SUPPLEMENT TO

M A N A G E D

Care
Immunization Strategies
For Reducing Influenza’s Burden
On Public Health
Based on an expert panel roundtable discussion
held in Dallas, June 30, 2008

HIGHLIGHTS
• Introduction to Influenza

• Societal and Economic Consequences

• Challenges for Health Plans

• Prevention and Population Health Management

• Primary Care Perspectives

This activity is sponsored by

The Chatham Institute

This activity is supported by an educational grant

from MedImmune
Volume 17, No. 10
Supplement 10
October 2008
 WELCOME
SELF-STUDY CONTINUING EDUCATION ACTIVITY
M A N A G E D Immunization Strategies for Reducing Influenza’s Burden on Public Health

Care
Editor
Overview/needs assessment
Annual influenza epidemics generate a sig-
nificant public health burden each year in the
United States. Medical and public health pro-
fessionals, government officials and agencies,
ACPE Universal Program Number (UPN):
812-000-08-019-H01-P
Release Date: Oct. 15, 2008
Expiration Date: Oct. 15, 2009
Medium: Journal supplement
JOHN MARCILLE and nongovernmental organizations have
Planning committee members
Managing Editor long called for increasing influenza vaccine
Robert Belshe, MD; Pedro Piedra, MD;
FRANK DIAMOND usage in the United States and around the
Michael Kaufman, MD, Allan Jay Kogan, MD,
world. The reasons for doing so include reduc-
MSS, ABFP, FAAFP, CPE; Alyce Kuhn, RN, RRT,
Associate Editor ing influenza-associated morbidity and mortal-
MSHA; Richard Collins, MD; Steven R. Peskin,
TONY BERBERABE ity, reducing the economic burden of in-
MD, MBA, The Chatham Institute; and Amy Kra-
fluenza, preparing for pandemic influenza, and
Design Director jacic, editor.
fostering bioterrorism preparedness.
PHILIP DENLINGER This assessment examines the burden of an- Conflict-of-interest policy and disclosures
nual influenza epidemics in the United States. of significant relationships
Other areas discussed include prevention and It is the policy of The Chatham Institute to
MediMedia Managed management of influenza, access to care, and ensure balance, independence, objectivity,
Markets Publishing the idea of universal vaccinations. and scientific rigor in all of its educational pro-
grams. The Chatham Institute requires the dis-
Editor, Custom Target audience closure of any significant financial interest or
Publications This program is targeted to medical direc- any other relationship a faculty member may
MICHAEL D. DALZELL tors, physicians, and pharmacists within man- have with the manufacturer(s) of any commer-
Senior Editors, aged care organizations. cial product(s) or device(s). Further, faculty
Custom Publications members are required to disclosure discussion
Educational objectives
KATHERINE T. ADAMS of any off-label uses in their presentation. Any
After reading this publication, participants
AMY KRAJACIC faculty members not complying the disclosure
will be able to:
policy are not permitted to participate in the
• Discuss strategies used for influenza preven-
Contributing editors educational activity.
tion, diagnosis, and management, especially
to this supplement All program content has been peer re-
in vulnerable populations.
MAXINE LOSSEFF viewed for balance and any potential bias. The
• Assess burden of disease associated with
E. SCHUYLER MATTHEWS process to resolve conflicts of interest aims to
influenza in all populations.
ensure that financial relationships with com-
Group Publisher • Evaluate the economic impact of influenza
mercial interests and resultant loyalties do not
TIMOTHY P. SEARCH, RPH on the health care system.
supersede the public interest in the design and
• Review Advisory Committee on Immuniza-
Director of New Product delivery of continuing medical activities for the
tion Practices meeting discussions and
Development profession.
notes.
TIMOTHY J. STEZZI The faculty of this program and the editorial
• Discuss appropriateness and means for
staff of this monograph has disclosed the fol-
universal influenza vaccination.
Eastern Sales Manager lowing:
SCOTT MACDONALD Method of instruction
Robert Belshe, MD: honoraria from Med-
Senior Account Manager Participants should read the learning objectives
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WANETA PEART Merck, and MedImmune.
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 S U P P L E M E N T T O

M A N A G E D

Immunization Strategies for

Care October 2008

Reducing Influenza’s Burden on Public Health

Based on an expert panel roundtable discussion held in Dallas, June 30, 2008
A Continuing Education Activity

FACULTY PRESENTATIONS
An Introduction to Influenza:
Lessons From the Past in Epidemiology, Prevention, and Treatment........2
ROBERT B. BELSHE, MD
Professor of Medicine, St. Louis University

Societal and Economic Consequences of Influenza....................................8

PEDRO A. PIEDRA, MD
Professor, Department of Molecular Virology, Microbiology, and Pediatrics
Baylor College of Medicine
Challenges for Health Plans in Influenza Immunization.........................15
MICHAEL A. KAUFMAN, MD,1 AND ALAN J. KOGAN, MD, MSS, ABFP, FAAFP, CPE2
1
Senior Medical Director, OptumHealth, UnitedHealth Group
2
Vice President and Regional Medical Director, Great-West Healthcare
Influenza Prevention and Population Health Management ....................17
ALYCE KUHN, RN, RRT, MSHA
Vice President, Client Management, Matria Healthcare

“In the Trenches”: Primary Care Perspectives

On Implementation, Prevention, and Treatment .....................................18
RICHARD L. COLLINS, MD
Internist, Buffalo Medical Group;
Clinical Assistant Professor of Medicine, Buffalo General Hospital

CONTINUING EDUCATION
Continuing Education Objectives ........................................................................................2
Answer Sheet........................................................................................................................20
Post-Test ...............................................................................................................................21
This supplement is supported by an educational grant from MedImmune. The material in this supplement
has been independently peer reviewed. The grantor played no role in reviewer selection.
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or of MedImmune; The Chatham Institute; MediMedia USA; or the publisher, editor, or editorial board of
MANAGED CARE.
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the same as indicated on the approved package insert. Please consult the complete prescribing information
on any products mentioned in this publication.
MediMedia USA assumes no liability for the material published herein.
 FACULTY PRESENTATION
An Introduction to Influenza:
Lessons From the Past in Epidemiology,
Prevention, and Treatment
ROBERT B. BELSHE, MD
St. Louis University, St. Louis
SUMMARY
Better understanding of viral biology and
the origins of influenza epidemics and pan-
demics may improve diagnosis and disease
control. Advances to stop the spread of dis-
ease, including live-attenuated and in-
activated vaccines and new antiviral agents,
promise to reduce disease burden, mortal-
ity, and morbidity.
Influenza is a prevalent disease with a large burden of
morbidity and mortality (Couch 1986, Sullivan
1993, Simonson 1997). With annual outbreaks
of epidemic or pandemic proportions and a
relatively high death toll among vaccine-pre-
ventable diseases, control of influenza has be-
come a major public health goal. Over the last
30 years, understanding of the molecular biol-
ogy of the virus and the pathophysiology, nat-
ural history, and treatment of the illness has ad-
vanced enormously, yet there has not been
much progress in reducing death from in-
fluenza. Advances in disease control, including ROBERT B.
the availability of new antiviral agents and both BELSHE, MD
inactivated and live-attenuated vaccines, as well as im-
proved understanding of how the disease spreads, hold
promise that effective control of influenza might reduce
its medical and economic impact within our lifetimes.
The influenza virus
Studies of the molecular biology of the influenza virus
have revealed important insights into the genetics of in-
fluenza and how its evolution affects human infection
during influenza epidemics and pandemics. Influenza
virus is a spherical or ovoid body with a lipid bilayer en-
Robert B. Belshe, MD, is professor of medicine at St. Louis
University.
2 MANAGED CARE / SUPPLEMENT
velope composed primarily of the antigenic surface pro-
tein hemagglutinin (approximately 70 percent) and the
enzyme neuraminidase (approximately 30 percent). Less
than 1 percent consists of the M2 ion channel. Inside the
envelope is an antigenic matrix protein lining. The virus
genome exists within this structure and comprises eight
pieces of single-stranded RNA formed into a ribonucle-
oprotein helix. The hemagglutinin on the surface pro-
vides the site of attachment for the virus to the host cell.
The neuraminidase is responsible for facilitating the re-
lease of new virus from host cells and, together with the
M2 ion channel protein, is a major target for drug inter-
vention. Mutations in the antigenic components are pre-
dominantly responsible for the development of virus
subtypes and alternative strains.
There are two major types of human in-
fluenza virus — influenza A and influenza B. (A
third type, influenza C, does not cause much
illness and is not addressed here.) Influenza A,
a form that can be found in certain animal
species and humans, is responsible for most
cases of seasonal flu, especially broad-reaching
epidemics and pandemics. Influenza A is sub-
ject to frequent antigenic drift, or changes in its
antigenic profile due to point mutations in the
gene encoding hemagglutinin that occur dur-
ing viral replication. Influenza B is a more sta-
ble virion found primarily in humans, and is identified
most often as the cause of local outbreaks. Because of ge-
netic similarities in human and animal forms of in-
fluenza A, it is possible for RNA from animal viruses to
exchange segments with the human influenza virus
genome. It has been shown that this type of “reassort-
ment” event, in which the genetic material from animal
virus is integrated into the genome of a related human
type A strain during co-infection, can produce a new viral
strain of high virulence (Mumford 2007, Jin 2005).
Whereas the body develops immunity upon exposure to
one influenza virus strain and its antigenic relatives, new
cross-species antigenic variants may not be recognized by
the immune system, therefore causing widespread and
severe illness (CDC 2008a).
Three influenza pandemics have been studied in an ef-
fort to gain a better understanding of the genetic diver-
sity of the virus: the 1918 Spanish influenza (H1N1); the
1957 Asian influenza (H2N2); and the 1968 Hong Kong
influenza (H3N2). Both the 1957 and 1968 pandemics
were caused by viruses that clearly resulted from genetic
reassortment events of the prevailing strain. The 1957
pandemic was caused by a hybrid virus resulting from a
dual infection with the avian H2N2 and human H1N1
influenza strains. The resultant species contained a
hemagglutinin, a neuraminidase, and a gene for a poly-
merase protein from the avian virus and five genetic seg-
ments from the human virus (Figure 1). In the 1968
variant, the hemagglutinin and polymerase genes of this
virus were further replaced with alternative avian genes
to form H3N2. This viral form continues to be the major
source of influenza infections in humans today.
Interestingly, however, Taubenberger (2005) found
that the 1918 pandemic was caused not by a virus formed
by reassortment, but by the mutation of a purely avian
strain into an excessively virulent species that adapted to
humans. Researchers worked with two preserved virus
specimens from the 1918 pandemic — one, a soldier’s
lung sample that had been stored at Walter Reed Medi-
cal Center, in Washington, and the other from an Eskimo
who died in the pandemic and had been buried frozen
in permafrost in Alaska — and were able to sequence the
genes of the viral isolate. They found that all eight genes
of the viral strain were derived from a duck virus that had
adapted or mutated over time to permit human-to-
human transmission. This finding may have alarming
implications for the future. A current avian virus, H5N1
influenza A, is extremely pathogenic and is decimating
the fowl population in at least eight Asian countries. The
strain has been spreading to new avian and nonavian
species. The virus has infected 379 humans, causing 239
deaths (WHO 2008). If it were to adapt for widespread
human transmission, there is fear of a pandemic of un-
usually high morbidity and mortality.
Influenza epidemics
The “flu” is perhaps the most widely disseminated res-
piratory infection in the world. There are approximately

