Feb 24, 2010 (CIDRAP News) – In the wake of the H1N1 influenza pandemic, the US Advisory Committee on Immunization Practices (ACIP) today took the long-discussed step of recommending seasonal flu immunizations for nearly everyone, leaving out only small babies.
The step extends the recommendation to all adults for the first time. Previous ACIP recommendations for seasonal flu immunization covered about 85% of the population but excepted healthy adults aged 19 to 49 who are not close contacts of people at risk for serious flu complications. Babies younger than 6 months are also excluded, as vaccination is considered too risky for them.
The new recommendation, which passed on a 12-0 vote with one abstention, was prompted in part by factors related to the H1N1 pandemic, including its impact on younger adults, the recognition of obesity as a possible risk factor for severe disease, and disproportionate effects on minority groups. The pandemic virus will be included in the 2010-11 seasonal vaccine.
A universal recommendation will simplify and clarify the government's advice about flu immunization, ACIP members said in voicing support for the move today. The group's meeting was streamed over the Web.
In a news release after the meeting, the Centers for Disease Control and Prevention (CDC) said, "Many people in currently recommended 'higher risk' groups are unaware of their risk factor or that they are recommended for vaccination. The ACIP discussion also recognized the practicality and value of issuing a simple and clear message regarding the importance of influenza vaccination in the hopes that this would remove impediments to vaccination and expand coverage."
Today's vote completes a series of steps the ACIP has taken over the years to extend flu vaccine recommendations to more of the population. The last big change came with the 2008-09 flu season, when the panel recommended immunization for all school-age children.
Dr. Anthony Fiore of the CDC's Influenza Division reported to the committee the findings of a CDC working group that recommended moving to universal flu immunization.
"We estimate only about 15% of the population does not have an indication for vaccination at this point," he said.
About half of adults between ages 19 and 49 already have an indication for vaccination, because of pregnancy or having close contact with risk groups, such as children under 5, adults with chronic health conditions, and older adults, Fiore said.
Universal vaccination has been discussed by the ACIP for years. The decision to bring it up again now, he said, was sparked by developments during the H1N1 pandemic, including:
- About 87% of hospitalizations and deaths occurred in people younger than 65, including many in the 19-49-year-old group.
- H1N1 triggered unprecedented demand for both the H1N1 and seasonal vaccines.
- H1N1-like viruses are likely to continue circulating during the next flu season.
Another factor that helped drive the move was the finding that a disproportionate number of those severely affected by H1N1 were obese, Fiore reported. He said one unpublished analysis found obesity to be an independent risk factor for severe illness, and 34% of the population is obese (including 5% who are morbidly obese).
Still another factor supporting universal vaccination is the increased impact of H1N1 on minority groups, he said. African-Americans and Hispanics have had higher hospitalization rates, while American Indians and Alaska natives had fourfold higher mortality, compared with other groups.
Fiore said the working group looked at several options, including adding new risk factor indications or making a "provisional" universal immunization recommendation as a trial for this season. Everyone favored moving to the universal recommendation, with the main issue being whether to adopt it immediately or phase it in, he reported.
The working group decided to suggest two options: to recommend vaccination of all adults for the 2010-11 season, or to recommend "annual vaccination of all adults starting in September or as soon as vaccine is available, but no later than the 2011-12 season," he said.
Those who supported immediate adoption said H1N1 will continue to circulate and hit young adults, and they were concerned that a phased approach might cause confusion and would fail to take advantage of new immunization approaches tried during the pandemic, Fiore said.
Those views were echoed during the ensuing ACIP discussion, in which most members expressed support for going to full adoption immediately.
"We've been practicing creeping staging of this for the past 15 years," said member Dr. Franklyn N. Judson, MD, of the Colorado School of Public Health. He said the number of manufacturers has increased, making vaccine supply less of a concern than in the past.
Also, he said, "It's more difficult and costly to sort out the 15% for whom it's not recommended than to just go ahead and order it for everybody."
Kris Ehresmann, immunization director for the Minnesota Department of Health, commented, "I think in an ideal world we'd be looking at implementing a universal vaccination recommendation while we already had an infrastructure in place for an adult vaccination program, but we don't live in an ideal world, so we should move forward in the absence of that."
Susan Lett, MD, MPH, of the Massachusetts Department of Public Health, said most immunization program managers favor a phased approach and feel that immediate full adoption will be burdensome for the public sector. She commented that vaccine orders for next fall have already been prebooked.
Janet Englund, MD, of Children's Hospital and Regional Medical Center in Seattle, said she favored a phased approach because of likely administrative and logistical problems. When the recommendation to vaccinate school-age children was made, pediatricians welcomed the fact that it was phased in, she said.
Dr. Dale Morse, a former ACIP member who is now a liaison representative from the Council of State and Territorial Epidemiologists, said he voted against a move to universal recommendation about 4 years ago, when the proposal failed on a 7-8 vote, because he felt the plan hadn't been adequately studied. But he said the case for it has since been made and has now been strengthened by the pandemic experience.
Referring to all those now targeted for vaccination, Morse added, "When you added all these groups together, you covered almost everybody anyway, so why not go for the gold?"
The discussion ended with a 12-0 vote in favor of immediately recommending universal vaccination, with Englund abstaining. The vote was greeted by a round of applause form the crowded meeting room.