"Influenza & Pneumococcal Vaccines for Adults" Press Conference
Webcast on ConnectLive.com Networks
Wednesday, October 25, 1999 at 10:00 a.m. EDT

[Note: Ellipses (...) indicate inaudible words.]

DR. WILLIAM MARTONE: Good morning. Members of the press, distinguished faculty, and friends. I'm Dr. Bill Martone, the Senior Executive Director of the National Foundation for Infectious Diseases, or NFID. On behalf of NFID and the National Coalition for Adult Immunization, let me welcome you to this year's influenza and pneumococcal disease press conference. Today we're bringing important and urgent health messages about these deadly diseases and ways you can protect yourself.

Let me introduce you to this morning's moderator for the conference, Dr. Steven Mostow. Dr. Mostow is a member of the NFID Board of Directors, and he is Director and Associate Dean for Outreach at the University of Colorado Health Sciences Center. Dr. Mostow.

DR. STEVEN MOSTOW: Good morning, everyone. Thank you for coming. Influenza is such an important disease. I fell in love with this virus in 1966, when I was at the Centers for Disease Control, and it continues to be an incredibly important disease for the United States, and a disease that we can control by working together with you, with physicians, nurses, and the press is very important in getting the message to the people who are most at risk. And this year, of course, that's very, very important.

I'll be moderating the questions and answers at the end. And I will first begin by introducing a man who has done so much for the United States, Dr. David Satcher, the Surgeon General of the United States. And I do want to put in a plug for Case Western Reserve University. We went to the same med school. Dr. Satcher.

DR. DAVID SATCHER: Thank you very much, Dr. Mostow, and good morning. Each year just prior to the influenza and pneumococcal season I look forward to this opportunity to try to remind the American people how far we've come in our ability to ward off these potentially deadly microorganisms. And I think the reason I look forward to it is because I realize that despite our tremendous scientific advances, we're not at the place where we can prevent the spread of every infectious disease, but we can do something about flu and pneumonia.

Fortunately, effective vaccines exist that allow us to protect ourselves against influenza and pneumococcal disease. And these vaccines are the best tools to prevent unnecessary, severe illness and death among the elderly and among people who are chronically ill. Unfortunately, too many adults are missing valuable opportunities to prevent the spread of flu and pneumonia by not getting immunized. As a result, 20,000 Americans die unnecessarily from influenza each year, and 12,500 die needlessly from pneumococcal disease. So, as you can see, combined these two diseases are responsible for 32,000 deaths.

Joining me here today to stress the importance of getting influenza and pneumococcal vaccines, along with the National Foundation for Infectious Diseases, we have the National Coalition for Adult Immunization, we have the Centers for Disease Control and Prevention, the Health Care Financing Administration, the American College of Physicians and the American Society of Internal Medicine, and the National Medical Association. We've gathered to ask the nation's physicians, nurses, and other healthcare providers to make sure that those who are most at risk for influenza disease are immunized first this year.

Because of delays in production of the influenza vaccine, this time we have to be more strategic in our distribution. So we're urging that through the month of November, healthcare providers focus first on immunizing the elderly and the chronically ill and women who will be in their second or third trimester of pregnancy during the flu season -- those groups who are most at risk. And certainly those healthcare workers who work in institutions where they take care of those most at risk should also be immunized in order to protect themselves but also to protect those that have highest risk.

We expect to administer flu vaccines to high-risk populations and the healthcare workers who care for them by the end of November. After that we'll encourage other persons -- we refer to them as "healthy" persons, the low-risk persons -- to get their flu shots. And I think if we can get people immunized by the end of December we will be in great shape for everybody.

We do not anticipate a shortage of vaccines. This year's supply should be approximately equal to what was distributed last year, but it is true that a substantial amount of vaccines will merely reach providers later than usual. Based on information provided by manufacturers, we anticipate about 75 million doses of vaccines, of flu vaccine. And last year we netted about 74 million doses, so we don't anticipate a shortage compared to last year.

Whereas in the past, most vaccine doses usually became available to providers by October, with 99 percent of distributed doses available before December. This year we expect to distribute some 18 million doses to healthy individuals awaiting vaccines by December. The degree of delay will vary for individual providers. We urge high-risk persons to remain patient but persistent with their healthcare providers to obtain their annual flu vaccines when it becomes available. I think persistence is important here. We want people to be patient on the one hand but we also want them to be persistent. It's important to get the immunization.

The degree of delay will certainly vary for individual providers, and therefore it is important to keep that in mind. CDC is working with individual states and the vaccine manufacturers and the healthcare system to help providers obtain vaccines for high-risk persons. You will hear more about that.

Just a word about the pneumococcal vaccine. Because we're very concerned that with so many people in this country over 65 are still not receiving the pneumococcal vaccine, and most of them only need to receive it once. Yet the data that we have, as you'll hear later, suggests that we can do much better. We do not foresee any delays in pneumococcal vaccine this year, and we recommend that everyone, especially these same, high-risk individuals, also get the one-time vaccination against pneumococcal disease early in the season, if they haven't already done so. Even in cases where the influenza vaccine is not yet available, we recommend getting a pneumococcal vaccination. But let me stress that it's not a substitute for the influenza vaccination, and the patients need to return for the influenza vaccine when it is available if it's not available when they first seek it.

