Get Shots First, Ask Questions Later

By SAM URETSKY

On Feb. 2, the Washington Post published a report, “This flu season’s hospitalizations are highest in nearly a decade.” The same day, the New York Times reported, “Flu Patients Arrive in Droves, and a Hospital Rolls Out the ‘Surge Tent’.“ Based on National Center for Health Statistics (NCHS), mortality surveillance data indicated 9.1% of the deaths occurring during the week ending Jan. 6, (week 1) were due to pneumonia and influenza (P&I). This is above the epidemic threshold of 7.2% for week 1. What this reduces to is that this is a lousy year as far as influenza is concerned. Even then, these statistics may be low, and will probably be adjusted upwards when all the reports are in.

We’ve come to think of the flu as a bad cold. It’s not. Historically there have been pandemics that have killed millions of people. The first, and worst influenza pandemic of the 20th century, in 1918-19, killed between 20 and 100 million people worldwide and about 675,000 in the US. The third, in 1968, killed about 700,000 people worldwide and 34,000 in the US. This year the number of case reports and deaths are similar to those of 2014-2015 when, according to the Centers for Disease Control and Prevention estimates, 34 million Americans got the flu, 710,000 were hospitalized and about 56,000 died.

The decline in mortality reflects steady improvement in both therapeutics and public health. Even so, there is room for improvement. The Jan. 4, 2018, issue of the New England Journal of Medicine featured an essay “Chasing Seasonal Influenza — The Need for a Universal Influenza Vaccine,” written by official of the National Institute of Allergy and Infectious Diseases, (US), World Health Organization (UN), and Peter Doherty Institute for Infection and Immunity (Australia). They discuss the way in which influenza vaccines are formulated each year, because the virus causing illness changes from year to year and so far it hasn’t been possible to create a vaccine that gives long-term immunity.

Beyond that, if the virus changes after the vaccine has been formulated, the effectiveness of the vaccine may be dangerously low. This occurred in Australia this year, when the vaccine was only about 10% effective against circulating virus, and in the US in 2014-2015, when the vaccine had an effectiveness of 13%. The authors suggest improvements that could be made in vaccine preparation.

In the 1980s the tax laws gave special benefits to industries investing in Puerto Rico, and these attracted several pharmaceutical manufacturers, including one that made small volume infusion bags. These are bags of saline or dextrose solution that are used in hospitals to administer intravenous medication. The web site status.pr indicates that the tourism industry focused on San Juan has largely recovered from Hurricane Maria, the rest of the island and the pharmaceutical industry is still struggling, and this has led to a shortage of the small volume intravenous bags. Along with many other intravenous solutions, these solutions are generally essential for administering antibiotics which are needed to treat the pneumonia that may result from influenza.

The American Society of Health System Pharmacists has published a number of suggestions for dealing with the shortage, such as giving drugs orally instead of intravenously, or by intravenous push instead of intravenous drip. Still, the answer lies in increased support for recovery in Puerto Rico. On Jan. 19, ReliefWeb wrote, “Despite the need, Puerto Rico has struggled to secure adequate relief funds from the US government. A billion-dollar loan recently approved by Congress is now being withheld for the time being.”

There have been several studies of the cost effectiveness of influenza vaccine, and while they vary in many regards – should the vaccine be given to everyone or just high risk populations? Which vaccine should be used? How does vaccination compare with treatment with oseltamivir (Tamiflu ®)? In each case, vaccination has been the most economically practical method.

Based on these results it appears to be generally desirable to make influenza vaccine generally available but, perhaps typically, the methods of paying for the shot are highly fragmented. Note that the web site vaccines.gov offers advice for the uninsured: “The Affordable Care Act – the health insurance reform legislation passed by Congress and signed into law by President Obama in March 2010 – requires new health plans to cover preventive services and eliminates cost sharing (such as co-pays and deductibles for certain services). You may be eligible for preventive services including coverage for vaccines.” The advice was written in 2014 and there’s no indication of the last time it was reviewed. It’s unclear whether these requirements still apply under the present administration.

There is no information about Medicaid, and the reasonable concern for the vaccination of undocumented immigrants. Readily available vaccination for everyone, regardless of immigration status, would seem to be the greatest social as well as economic benefit, and a reduction in the number of carriers of infectious disease would be an extra benefit of a universal single-payer healthcare system. Without that, it would be rational to provide influenza vaccine to everybody at least during pandemic years – years when the influenza season is unusually virulent.

On Jan. 26, the New York Times reported, “(the flu epidemic) is now on track to equal or surpass that of the 2014-2015 flu season. In that year, the Centers for Disease Control and Prevention estimates, 34 million Americans got the flu, 710,000 were hospitalized and about 56,000 died.” This would have been a good time to give out the shots and stop asking questions.

Sam Uretsky is a writer and pharmacist living in New York. Email sdu01@outlook.com.

From The Progressive Populist, March 1, 2018

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