Flu Shot Priorities

Related articles

This article appeared November 9, 2005 in the Washington Times.

If our public health authorities really want to make a dent in the toll of flu and pneumonia -- more than 60,000 dead each and every year -- we should stop fooling ourselves. Business as usual means trying to get seniors and the chronically ill (and their care-givers) vaccinated against influenza annually, and against the pneumococcus (a microbe implicated as often causing pneumonia) every seven years or so. Well, that approach hasn't worked.

Flu still kills more than 30,000 Americans every year, mainly among the elderly and sick. Pneumonia takes another 30,000 plus. We should try something new, and evidence exists to support the new plan's efficacy in saving lives: Vaccinate schoolchildren and toddlers against these infectious diseases in addition to the older target group.

The idea of vaccinating one population to rescue another will strike some as counterintuitive -- and may even seem unethical, in an era when groundless scare stories have made many people paranoid about vaccinations. Yet vaccinating the young against flu and pneumonia may be the best way to save the lives of the elderly who might come into contact with them.

The basic dilemma is this: While the elderly, not the young, are likeliest to die from flu or pneumonia, it is the young for whom flu and pneumonia vaccination programs are most effective. Few elderly people seek out the pneumonia vaccine, while the flu vaccine has little protective power, even for the 60 percent of elderly patients who actually get a shot. The best hope for our older population, then, is to prevent flu and pneumonia in the children with whom they come in contact.

We already have some statistical evidence that the plan makes sense: Vaccinating schoolchildren against influenza ("the flu") in Japan in the 1970s and '80s dramatically reduced influenza illness and death among older Japanese. This was due to reduced exposure to sick children among older relatives who lived in the same household (see my letter in the September 26, 2005 Archives of Internal Medicine, "Vaccinate schoolchildren to reduce influenza toll").

And a recent report in the Journal of the American Medical Association (JAMA) indicates vaccinating infants and toddlers against a group of pneumonia-causing bacteria has unintentionally reduced the toll of "invasive pneumococcal disease" (IPD) among older Americans as well (the vaccine is called PCV-7; the serious diseases caused by the pneumococcus are pneumonia, bacteremia, and meningitis).

The study was supervised by a multicenter group of physicians, the Active Bacterial Core Surveillance Network. Researchers studied patients from eight U.S. geographical regions with a more than 18 million people. They evaluated IPD incidence in 1998-9 and compared it to 2002-3. (The PCV-7 vaccine was licensed for use in infants and toddlers in March 2000.)

In those over age 50, tpneumococcal pneumonia, bacteremia (bloodstream infection), and meningitis were found to have declined a whopping 28 percent (and the IPD reduction in the target child population -- those under 5 -- was an even more dramatic 75 percent).

The reduction in IPD in the older group was noted to have begun in 2001, the year after the childhood vaccine was introduced. The effect was more pronounced each year thereafter through 2002-3.

Even more impressive: There was a 55 percent decline within that subset of all expected IPD cases specifically associated with the seven variants of pneumococcus in the vaccine.

While there is a "pneumonia vaccine" aimed at older adults, the proportion of seniors who receive this vaccine is minuscule, compared to the at-risk target group.

The flu vaccine -- like all the recommended children's vaccines -- is safe, so vaccinating them to prevent what is an annoyance for them but a lifesaver for their grandparents is quite appropriate. The CDC now recommends a parallel course: pushing booster shots against pertussis (whooping cough) for adults, in whom the disease is relatively benign, to prevent lethal contagion in infants.

Let's focus on a serious problem we should confront here and now: I propose our public health authorities -- the Centers for Disease Control, the National Institutes of Health and the Department of Health and Human Services -- consider endorsing universal vaccination of schoolchildren, and perhaps toddlers too, against both flu and pneumococcus. This is very likely to dramatically reduce the deadly toll of these diseases in older Americans.