1918 “Spanish influenza” 1957 “Asian influenza” 1968 “Hong Kong influenza” Next pandemic influenza

H1N1 influenza virus H2N2 influenza virus H3N2 influenza virus

H2N2 H1N1 H2N2

avian virus human virus H3 avian virus human virus Avian virus
or H3N2
Bird-to-human avian virus human virus
transmission of H1N1 virus

Reassortment Reassortment

Hemagglutinin Neuraminidase

All 8 genetic segments
thought to have originated
from avian influenza virus
3 new genetic segments from
avian influenza virus introduced
(HA, NA, PB1);
contained 5 RNA segments
from 1918
2 new genetic segments from All 8 genes new or further
avian influenza virus introduced derivative of 1918 virus
(HA, PB1);
contained 5 RNA segments
from 1918

FIGURE 1 Mechanism of genetic reassortment in influenza virus: origin of the 1957 and 1968 strains
Source: Belshe 2005
Copyright© 2005 Massachusetts Medical Society. All rights reserved.

IMMUNIZATION STRATEGIES / MANAGED CARE 3

 10 million to 60 million cases of acute influenza each year
in the United States, leading to as many as 25 million of-
fice visits, 200,000 hospitalizations, and 36,000 deaths
(CDC 2008b, Couch 2000, U.S. Census Bureau 2008).
Virus transmission. Influenza is transmitted prima-
rily via airborne respiratory secretions released in the
event of a cough or a sneeze. It is believed that the virus
settles in the host trachea and lungs and is absorbed
into tissue by endocytosis. The virus replicates in the
lower airway, with onset of cough and fever within 1 to
2 days of infection (Moser 1979). The highest mortality
related to influenza occurs among elderly patients over
age 65 and among patients with chronic conditions that
are risk factors for influenza complications.
An aggressive effort to mitigate the disease with medi-
cation and vaccination has long existed in these high-risk
populations. Today, however, it is becoming increasingly
clear that children, in fact, bear the greater burden of in-
fection. Although death rates are lower in this group,
children experience the highest rates of sero-positive in-
fection and are hospitalized for flu symptoms in much
higher numbers than the elderly (CDC 2001a). One study
estimated a rate of 1,000 children per 100,000 population
versus 150 elderly per 100,000 population (Neuzil 2000).
Children also are responsible for most of the virus
transmission throughout the community. Glezen (1997)
followed patterns of influenza in 145 Houston-area fam-
ilies and reported an overall infection rate of 32.8 per 100
patient-years. The highest rate of 47.7 per 100 patient-
years was observed in children aged
6 to 10 (Figure 2). Rates of infection
Rates of influenza and influenza-related illnesses are highest in
decreased progressively in each ad- children aged 6 to 10 and lowest in the adult population
vancing age group, and actual rates
of infection were lowest among 50
adults older than age 25.
Thus, what begins as a disease of
children, acquired and circulated in 40
the closed community of school, is
Rate per 100 persons
which usually lasts about 3 months. This spike is a bell
curve that reflects the period of rapid spread and peak-
ing of the epidemic, and the subsequent mounting of an
immune response that mitigates the illness in the indi-
vidual patient within 2 to 3 days (CDC 2008c). There is
often a second surge of influenza infection caused by the
B virus several weeks later due to lower and slower rates
of transmission of influenza B, although in the
2007–2008 U.S. influenza season, A and B illnesses ap-
peared to circulate simultaneously. Similarly, the peak
month of illness generally falls in January or February,
but has been reported as early as November and as late
as April (CDC 2008c).
Diagnosis trends
The clinical diagnosis of influenza is moderately reli-
able in the event of a flu epidemic; in a community with
widespread flu, the presence of cough and the acute
onset of fever indicates influenza with 70 percent speci-
ficity (Hayden 2004). Without prevalent flu, however, it
is much harder to diagnose influenza, because these com-
mon symptoms can suggest a wide range of alternative
disorders.
Laboratory culture is the standard method used to
establish the presence of influenza infection, but it is a
time-consuming procedure. Polymerase chain reaction
(PCR) tests are equivalent to, or better than, laboratory
culture, offering greater sensitivity. PCR utilizes nasopha-
ryngeal aspirate or nose/throat swab to detect influenza
Influenza virus infection
Acute respiratory infection
Lower respiratory infection

now believed to pass on secondar-

ily to adults, first within the home, 30
then into the local environment
(neighborhoods and regular con-
tacts), and ultimately, reaching the 20
greater community at large. Trans-
mission from child to child in the
school setting expands this infected 10
universe by multiples (Elveback
1976).
Patterns of epidemics. The re- 0
<2 2–5 6–10 11–17 18–24 25–34 ≥35
sultant disease epidemics take on Age (years)
fairly predictable patterns of pro-
gression. After a gradual increase in FIGURE 2 Age-specific annual influenza infection rates, Houston family study,
the proportion of patients with iso- 1976–1984
lates of type A influenza, there is a Source: Glezen 1997
rapid spike in infection prevalence,

4 MANAGED CARE / SUPPLEMENT

viral RNA in as little as 15 minutes in the laboratory. In
addition, rapid diagnostic tests are becoming more com-
mon and more reliable, allowing physicians to confirm
the clinical diagnosis in the office setting. More than
five rapid antigen-detection tests are available. Although
modest in sensitivity (approximately 60 percent), these
tests offer a rapid reading and, when positive, permit
early initiation of antiviral therapy (CDC 2006). These
tools are meeting with mixed reception among com-
munity physicians due to concerns about reliability and
cost, but if nothing else, they will play a role in commu-
nity influenza surveillance, particularly in less urban or
academic settings.
Prevention trends
Over the years, many attempts have been made to
suppress the spread of the influenza virus through such
actions as isolating people, gargling with antiseptic, and
wearing a mask. It was not until the development of in-
fluenza vaccine, however, that reliable protection against
the spread of influenza could be achieved.
Today’s influenza vaccine is the most effective means
to reduce the impact of influenza infection and virus-
related illness. The vaccine is a trivalent compound; that
is, it contains the three strains of viruses, including H1N1
and H3N2 type A and the type B influenzas, commonly
found in the United States. There are two types of vac-
cines: a trivalent inactivated vaccine (TIV) and a live-
attenuated influenza vaccine (LAIV). The former is made
from highly purified, egg-grown virus that is killed, and
the hemagglutinin presented in the vaccine raises an
immune response (Kilbourne 1987). This vaccine is de-
livered by intramuscular (IM) injection. The LAIV uses
live but weakened egg-grown virus delivered via a nasal
spray. Some inactivated viruses are approved for use in
children as young as 6 months, whereas the LAIV is used
starting at age 24 months through 49 years (Table). LAIV
is not approved for children younger than 24 months of
age due to adverse events, primarily wheezing, that may
occur in a small percentage of patients. The most com-
mon adverse reactions found to occur with the use of
LAIV are runny nose or nasal congestions in children and
TABLE
Current indications and contraindications for live-attenuated
influenza vaccine (LAIV) vs. trivalent inactivated vaccine (TIV)
LAIV TIV
Indicated for ages 24 mo.–49 yr. Indicated for age older than 6 mos.*
Contraindications: egg allergy, Contraindications: egg allergy,
Guillain-Barré syndrome Guillain-Barré syndrome
Not for recurrent wheezers
Not for pregnant women
*
Different manufacturers have various ages indicated.
IMMUNIZATION STRATEGIES / MANAGED CARE
adults, fever of more than 100°F in children aged 2 to 6,
and sore throat in adults (IIV 2008).
The efficacy of influenza vaccination is related to both
age and immune competency, and depends on a match
with the circulating virus of the season. If the vaccine
does not contain strains that reflect the circulating viral
population, it may not protect against onset of influenza.
When appropriately matched and used in healthy chil-
dren and adults under age 65 years, the vaccine has been
reported to prevent disease onset in 70 to 90 percent of
treated subjects (Palache 1997). The immune-senescent
elderly, however, achieve lower post-vaccination anti-
body titers, and, as a result, realize only 30 to 40 percent
protection against onset of influenza-related illness
(Blumberg 1996, Dorrell 1997, Nichol 1998). Elderly
persons in nursing homes or chronic-care facilities ben-
efit from a 50 to 60 percent reduction in hospitalization
or pneumonia and an 80 percent decrease in death
(CDC 2001a, Patriarca 1985, Arden 1986). Current re-
search is focused on improving vaccines for the elderly,
either by increasing the amount of antigen or by adding
an adjuvant compound that might stimulate the im-
mune response to achieve better outcomes.
A recent study examined the relative efficacy of LAIV
compared with TIV (Belshe 2007). In this head-to-head
trial, approximately 8,000 children aged 6 months to 5
years were randomly assigned to vaccination with either
IM injection of TIV, or to the cold-adapted trivalent
LAIV (a refrigeration-stable formulation) nasal spray.
Children who developed influenza-like symptoms were
cultured to determine virus strain and titer.
Investigators observed a significant difference in the
number of culture-confirmed cases of influenza that oc-
curred in subjects receiving LAIV versus TIV (153 vs. 338
cases, respectively; P<.001). The reduced rate of infection
associated with LAIV was consistent across age groups
and for both antigenically well-matched influenza and
virus variants (Figure 3, page 6). In addition, there was
a 50.6 percent greater reduction in rates of symptomatic
influenza (P<.001), a 45.9 percent greater reduction in
lower respiratory infections (P=.046), and a 50.6 percent
improvement in rates of acute otitis media associated
with LAIV versus TIV (P=.003).
The broad coverage across multiple
strains of influenza virus achieved with
LAIV was confirmed in another study
in which the antibody response to a
Nanchang strain vaccine protected
against multiple alternate viral strains,
including the Sydney, Thessaloniki,
Russian, and Johannesburg strains
(Belshe 2000). LAIV provided better
immune protection and a broader
range of activity than TIV. This broad
protection advantage should enable
5
 Comparative efficacy against culture-confirmed, modified CDC-ILI (ATP population)
TIV n=1,852, 6–23 months
10 55.7% 9.8 54.4% n=2,084, 24–59 months
(P< .001) (P< .001)
9 LAIV n=1,834, 6–23 months
8 n=2,082, 24–59 months
7.2

