Annals Tackles Influenza Immunization, Other Topics

The November/December issue of Annals of Family Medicine dishes up good news and bad news on the influenza immunization front. Certain strategies can "modestly" help boost immunization rates among high-risk children in low-income areas, says one study; another study tracks negative effects of an influenza vaccine shortage on continuity of care. The November/December Annals also covers a variety of other topics.

"Improving Influenza Vaccination Rates of High-Risk Inner-City Children Over 2 Intervention Years" reports on strategies that helped increase immunization rates among high-risk children ages 2 to 17 in low-income areas in or near Pittsburgh. The strategies, which medical and nursing staff at each of the study sites selected from a menu of options and which could be changed in the second year, included placing posters in exam and reception rooms; mailing letters or fliers to patients' parents; educating clinicians; and issuing standing orders for nurses to vaccinate children with high-risk conditions, including those with asthma, sickle cell disease, HIV infection and diabetes.

A pediatrics residency, two family medicine residencies and two faith-based community health centers participated in the study. The combined baseline for the sites was immunization of 10.4 percent of high-risk children during the influenza season of 2001-02, which was called the preintervention year. The proportion of high-risk children immunized against seasonal influenza rose to 13.1 percent in the first intervention year and to 18.7 percent in the second intervention year. The faith-based centers achieved the highest proportion of eligible youth immunized, with 31 percent of high-risk children seen at these centers receiving their seasonal influenza immunizations during the second intervention year.

On the downside, another article reports the impact of the influenza vaccine shortage on individual physicians' influenza immunization activity in West Virginia from Sept. 1 to Dec. 31, 2004. The shortage "had a severe impact on influenza immunization rates in private physicians' offices, disrupting continuity of care," concludes "Impact of the 2004 Influenza Vaccine Shortage on Repeat Immunization Rates." The authors used 1998-2004 Medicare claims data to track private physicians' influenza immunization rates.

The study presents physician continuity rates -- namely, the percentage of physicians in a given year who immunized the same patients against seasonal influenza they had immunized the previous year. Individual physicians submitted 33,407 claims for influenza immunization in 2004, compared with 77,065 in 2003, say the study's authors. In contrast, so-called mass vaccinators provided 20,559 influenza immunizations to Medicare beneficiaries 65 and older in 2004, compared with 11,063 in 2003.

"In 2004, total claims and number of physicians with 25 or more claims declined by more than 50 percent from the previous year, and average claims per physician declined by almost one-third," the authors note. By comparison, the number of mass vaccinators rose during the study period. "The number of such clinician vaccinators increased by almost one-third from 1999, whereas their number of claims doubled, owing principally to a sudden increase between 2003 and 2004," they say.

Disruption of continuity of care was an "important consequence" of the 2004 influenza vaccine shortage, the study authors contend. When continuity of care fails, "the most vulnerable individuals, e.g., those who lack transportation or who are too chronically ill to locate an alternative clinician, would be the most likely not to get vaccine," they note.

"Mass vaccinators may be convenient to many, but they lack the outreach and follow-up capability that is known to improve immunization uptake," say the authors. What's needed, they note, is "intervention at the policy level."

"Physicians have told us they need a predictable supply of vaccine at a reasonable price if they are to continue giving influenza immunizations to their patients."

The article describes the Vaccines for Children, or VFC, program, in which physicians obtain publicly purchased vaccine they can provide free to children in low-income families, and the article quotes a CDC statement that says, "By decreasing referrals to public health departments, the VFC program has improved the continuity of care, promoted the 'medical home' concept and contributed to high vaccination coverage levels." The Annals article asks, "When will we have a Vaccine for Adults program?"

Other articles in the November/December issue of Annals include