Now, with that said, let me introduce some of the members of this outstanding panel. This press conference is a great opportunity to underscore and to review recent CDC recommendations prioritizing flu and pneumococcal vaccinations for the year. And Dr. Keiji Fukuda from the CDC will explain these recommendations in greater detail in a few moments. But now I'd like to introduce Dr. Kristin Nichol from the VA Medical Center in Minneapolis. Dr. Nichol, who has joined us before, is an expert in infectious diseases, particularly influenza and pneumococcal diseases, and she is a member of the CDC's Advisory Council on Immunization Practices, ACIP. She will give you background on these diseases and explain in greater detail who is considered high risk for these diseases and will need priority vaccinations. Dr. Nichol.

DR. KRISTIN NICHOL: Thank you and good morning. Influenza is one of the great plagues of humankind -- at least that's the way I think about it. Each year about 10 to 20 percent of the population becomes ill with influenza. The typical case creates substantial misery as the victim suffers through the sudden onset of fever, sore throat, dry cough, muscle aches, malaise and headaches. Symptoms last, on average, five to six days, but one-fifth of people with influenza may have symptoms that last ten days or longer.

The implication for society can be significant, and include increases in school and work absenteeism, healthcare use and even mortality rate. Even though most people with influenza recover uneventfully, the final toll of influenza in terms of illness, social disruption and lives lost is often much greater than might initially be appreciated. Each year influenza is responsible for about 20,000 excess deaths, more than 100,000 excess hospitalizations, and billions of dollars in healthcare cost. Influenza, together with pneumonia, remains the sixth leading cause of death in the United States. Influenza causes more deaths each year than any other single vaccine-preventable disease in this country.

Now, influenza affects all segments of society, but it is the elderly and others with chronic medical conditions that are particularly susceptible to the serious complications of influenza. Examples of these serious complications include secondary bacterial pneumonia, exacerbation of underlying chronic medical conditions such as chronic heart or lung disease, and death. About 90 percent of the excess deaths from influenza each year occur among the elderly, and nearly half of the excess hospitalizations occur among the elderly.

The flu is truly bad news for those who become ill and experience its complications. Again, to reiterate, those groups at highest risk for the serious complications from influenza include the following groups: all persons ages 65 years and older; residents of nursing homes and other long-term care facilities; children and adults who have chronic heart or lung conditions; children and adults who require regular medical care for other serious medical conditions such as diabetes, kidney disease, hemoglobinopathies or suppression of their immune system; children and adolescents aged six months to 18 years who receive long?term aspirin therapy; and women who will be in the second or third trimester of pregnancy during the flu season.

Vaccination remains the mainstay of efforts to reduce the impact of influenza, and may provide health benefits to anyone age six months and older who wishes to avoid illness. Vaccination activities, however, should ensure as a priority that persons in the high-risk groups I've mentioned, as well as the healthcare workers who care for them, are targeted for vaccination, especially this year with delays in vaccine availability. Because at least one of the three viral strains contained in the influenza vaccine usually change each year, we closely recommend vaccination annually.

Fortunately we have safe and effective vaccines to help fight the flu. Currently licensed influenza vaccines are inactivated virus vaccines -- that is, they contain killed virus particles. And while fever, malaise, and other systemic symptoms can occur following vaccination, especially among young children who previously have not had exposure to the influenza virus antigens, research studies both in healthy, younger adult populations as well as in elderly populations have demonstrated convincingly that systemic symptoms such as fever, malaise and headache occur otherwise at similar rates whether or not the participants received the vaccine or inactive placebo injections. Vaccine recipients are, however, more likely to have soreness or swelling in their arm at the injection site, but these kinds of local symptoms are almost always mild or moderate and infrequently interfere with daily activities. We simply do not and cannot get the flu from a flu shot. This is an important message for our high-risk patients, especially this year.

The benefits of vaccination are impressive. Among community-dwelling elderly, for example, vaccination can reduce the risk of hospitalization for pneumonia by 30 to 70 percent, and the risk of death by about 50 percent. Among nursing-home residents vaccination is 50 percent to 60 percent effective in preventing hospitalization pneumonia, and about 80 percent effective in preventing death. Vaccination may also be cost saving, at least among the elderly.

Influenza is a bad disease and influenza vaccine is a good vaccine. Our current immunization rates are too low. It is so important that healthcare providers and their patients work together to assure that the benefits of this vaccination are realized by those who need it most.

Now, many of the high-risk groups for the serious complications of influenza are also the high-risk groups for serious pneumococcal disease. Whenever flu shots are given, it is an important opportunity to review the pneumococcal vaccination status of the vaccine recipient as well. Pneumococcal disease is caused by the bacterium streptococcus pneumonae. It is the leading cause of illness in children and adults worldwide. In this country, pneumococcal disease accounts for an estimated 150,000 to 500,000 cases of pneumonia, 50,000 cases of bacteremia or bloodstream infections, 3,000 cases of meningitis, and millions of cases of otitis media. Every year pneumococcal disease causes about 12,000 deaths among hospitalized patients. Most of these deaths occur among the elderly and others who have underlying medical conditions.