Attack rate (%)

7
6
5 Solid bars = matched
4.5
4 Hatched bars = mismatched
3.2
3
2
1
0
Age group 6–23 months 24–59 months
Number of cases 133 59 205 94

FIGURE 3 Study MI-CP111. Efficacy comparison by age: all strains

SOURCE: Belshe 2007

ATP=according to protocol, CDC-ILI=influenza-like illness as defined by the Centers for Disease Control and Prevention, LAIV=live-attenuated influenza
vaccine, TIV=trivalent inactivated vaccine.

better outcomes with empiric therapy, and without the
need to identify target virus, and to develop a vaccine
aimed specifically at prevailing strains.
Antiviral drugs
Influenza-specific antiviral drugs are valuable ad-
juncts to vaccine in the management of influenza. Pro-
phylactic or early (less than 48 hours after symptom ini-
tiation) treatment with these agents has been shown to
reduce peak viral titers and limit the severity and dura-
tion of influenza-like illness. The agents available today
target either the M2 ion channel of the viral envelope
(amantadine or rimantadine) or the surface enzyme
neuraminidase (oseltamivir or zanamivir).
Neuraminidase is an enzyme that breaks down sialic
acid on the host cell surface. In the natural history of the
influenza virus, the cleavage of sialic acid enables entry
of virus into the host cell, as well as the release of repli-
cated virus from infected cells back into the environ-
ment. Thus, the neuraminidase inhibitors work both to
prevent spread of influenza by blocking release of viral
replicates and to reduce severity of illness in the treated
patients by blocking virus uptake.
The neuraminidase inhibitors have been reported to
be 70 to 90 percent effective at preventing onset of both
A and B viral influenza, depending on the population
studied (Cooper 2003). Prophylactic treatment is cum-
bersome, however, necessitating daily intake for the du-
ration of an epidemic, generally about 6 to 10 weeks.
These agents have proven valuable for reducing the du-
ration and severity of influenza symptoms, lessening the
burden of pneumonia and otitis media, and reducing
hospitalizations of infected patients (Cooper 2003). The
drug must be given within 48 hours of the onset of ill-
ness — during which time culture-confirmed diagno-
sis, prescription, and fulfillment must all be completed
— or viral replication will have peaked and the drugs
will no longer provide a beneficial effect (oseltamivir
phosphate 2008). The ion channel blockers also pre-
vent the virus from penetrating the host cell. As a result,
the virus does not replicate. These drugs are generally
about 50 percent effective at preventing and 70 percent
to 90 percent effective at reducing the intensity of in-
fluenza A but not B infection (Couch 1997). A problem
occurs, however, when any of the amino acids lining the
M2 ion channel mutate, which renders the drug ineffec-
tive. Changes in the amino acids are quite common, oc-
curring in about 1 of 1,000 viral particles (Belshe 1989).
In this case, when a patient is treated with an ion chan-
nel blocker, the stable viruses are eliminated, but resist-
ant, or altered, viruses survive. As they are shed and
begin to spread, there is a wave of resistant influenza,
which has become a widespread problem limiting the use
of these drugs.
Conclusion
Although influenza is a common and generally be-
nign disease that has at one time or another affected
every American in some way, it can in fact be quite
devastating. Morbidity from influenza is a major pub-
lic health concern, and flu pandemics that result from
genetic reassortment or viral mutations have caused

6 MANAGED CARE / SUPPLEMENT

hundreds of thousands of deaths around the world.
Fortunately, contemporary molecular biology and ad-
vanced genetic techniques allow for a better under-
standing of viral biology and the origins of influenza
pandemics that may enable improved diagnosis and
disease control.
The influenza vaccine has reduced the disease burden
of flu, but has not significantly lowered the death rate.
This is a result of the combined factors of underutiliza-
tion of the vaccine and a revised understanding of dis-
ease spread. It is imperative that vaccination rates im-
prove, particularly among the high-risk elderly
population and health care workers. It also is clear that
targeting children for universal vaccination can help to
control spread of the virus and reduce morbidity and
mortality in all age groups.
References
Arden NH, Patriarca PA, Kendal AP. Experiences in the use and
efficacy of inactivated influenza vaccine in nursing homes.
In: Kendal AP, Patriarca PA, eds. Options for the control of
influenza. New York: Alan R. Liss Inc. 1986:155–168.
Belshe RB. The origins of pandemic influenza: lessons from the
1918 virus. N Engl J Med. 2005;353:2209–2211.
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inactivated influenza vaccine in infants and young children.
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Belshe RB, Gruber WC. Prevention of otitis media in children
with live attenuated influenza vaccine given intranasally.
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influenza A viruses. J Resp Dis. 1989;10:S52–S61.
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and control of influenza: recommendations of the Advisory
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flu/keyfacts.htm». Accessed Sept. 25, 2008.
CDC. Fluview: a weekly influenza surveillance report prepared
by the influenza division. 2008c. «http://www.cdc.gov/
flu/weekly.» Accessed Sept. 25, 2008.
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clinical laboratory directors. December 2006. «http://www.
cdc.gov/flu/professionals/diagnosis/rapidlab.htm».
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sponses to an inactivated influenza vaccine in adults with
HIV infection, diabetes, obstructive airways disease, elderly
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adults and healthy volunteers. Int J STD AIDS.1997;8:
776–779.
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model for immunization studies. Am J Epidemiol. 1976;103:
152–165.
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in infants. Pediatr Infect Dis J. 1997;16:1065–1068.
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fluenza in households: a prospective randomized compari-
son of oseltamivir treatment with or without postexposure
prophylaxis. J Infect Dis. 2004;189:440–449.
IIV (Influenza virus vaccine live, intranasal [FluMist]) [prescrib-
ing information]. Gaithersburg, Md: MedImmune; June
2008.
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threat. Cleve Clin J Med. 2005;72:1129–1134.
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1987.
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fluenza abroad a commercial airliner. Am J Epidemiol.
1979;1101:1–6.
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pitalizations, outpatient visits, and courses of antibiotics in
children. N Engl J Med. 2000;342:225–231.
Nichol KL, Wuorenma J, Von Sternberg T. Benefits of influenza
vaccination for low-, intermediate-, and high-risk senior
citizens. Arch Intern Med. 1998;158:1769–1776.
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1997;54:841–856.
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vaccine in nursing homes: reduction in illness and compli-
cations during an influenza A (H3N2) epidemic. JAMA.
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fluenza epidemics on mortality: introducing a severity
index. Am J Public Health.1997;87:1944–1950.
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health impact of influenza. Am J Public Health. 1993;83:
1712–1716.
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of the 1918 influenza virus polymerase genes. Nature.
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«http://www.census.gov/main/www/popclock.html».
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en/index.html». Accessed Aug. 8, 2008.
Disclosure: Robert Belshe, MD, has received grant/research sup-
port from Merck, has served as a consultant for MedImmune and
Merck, and has served on the speaker’s bureau for sanofi-aventis,
Merck, and MedImmune. He reports having been compensated
for work related to the influenza virus vaccine live, intranasal
(FluMist), the influenza virus vaccine suspension for intramuscular
injection (Fluzone), and an investigational product from Merck.
7
 FACULTY PRESENTATION
Societal and Economic Consequences
Of Influenza
PEDRO A. PIEDRA, MD
Baylor College of Medicine, Houston
SUMMARY
High rates of vaccination coverage for
preschool and school-aged children can
reduce morbidity and mortality related to
influenza outbreak. More focused and effec-
tive influenza prevention strategies are
necessary to improve quality of life and to
limit the burden of flu complications.
Influenza is a disease with a significant impact on pub-
lic health, affecting between 5 and 20 percent of the U.S.
population each year. It occurs with substantially greater
frequency and significantly more mortality than
is observed with any other vaccine-preventable
disease. For example, in comparison with pneu-
mococcal disease (40,000 cases and 5,500
deaths), human papillomavirus (10,532 cases
and 3,900 deaths), hepatitis B (6,741 cases and
685 deaths), and varicella (20,948 cases and 16
deaths), there are about 31 million cases of in-
fluenza in the United States, leading to approx-
imately 36,000 excess deaths annually (Thomp-
son 2003, Weycker 2005, CDC 2008, ACS 2004). PEDRO A.
Furthermore, this disproportionate incidence of PIEDRA, MD
influenza occurs in a relatively short time period
— generally about 10 to 12 weeks — that reflects the sea-
sonal profile of the epidemic.
Traditionally, the approach to vaccine control of in-
fluenza has been based on covering high-risk popula-
tions. Until recently, vaccination efforts primarily have
focused on individuals 50 years of age or older, residents
of chronic care facilities, children and adults with chronic
conditions that place them at high risk for influenza
complications, and, more recently, children younger than
5 years of age. Pregnant women and health care workers
Pedro A. Piedra, MD, is a professor in the Department of
Molecular Virology, Microbiology, and Pediatrics, Baylor Col-
lege of Medicine.
8 MANAGED CARE / SUPPLEMENT
also are priority populations for influenza immunization.
It is now clear, however, that this risk-based approach has
not been successful in reducing overall morbidity and
mortality from the disease, and the medical community
is beginning to consider new strategies for influenza pre-
vention.
Disease burden
Influenza is a major medical and economic burden in
the United States. According to a systematic evaluation
of influenza outcomes from 2001 to 2003, about 31 mil-
lion outpatient visits each year are related to flu symp-
toms, accounting for about 3.1 million hospitalized days
(Molinari 2007). Influenza is the number one vaccine-
preventable cause of death among both adults and chil-
dren, leading to an estimated 610,660 life-years
lost (Molinari 2007).
Direct medical costs due to influenza, ad-
justed to 2003 prices, average $10.4 billion, and
projected lost earnings as a result of illness and
loss of life account for $16.3 billion (Molinari
2007). The total annual economic burden from
influenza across all age groups (using projected
statistical life values) is $87.1 billion. When as-
sociated with health outcome, 83 percent of
the total cost of influenza is attributable to
death, 7 percent to hospitalizations, and 8 per-
cent to outpatient care. These results empha-
size that the impact of influenza in the United States re-
mains high, with an exorbitant cost related to lost
productivity and disease-related death rather than from
hospitalization. In addition, the loss of productivity and
the time away from work hinders national economic
growth. Thus, more focused and effective prevention
strategies would not only improve quality of life for in-
dividual Americans affected by influenza, but also would
positively affect the country’s economy.
Changing recommendations for vaccination
The failure of a risk-based vaccination strategy to im-
prove morbidity and mortality from influenza has in re-
cent years led a number of monitoring agencies to recon-
sider strategic guidelines for immunization. The Advi- percent at the time of the review. This is reflected in the
sory Committee on Immunization Practice (ACIP) tra- rates for adults aged 50 to 64 with comorbidity (48.4 per-
ditionally had called for annual immunization against in- cent), adults aged 50 to 64 without comorbidities (32.2
fluenza among adults aged 50 and older; residents of percent), adults aged 18 to 49 with or without high-risk
chronic care facilities; children and adults with chronic conditions (30.5 percent and 18.3 percent, respectively),
health conditions, such as chronic pulmonary disease, and children aged 6 months to 23 months (20.6 percent
renal dysfunction, or immunosuppression from HIV; fully vaccinated) (CDC 2007a, 2007b, 2007c).
pregnant women; and children aged 6 months to 18 In addition, there are two demographic groups for
years who receive long-term aspirin therapy (ACIP 2006, whom suboptimal coverage has far-reaching implica-
Bridges 2003). However, due to high rates of influenza- tions. Vaccination among pregnant women in 2004 was
related medical care for children, along with their role in only 14.4 percent (Figure 1, page 10), despite the fact that
the spread of influenza to susceptible household contacts this population is more likely to develop serious medical
and the community, ACIP recently voted to expand im- complications and require hospitalization for flu symp-
munization recommendations to include universal vac- toms than age-matched, nonpregnant peers (Lu 2008).
cination for all children aged 6 months through 18 years Furthermore, vaccinating a pregnant woman has the po-
(Table). The committee also advised that inadequate tential to also protect the newborn infant via the trans-
vaccination for children younger than age 9 — i.e., only fer of maternal antibodies through the placenta to the de-
one dose in their first vaccination year — should be cor- veloping fetus so that the child is born with a degree of
rected by giving two doses 4 weeks apart in the subse- protective immunity (Zaman 2008). Although concerns
quent year. Another key point was the recommendation about the safety of immunization to both mother and
to vaccinate household members and out-of-home care child might play a role in the inadequate uptake in this
providers of all children who are at high risk, and of all population, there is no documented evidence of harm to
healthy children younger than 5 years of age. the pregnant mother or fetus associated with influenza
vaccine (Munoz 2005, Heinonen 1973). Similarly, al-
Current vaccination statistics though there has been a trend toward improved immu-
Vaccination is the most effective method for prevent- nization rates among health care workers, maximum
ing influenza and reducing the burden of flu
complications. Achieving national goals for
immunization as established by the ACIP, TABLE
however, has been a challenge (ACIP 2006, Recommendations for influenza vaccination
Committee on Infectious Diseases 2008). As Advisory Committee on Immunization Practices
shown in Figure 1 (page 10), immunization • Adults aged 50 or older, residents of chronic care facilities, chil-
guidelines have been well adopted by adults dren and adults with chronic conditions, pregnant women, and
older than 65, who achieved an immuniza- children 6 months to 18 years who are on aspirin therapy should
tion rate of 65 to 70 percent in 2004. In addi- be immunized against influenza.
tion, the elderly with comorbid conditions • Immunization providers should begin efforts to offer influenza
reached a rate as high as 75 percent. Meeting vaccination to all children aged 6 months through 18 years in the
the goals for other populations, however, has 2008–2009 influenza season, if feasible.
been less successful (Lu 2008). Influenza vac- • Annual vaccination for all children aged 6 months through 18
cination coverage in 2004 was only 50.5 per- years should begin in the 2009–2010 influenza season.
cent for adults aged 50 to 64, and 27.2 percent • Children aged 6 months to 18 years who have not been vacci-
for those aged 18 to 49. nated previously or who were vaccinated for the first time during
The U.S. Centers for Disease Control and the previous season and received only one dose should receive
two doses of vaccine.
Prevention’s (CDC) Healthy People 2010 ini-
• The first dose should be as soon as is feasible after vaccine be-
tiative also has rather rigorous influenza vac-
comes available, so that both doses can be administered before
cination objectives (CDC 2005). With recom-
the onset of influenza activity.
mendations for 90 percent vaccination among
noninstitutionalized adults older than age 65, Healthy People 2010
90 percent vaccination of institutionalized • 90 percent vaccination rate for noninstitutionalized persons
adults, and 60 percent vaccination for other ≥65 years of age
risk groups by the year 2010, a mid-course re- • 90 percent vaccination rate for institutionalized adults
view determined that these goals are not being • 60 percent vaccination for other risk groups
met. Immunization rates for adults over age 65
Sources: ACIP 2006, ACIP 2008, CDC 2005
reached 69.3 percent, but none of the other age
and risk categories had achieved rates above 50

