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Am Fam Physician. 2008;78(8):923

See related Practice Guideline on page 996.

As children return to school, another sometimes unrecognized cycle begins in primary care practices throughout the country. The rate of acute respiratory infections typically reaches its annual nadir in the weeks before schools open, then starts the slow climb to its maximum, which corresponds to the peak of influenza activity in the United States. Against this backdrop, influenza viruses provide a constantly moving target for physicians involved in prevention and control efforts.

After two relatively mild years, the 2007–08 influenza season was marked by significant morbidity and mortality, further compounded by the mismatch between the circulating viruses and the vaccine strains. Despite the mismatch, however, vaccine effectiveness in patient populations was still estimated at 40 percent.1

To adjust for the changing epidemiology of influenza infection, this year's vaccines contain three new antigenic strains and come with a new challenge. In February 2008, the Advisory Committee on Immunization Practices recommended that all children—from six months to 18 years of age—be immunized against influenza.2 This recommendation takes full force in the 2009–10 season, but family physicians are encouraged to adopt it as soon as possible.

This expansion encompasses roughly 50 million additional vaccine recipients and includes some of the most difficult patients to corral, namely adolescents. Such an endeavor can strain an already overburdened vaccine delivery system. Given an historic abundance of vaccine this year, family physicians are encouraged to vaccinate all interested patients at any opportunity, as soon as vaccine arrives. In other words, if you've got it, give it. Reminders should be sent to patients in the traditional high-risk groups, and standing orders can facilitate vaccine distribution.

Currently, a remnant “unrecommended” minority exists. This group comprises healthy, nonpregnant adults between 19 and 49 years of age in the “forgotten” three decades of life. The lack of a specific age-based recommendation for this group often extends to the subset of health care professionals. In addition, physicians often overlook the household contacts of high-risk persons and others who can transmit influenza to high-risk persons. These groups are also primary targets for vaccination.

Although the annual American Academy of Family Physicians immunization survey typically reveals high levels of immunization among family physicians, health care professionals generally have an overall vaccine coverage rate below 40 percent.3 To combat this low coverage, more attention has been focused on health care professionals and approaches to influenza vaccination. In an assessment of the ethics of mandatory vaccination, van Delden and colleagues conclude, “The main justification stems from the duty of care givers not to harm one's patient when one knows there is a significant risk of harm and the intervention to reduce this chance has a favourable balance of benefit over burdens and risks.” 4

Short of mandates, many interventions are known to enhance vaccine acceptance among health care professionals.5 For example, declination forms that reflect the above ethical standard have been shown to be effective and can be easily implemented in practice settings.6

Influenza is coming. Effective vaccines are abundantly available. So this season, if you've got it, give it … to your patients, your clinical staff, and yourself.

editor's note: The author is a member of the Advisory Committee on Immunization Practices.

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