This article is more than 5 years old. Information may no longer be current.
Influenza vaccination in 2014: Familiar virus, but different season
The 2013-2014 influenza season has demonstrated again why the influenza A(H1N1) virus poses such a serious public health threat. As of Feb. 14, California has seen 243 influenza-related deaths in people younger than 65 years. This season also highlights some of the current challenges facing public health’s influenza response.
The 2009 influenza pandemic response, as hard as it was, was vitalizing for local public health, reminding us why we do what we do and how public health can be the hub of an organized community response. We are fortunate that this year, by contrast, our previous experience with the virus and the strain’s inclusion in the seasonal influenza vaccine made for a much more manageable campaign. But with widespread budget cuts at all levels, it’s uncertain whether local public health’s pandemic response of 5 years ago could be repeated now. Local health departments continue to use a patchwork of different models of service delivery in different communities. But the inexorable trend is toward public health assuring services are available in the community rather than providing those services directly. This shift can be clearly seen in immunization programs. A survey conducted by the National Association of County and City Health Officials (NACCHO) revealed that 48% of local health departments had seen cuts in services provided in 2012 alone, with 20% reporting cuts in their immunization programs. Now more than ever, public health must work effectively with community partners to assure that those who need vaccinations receive them.
Impact of health care reform
Changes introduced by the Affordable Care Act (ACA) will also profoundly affect public health immunization policy. Better assurance of insurance coverage is clearly a welcome development, and the ACA mandates provision of Advisory Committee on Immunization Practices-recommended vaccines at no cost-sharing for private and group health plans. But assuring adequate insurance coverage of vaccines is not the same as assuring an adequate immunization program. The Section 317 federal grant immunization program has historically supported public health initiatives aimed at underinsured children not eligible for the Vaccines for Children program, adults and outbreak control. It helps immunization programs to flexibly respond to the needs at hand, including influenza mass vaccination events. Adequate funding of the Section 317 program has been a chronic concern. Its funding in the future remains uncertain, since with ACA implementation Section 317 funding is no longer to be used to vaccinate those who have public or private insurance.
Matthew Zahn
This fiscal landscape will place further emphasis on paying for local public health immunization services by billing insurance. Public health has already begun adapting: A 2010 survey of local health departments found that 80% billed insurances for immunizations. But billing insurance for immunizations in a clinical setting is one thing, billing in a community mass vaccination setting is a very different matter. Public health has always prided itself on taking the vaccines to the people, setting up vaccination clinics in schools, homeless shelters, community centers and the like to make it easy for populations to access service. These outreach events are particularly crucial to vaccinating hard-to-reach populations. Such events become logistically more difficult when insurance billing is factored in; only 51% of local respondents to the previously mentioned survey reported that they billed insurance in these mass vaccination events. Adding a billing process means adding staff and infrastructure to these events. And many health departments treat these immunization events as “extra events,” which can make identifying staff and paying for their time difficult. Local departments will need to evolve their approach to these events to meet community need.
Working with partners
Pharmacies will continue to be an obvious partner, as 21.9% of adults received their influenza vaccination from a pharmacy, according to early estimates in the 2013-2014 season. Pharmacies have a natural reach because so many people will visit as part of their regular routine. They also have a larger geographic footprint than local health departments, which besides loss of staff have lost community facilities as well.
Pharmacies played a significant role in the 2009 pandemic response, both in terms of providing vaccinations and distributing antiviral medication. The worth of this relationship was demonstrated then and would likely be re-employed in any future pandemic and should be strengthened for annual influenza seasons. Further preplanning would allow local health departments to better incorporate pharmacies into their pandemic plans, and NACCHO and CDC have been partnering to further develop public health relationships with private pharmacies in antiviral distribution.
Working with pharmacies comes with challenges. Pharmacists are generally not licensed to vaccinate pediatric age groups. Keeping patients who receive vaccinations from pharmacies connected with their medical providers is a concern. And it remains to be seen whether pharmacies will continue to see providing immunizations as a useful aspect of their business model. But the pluses of this relationship clearly outweigh the minuses.
Immunization rates need improvement
All of these changes are occurring against a backdrop of influenza vaccination coverage rates that need to improve. The 2009 influenza A(H1N1) strain, with its emphasis on causing significant disease in younger adults, casts renewed light on a group that historically is undervaccinated. Only 35.7% of 18- to 64-year-olds received influenza vaccination in the 2012-2013 season, and only 47% of those in this age group with high-risk conditions were immunized.
We in public health have to absorb the changes that we see coming while striving to better protect those at risk from this deadly disease.
California Department of Public Health. Influenza (flu). Available at: cdph.ca.gov/HealthInfo/discond/Pages/Influenza(Flu).aspx.
CDC. Available at: cdc.gov/flu/fluvaxview/coverage-1213estimates.htm. Accessed Feb. 28, 2014.
CDC. Available at: cdc.gov/flu/fluvaxview/nifs-estimates-nov2013.htm. Accessed Feb. 28, 2014.
NACCHO. Available at: naccho.org/topics/infrastructure/lhdbudget/upload/Survey-Findings-Brief-8-13-13-3.pdf. Accessed Feb. 28, 2014.
Whitley M. J Public Health Management Practice. 2013;19:220-223.
Matthew Zahn, MD, is medical director for the Epidemiology and Assessment Program of the Orange County Health Care Agency. He can be reached at the Orange County Health Care Agency, 1719 W. 17th St., Santa Ana, CA 92706.
Disclosure: Zahn reports no relevant financial disclosures.