AAFP, ACIP, AAP Recommend Massive Expansion of Influenza Vaccine Coverage

The AAFP, together with the CDC's Advisory Committee on Immunization Practices, or ACIP, and the American Academy of Pediatrics, or AAP, recently moved one step closer to realizing a joint goal of universal immunization against seasonal influenza. On March 13, AAFP Board Chair Rick Kellerman, M.D., of Wichita, Kan., gave an official thumbs-up to a recommendation from the three groups that calls for expanding annual influenza immunizations to include all children ages 6 months to 18 years beginning no later than the 2009-2010 influenza season.

The provisional recommendation, (1-page PDF; About PDFs) which is expected to receive CDC approval this summer, was published on the CDC Web site on March 25.

According to a statement about the recommendation posted on the AAFP's Immunization Resources Web page, the move is part of an "overall framework" for expanding influenza immunization. That framework calls for providing annual influenza immunizations to all school-aged children "as soon as feasible, but no later than the 2009-2010 season." Household contacts of these children would be added by 2010-2011, with 2012-2013 ushering in "universal vaccination."

According to the AAFP statement, the incidence of influenza infection is highest among children ages 5 to 14 years, accounting for between five and seven of every 100 outpatient visits and between 10 and 30 of every 100 episodes of illness in this age group.

"Vaccine effectiveness is quite high," says the AAFP statement, "and there may be indirect protective effects (herd immunity)" associated with more extensive immunization coverage.

The Academy's statement also notes that expectations for coverage among the targeted populations would be low for the "first few years," given the challenges associated with such an ambitious increase. In fact, alternate immunization sites should be considered "as the medical home may not have the capacity to immunize this group."

Interestingly, a survey the AAFP fielded in 2006 asked members specifically to identify "acceptable sites to administer influenza vaccine." "Physician office" was the most commonly cited response (98.6 percent of respondents). Other top-ranking sites were

"Work site," "retail health clinic (e.g. MinuteClinic, RediClinic)" and "school" also ranked fairly high in the mix, coming in at 62.1 percent, 62.0 percent and 58.3 percent, respectively. "Pharmacy" garnered a 44.3 percent ranking; "other retail location (e.g. grocery store, department store)" was cited by only 26.5 percent of respondents.

Jonathan Temte, M.D., Ph.D., of Madison, Wis., one of two AAFP liaisons to the ACIP, says that although the Academy concurred with expanding the vaccine recommendation, both he and a representative from the AAP expressed reservations during the committee's February meeting, when some ACIP members pressed for a 2008-2009 implementation timeline. According to Temte, both the Academy and the AAP advocated "a doctrine of 'fair warning'" for clinicians, allowing them sufficient time to prepare for the change.

Temte says his primary concerns about the proposed accelerated timeline for implementing this ambitious change were threefold. First, many family medicine practices have already preordered vaccine for the 2008-2009 influenza season. How much additional vaccine will be available, given that vaccine manufacturers use those prebooking figures as a foundation on which to base their overall supply projections, has yet to be determined. FPs who are thinking about implementing the new recommendation for the 2008-2009 season would be wise to check with their vaccine suppliers soon about ordering more vaccine.

Second, as announced earlier this year by the World Health Organization and the FDA's Vaccines and Related Biological Products Advisory Committee, the influenza vaccine for the 2008-2009 season will contain three entirely new antigens, a situation Temte terms "unprecedented" and one that he says could heighten the risk of vaccine shortages or delays.

Finally, according to Temte, "the new recommendation calls for 76 million children to be vaccinated," a jump of 40 million from what's currently recommended. "There is no good guidance as to how this should be accomplished," he notes.

Even so, says the AAFP statement, "An expanded recommendation for universal coverage from age 6 months through 18 years is a worthwhile change. Such a recommendation will simplify influenza vaccine delivery.

"The proposed implementation starting with provision of 'no later than 2009-2010' is appreciated, thus allowing family physicians to gear up to vaccinate this widened population. As a result, continued educational initiatives to support more widespread immunization are necessary."