IMMUNIZATION STRATEGIES / MANAGED CARE 9

 coverage achieved in 2004 was 43.2 percent
(Lu 2008). A failure to meet vaccination
70%
goals in this group has the potential to in-
crease influenza-related risk to patients and 60%

Vaccination coverage
— particularly among the elderly and seri- 65+
ously ill — to increase influenza-related 50%
50–64 HR
death as well. If caretakers are going to be 40%
true advocates for vaccination, it is incum-
bent on them to serve as role models by 30% 18–49 HR
being vaccinated themselves. 20%
One might expect to see a reduction in 18–64 HH
HCW
the number of deaths in the older-than-65 10%
Pregnant women
age group, given their relatively high rate of 0%
vaccination, but this is not the case. Among 1989 1993 1995 1998 2000 2002 2004
all-cause deaths between 1990 and 2000, Survey year
the total number of cases remained un-
abated, with about 90 percent of influenza FIGURE 1 Self-reported influenza vaccination coverage trends
deaths occurring in the elderly population among adults by age groups and health care work status: 1989–2006
(Thompson 2003, Thompson 2004). This HCW=health care worker, HH=household contacts, HR=high-risk individuals.
may be due in part to senescence of the im- Reprinted from Vaccine, Volume 26, Lu, Bridges, Euler, Singleton, Influenza vaccination
of recommended adult population, U.S., 1989–2005, 1786–1793, Copyright (2008), with
mune system and the resultant failure of permission from Elsevier.
the vaccine to provide optimal protection.
On the other hand, low vaccination rates in
the index group, which, as described below, Community at large
is generally made up of school-aged chil- • Persons at increased risk
of complications
dren, may lead to poor disease control and • Community-dwelling elderly
rapid viral transmission throughout the • Social contacts of 1°, 2°, and 3° cases
community, affecting the frail elderly inor- Family members of schoolchildren
3° • Working adults (parents)
dinately. • Younger siblings
• Other contacts
Influenza virus transmission
2° More schoolchildren infected
Children appear to play an important
role in dissemination of the influenza virus,
particularly during the early phase of a flu 1° Index case – immunologically naïve schoolchild
epidemic when the index events first enter
the community (Figure 2). According to
Glezen (1982), school-age children repre- FIGURE 2 Transmission of influenza
sent a disproportionate number of in- Elveback LR, Fox JP, Ackerman E, et al. An influenza simulation model for immunization
fluenza cases in the early period of a flu studies. Am J Epidemiol. 1976;103:152–165, by permission of Oxford University Press.
epidemic, with a subsequent age shift in the
population presenting for medical care. It was reported groups of classmates. Infected children then transport the
that children 5 to 19 years of age represent more than 50 virus home to siblings, parents, and caretakers, and ulti-
percent of cases seen in the early phase but only 35 per- mately, to other contacts in the community. If children
cent during the later phase of the outbreak. In contrast, are key transmitters of disease early in an epidemic, does
the incidence of positive influenza cultures among adults focusing on immunization of the elderly and chroni-
aged 20 to 44 rose from 20.7 percent in the early phase cally ill population achieve the goal of deterring spread
to 28.9 percent in the late phase and from 7.3 to 11.4 per- of the disease? It might be more rational to prevent out-
cent among adults aged 45 or older in this same time breaks among school-age children to break the cycle of
frame (Glezen 1982). progressive spread among susceptible individuals in the
This has led some scientists to question the validity of community.
the high-risk approach to influenza vaccination. School In fact, the advantage of vaccinating children for im-
and daycare settings are recognized incubators for viral proved control of influenza morbidity and mortality was
spread due to children’s susceptibility to influenza infec- suggested as long ago as 1970. Investigators attempted to
tion, high student density, poor understanding of hy- change the course of the 1968 pandemic outbreak caused
giene, and exposure to common items shared by large by influenza A/Hong Kong (H3N2) in Tecumseh, Mich.,