The high-risk groups for pneumococcal disease include the following: again, persons ages 65 years of age and older; all children ages 2 months to 23 months -- this is in the recommendation; children and adults who have chronic medical conditions such as heart disease, lung disease, diabetes, kidney disease or liver disease; children and adults who have a suppressed immune system due to cancer or other disease, or who have functional or anatomic asplenia. In addition, children and adults who are members of certain racial and ethnic groups, and persons who live in special environments, and children who live in daycare centers, are also potentially at high risk.

As is the case with influenza, for pneumococcal disease we have safe and effective vaccines that represent the mainstay of effort to prevent and control serious pneumococcal disease. This is particularly in an era of increasing resistance of the bacteria to the antibiotics most commonly used to treat pneumococcal infections. Pneumococcal vaccinations can be given any time of year. However, because of the timing of influenza vaccination activities, we especially like to target people for pneumococcal vaccinations at the same time.

Currently there are two vaccines available for the prevention of pneumococcal disease -- the polysaccharide vaccine for adults and children ages five years and older, and the relatively newly licensed conjugate vaccine for use in children 2 months to 59 months of age. Vaccination with a polysaccharide vaccine in adults has shown to be especially effective in preventing bacteremia, and may even be cost saving among the elderly. Among young children, the conjugate vaccine has also been shown to be highly effective in reducing not only invasive pneumococcal disease but also pneumonia and even otitis media.

Clearly, influenza and pneumococcal diseases are responsible for a substantial and yet largely preventable burden of disease illness and death in this country. Despite our having safe and effective vaccines, vaccination rates remain too low. Physicians, other healthcare providers, high-risk patients and their families should all renew their effort to make sure that these vaccines are used to preserve and protect the health of all high-risk persons. Tens of thousands of lives are at stake. Thank you.

And now I would like to introduce Dr. Keiji Fukuda, who is the chief of the Epidemiology Section for the Influenza branch at the Centers for Disease Control and Prevention in Atlanta.

DR. KEIJI FUKUDA: Good morning. I think I want to start off by emphasizing on really the two main points that were brought up by Dr. Satcher and by Dr. Nichol. And these really are the most important points, I think, to take home.

The first thing is that influenza is a really very significant disease which has a major public health impact on the United States. Both Dr. Satcher and Dr. Nichol gave you the numbers -- an average of 20,000 deaths and over 110,000 hospitalizations a year. These are enormous numbers.

The second, and perhaps even more important message, is that this is something that we can do something about. Because of this vaccine supply situation, there has been a lot of attention paid on how we vaccinate people this year. But it's important to realize, for example, among one of the high-risk groups, the elderly, vaccinating a million elderly people prevents, on average, 900 deaths and 1,300 hospitalizations. Again, these are enormous numbers. This is something that we can really do something about, and that lends urgency to this season.

Now, it is an unusual year, and it's unusual because of the vaccine delay. As Dr. Satcher mentioned, this is a year in which we will have enough vaccine. We'll have as much vaccine about as last year, but vaccine is going to be coming out a little bit slower than it has in previous years. We're going to see substantial amounts of vaccine coming out in October, in November and December. And because of that situation, I want to point out that there has been a great deal of work done both by the manufacturing community, different medical groups, and the public health community to figure out what are we going to do with this situation? How do we handle this?

One of the things that has been done is that on September 28th, the Advisory Community on Immunization Practices had a special meeting, and the results of that meeting are published in the MMWR on October 6th. And there are some updated recommendations for the country this year, and that's what I want to talk about specifically.

In going over the specific recommendation, I want to point out again that the overall concern, the overall basis for all these recommendation, is to try to get vaccine to the people that are at highest risk both for dying and from other serious complications like hospitalization.

The first recommendation is that when vaccine is available, efforts should be focused on getting vaccine into those people that are at high risk and the healthcare workers that take care of them. And the reason why we highlight the healthcare workers also is that this is a group of people that takes care of high-risk people at a time when the high-risk people are particularly vulnerable.

I also want to point out, among these high-risk groups, it is very important to get them vaccinated early, and I'm talking particularly about young children. Young children are a group of kids or people who often need to get vaccinated twice to have a response to vaccine. In young children under nine, many of them have to get vaccinated two times separated by at least a month, again, lending urgency to get that group of kids vaccinated. And these are kids who have diseases such as asthma.

Now, the second main recommendation is that mass vaccine campaigns ought to take place later than usual. And in practice what we're talking about, really, is November and December. And they ought to take place at a time when the vaccines clearly know that they are going to be receiving vaccines. And again, the reason for that recommendation is so that there are few vaccine campaigns that are canceled because they don't have vaccines.

Now, the third main recommendation is that in December there ought to be special efforts to vaccinate people who are in the age group of 50 to 64 years, including people in that age group who are at low risk for complications of influenza. So again, in December trying to vaccinate that group of people who are 50 to 64-year-olds, all of them.

The fourth main recommendation -- and this is one which I think is particularly important -- is that vaccination efforts really need to continue longer than many people frequently do, and they ought to continue into December and later, as long as influenza vaccine is available. And let me explain this recommendation and put it in context.

Now, normally the optimal time to vaccinate people against influenza is between October and mid-November, but what's clear is that after mid-November a lot of people who are at high risk from complications don't get vaccinated. There's no reason not to continue vaccinating that group of people and every reason to keep vaccinating that group of people. This is especially true this year when we know that there's going to be a delay, and much of the vaccine which is going to be available is going to be rolling out in November and December. So that's a key message to take home, and I think it's key behavior change that physicians need to begin adopting.

