Implementation of Recommendations for Influenza Control

A symposium, "Options for the Control of Influenza," was organized by CDC and held April 20-25, 1985, in Keystone, Colorado, as part of the 1985 University of California, Los Angeles, Symposia series. The program included a roundtable discussion to consider ways to improve influenza control measures in several populations.* This article summarizes the major viewpoints emerging from that discussion and includes suggestions for expanding the use of influenza vaccine. TARGET GROUPS

Among the topics discussed were improving implementation of the current U.S. Public Health Service (PHS) Immunization Practices Advisory Committee (ACIP) recommendations for prevention and control of influenza among persons in the high-priority groups for annual vaccination (1) and broadening those recommendations to include persons not currently included in the ACIP's high-priority groups.

Children. Morbidity rates during influenza epidemics are often highest among children; children also are believed to have an important role in disseminating infection. Therefore, annual immunization of children who are household contacts of high-risk persons was suggested. For this suggestion to be implemented effectively, cooperation between pediatricians and other physicians providing care for families with high-risk persons must be encouraged. The high-risk groups should be expanded to include children with reactive airway disease.

Healthy Adults. With improved community surveillance and application of rapid diagnostic methods, offering vaccine to healthy adults when an influenza epidemic begins could lessen the impact of the epidemic.

Outbreaks may last 6-8 weeks in an average community. Vaccine may be administered when influenza-like illness is first identified. In addition, during type A epidemics, amantadine can be given to provide protection during the 2-week postvaccination period before effective antibody levels have developed. The following groups of healthy adults should be given special consideration as vaccine candidates during epidemics:

1. Household contacts of high-risk children or adults.

2. Persons who provide essential community services or whose absence from work would have greater than normal consequences for the individual or employer.

3. Pregnant women whose third trimester coincides with the influenza season. Except for data from pandemic years, data suggesting an increased risk of influenza-related complications in pregnant women is primarily anecdotal. However, immunizing women who are in their third trimester during an influenza epidemic may provide antenatal protection to the mother and the fetus. Passive transfer of maternal antibody might also protect neonates born during or shortly before an influenza epidemic.

4. Resident students at schools or colleges. Based on experience with military recruits, large-scale influenza immunization of student populations could potentially reduce the impact of outbreaks of disease in these large groups of young adults (2). Noninstitutionalized High-Risk Adults. The high immunization

levels recommended by the ACIP will require a sustained vigorous effort. Systematic immunization programs can be incorporated into routine care of high-risk adults. Many high-risk persons could be vaccinated when they encounter health-care providers during the late fall or early winter. High-risk persons who do not require routine follow-up during the year should have special appointments made for the purpose of influenza immunization. Review of patients' immunization status should be routine when patients schedule visits. A uniform adult immunization record card could be developed to provide the patient, physician, and office staff with immediate information about immunization status. The card could be used to document that a patient was offered vaccine at the appropriate time of year. High-risk patients could indicate by signature if they elect not to receive vaccine. This latter practice would reinforce the importance attached to routine immunizations.

Institutionalized High-Risk Adults. Most nursing homes organize programs for annual immunizations, but many of these programs could be improved to reach the ACIP's objective of an 80% vaccination rate. Guidelines could be developed to assist such institutions in implementing immunization programs. Certain mandatory requirements, including the following, could also be considered:

1. An approved immunization program for residents and staff as a requirement for licensure of the institution.

2. An approved immunization program as a requirement for the institution to be eligible for Medicare reimbursement.

3. An influenza immunization policy established as a standard of medical practice by the American Medical Association or other group. In many nursing homes, separate, signed consent for influenza

immunization is required. These requirements pose a barrier to immunization of institutionalized adults. The barrier could be removed if permission for annual influenza immunization were obtained when the resident is admitted to the home. Educational materials suitable for staff, residents, and family members are needed. OTHER ISSUES

Research Needs. Additional data are needed to: (1) define the level of immunization necessary to prevent influenza outbreaks through the establishment of "herd immunity"; (2) understand the basis of diminished immune response to, and efficacy of, vaccine in the elderly; (3) monitor the immune status of high-risk persons who are revaccinated annually; and (4) document the costs and benefits of immunization in different groups.

Antiviral Chemotherapy and Chemoprophylaxis. In addition to specific recommendations for using amantadine in therapy and prophylaxis, particularly for high-risk persons (1), amantadine was recommended for all members of households with high-risk persons once a suspected index case of influenza A infection occurs. Improved rapid diagnostic tests would facilitate implementation of this recommendation. The frequency and significance of amantadine-resistant strains should also be evaluated.

Vaccination Costs and Liability. Three complex issues affecting implementation of immunization recommendations were recognized: (1) detection and compensation for vaccine-associated reactions; (2) relative benefits of health-care resources used for prevention of disease, compared with treatment of illness; and (3) current discrepancy between Medicare reimbursement for pneumococcal vaccine and influenza vaccine. Reported by C Wilfert, MD, Duke University School of Medicine, Durham, North Carolina; Influenza Br, Div of Viral Diseases, Center for Infectious Diseases, CDC.

Editorial Note

Editorial Note: Influenza epidemics are generally unpredictable in their frequency and severity but normally are associated with increased hospitalizations and mortality among the elderly and persons with certain chronic illnesses (3). For example, surveillance during 1984-1985, when influenza A(H3N2) viruses predominated, demonstrated the highest mortality since 1975-1976, a situation that could not have been anticipated in advance of the epidemic. Over 80% of excess mortality occurs among persons 65 years and older.

The ACIP strongly recommends annual immunization of high-risk persons with inactivated influenza vaccine as the most important way to reduce the impact of influenza. Despite these recommendations, and the apparent benefits of influenza vaccination programs (4,5), the use of inactivated influenza vaccine by high-risk groups remains low, averaging 20% (6), with 55%-60% of residents in U.S. nursing homes receiving vaccine (7).

The suggestions arising from the Keystone symposium are an extension of existing ACIP recommendations and PHS policies. They were developed to assist persons concerned about the occurrence of severe influenza infections, particularly among high-risk patients. Certain general trends appear in the suggestions:

1. A desire to provide protection for high-risk persons by immunization or amantadine chemoprophylaxis of household contacts, particularly at times of epidemic activity. This approach is an extension of the recent ACIP recommendations that medical personnel caring for high-risk persons should be vaccinated to prevent nosocomial outbreaks and to reduce the opportunity for virus to be introduced into institutions caring for high-risk persons.

2. A need to establish the concept that providing influenza vaccine to high-risk persons is an ongoing responsibility for medical-care personnel, rather than an option.

3. An attempt to eliminate administrative obstacles hindering delivery of vaccine in physician offices, in clinics, and in other institutions. The effectiveness of these suggestions depends on medical

professionals' being convinced that worthwhile reductions in influenza illness and its complications can be achieved, although influenza vaccine does not guarantee protection to each person who receives it.

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