10 MANAGED CARE / SUPPLEMENT

by initiating a school-based effort aimed at
universal immunization of schoolchildren
Weekly mean rates of respiratory illness (%)
18
with an inactivated virus vaccine (Monto
1970). The course of the pandemic out- 16
break was then compared with that seen in
neighboring Adrian, Mich., as well as in 14
Flint and Lansing, Mich., where widespread 12
immunization was not carried out. The in-
10
vestigators achieved an overall rate of vac-
cination of 85.8 percent among students 8
enrolled in Tecumseh schools, which was
6
completed approximately 2 weeks before
the influenza virus was first isolated in the 4
district. On follow-up, the investigators ob- 2
served a 26.7 percent overall effectiveness
rate in deterring respiratory illness during 0
0–4
the pandemic. The reduction in respiratory
illness was reported in all age groups over
the course of the 10-week pandemic (Fig- FIGURE 3 Tecumseh, Mich.: Modification of influenza outbreak
ure 3), indicating that protection was not Adapted with permission from Monto AS, et al. J Infect Dis. 1970;122:16–25
limited to the schoolchildren immunized,
but also extended to adult members of the community
as well.
Similar benefits during pandemic and epidemic in-
fluenza were ascribed to widespread immunization in
several other investigations. An Australian study reported
limited spread of H3N2 influenza in a small community
where individuals with chronic medical conditions, eld-
erly adults, and children between 1 and 5 years of age
were assigned to vaccination (Warburton 1972). In Japan,
a country that was an early proponent of widespread vac-
cination of schoolchildren to control epidemic or sea-
sonal influenza, administration of an inactivated in-
fluenza virus vaccine to 80 percent of schoolchildren
who were 7 to 15 years of age was found to prevent
between 37,000 and 49,000 excess deaths annually (Re-
ichert 2001). A mass vaccination campaign among Russ-
ian schoolchildren (aged 3 to 17 years) in two commu-
nities near Moscow led to a statistically significant
(P<.01) 3.4-fold reduction in cases of influenza-like ill-
ness among more than 82,000 noninstitutionalized
adults older than age 60 when compared with results in
the approximately 76,000 elderly subjects in two control
communities (Ghendon 2006). Vaccination with a triva-
lent live attenuated influenza vaccine (LAIV-T) among
15 percent of children aged 1.5 to 18 enrolled in a cen-
tral Texas program reduced the rate of medically at-
tended influenza-related illnesses by 8 to 18 percent in
adults aged 35 or older (Piedra 2005, Piedra 2007a).
The findings in all of these studies helped to establish
the concept of “herd” immunity, or indirect protection,
in a community as a result of effective immunization of
preschool and school-age children — a large index group.
The concept of herd protection has been documented,
and aggressive immunization of preschool and school-
Adrian (unvaccinated)
Tecumseh (vaccinated)
5–9 10–14 15–19 20–29 30–39 40+
Age groups (years)
aged children appears to be an effective way to slow the
progression of viral illness in the community (Monto
1970, Reichert 2001, Piedra 2005, Piedra 2007a). Our
data show that reaching 15 to 25 percent of children in
the community can yield up to an 18 percent reduction
in influenza-like illness cases in adults over age 35 (Piedra
2005). A more recent study indicated that administering
LAIV-T to children age 5 to 18 during the 2003–2004 in-
fluenza outbreak reduced the rate of influenza-positive
cultures by 37.3 percent and pneumonia and influenza
events by 50 percent, even though the outbreak arrived
early, was intense, and was caused by a drifted variant
(Piedra 2007a). Indirect protection against medically at-
tended acute respiratory illness among adults aged 35 to
44 and children aged 5 to 11 who were not vaccinated also
was observed.
Results of a community-based universal
child immunization program
In 1998, a National Institutes of Health-sponsored
clinical trial for widespread vaccination of children was
initiated in central Texas as a means to cover as large a
base as possible with influenza protection. The trial was
initiated by the Baylor College of Medicine, in Houston,
in collaboration with the Scott & White Clinic, in Tem-
ple, Texas, one of the nation’s largest health care sys-
tems. Children were vaccinated with LAIV-T, adminis-
tered by nasal spray, or the inactivated influenza vaccine
(IIV-T), administered by intramuscular injection in
schools in several towns in central Texas. Healthy children
in the intervention cities received LAIV-T, whereas chil-
dren with an at-risk condition received IIV-T. Age-eligi-
ble children in the comparison cities were not offered an
influenza vaccine through the trial. Over the years, the
IMMUNIZATION STRATEGIES / MANAGED CARE 11
 school-based influenza vaccination pro-
Influenza vaccination coverage in Scott & White Clinic population gram has been the most successful of our
in the comparison cities, by age group programs in vaccinating all children in
100%
the intervention communities. This vacci-
<5 12 to 17 25 to 34 45 to 54 65+ nation program required buy-in from
many stakeholders, including independ-
5 to 11 18 to 24 35 to 44 55 to 64
80% ent school districts, the Bell County
(Texas) Health Department, and regional
medical education institutions: Baylor
60% College of Medicine; Scott & White Clinic;
and University of Mary Hardin–Baylor
School of Nursing, in Belton, Texas.
40% Building community awareness regard-
ing the burden of influenza and the ben-
efit of vaccination continues to be a major
20% emphasis of our program in the interven-
tion cities. Community education is
accomplished through press releases,
0%
1998 1999 2000* 2001* 2002 2003 2004* 2005 2006
newspaper articles and ads, informational
posters and pamphlets given to schools
Influenza vaccination coverage in Scott & White Clinic population and clinics, and school-based educational
in the intervention cities, by age group events. The education and vaccination
100% campaigns are conducted in the inven-
<5 12 to 17 25 to 34 45 to 54 65+ tion cities, which include Academy, Bel-
5 to 11 18 to 24 35 to 44 55 to 64
ton, Holland, Rogers, Salado, Temple, and
80% Troy, all based in central Texas. The
school-based influenza vaccination pro-
gram complements the community physi-
60% cians’ efforts against influenza. In the
comparison cities, including Bryan, Col-
lege Station, and Waco, all of which also
40% are in central Texas, the education and
prevention of influenza are conducted by
the community physicians.
20%
For the school-based influenza vacci-
nation program, it is crucial that schools
0%
are well aligned with the program, as time
1998 1999 2000* 2001* 2002 2003 2004* 2005 2006 is needed for scheduling the vaccination
date, delivering the consent packets
through the schools, having the packets
FIGURE 4 Influenza vaccination patterns in treated (bottom) cities
returned to the school with the signed
show improved coverage in school-aged children versus control (top)
consent and assent forms, sending re-
versus during a community vaccination outreach effort.
minders of the vaccination dates, and con-
*Vaccine shortage years. ducting in-school vaccination. The con-
2003: LAIV-T was licensed in the United States & ACIP-recommended children 6-23 months for
influenza vaccination sent packets are delivered in elementary
Source: Piedra 2006 schools to children in the classroom or by
mail to the homes of children in the mid-
trial also brought vaccination to malls, supermarkets, dle and high schools. The signed consent forms are re-
churches, and schools, and also was conducted out of a turned to the school in time for vaccination.
community van that traveled around the region. The trial For this program, the vaccination process is best con-
evolved from a clinic-based program to a community- ducted during the months of September, October, and
based program, and in 2007–2008, to a school-based in- November, and completed just prior to Thanksgiving.
fluenza vaccination program. The goal of the program, Such outcomes as school absenteeism and health care uti-
however, has remained unchanged: control seasonal in- lization for influenza-related illnesses are examined.
fluenza by vaccinating as many children as possible. The Demonstrating a beneficial impact on schools, families,