And I want to point out that this recommendation really is supported by the previous experience. When we've gone back and looked at surveillance data from the past 18 years, we've seen that in the previous, in 14 of those 18 years, influenza activity has peaked after December. That is either in January or February or March. So vaccinating after November really is going to confer substantial protection to a great number of people.

The fifth main recommendation is that when the person comes in to get vaccinated for influenza, this is really an excellent time to review their pneumococcal vaccine status. Dr. Nichol discussed pneumococcal infections and their impact on the country and the availability of pneumococcal vaccines. And she also pointed out that many of the people that are at high risk for influenza are also at high risk for pneumococcal diseases. And so, I want to highlight particularly the elderly and those people with chronic medical conditions. But again, this is an excellent time to review their pneumococcal vaccine status. And even if you don't have influenza vaccine to provide, if you have the pneumococcal vaccine, go ahead and give it.

Now, in addition to those recommendations, I want to just point out that there have been additional steps taken to deal with the situation.

The first one is that there really have been tremendous increased efforts by state health departments, by medical groups and others really to get the message out to high-risk groups. I think there's clearly stepped-up activity across the country.

A second thing which has been done is that CDC has gone ahead to contract an additional 9 million doses of vaccine from one manufacturer, and these doses will be available in December. And the purpose of that is to make sure that if there are high-risk groups that haven't been able to get vaccine, that there will be vaccine available for them.

A third step which has been taken is that the National Immunization program at CDC has gone ahead to set up a Web site. And what this Web site will do, it will allow people who are looking for vaccine to find vaccine, if that is a way to facilitate that.

And then, finally, there have been stepped-up educational efforts at CDC, and these include things such as the development of information brochures. And I think that pretty soon you'll be seeing intensive efforts to reach certain communities of high-risk people, particularly those among African-Americans and Hispanic population, as well as the general population.

So I think that I'll stop there and introduce the next speaker who is Dr. Bonnie Word. Bonnie is both a pediatrician and an infectious disease specialist. She is here representing the National Medical Association, and she's also a member of the Advisory Committee on Immunization Practices, and I want to point out that she's chairman of the Working Group on Influenza.

DR. BONNIE WORD: Good morning. Why in the year 2000 are we still seeing reports about racial and ethnic disparity among influenza and pneumococcal vaccine recipients? A lot of you, inside of your folders that you received, have copies of the CDC's surveillance that in terms of what is the immunization rate in U.S. citizens here? That's inside of your copy. A lot of the earlier discussions focused on the need and the importance of having pneumococcal and influenza vaccines. My question is as we go through that, you're beginning to see there are some disparities and that's what I'm here specifically, I'd like to address with you.

As I said, why are we still here about it in the year 2000? More disturbing is that that disparity exists, even in those patients 65 years of age or older, who have at least five or more physician contacts in one year -- a number identical to their highly vaccinated white counterparts. So, clearly, the lack of medical contact was not a major issue in that situation.

So I should probably tell you how significant are the disparities? Well, first, if we take a look at influenza, in adults 65 years of age or older, 61 percent of whites but only 40 percent of blacks and 50 percent of Hispanics reported receipt of influenza vaccine. Even in those adults between 50 and 64 years of age who are known to have at least one chronic medical condition, disparity still was evident. Thirty percent of whites received influenza vaccine compared to 25 percent of blacks. The only age groups in which there was no disparity between the racial groups or ethnic groups was in the young adults, between 18 and 23 years of age.

Although immunization rates for pneumococcal vaccine overall are much lower when compared to influenza, white respondents were still more likely to report receipt of vaccine. Thirty-six percent of whites at least 65 years of age and older compared to 22 percent of blacks and 23 percent of Hispanics in the same age group actually received pneumococcal vaccination. When we look at the individuals between 50 and 64 years of age, who again have some known chronic medical illness, we see the vaccinations are reported in 21 percent of white individuals and only 12 percent in the blacks, and 19 percent of the Hispanics. Again, vaccine receipt was similar in all groups in the 18 to 24-year-old age range.

What are some of the more probable rationale for these continued disparities? Are they influenced by one's socioeconomic status, level of education, or even access to medical care? Based on the most recent study that you have in your packet, whites were still more likely to have received vaccines or been immunized even if those variables were looked at -- specifically at all levels -- all poverty levels, all levels of education, as well as the number of contacts that individuals reported having with the healthcare provider, whites still were noticed to have higher vaccination rates than other racial and ethnic minorities. Large disparities between blacks and whites were even observed by persons living above the poverty level, and those individuals who had greater than a high-school education, and in those individuals who had more than five visits with a physician in one year.

Well, another thought is that one might actually question if optimal medical care is provided to all patients. And I say this because, just to recall, that even when racial and ethnic minority individuals have the same number of physician encounters, this disparity persisted.

There was another study done in New York City among physicians who work predominantly with black or Hispanic populations, and they noticed that these physicians were less likely to recommend pneumococcal or influenza vaccine to their patients, compared to those physicians who had a predominantly white population that they were serving. In that same report essentially minority populations were only recommended influenza vaccine 47 percent of the time compared to 74 percent of the time in their caucasian counterparts. Pneumococcal vaccine was recommended 27 percent of the time to minority individuals where it was recommended 54 percent of the time to whites. Although this study was published in the late '80s, some of the information or the data we're seeing tells us this still exists today. There is a differential.

