, M.D., M.P.H.
Departments of Family Medicine and Clinical Epidemiology and Health Services Administration
M-200 Scaife Hall
University of Pittsburgh
Pittsburgh, PA 15261
Genetic Testing
TO THE EDITOR: The "Medicine and Society" commentary by White, Callif-Daley and Donnelly titled, "Genetic Testing for Disease Susceptibility: Social, Ethical and Legal Issues for Family Physicians"1 barely scratches the surface of the three areas they address. With the rapid development of many potential gene therapies just on the horizon, all physicians will have major continuing medical education needs in the area of genetic diseases. The article hints at the development methodology of DNA transfer therapy whereby defective genomes are "replaced" by introducing nonnative DNA into a patient's cells. Family physicians need to learn about this rapidly developing field.
Gene therapies for several illnesses are under study for diseases (e.g., cystic fibrosis, Alzheimer's disease). The National Institutes of Health has prioritized the "top 100" genetic diseases for research, including many cancers. Another question is whether fetuses should be screened for the Huntington's chorea gene and aborted if the results are positive. Mixed patient reaction to this advance is illustrated by the fact that only 200 of the potential 150,000 affected persons have elected to be screened.2
The confidentiality issues related to data banks of genetic information are enormous. Informed consent is not really an individual decision any more. Other stakeholders may feel it is a family-wide issue. One potential for privacy abuse is illustrated by the military data bank collected for the purpose of avoiding "unknown soldiers." Several groups are interested in the research potential for the genetic information in this large data bank of chromosomes collected on every military recruit. Once a person's DNA is stored, protection of that information is only part of the issue. Without consent, research with the actual genes themselves is a potential risk.
The discrimination based on genetic information could parallel what has happened with screening persons for human immunodeficiency virus (HIV). Also, the misuse of genetic information potentially places families and relatives at risk for a lifetime of health and life insurance denials--genetic risks that in many cases will never develop expression. Despite the Health Insurance Portability and Accountability Act of 1996, the potential for great pressure from financial concerns exists. Relatives in the genogram of the tested person will demand a right to know this confidential information for their own risk determination. Laws have been passed governing the patent and commercial profit potential from this research. Limitations on the "enhancement" uses of gene alteration have been suggested, and care is being taken to limit the risk of permanent alteration of the human germ cell pool, sometimes described by the term "slippery slope." The risk of permanently introducing unintended alterations into the human germ cell line is a vitally important concern.
The authors of the article1 did not mention the Ethical, Legal and Social Issues of the Human Genome Project (ELSI Committee) at the National Institutes of Health.3 The release of information from this committee is a potential resource for new information involving developments with gene therapy. Family physicians should also be interested in the ethical limitations being placed on the use of governmental research funds for genetic enhancement. The issues raised here are only some examples of the explosion in ethical dilemmas we are about to face from the field of genetics.
PAUL S. WILLIAMSON, M.D.
Georgetown University School of Medicine
Silver Spring, MD 20910RFERENCES
- White MT, Callif-Daley F, Donnelly J. Genetic testing for disease susceptibility: social, ethical and legal issues for family physicians [Medicine and Society]. Am Fam Physician 1999;60:748-55.
- Clark WR. The new healers: the promise and problems of molecular medicine in the twenty-first century. New York: Oxford University Press, 1997:217.
- National Human Genome Research Institute. Ethical, Legal and Social Issues (ELSI) of human genetics research. Available at: http://www.nhgri.nih.gov/ELSI/. Accessed April 3, 2000.
IN REPLY: Dr. Williamson rightly points out that our article1 only "scratches the surface" of the social, ethical and legal issues involved in disease susceptibility testing. Physicians who wish their patients to pursue genetic testing need a far more substantial grasp of each of the concerns mentioned, as well as a solid understanding of the genetics of the disease in question. Moreover, our article only addresses disease susceptibility testing.
As Dr. Williamson notes, physicians should also be aware of the numerous social, ethical and legal concerns that accompany other aspects of medical genetics, including genetic screening, prenatal testing, genetic research, data banking, gene patenting and gene therapy. However, recent studies suggest that few practicing physicians have more than a rudimentary grasp of the role of genetics in disease causation,2,3 and that medical journals in some generalist fields may not be keeping pace with advances in genetic research.4 We wrote our article for these reasons, in hopes of furthering discussion of the emerging place of genetics in primary care.
The need for education has been recognized at the national level, where educational efforts include a Coalition of Health Professionals that has begun to develop initiatives for genetics education through web sites, conferences, curriculum development and the inclusion of genetics on board and licensure examinations.5 But until medical genetics is smoothly integrated into clinical practice, family physicians may best serve their patients by becoming familiar with the services provided by the genetics specialists in their areas.
MARY TERRELL WHITE, PH.D.
Wright State University School of Medicine
Department of Community Health
Dayton, OH 45401FAITH CALLIF-DALEY, M.S.
Children's Medical Center
Dayton, OH 45404JOHN DONNELLY, M.D.
Wright State University
Department of Family Medicine
Franciscan Medical Center
Dayton, OH 45408REFERENCES
- White MT, Callif-Daley F, Donnelly J. Genetic testing for disease susceptibility: social, ethical and legal issues for family physicians [Medicine and Society]. Am Fam Physician 1999;60:748-55.
- Giardiello FM, Brensinger JD, Petersen GM, Luce MC, Hylind LM, Bacon JA, et al. The use and interpretation of commercial APC gene testing for familial adenomatous polyposis. N Engl J Med 1997;336:823-7.
- Hayflick SJ, Eiff PE, Carpenter L, Steinberg J. Primary care physicians utilization and perceptions of genetics services. Genetics Medicine 1998;1:13-21.
- Wilson WG, Where is the "gene" in the generalist literature? Acad Med 1998;73:931-2.
- Collins FS. Preparing health professionals for the genetic revolution. JAMA 1997;278:1285-6.
An item in "Tips from Other Journals," entitled "Overview of Methods for Treating Allergic Rhinitis" (January 1, 2000, page 207), contained dosage errors in the accompanying table on second-generation antihistamines. The dosage approved by the U.S. Food and Drug Administration for cetirizine is 5 to 10 mg once daily; the approved dosage for loratadine is 10 mg once daily and the approved dosage for loratadine with pseudoephedrine is 10 mg/240 mg once daily. The half-life of claritin was misstated; it is 28 hours. The corrected table is reprinted below.
*These corrections have been made to the online version of AFP. The links above will take you to the corrected items, which remain part of the online issues in which they were originally published.
Send letters to Jay Siwek, M.D., Editor, American Family Physician, 11400 Tomahawk Creek Parkway, Leawood, KS 66211-2672; fax:913-906-6080; e-mail: afplet@aafp.org. Please include your complete address, telephone number and fax number. Letters should be double-spaced, fewer than 500 words and limited to one table or figure and six references. Please submit a word count. Letters submitted for publication in AFP must not be submitted to any other publication. Possible conflicts of interest must be disclosed at time of submission. Submission of a letter constitutes transfer of copyright to the American Academy of Family Physicians. The editors may edit letters to meet style and space requirements.
Copyright © 2000 by the American Academy of Family Physicians.
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