12 MANAGED CARE / SUPPLEMENT

and the community makes a strong argument for sustain-
ing the school-based influenza vaccination program.
Outcomes were examined in a nonrandomized, open-
label, community influenza vaccination trial in children.
Influenza vaccination coverage was about 2.5- to 3-fold
higher in school-aged children in the intervention commu-
nities compared with the comparison communities (Fig-
ure 4). In 2003–2005, children 5–11 and 12–17 years of age
who received care at the Scott & White Clinic had greater
vaccination coverage, approximately 60 and 40 percent, re-
spectively, than most other age groups, other than adults
older than age 65 who received care at the clinic.
As a result of the higher coverage of school-aged chil-
dren, the relative risk (RR) of medically attended
influenza-related illnesses fell in the intervention cities
compared with the comparison cities (Piedra 2006).
During the epidemic of the 2004–2005 flu season, adult
subjects in the intervention communities experienced a
substantial RR reduction for acute respiratory illnesses
in comparison with control peers. The RR ratio reverted
back to pre-epidemic values after the influenza season,
supporting the concept of herd protection during the ac-
tive flu season.
During the subsequent epidemic (2005–2006), the in-
vestigators achieved approximately 30 percent coverage
of children aged 5 to 18 in the intervention communi-
ties and observed direct and indirect protection against
influenza — including the ability to prevent the second
influenza wave, which was dominated by influenza B
(Piedra 2007b). In the vaccination year 2005–2006, cov-
erage in the 5–18-year age range who received care at the
Scott & White Clinic was approximately 2.5- to 3-fold
greater in the intervention cities than in the comparison
cities. The school-based influenza vaccination program,
which was initiated for 2007–2008 and limited primarily
to elementary schools, reached 5,144 elementary-grade
students, 887 school staff members, and 996 additional
school-age children through the outreach and clinic-
based vaccination efforts (Gaglani 2008).
For the 2008–2009 influenza season, there are plans to
expand the school-based vaccination program to in-
clude all of the middle and high schools in the interven-
tion cities, reaching more children and school staff mem-
bers, and offering parent and student participation in
focus groups. It will be valuable to see how an increase
in vaccination coverage relates to morbidity and mortal-
ity from influenza in the intervention communities. The
success of the program to date suggests that universal vac-
cination of children may be an important means to help
control seasonal influenza and should be considered in
any pandemic preparedness plan.
Barriers to universal vaccination
The clinical benefit of influenza vaccination of school
children has now been documented in the United States,
IMMUNIZATION STRATEGIES / MANAGED CARE
Italy, Japan, and Russia. A number of barriers must be
addressed, however, if universal vaccination is to be
achieved. Among the most important barriers are pa-
tient factors, including safety or side-effect concerns
that might deter patient use, a misunderstanding that
generally can be reversed with education.
Another common barrier is that some people have
time limitations that prevent them from reaching vac-
cination sites, or are concerned about reimbursement
from insurers, or are unable to pay. These situations
suggest the need for providing easier access to vaccina-
tion sites, influenza vaccine coverage (LAIV-T and IIV-
T) by third-party payers, and umbrella policies for the
uninsured, respectively. Yet another common, but less
often considered, barrier is the lack of physician recom-
mendation. Without a prompt from their health care
provider, many people will not seek vaccination as a
standard of care.
There also are vaccine availability factors that can in-
terfere with widespread immunization, including an in-
adequate supply, distribution problems, or product re-
calls. Perhaps the most important challenge, however, lies
with the medical provider: if the physician or nurse does
not take every opportunity to encourage patients to re-
ceive a flu vaccine, widespread coverage will not be ac-
complished.
Conclusion
Influenza is a disease of substantial morbidity and
mortality and has been the focus of aggressive prevention
efforts for many years. Vaccination has proven to be the
best means to control viral spread and to reduce the bur-
den of the disease. However, older vaccination guidelines,
which focused on treating people at high risk for com-
plications, prompted neither a significant reduction in
influenza incidence nor a substantial improvement in
disease mortality. As a result, national guidelines have
changed to promote universal vaccination of children age
6 months through 18 years. Vaccination of school-aged
children not only provides direct benefit to the children,
but also offers indirect benefit to their families and the
community, because children are the major transmitters
of influenza to other suspectible family and community
members.
It seems clear that high vaccination coverage of pre-
school and school-aged children can reduce the morbid-
ity and mortality related to influenza outbreak in the
community. In my experience, the vaccination of chil-
dren and staff members through a school-based initia-
tive that is supported by the community, including the
medical establishment, offers an option for rapid and ef-
ficient control of influenza outbreaks. A universal vacci-
nation program may help to reduce the morbidity of sea-
sonal influenza and protect against reduced productivity
and loss of life.
13
 References
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vention and control of influenza: Recommendations of the
Advisory Committee on Immunization Practices (ACIP).
MMWR Recomm Rep. 2006;55(RR10):1–42.
ACIP. ACIP provisional recommendations for the prevention
and control of influenza. 2008. «http://www.cdc.gov/vac-
cines/recs/provisional/downloads/flu-3-21-08-508.pdf».
Accessed July 31, 2008.
ACS (American Cancer Society). Cancer Facts and Figures 2004.
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PWSecured.pdf». Accessed July 31, 2008.
Bridges CB, Harper SA, Fukuda K, et al. Prevention and control
of influenza: Recommendations of the Advisory Commit-
tee on Immunization Practices (ACIP). MMWR Recomm
Rep. 2003;52(RR08):1–36.
CDC (Centers for Disease Control and Prevention). Pink book,
10th edition. Epidemiology and prevention of vaccine pre-
ventable diseases. 2nd Printing (March 2008).
«http://www.cdc.gov/vaccines/pubs/pinkbook/pink-
chapters.htm». Accessed Sept. 22, 2008.
CDC. Influenza vaccination coverage among children aged 6–59
months — six immunization information system sentinel
sites, United States, 2006–07 influenza season. MMWR
Morb Mortal Wkly Rep. 2007a;56:963–965.
CDC. Influenza vaccination coverage among children aged 6–23
months — United States, 2005–06 influenza season.
MMWR Morb Mortal Wkly Rep. 2007b;56:959–963.
CDC. State-specific influenza vaccination coverage among
adults aged > or =18 years — United States, 2003–04 and
2005–06 influenza seasons. MMWR Morb Mortal Wkly Rep.
2007c;56:953–959.
CDC. Healthy People 2010 midcourse review, 2005.
«http://www.healthypeople.gov/Data/midcourse/
comments/faobjective.asp?id=14&subid=29». Accessed
July 24, 2008.
Committee on Infectious Diseases. Policy statement: prevention
of influenza: recommendations for influenza immuniza-
tion of children, 2008-09. Pediatrics. 2008;122:1–7
Elveback LR, Fox JP, Ackerman E, et al. An influenza simulation
model for immunization studies. Am J Epidemiol.
1976;103:152–165..
Gaglani M, Piedra PA, Kozinetz CA, et al. Effective implementa-
tion of a school-based influenza vaccination and herd pro-
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stract #S27, 66.
Ghendon AZ, Kaira AN, Elshina GA. The effect of mass in-
fluenza immunization in children on the morbidity of the
unvaccinated elderly. Epidemiol Infect. 2006;134:71–78.
Glezen WB. Serious morbidity and mortality associated with in-
fluenza epidemics. Epidemiol Rev. 1982;4:25–44.
Heinonen OP, Shapiro S, Monson RR, et al. Immunization dur-
ing pregnancy against poliomyelitis and influenza in rela-
tion to childhood malignancy. Int J Epidemiol.
1973;2:229–235.
Lu P, Bridges CB, Euler GL, Singleton JA. Influenza vaccination
of recommended adult populations, U.S., 1989–2005. Vac-
cine. 2008;26:1786–1793.
Molinari NA, Ortega-Sanchez IR, Messonnier ML, et al. The an-
nual impact of seasonal influenza in the US: measuring dis-
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cination of schoolchildren. J Infect Dis. 1970;122:16–25.
14 MANAGED CARE / SUPPLEMENT
Munoz FM, Greisinger AJ, Wehmanene OA, et al. Safety of in-
fluenza vaccination during pregnancy. Am J Obstet Gynecol.
2005;192:1098–1106.
Piedra PA, Gaglani MJ, Fewlass C, et al. Herd immunity in adults
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Piedra PA, Gaglani MJ, Kozinetz CA, et al. Herd immunity in
adults against influenza-related illnesses with use of the
trivalent-live attenuated influenza vaccine (CAIV-T) in
children. Vaccine. 2005;23:1540–1548.
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Reichert TA, Sugaya N, Fedson DS, et al. The Japanese experi-
ence with vaccinating schoolchildren against influenza.
N Engl J Med. 2001;344:889–896.
Thompson W, Shay DK, Weintraub E, et al. Mortality associated
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States. JAMA. 2003;289:179–186.
Thompson W, Shay DK, Weintraub E, et al. Influenza-associated
hospitalizations in the United States. JAMA. 2004;292:
1333–1340.
Warburton MF, Jacobs DS, Langsford WA, White GE. Herd im-
munity following subunit influenza vaccine administration.
Med J Aust. 1972;2:67–70.
Weycker D, Edelsberg J, Halloran ME, et al. Population-wide
benefits of routine vaccination of children against in-
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Zaman K, Roy E, Arifeen SE, et al. Effectiveness of maternal in-
fluenza immunization in mothers and infants. N Engl J
Med. 2008;359:1–10.
Disclosure: Pedro A. Piedra, MD, has received consulting fees
from Merck, MedImmune, Novartis, Roche, and sanofi pasteur, has
performed contracted research for MedImmune, Novartis, and
sanofi pasteur, and serves on the speaker’s bureau for MedIm-
mune. He reports no real or apparent conflicts of interest with re-
spect to proprietary products mentioned in this article.
FACULTY PRESENTATION
Challenges for Health Plans
In Influenza Immunization
MICHAEL A. KAUFMAN, MD and ALLAN J. KOGAN, MD, MSS, AFBP, FAAFP, CPE
OptumHealth, Division of UnitedHealth Group Great-West Healthcare, Dallas
SUMMARY
Balancing the interests of patients and
physicians is one of many challenges health
plans experience. Although it is clear that in-
fluenza vaccination is an important part of
any wellness program, the question of who
should pay for it remains an important issue.
Business is decreasing for HMOs as Medicare and
Medicaid increase their coverage. With the advent of
health reimbursement accounts, health savings accounts
(HSAs), and flexible spending accounts (FSAs), the focus
turns to reimbursement, and more flexibility exists as to
how and where members can receive their care —
whether in a physician’s office or convenient care clinics,
also known as “minute clinics.” Operating mainly out of
grocery stores and chain pharmacies, these clinics pro-
vide basic medical services, including vaccinations, on a
walk-in basis. Their presence is growing. A recent study
conducted by the Deloitte Center for Health Solutions
(2008) found that more than 1 in 3 consumers are recep-
tive to the idea of using minute clinics, and 1 in 6 already
has visited one.
Vaccinations often are considered loss leaders in physi-
cian offices and pharmacies. In the case of the former, the
influenza vaccination has typically been a part of a gen-
eral health update. With pharmacies, the hope exists that
a patient will buy other items during the time spent in
there for an influenza vaccination.
When offered by employers, vaccination programs
may be initiated with the goal of improving employee
productivity. Most people understand the connection
between illness and lost productivity, but not everyone
Michael A. Kaufman, MD, is senior medical director,
OptumHealth, a division of UnitedHealth Group. Allan J.
Kogan, MD, is vice president and regional medical direc-
tor for Great-West Healthcare, a Cigna company.
IMMUNIZATION STRATEGIES / MANAGED CARE
understands how much lost productivity in the work-
place is attributed to single parents and women, who are
vulnerable to absenteeism due to their caregiving roles.
Health care workers and the so-called sandwich genera-
tion — the middle-aged parents who also care for eld-
erly parents — are two additional groups that need pro-
tection from the influenza virus. Although it is clear that
influenza vaccination is an important part of a wellness
program, these programs have a poor track record when
it comes to return on investment (ROI). So when it
comes to influenza vaccination, the question is, as always,
“Who pays?”
Minute clinics and primary care
Pediatricians once administered vaccines for protec-
tion against childhood diseases separately to children,
and charged an administration fee with each injection.
Now, five different vaccines are combined into one injec-
tion, so whereas in the past a physician would receive $20
for the administration, that physician now makes $4. It
might not seem like much money is at stake, but physi-
cians need the income stream. The more influenza vac-
cinations are given outside the physician’s office, such as
those provided at minute clinics, the more income physi-
cians lose. Primary care is shrinking, because the money
is just not there, even with subsidization.
Health plans understand that the market will drive
minute clinics, which will take business away from pri-
mary care providers. MCOs have not fully embraced this
alternative, because they need the providers. If and when
MCOs do embrace minute clinics, these clinics will fall
under the urgent care rubric, and minute clinic care will
be billed through HSAs and FSAs. At least one reason ex-
ists to support these clinics — they provide a less costly
alternative to an emergency room visit.
Balancing both the interests of patients and physi-
cians is a challenge. On one hand, the proliferation of
minute clinics, through their visibility and accessibility,
would probably increase vaccination rates . On the other
hand, it is vital for physicians to determine how to keep
their practices relevant and to effectively communicate
to their patients that they remain central to their medi-
15
 cal care, especially when complex health care issues are
involved.
Although it does not endorse the spread of minute
clinics, the American Academy of Family Physicians
(AAFP) has published a list of desired attributes for
them (Box). The AAFP’s attributes include the use of
electronic health record (EHR) systems. A recent survey
concluded that only 12.4 percent of physicians used
comprehensive EHR systems in 2006 (Hing 2007).
Minute clinics, on the other hand, tend to be more up to
date when it comes to using computers to digitize med-
ical information.
Strategies for increasing
influenza vaccination rates
In the past, UnitedHealth Group has aggressively en-
couraged influenza vaccinations for high-risk popula-
tions, as part of a disease management program for
people with such conditions as asthma and chronic ob-
structive pulmonary disease. But in light of the high rate
of hospitalization due to influenza in the population
younger than 6 months, more needs to be done for this
age group as well. Informing pregnant women — espe-
cially high-risk pregnant women — about the impor-
tance of influenza vaccinations in the neonatal age group
through healthy pregnancy programs could be a way to
increase vaccination in the neonatal age group. Such an
initiative would appear to have a good ROI.
When considering adult immunization, the best ap-
Desired attributes of retail health clinics
Scope of service — Retail clinics must have a well-defined and
limited scope of clinical services.
Evidence-based medicine — Clinical services and treatment
must be evidence-based and quality-improvement oriented.
Team-based approach — The clinic should have a formal con-
nection with physician practices in the local community,
preferably with family physicians, to provide continuity of
care. Other health professionals, such as nurse practitioners,
should only operate in accordance with state and local regu-
lations, as part of a team-based approach to health care and
under responsible supervision of a practicing, licensed physi-
cian.
Referrals — The clinic must have a referral system to physician
practices or to other entities appropriate to the patient’s