Another aspect is, is there a lack of awareness of the benefits of vaccination by the general population as well as lack of education of healthcare providers who either are unaware or choose not to follow adult immunization guidelines? In 1996 there was a national Medicare survey and it revealed that the most frequent response that was elicited from individuals of why they didn't receive these vaccines were, "I didn't know I needed it." That's the number-one response." That response was noted in greater than 50 percent of individuals who failed to receive pneumococcal vaccine and in 19 percent of those who failed to receive influenza vaccine. Another 13 percent of the individuals stated they didn't receive the pneumococcal vaccine because their doctor didn't tell them they needed it.

Another factor for this disparity may be that there's unnecessary fears and misconceptions regarding vaccine safety and efficacy as perceived by some minority populations. Or actually it can also be perceived by the general population, too, because as we've heard overall, immunization rates are low.

In that same Medicare study, in dealing with individuals greater than 65, 39 percent of participants in that study stated they thought that receipt of the influenza vaccine could give them influenza, it wouldn't keep them from getting influenza, or it had a lot of bad side effects. Additional focus groups that have been conducted by some of the governmental agencies has suggested in particular with some of the minority patients that, again, they don't think they're going to get as sick with it, it's for older people. And sometimes you have some seniors who don't quite identify themselves as seniors even though they're at that age, but it's for the other people. And actually one comment that someone shared with me was that they're religious and God will take care of them type of thing. So we still have that element.

And there are several other additional possibilities that serve as potential barriers to adult immunization. Although they are not unique in terms of being the cause of the disparity of ethnic and racial groups, I think they still play a part in it. One is that adult immunization has not been perceived as a preventive health measure. Second, in contrast with childhood immunization, indications for adult immunization are more selective, and each vaccine may have a different target group. Basically, the concept of adult immunization is just not existent. All of us -- I think most of us who have children in here -- you know what childhood immunizations are; you know what it means. Most people, their concept of adult immunizations, routine adult immunization, it just doesn't exist yet. Unlike the other thing, unlike childhood immunization, there are no statutory requirements for adult immunization. How many of you have ever tried to get your child in school? You know that you must have immunization. Well, there's nothing comparable in the adult population.

Another area is missed opportunity by healthcare workers. This is evident, if you look at the higher levels of influenza vaccine that were administered within most individuals across the board compared to pneumococcal vaccine. In addition, if you look at some of your high-risk individuals -- and this is in your packet that you have, the CDC report -- you'll see that individuals who had a number of physician encounters, even if they were high risk, if you can reflect things into the number of or the higher percentage of those individuals having received pneumococcal vaccine, so there is a missed opportunity.

So now we say what type of strategies can be implemented to reduce or abate racial and ethnic disparities? The National Medical Association continues to recommend that adult immunization practices be incorporated as standard of care by all physicians. The NMA is working on a variety of projects with the CDC and other governmental agencies to increase immunization rates among minority adults, and these include the following.

One, there's a physician educational program entitled "Immunization: A Family Affair." And the goal of this program is to develop a national physician and healthcare professional education and information program on adult immunization. The basic premise is to increase the knowledge base and to promote the use of immunizations as a preventive health measure for African-American adults. This is going to be done by conducting at least eleven education programs throughout the year 2000. If anybody wants to know the cities, I'll tell you later on, but that will just take up some time right now. It's only eleven, but it's eleven more than there were last year.

The NMA has also developed a brochure to coincide with this called "It's a Family Affair." And what that brochure does, it tries to emphasize the importance and the principle of raising the immunization rates not only among adults but among children and adolescents. And the point is that if you can get them all involved, if you bring in the whole community, it also emphasizes that vaccines are an important part of preventive healthcare, and it's one of the most important things that you can do to keep your family happy. So this way it's not just childhood immunization but it's family immunization, and so that's where the thrust will be.

In collaboration with the CDC, the Adult Vaccine-Preventable Diseases branch, the NMA will conduct four focus groups and distribute a survey to its member physicians to assess their knowledge and attitude and practices regarding influenza pneumococcal vaccination. Based on the results of the survey, a multifaceted intervention approach will be developed.

Many strategies that have previously been suggested and implemented for the population at large, such as provider reminder recall systems or client reminder recall systems, have proven to be successful -- however, in only one segment of the population. The time has come for the process to be consumer driven. As stated in the NMA consensus paper, the need for extensive information, education and trust concerning vaccines within racial communities is clear. It is fundamental to the success of any vaccine program. And the educated consumer will request preventive care, even when the care provider fails to offer it.

Vaccine information must be disseminated where target populations gather information such as in the workplace, places of worship, TV, news publications, and radio programming whose primary listening or reading audiences are racial and ethnic minorities. Vaccine information shall also illustrate the diverse population it is targeting. People will no longer believe that this disease does not affect people who look like them. The high-risk ratio on ethnic minority population must be able to comprehend that the message to vaccinate is all-inclusive, and not solely directed to the non-Hispanic, white community.

