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Increase in Flu Deaths Ups Incentive to Vaccinate

Kate Traynor

More than 90 million doses of influenza vaccine have been produced for the 2002–03 flu season, and the Centers for Disease Control and Prevention (CDC) continues to emphasize the need to vaccinate vulnerable people throughout the season.

This recommendation is underscored by CDC's recent conclusion that flu-related deaths have been on the rise during the past decade.

CDC researchers estimated in the Jan. 8 issue of the Journal of the American Medical Association that, in the 1990s, an average of 36,000 Americans per year died of influenza or its complications. In severe influenza seasons, upward of 60,000 people succumbed to the virus. Death rates were particularly striking among people 85 years or older, who were 32 times more likely than seniors age 65–69 to die of influenza and underlying pneumonia.

Based on national epidemiologic data from the mid-1970s through the 1980s, the researchers estimated that 20,000 flu deaths occurred each year, on average, with 30,000–50,000 deaths during severe influenza seasons.

Keiji Fukuda, M.D., M.P.H., one of the report's authors, attributed the increase in influenza deaths to the aging of the U.S. population and the growing predominance of virus subtype A(H3N2), which is particularly virulent, during flu seasons.

"The influenza A(H3N2) viruses have typically been associated with higher rates of death and serious illnesses than the other two viruses" in the trivalent inactivated vaccine, Fukuda said during a Jan. 7 telebriefing. "That's also the [strain] which has been the most common in this decade."

According to the report, the A(H3N2) strain was responsible for 80 percent of the influenza-related deaths in the 1990s.

The report also examined deaths from infection with respiratory syncytial virus (RSV), which was estimated to have killed about 11,000 people, on average, each year during the 1990s. Fukuda described infection with influenza, RSV, and other respiratory viruses as "underappreciated health problems."

"A lot of people tend to think of them as causes of things like colds," Fukuda said, adding that his research team's findings support the view that influenza and RSV are "major causes of serious illnesses and death in the United States."

Although there is no licensed vaccine to prevent RSV in adults and children older than age 2, influenza vaccines have been around for years, and Fukuda strongly promoted vaccination to prevent the flu.

Particularly for those who are at risk for influenza-related complications or who could spread the virus to vulnerable people, "there's every reason to get vaccinated and no reason not to get vaccinated," Fukuda said.

Included on Fukuda's list of those who should be vaccinated are health care workers.

But Noreen Tompkins, Pharm.D., a clinical specialist in infectious diseases at Pittsburgh's Allegheny General Hospital, said that getting her colleagues vaccinated is not as easy as it could be.

"Every year, when we have our flu task force and we're trying to get our health care professionals vaccinated, we have to pass out a facts-versus-myths brochure," Tompkins said. "It's very frustrating when we can't convince health care professionals to get the flu shots."

One of the common myths Tompkins tries to dispel is that the influenza vaccine can cause the flu. She also said patients who refuse the flu shot often do so because they fear the potential adverse events.

According to CDC, a sore arm is the most likely adverse event among people who receive a flu shot. The agency states that the risk of suffering complications from influenza infection is greater than the risk of having an allergic reaction after being vaccinated. CDC notes that the egg-derived flu vaccine is contraindicated in people who are allergic to eggs.

Tompkins said that, over the years, Allegheny has tried various ways to improve the influenza vaccination rate among inpatients. At one point, Tompkins and an infectious diseases physician placed a "flu sticker" on the outside of all incoming patients' charts to remind the physician to ask the patient about receiving that year’s vaccine. A couple of years later, Tompkins and a pharmacy resident focused on inpatients age 65 years or older, placing a communication sheet on the charts of inpatients in whom the vaccine was indicated.

Such efforts, Tompkins said, have raised the hospital's influenza vaccination rates from the single digits to about 43 percent among patients in whom vaccination is indicated—and she is looking at ways to further increase vaccine coverage.

"Our most recent venture," Tompkins said, "has been to add ... the influenza vaccine and the pneumococcal vaccine on our standing community-acquired pneumonia preprinted orders."

Tompkins is also optimistic that Pennsylvania’s new law on collaborative drug therapy management, enacted late last year, could pave the way for pharmacists to administer the flu vaccine, which could help boost coverage.

"We're all excited that it's moving in the right direction," Tompkins said. "Being able to help more with the vaccination programs could be useful."

Tompkins said she supports CDC's recommendation to continue vaccination campaigns through the winter months. "We actually promote [vaccination] all the way until ... March, just because of potential late flu patients," she said.

CDC’s Fukuda indicated that there is still time left to vaccinate people during the current flu season.

"In terms of this year's [influenza] activity," Fukuda said, "I think it appears to be fairly early in the season."

He added: "Right now, activity levels in general have been pretty low in the country. But when I look at the [surveillance] curves, it appears to me that we can clearly expect activity to pick up later on ... perhaps in a several weeks."

"Vaccination activities," Fukuda said, "ought to continue as long as vaccine is available and as long as people who are at high risk remain unvaccinated."