symptoms beyond the clinic’s scope of work. The clinic
should encourage all patients to have a “medical home.”
Electronic health records (EHRs) — The clinic should include
an EHR system sufficient to gather and communicate the pa-
tient’s information with the family physician’s office, prefer-
ably one that is compatible with the Continuity of Care
Record supported by AAFP and others.
Source: AAFP 2008
16 MANAGED CARE / SUPPLEMENT
proach for health plans may be to partner with employ-
ers rather than to transfer accountability to the individ-
ual member. Many employers are self-insured and have
a stake in immunizing employees so that they are produc-
tive at work or not have to leave work to tend to ill fam-
ily members. Plans also should continue to include re-
minders about influenza vaccination in the literature
that is sent out to members. But, ultimately, even if plans
cover the influenza vaccine, it is the members who decide
for themselves whether to receive it.
Navigating the cost of immunization
Although access to the influenza vaccine is certainly
important, a health plan has to look at the cost of in-
fluenza vaccination to an organization. Plans often are
presented with the cost-offset model and are asked to pay
up front in the hope that money will be saved in the fu-
ture, typically through the prevention of future hospital-
izations. Unlike other kinds of vaccinations that need to
be administered several times, the influenza vaccine is an-
nual. Manufacturers of new vaccine products, such as the
live-attenuated influenza virus vaccine, must be able to
show that their product is worth its cost because of a
higher effectiveness rate and faster administration.
Otherwise, health plans will question spending money
on a vaccination that the public may perceive as un-
predictable in its effectiveness.
Although it may be unrealistic to expect one health
plan to take on universal influenza immunization, a state
association of health plans could organize indi-
vidual plans to work collaboratively with each
other or with community foundations to get
everyone vaccinated. Each plan could be encour-
aged to contribute to a collective pot, adding in
what it already pays to cover vaccinations. If there
were data that show that the cost of vaccination
was less than the cost of lost productivity result-
ing from the influenza virus, then jointly-funded
programs could be particularly effective. How-
ever, the government — be it city, state, or federal
— is in a better position than health plans to im-
plement a universal vaccination program, be-
cause there are many people in the United States
who are uninsured. Perhaps governments could
create a specific immunization tax. Schools also
are important to universal vaccination and cre-
ating herd immunity, as they capture the entire
population of children, regardless of whether
they are insured or uninsured or legal or illegal
residents of the United States.
Flu vaccination will remain part of our com-
mitment to vaccination, immunization, and
preventive care. The key is to determine how
best to invest our resources to significantly in-
crease the compliance rate.
References
AAFP (American Academy of Family Physicians). Retail health
clinics. 2008. «http://www.aafp.org/online/en/home/
policy/policies/r/retailhealthclinics.html». Accessed Aug.
12, 2008.
Deloitte Center for Health Solutions. Growth of retail clinics:
2008 Survey of Health Care Consumers.
«http://www.deloitte.com/dtt/article/0%2C1002%2Ccid%
25253D192463%2C00.html». Accessed Aug. 12, 2008.
FACULTY PRESENTATION
Influenza Prevention and
Population Health Management
ALYCE KUHN, RN, RRT, MSHA
Matria Healthcare, Dallas
SUMMARY
Modifiable health risk factors can be im-
proved through effective health promotion
and disease management efforts, such as
vaccinations. Employers must understand
that employee illness is related to not only
medical and pharmaceutical costs, but to
productivity costs as well.
Matria Healthcare began as a maternity high-risk pro-
gram, but through the years it has purchased other com-
panies to add to its array of services. We now offer serv-
ices that run “from cradle to grave,” and include oncology
services, diabetes programs, and a wellness program.
We believe that a large proportion of diseases and dis-
orders are preventable. Our main goal is to examine
modifiable health risk factors that can be improved
through effective health promotion and disease manage-
ment and prevention, such as vaccinations, and we then
provide the outcome to the employer. Focusing on the
context of prevention, we have utilized previous research
to help formulate our productivity and health-screening
tools (Edington 2001, Kessler 2003). Work conducted by
Edington and Kessler has been instrumental in helping
us to determine which of our programs’ participants ex-
hibit characteristics that place them at high risk for dis-
ease, such as those individuals who are overweight, or
smoke, or have unhealthy diets.
For those program participants who are chronically ill,
Alyce Kuhn, RN, is vice president for client management at
Matria Healthcare.
IMMUNIZATION STRATEGIES / MANAGED CARE
Hing ES, Burt CW, Woodwell DA. Electronic medical record use
by office-based physicians and their practices: United
States, 2006. Adv Dat. 2007;26:1–7.
Disclosures: Michael A. Kaufman, MD, and Allan J. Kogan, MD, re-
port no real or apparent conflicts of interest with respect to com-
panies, organizations, or proprietary products mentioned in this
article.
we implement disease management programs, which in-
clude programs for managing asthma, diabetes, and
chronic obstructive pulmonary disease. Nurses work with
participants to make sure they adhere to guidelines, and
teach them what to focus on and what questions to ask
in a typical 7- to 10-minute visit at the physician’s office.
Twelve percent of our participants are considered
high-risk or chronically ill and are in need of telephone
coaching regarding proper health habits. We communi-
cate with these members by way of telephone,
e-mail, and text messaging to ensure that information
pertaining to the importance of vaccination is received.
Of these high-risk members, approximately 89 percent
have reported receiving vaccination against influenza.
One hundred percent participation in vaccination pro-
grams has been unattainable, as some people are uncer-
tain about the safety of the vaccine.
Encouraging influenza vaccination
After finishing their health assessment, participants re-
ceive a personal health report, along with ongoing e-
mails and other communications regarding preventive
measures that can be taken. We have a system of clinical
alerts, utilizing automated phone calls based on voice
recognition technology, that remind patients to get their
vaccinations. These care-alert calls address different
health issues, depending on the season of the year; for ex-
ample, we ask people in the fall if they have had their in-
fluenza vaccination. Our system bases its screening rec-
ommendations on personal information like gender, age,
and geographical location. In the future, we aim to em-
phasize in our messages the importance of vaccinations
for all age groups, especially for school-aged children.
After trying different means of communicating the
importance of preventive health measures, we have found
17
 that letters do not work: postcards are better. Shorter
messages are more effective, and telling people to do
something (“You need to get your flu vaccine”) is more
effective than taking an educational approach.
Employers and employee wellness
Past efforts have shown that people need incentives to
adhere to wellness programs. We use a point system to
reward participants for getting screenings, like mammo-
grams, and for taking preventive measures, like getting
the influenza vaccine. Some companies have the means
to use financial incentives, but some use other strategies.
For example, a cultural example may be set when corpo-
rate executives send messages, provide information, and
create challenges for employees. We have found that one
of the 10 best things companies can do to increase par-
ticipation in wellness programs is to lead by example.
Leaders should “walk the walk and not just talk the talk.”
This approach can even be more successful in increasing
participation than financial incentives.
Employers understand that the overall cost of an em-
ployee illness is not limited to medical and pharmaceu-
tical costs — a health-related productivity cost exists as
well. Companies have moved beyond just wanting a re-
turn on their investment (ROI) in wellness, and are now
more concerned with the value of their investment. We
have worked with a variety of companies to assist in the
implementation of an influenza vaccination program
that utilizes on-site clinics. By spending the money up
front, they are looking toward establishing an increased
vaccination rate and, in turn, a healthier and more pro-
In the Trenches: Primary Care Perspectives
On Implementation, Prevention, and Treatment
RICHARD L. COLLINS, MD
Buffalo Medical Group; Buffalo General Hospital, Buffalo, N.Y.
SUMMARY
A yearly influenza clinic with convenient
hours and location is an efficient way to
ensure that primary care patients receive
their influenza vaccination. Physicians
should also receive the influenza vaccine
themselves, to lead by example and to help
to dispel some of the myths that surround its
administration.
18 MANAGED CARE / SUPPLEMENT
ductive employee population. Those employees who
want information about vaccine safety or about how
new products compare with older ones can call a 24-hour
nurse line or read provided literature.
We work with employers to show them the association
between health risks and absenteeism. Tailored analyses
based on specific employee populations show the cost of
employee illness to companies. Six months after we
launch our program, we do another analysis, after which
we provide quarterly outcomes. When it comes to risks
due to conditions like influenza, it can take time for re-
sults to appear; positive outcomes may not be immedi-
ately visible.
We have found that people initially buy our services
based on faith, but they renew their contracts based on the
value of the services that we provide. We believe that well-
designed and well-implemented health promotion and
disease prevention programs can be cost-effective to health
plans and beneficial to program members. Reductions in
health costs, improvements in productivity, and a positive
ROI are valuable outcomes for all involved parties.
References
Edington DW. Emerging research: a view from one research cen-
ter. Am J Health Promot. 2001;15:341–349.
Kessler RC, Barber C, Beck A, et al. The World Health Organiza-
tion Health and Work Performance Questionnaire
(HPQ).Occup Environ Med. 2003;45:156–174.
Disclosure: Alyce Kuhn, RN, RRT, MSHA, reports no real or appar-
ent conflicts of interest with respect to companies, organizations,
or proprietary products mentioned in this article.
I am an internist for a large private practice group in
Buffalo, N.Y. Our group is made up of approximately 120
physicians who cover almost 300,000 lives. We take in-
fluenza vaccination seriously, and our group aims for 100
percent immunization of our targeted population. The
physicians in our group meet regularly to discuss strate-
gies to improve vaccination rates, retinal examinations
for patients with diabetes, colonoscopies, and other im-
portant preventive procedures.
Richard L. Collins, MD, is an internist with the Buffalo
Medical Group, and is a clinical assistant professor of medi-
cine at Buffalo General Hospital.
 I have a personal interest in the influenza vaccine, as
a few years ago my daughter had the flu. When I took her
to her pediatrician, he asked me if I had received the flu
shot. When I replied that I had not, he told me, “You
likely have yourself to thank, as both a health care worker
and father, for not getting vaccinated. Your not getting
vaccinated placed her at increased risk.” From that point
on, I vowed to get the flu shot every year. Before that time,
my patients often would ask me, “Do you get the flu
shot?” If I shrugged, indicating a negative re-
sponse, they typically would not get the shot,
either. In retrospect, I can see that this was not
the best way to impress upon the patients the
importance of the flu vaccine. I need to lead by
example.
How we encourage and administer
influenza vaccinations
Each year, on July 1, we begin to alert our pa-
tients to the fact that the flu vaccine will be RICHARD L.
available to them on Oct. 1. We have three large COLLINS, MD
offices in Western New York, and we put out
signs that say “Flu shots will be available here.” In the fall,
our flu vaccine clinics are open 3 days a week, from 5 pm
until 9 pm, and on weekends at each of our three loca-
tions downtown and in the suburbs. We try to make it
as easy and convenient as possible for each patient to re-
ceive the flu vaccine. We stress ease of access. As long as
someone is a member of our practice, that patient can
walk in the door and receive a vaccination. We also use
our Web site to disseminate information.
We have found that what really brings people into
our clinics is the word “shortage.” In the past, when the
media has reported a shortage of influenza vaccine,
the number of visits increased markedly, and the lines
for the influenza vaccine were out the door. In general,
we aim for a 15-minute process, from the time a patient
walks in the door to the time that patient walks out the
door.
As a rule, we softly discourage patients from getting
the influenza vaccine during their routine care. However,
if a patient has congestive heart failure and diabetes, for
example, and requests the vaccination, we will adminis-
ter it on the spot. Approximately 80 percent of our pa-
tients who receive the vaccine come to our flu vaccine
clinics. Across the country, 60 percent of our patients
over age 65 are vaccinated; the number drops to 34 per-
cent in the group of patients between the ages of 50 and
65. Unfortunately, only 34 percent of health care work-
ers receive the vaccine. Clearly, this number must be im-
proved.
Common misconceptions
Our nursing staff is trained to answer the same ques-
tion it receives over and over: “Am I going to get sick as
IMMUNIZATION STRATEGIES / MANAGED CARE
a result of receiving the flu vaccine?” We distribute a
handout from the Centers for Disease Control and Pre-
vention that explains that the influenza vaccine does not
make people sick and explains the local reaction to the
injection.
I decided to ask the question to people around me:
“Why don’t you get the flu shot?” My wife responded,
“Because I’m going to get sick.” This is the most common
reason people give for not getting vaccinated — the fear
of being ill. Also, many people avoid the in-
fluenza vaccine thinking it is a “guessing game
vaccine,” an idea that could be due in part to the
media’s coverage of instances in which in-
fluenza strains differed from what had been
anticipated. There also is concern about the
vaccine containing a live-attenuated virus —
the fear, again, is that a vaccine containing live
virus could make one sick with the flu.
I asked my sister-in-law the same question,
and she said, “I get the flu shot, but I don’t have
time for the kids. If the kids get sick, I’ll take
care of the kids.” A neighbor responded to the
question in a similar fashion. Her answer was, “I’m a min-
imalist. I don’t want to get flu shots, I don’t want to get
anything that is unnecessary.” Parents do not seem to be
aware that children should receive influenza vaccina-
tions; there is an idea that it is not necessary. But we have
had some tragic pediatric deaths in our community in
the last few years due to influenza. There may be ways that
the mainstream media could more effectively get the
message across to stay-at-home mothers that the in-
fluenza vaccination is necessary both for them and for
their healthy children.
The analogy I like to use in the face of these miscon-
ceptions is that of the “scouting report” in football. This
advance report gives a team a preview of what’s coming,
how to play against it, and what tricks are going to be
used. The influenza vaccine is a scouting report that
gives your body a preview of what’s coming this winter.
As an internist and father, I think that giving and re-
ceiving the flu vaccine are two important goals for each
fall season. I try to stress the importance of the flu vac-
cine on a daily basis at home and in the office between
Oct. 1 and Jan. 1 every year. I think every health care pro-
fessional should do the same.
Disclosure: Richard L. Collins, MD, reports no real or apparent
conflicts of interest with respect to companies, organizations, or
proprietary products mentioned in this article.
19
 CONTINUING MEDICAL EDUCATION ASSESSMENT/EVALUATION/CERTIFICATE REQUEST
Immunization Strategies for Reducing Influenza’s Burden on Public Health