So I think I've said enough here, but I guess the last thing I'll just probably add in is to say the time has come for the consumer to be proactive, and that's one of the things we'd like to tell many people in these two communities. So, without going on, I'd like to introduce Dr. Sandra Fryhofer. And Dr. Fryhofer is the president of the American College of Physicians and she's going to speak to you about some other interventions that they are targeting towards physicians.

DR. SANDRA ADAMSON FRYHOFER: Thank you, Bonnie, and good morning. I'm Dr. Sandra Adamson Fryhofer, president of the American College of Physicians, American Society of Internal Medicine, the nation's largest medical specialty society, representing over 115,000 doctors of internal medicine and medical students throughout the country. Doctors of internal medicine are doctors for adults, and we provide the majority of primary care to adult men and adult women in this country.

The American College of Physicians and the American Society of Internal Medicine supports the recommendations you've heard today from the CDC. We are urging all physicians to priority vaccinate high-risk people now, and this is not only with the influenza vaccine but also with the pneumonia shot, and wait until December to vaccinate other healthy individuals. And again, the high-risk patients include the elderly, those greater than 65 years of age, adults and children that have chronic medical conditions like asthma, diabetes, heart problems, patients that have immune system problems, and pregnant women who will be in their second and third trimester during the flu season, and in addition, healthcare workers and other volunteers and family members who work and live around these high-risk individuals.

Now, when these recommendations came out on October 6th in the MMWR, we immediately alerted our members. As internists or doctors for adults, the American College of Physicians is committed to leadership in protecting our patients from vaccine-preventable disease. And I'm proud to announce today is the kickoff of a three-year initiative to increase and improve rates of adult immunization in internal medicine practices.

Our program has three main components. We are publishing the fourth edition of "Guide for Immunization," which for 15 years has been a trusted handbook that tells you exactly who to vaccinate and when. And we're going to distribute this book not only to physicians but also to the managed-care companies so they'll know what vaccinations our adults need in order to stay healthy.

We're also developing a tool kit to help our physician members incorporate these guidelines into their practices and to help our physicians integrate immunization into their office management system. And again, we're going to continue to advocate for reimbursement rates from insurers to increase the chances that our adults can get the immunizations that they need.

Now, additional information about our program is available on the table outside this room, and I encourage each of you to make sure you pick up one of the handouts. Again, the American College of Physicians, American Society of Internet Medicine, is proud to support the issue of adult immunization and to take positive steps to see that immunization is fully integrated into internal medicine practices.

Well, today we've heard about how important it is to get not only the flu shot with an pneumonia shot, we've heard about the therapies and the groups that are getting it and not getting it. We've heard who needs it now -- the high-risk people you vaccinate now; wait till December to vaccinate the healthy individuals -- and now we're going to hear about how we're going to pay for it. [Laughter] I'd like to introduce Dr. Jeff Kang who is Chief Clinical Officer for HCFA.

DR. JEFFREY KANG: Thank you very much, Sandra. My name is Dr. Jeffrey Kang. I am the Chief Clinical Officer for the Health Care Financing Administration which runs both the Medicare and Medicaid program. I'm also a geriatrician by training.

Most of what has been said I don't want to repeat. The Medicare and Medicaid program, though, is doing a tremendous amount to promote the utilization of flu shots and pneumococcal shots in both its populations, and there's material in your press kits as to what we're doing. What I would like to do though is take this opportunity to leave four key messages for the Medicare beneficiary.

Number one, flu shots and pneumococcal shots are a covered Medicare benefit and also a covered Medicaid benefit. We actually are covering them fully so there is no coinsurance or copayment for either of those vaccinations.

Number two, as you heard from the previous presenters, among the high-risk patients are disabled beneficiaries and elderly beneficiaries. Well, Medicare, as the program for the disabled and the elderly, as a health insurance program, that means that all Medicare beneficiaries -- and I mean all Medicare beneficiaries -- are at high risk and should get their flu and pneumococcal shots.

Number three, as you heard, there will be enough vaccine, and so what I would like to tell all Medicare beneficiaries is get your vaccine as soon as possible. Please do not be discouraged by what you may or may not have heard in the news. And, as a certain general has said, the watchword here is be patient and persistent.

And then the last point, the number-four point that I would like to make for Medicare beneficiaries, is that as you heard from Dr. Fukuda, the flu season typically peaks in January, February or March, which means that flu shots given as late as December are overwhelmingly likely to be effective. So, again, the code word here, or the watchword, is be patient and persistent.

Thank you very much. And on that note, maybe I should turn it over for questions and answers.

DR. STEVEN MOSTOW: Thank you. We are going to now have a question-and-answer period, and I will be screening the questions that are coming in on the Internet. By the way, this is on the Internet live as we speak. And I also want you to know that although some of our presenters do have to leave at 11:00 for other commitments, some of us will be very happy to stay and answer questions until you're tired of asking them. [Chuckles] So let me call on you in the back there. Yes, ma'am.

WOMAN: ... issue. Why is it that it seems that many large supermarket chains and other people are getting the flu vaccine before doctors ... and Medicare and Medicaid patients? Why is that and what are you doing to address that?

DR. STEVEN MOSTOW: The question is, so that those of you who couldn't hear it, is why are some of the supermarket chains and some of the nursing providers using vaccines sort of ahead of the game, perhaps not specifically targeting high-risk people? Let me toss that to you, Keiji.

