Influenza immunization remains the best defense against the morbidity and mortality associated with influenza infection. National influenza immunization guidelines are in place and are updated annually to identify the groups of individuals that should be vaccinated each year and to provide counsel on how and when vaccine should be administered.1 Despite this specific guidance to clinicians, community immunizers, and public health workers, there is broad-based evidence of influenza vaccine underutilization in all groups for whom vaccination is warranted,2 resulting in potentially preventable illness and complications of influenza (pneumonia, hospitalization, and death).3 One of the contributions to immunization rates that fall far below target levels is a sizable number of missed opportunities throughout the vaccination season (i.e., healthcare visits during which at-risk patients are not vaccinated).
The Centers for Disease Control and Prevention (CDC) and other health experts have slightly differing definitions of the influenza vaccination season. Although administration of influenza vaccine in October and November is traditional, it has become clear that full implementation of CDC recommendations cannot be accomplished if vaccination occurs only in the fall, in advance of the influenza season. The CDC and others advocate broadening the influenza vaccination season, such that patients are immunized even after influenza activity has begun in a community. To maintain consistency throughout this supplement to The American Journal of Medicine, we are using terminology based on CDC influenza recommendations and defining the influenza disease season as October through May and the influenza vaccination season as October into January and beyond.1 This shift in the vaccination timing paradigm requests all healthcare professionals to recognize the value and medical need of vaccines given throughout the season and to vaccinate at-risk patients at every opportunity. In meeting public health vaccination goals, healthcare professionals are also called upon to increase their own influenza immunization rates. Healthcare professionals should view annual influenza vaccine as a professional responsibility for many reasons: it make us positive role models for our patients, it minimizes the likelihood that we will get influenza and be unable to work at a time when the healthcare system needs us most, and it will help us avoid doing harm by infecting patients in our care.
Given the emphasis on influenza immunization in US public health policy, a series of articles on the topic have been published together in this supplement. The subjects discussed in these articles are as follows: missed vaccination opportunities, practice-proven interventions that increase immunization rates, the delicate balance between vaccine supply and demand, and adult immunization barriers.
In the first article, Drs. Gregory A. Poland and David R. Johnson set the stage by discussing the substantial burden of influenza infection on affected individuals, the healthcare system, and society at large. Given the availability of an effective and safe vaccine, the authors then review in some detail the rationale for the current CDC recommendation that at-risk patients be vaccinated throughout the influenza season, beginning when vaccine first becomes available to the time when supply is exhausted. They develop the rationale that vaccination throughout the influenza season is medically relevant and feasible. The authors also present results from a newly released study in which patients at risk for influenza saw a healthcare provider on average 2.2 times between November and February, yet did not receive influenza vaccine. These findings underscore the frequency with which missed vaccination opportunities contribute to suboptimal vaccination levels. With the supply of influenza vaccine now plentiful, efforts must be focused on reducing missed vaccination opportunities such that national target objectives are achieved. Healthcare providers are encouraged to use all opportunities to vaccinate, which now represents best practice.
In the second article, Nurse Practitioner Patricia K. Stinchfield presents a literature-based review of practice-proven interventions that increase influenza immunization rates and extend the vaccination season. In this regard, interventions that increase patient demand and vaccine access and overcome practice-related barriers (e.g., standing orders, reminder and recall efforts, vaccination-only clinics) are discussed. It is suggested that sites select and implement ≥1 intervention that addresses site-specific needs, with choices based on necessary resources and other factors to optimize the reach of vaccination. By way of example, the author provides case studies of practices that deliver influenza vaccine efficiently and effectively to a large proportion of their target patients.
The focus of the third article, coauthored by Dr. Walter A. Orenstein and me, is the delicate balance between vaccine supply and demand and its impact on the realization of influenza immunization goals. The complexities of vaccine production and distribution, and financing are reviewed, with a particular focus on the implications for the provider. With substantial growth in supply expected over the coming years, demand for the influenza vaccine should be increased. A number of strategies are discussed to promote improved vaccine uptake.
In the final article, Dr. Johnson and colleagues present the results of a structured telephone survey, which was conducted to determine the attitudes and knowledge of consumers and healthcare providers about adult vaccines (influenza, pneumococcal, and tetanus). Factors affecting vaccination decisions were assessed. According to the survey responses, immunization rates for adults are much lower than target rates established by national guidelines. Of note, the reasons consumers gave for not receiving vaccinations were not consistent with those given by healthcare providers. The researchers provide us with a sampling of these reasons, which can be used to inform and refine policies to increase immunization rates in adults.
It is the hope of the authors that these articles will help to shape new viewpoints and practices, culminating in the vaccination of all persons at risk for influenza illness and transmission of influenza to others.
Author disclosures
The author of this article has disclosed the following industry relationships:
William Schaffner, MD, serves as a consultant to GlaxoSmithKline, MedImmune, Merck & Co., Novartis, Sanofi Pasteur, Inc., and Wyeth Pharmaceuticals; and is a member of a data safety evaluation committee for experimental vaccines for Merck & Co.
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