CE Credit for Physicians/Pharmacists

I certify that I have completed this EXAMINATION: Place an X through Was this publication fair, balanced, and
educational activity and post-test and the box of the letter that represents free of commercial bias?
claim (please check one): the best answer to each question on  Yes  No
 Physician contact hours page 21. There is only ONE correct an- If no, please explain: __________________
 Pharmacist contact hours swer per question. Place all answers
on this form. ___________________________________
Signature: _______________________
A. B. C. D. ___________________________________
PLEASE PRINT CLEARLY 1.    
2.     ___________________________________
First name, MI ____________________ 3.  
4.     Please use the following scale to
Last name, degree ________________ 5.     answer the next four questions:
Title ____________________________ 6.    
7.     Strongly Agree .........................5
Affiliation _______________________ 8.   Agree..........................................4
9.     Neutral.......................................3
Mailing address __________________ 10.     Disagree ....................................2
________________________________ 11.     Strongly Disagree ...................1
12.   
City___________ State ___ ZIP______ 13.     Did this educational activity meet
14.     my needs, contribute to my personal
Day telephone (____) ______________ 15.     effectiveness, and improve my
Fax ( _____ ) _____________________ ability to:
PROGRAM EVALUATION
E-mail __________________________ So that we may assess the value Treat/manage patients?
of this self-study program, we ask that 5 4 3 2 1 N/A
Physicians — This activity is you please fill out this evaluation form.
designated for a maximum of 2.5 AMA Communicate with patients?
PRA Category 1 credits.™ 5 4 3 2 1 N/A
Have the objectives for the
activity been met? Manage my medical practice?
Pharmacists — This activity is 5 4 3 2 1 N/A
approved for 2.5 contact hours 1. Discuss strategies used for influenza
(0.25 CEU). prevention, diagnosis, and manage- Other ______________________________
ACPE Universal Program Number ment, especially in vulnerable popu-
lations. ____________________________________
(UPN): 812-000-08-019-H01-P
Release Date: Oct. 15, 2008  Yes  No 5 4 3 2 1 N/A
Expiration Date: Oct. 15, 2009
2. Assess burden of disease associated Effectiveness of this method
To receive credit, complete the with influenza in all populations. of presentation:
assessment/evaluation form and mail  Yes  No Very
or fax completed form to: Excellent good Good Fair Poor
5 4 3 2 1
The Chatham Institute 3. Evaluate the economic impact of in-
26 Main Street, Suite 350 fluenza on the health care system. What other topics would you like to see
Chatham, NJ 07928  Yes  No addressed? ________________________
Fax: (973) 701-2515
4. Review Advisory Committee on Im- ___________________________________
Allow 6–8 weeks for processing. munization Practices meeting dis-
cussions and notes. ___________________________________
This activity is sponsored by The  Yes  No
___________________________________
Chatham Institute and is provided at
no cost to the participant through an 5. Discuss appropriateness and means Comments:_________________________
educational grant from Medimmune. for universal influenza vaccination.
 Yes  No ___________________________________

___________________________________
T8M18-MG
___________________________________

20 MANAGED CARE / SUPPLEMENT

CONTINUING EDUCATION POST-TEST
Immunization Strategies for Reducing Influenza’s Burden on Public Health
Please tear out the assessment/evaluation form on page 20. On the answer sheet, place an X through the box of the
letter corresponding to the correct response for each question. There is only ONE correct answer to each question.
1. The antigenic components of
the influenza virus are:
a. M2 ions.
b. Hemagglutinin and
neuraminidase.
c. Viral RNA.
d. None of the above.
2. Antigenic drift is:
a. A change in the antigenic
profile of a virus due to
point mutations.
b. The onset of an influenza
epidemic.
c. The accumulation of virus
in an individual due to
viral replication.
d. A mutation of M2 ion
channel amino acids.
3. True or false: Inactiviated virus
vaccine has proven more effi-
cient than live-attenuated vac-
cine at protecting against multi-
ple strains of influenza virus.
a. True.
b. False.
4. Influenza outbreaks are
responsible annually for:
a. A total economic burden of
$87.1 billion.
b. 31 million outpatient
visits.
c. 3.1 million hospitalization
days.
d. All of the above.
5. Proper vaccination of young
children requires:
a. Three doses, 8 weeks apart.
b. Two doses, 4 weeks apart.
10. A good reason for medical plans
c. Two doses, 8 weeks apart.
d. Two doses, 1 year apart.
6. A community-based vaccine
access program in several Texas
communities increased vaccine
coverage by _____ compared
with control communities:
a. 20 percent
b. 50 percent
c. 2.5 to 3 times
d. 5 times
7. One of the 10 best things
employers can do to improve
employee wellness is to:
a. Improve cafeteria food.
b. Have company executives
lead by example.
c. Fire overweight
employees.
d. Give away movie tickets
as incentives.
8. Which kind of message is best
for encouraging people to get
an influenza vaccination?
a. One that is short.
b. One that is detailed.
9. The cost of employee illness
consists of:
a. 66 percent personal health
costs and 33 percent productiv-
ity costs.
b. 66 percent productivity costs
and 33 percent personal health
costs.
c. 99 percent productivity costs
and 1 percent personal health
costs.
d. 50 percent personal health
costs and 50 percent productiv-
ity costs.
to support the proliferation of
minute clinics is that these
clinics:
a. Cost less to visit than going to a
physician’s office.
b. Provide an alternative to a
physician’s office.
c. Provide an alternative to
an emergency room visit.
d. Provide better care than
a physician’s office would.
IMMUNIZATION STRATEGIES / MANAGED CARE
11. Which of the following is an
American Academy of Family
Physicians Desired Attribute of
Retail Health Clinics?
a. Electronic Health Record
systems.
b. Hours until midnight.
c. Noncompetition with
physicians.
d. Location at the workplace.
12. Schools are important to
universal vaccination because
they capture:
a. Uninsured children.
b. Children who are illegal
residents.
c. Both A and B.
13. Informing pregnant women
about the need to vaccinate
newborns against influenza is
important because:
a. Newborns are frequently hospi-
talized with influenza.
b. Pregnant women are at high
risk for contracting influenza.
c. Newborns spread influenza to
family members.
d. Newborns have a high mortality
rate due to influenza.
14. The difference between the
influenza vaccine and other
vaccines is that it:
a. Must be administered yearly.
b. Is relatively ineffective.
c. Costs less.
d. Must be administered more
than once.
15. The most commonly voiced mis-
conception about the influenza
vaccination is that:
a. It varies in effectiveness from
year to year.
b. It is not covered by health
plans.
c. It is too expensive.
d. It makes people sick.
21