DR. KEIJI FUKUDA: This is a question which has come up a lot over the last week or two. I think there's a couple of important things to point out. One is that the distribution of vaccine in the country, it really goes to the private industry or the private sector. You know, very little of the vaccine is handled by the government directly. And in most years this system works really well. You know, vaccine goes to distributors, it goes to end users, and it gets to high-risk people. This is an unusual year, and so I think there's been a lot of highlighted concern. And I think it's not clear in all instances why in some places large supermarket chains have gotten vaccine ahead of physicians and so on. And I don't think we also know the extent of that in the country. But I think in some instances it probably is tied to things such as that some of the larger corporations tend to order vaccine earlier, and because they've ordered it earlier they're on the delivery schedule earlier.

But I think the most important thing really to take home with that, because this is an unusual year, both providers and patients probably have to be a little bit more flexible about finding vaccines. So, if a supermarket chain has an influenza vaccine and your physician doesn't have it, then it makes all the sense in the world to go to where the vaccine is. This may not be what you do in a usual year, but this may be the year where you have to do something a little bit out of the ordinary. So, anyway, those are some points.

DR. STEVEN MOSTOW: Let me just elaborate on that one second. As you may know, supermarkets vaccine programs began about 17 years ago, 16 or 17 years ago, and initially physician groups were very anti this, thinking that the nursing groups were quote/unquote "stealing" their patients. But, in fact, it's raised awareness about influenza and pneumococcal disease. And, in fact, in the state of Colorado, which I represent, more than 1.3 million people got vaccine in supermarkets last year -- I'm sorry, in physician offices -- whereas ten years ago it was about 100,000. So, awareness was the deal. And even though there are going to be some groups that don't follow the guidelines to the tee, I think the idea here is to make people aware so that can go get their shot wherever they can find it.

MAN: I have a question for Dr. Satcher or maybe Dr. Fryhofer. What are you telling physicians to do then? If ... come your office and you have ... and someone who is one of your patients comes in who is not in the high-risk category and says, "Dr. I want a flu shot."

DR. STEVEN MOSTOW: That is an excellent question. The question is, the president of the bank of Norwest or whatever, Wells Fargo, comes in and says, "Darn it, I want my vaccine. I've got a $3 million deal in Chicago in two weeks and I don't want to have the flu." Dr. Satcher, I hope ...

DR. DAVID SATCHER: [Inaudible response; laughter, joking.]

DR. SANDRA FRYHOFER: Well, if a healthy individual comes into your office requesting a flu shot in October or November, just say, "No, you have to wait, and come back in December. Right now, in October and November, we've got to focus on the high-risk people. The healthy individuals are just going to have to wait their turn." It comes up.

DR. STEVEN MOSTOW: And it comes up every day, and physicians have to share in the responsibility. But they're really on the front line this year. This is the first year they've actually had to tell people no. Usually they're begging people to take the vaccine. This is the first year we've had to say wait, and that's an unusual position.

DR. SANDRA FRYHOFER: The concern is that some of the physicians offices don't have vaccine now to give to all their high-risk patients. And again, we have to encourage them to go where the vaccine is, read the paper. I'm sure these supermarkets that have the vaccine are going to advertise so they get people in those doors to buy their stuff. And if they can get a free shot and pick up their medicine, more power to them. Our goal here is to get these high-risk people vaccinated so we can keep this country healthy.

DR. DAVID SATCHER: One quick thing. I agree with the answer, but as Surgeon General I just want to say it's not just the no answer; it's also "Yes, we need you to help us with this public health issue." And I believe the American people understand the importance of taking care of our high-risk population, like their mothers and grandmothers. And also the fact that this is how we protect the ... By immunizing the high-risk people first, we actually protect a lot of other people who will not get the flu because it won't spread as fast. So, in addition to saying no, we're also calling upon people to continue to participate in a public health strategy in this country that can really work for the best of all of us in the long run. So it's both no and yes.

DR. STEVEN MOSTOW: Kristin wants to make a comment. Dr. Nichol.

DR. KRISTIN NICHOL: Thank you. I think in this regard that it's quite likely we will see a variety of strategies employed by practitioners and other healthcare organizations. And one strategy that I certainly encourage providers and organizations to take is to educate their patients and to encourage low-risk people voluntarily to wait until December, and to emphasize that it is the high-risk people that we want to prioritize for immunization first. I am certainly hopeful that voluntary waiting on the part of low-risk people will be effective in many settings so that we aren't faced with the need to actually say no.

Of course, the influenza vaccine has benefits to offer just about everyone. It's not a matter of it not being a good thing for a healthy, non-high-risk person; it's a matter of relative priorities who should get the vaccine first. So I think encouraging voluntary waiting is certainly a strategy that we hope will be effective.

DR. STEVEN MOSTOW: Yes, sir. Can you tell us who you represent?

PAUL REACH: Paul Reach with the AP. What do your epidemiologists say about the effect of delaying the availability, or the fact that the vaccine is late, or the people that normally get their vaccinations October and have to wait? What is the effect going to be on the rate of flu and on the period of time that it peaks?

DR. STEVEN MOSTOW: That's an excellent question. The question is, so that those in the audience can understand it, will this affect the way flu is spread through our country, and I think that's a great question for the Centers for Disease Control. So, Dr. Fukuda.

DR. KEIJI FUKUDA: Yeah, that is a good question. I want to point out that we vaccinate people primarily to prevent them from dying, from getting serious illnesses, and we don't really vaccinate people with the attempt of trying to mold the influenza season or trying to delay its onset or anything like that.

So I think the -- I mean, we don't know what [effect] the delay will have. It's the vast odds are that it's not going to -- we're going to be able to get vaccine into people before the influenza season really kicks into high gear. But that's something that the past seasons are telling us. Of course, we can't predict exactly what's going to happen for this coming season. But again, when you look in the past, it really looks like that if you get vaccine into people in November and December, we're going to be able to get it into them in in time for before-peak activity hits the country.

PAUL REACH: Okay. If it's not going to have any effect, as you now indicate, then why in previous years -- and I'm sure you plan in future years -- everybody gets shot in October? There is a reason that you've started in October, and the fact that you're not starting in October is bound to have an ... effect, and I'm asking you what that is.

DR. KEIJI FUKUDA: See, we recommend getting vaccinated between October and mid-November because that gives us the best chance of avoiding a lot of people getting sick from the flu. There are years in which influenza activity begins early and peaks early. It happens much less frequently than influenza peaking in later months, but it does happen. And because of that possibility and because we're so focused on trying to reduce illness in the country, that's why we recommend trying to get people vaccinated on the October to mid-November period. But again, this year, because of the delay in the recognition that the vaccine is going to be rolling out, and the fact that in most years activity peaks after December, we think that we have a pretty good chance of preventing a lot of illness by continuing the vaccine.

PAUL REACH: But it's a gamble. You're gambling.

DR. KEIJI FUKUDA: Sure. Everything's a gamble.

DR. DAVID SATCHER: We're not denying the fact that we have a problem here. We have a problem in that there's a delay in distribution of the vaccine this year, and I think this is how this discussion started. So we are responding to the fact that we have a problem. We would love to be able to distribute this vaccine and to immunize people as rapidly as possible, starting as early as possible. So we began this discussion by saying we have a problem; how are we going to deal with the problem? And with 14 out of the last 18 years the influenza epidemic has peaked after January, so it's a good gamble in terms of what we had witnessed in the past. So we don't expect -- the key word is "expect" -- we don't expect that this delay will have a major impact on the epidemic. But we don't have expertise in predicting exactly what's going to happen in any given year. We can only say what's happened in most years.

DR. STEVEN MOSTOW: The lovely thing about this virus, if there's something lovely, it's completely unpredictable. And so there is no way any of us can look into a crystal ball and say this will be a mild year, this will be a bad year, this will be an early year, this will be a late year. You just have to see what the virus will do. There is no way to predict it, so we have to do what we know we can do, and that is we have to immunize when vaccine is available.

We have an alternate strategy in the medical community, and that is we have four antiviral medications. So, in fact, if people start having influenza before vaccine is available, we can actually treat them or prevent from happening by putting people on these medicines. This is much more expensive. It is not a national strategy. But physicians in private practice, in university practice and HMOs, know how to take care of this should we have this problem. Yes, sir.

MAN: Jeff ... It goes back to the supermarket issue and the corporation issue. Has the federal government contacted these large buyers and done anything either voluntary or has been contemplating some kind of regulation or regulatory to try to keep them from taking away most of the vaccines for high-risk people? If the physicians are going to be told to just say no, is anyone telling the supermarkets just to say no?

DR. DAVID SATCHER: As Dr. Fukuda ... I think our charges in terms of communication has been primarily with health providers -- physicians, nurses -- and I believe most of the supermarket programs are run in coordination with healthcare providers -- Visiting Nurses Association and others. So we would hope that even in those settings the message about the need to prioritize the vaccine will be effective. But don't get me wrong. We're talking to all Americans, and that includes supermarkets and others, so that they will do everything they can to cooperate with this strategy. But it is true that our major target communication today has been with the healthcare providers and that's true ... And I'm going to have to leave ...

DR. STEVEN MOSTOW: Dr. Satcher, thank you very much for participating.

DR. KEIJI FUKUDA: Just to follow up on Dr. Satcher's remarks. I think we just need to recognize that the distribution and the use of vaccine in the country is a private enterprise by and large. And so what we have done is that we have made recommendations to the country; that it really is a volunteer effort. We do not go out there and tell people what they have to do. We recommend what we think is a reasonable thing to do to prevent these illnesses and these deaths, but it is a voluntary effort. But in that voluntary effort there has been a tremendous effort to get the message out to the entire country.

MAN: Then that's essentially a parallel thing, the big companies from buying up all the ...

DR. KEIJI FUKUDA: Yes. Again, we do not control that. We don't tell people what to do. We recommend what we think is the best thing to do.

DR. STEVEN MOSTOW: The truth of the matter is, that percentage of vaccine is relatively small when you look at 75 million doses for our country. It's a relatively small percentage that gets done in grocery stores. Most vaccine gets done in public health clinics, private physician offices, county health clinics, etc. That's where the majority of the vaccine is going.

We're going to have to close this conference officially. But as I mentioned, many of us are willing to stay, but the official closure is now. It's closed. [Laughter] But many of us are going to stay and answer questions if you have additional questions. Thank you very much, and I want to particularly thank NFID and the National Coalition and these organizations for collaborating in bringing this program.

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