Vaccines are extremely important from a public health standpoint. Vaccines and antibiotics together are the major reason life expectancy in the western world has almost doubled in the past 100 years. People, especially young healthy people, just don’t die of infectious diseases anymore. Vaccines are actually a wonderful way of preventing disease - they use the body’s own immune system to fight off disease. How cool is that?

Vaccines cause the body to make antibodies to specific diseases (called immunity) so the body can fight the invaders off before getting sick. In addition, when enough people in the community are vaccinated we get something called herd immunity. That occurs when most people are immune to an illness and there are not enough people to pass the disease around to those who are not immune. So vaccines can even protect those people who are not vaccinated! Therefore, it is very important to vaccinate as many people as possible in a community.

Anything can have adverse affects, including vaccines. All vaccines in use today rarely have adverse effects, especially compared to the benefits. (Of course, if you are the person who has the adverse effect, you may feel differently!) As you can tell by the tone of this article, I am generally a proponent of vaccines. I think they should be made available to everyone, preferably at no cost. The benefits are so tremendous, that no one should be denied the right to have any vaccine available.

This is now the second year that flu vaccine distribution has been chaotic. So, what happened? Last year (2004) there were only 2 companies producing and distributing flu vaccine to the US. One company had some issues with contamination, and their vaccine production was shut down. So we ended up with almost half the expected doses - and mass panic. This year that manufacturer was deemed to be free of contamination, but not until very recently. Hence the delay in shipment of vaccine.

Despite some anxious moments, it looks like there should be plenty of flu vaccine available this season. Unfortunately, vaccine distribution in this country is very dependent on $. Big companies who order lots of doses get first priority, and better rates. When there are plenty of doses for everyone, that may be fine. But if there is a shortage it’s important for those at highest risk to get the vaccine first. The CDC recommended only high risk people get the flu vaccine before 10/24 this year. I find it hard to believe that those giving vaccines at Costco, Giant, or CVS really restricted the vaccine to those who were high risk during that time. As a matter of fact, I know they didn’t, as many of my (non high risk) patients received the vaccine during that time.

I am not the only physician who’s shipment was delayed. The American Academy of Family Physicians solicited comments about this on their bulletin board, as so many physicians complained about not receiving the vaccine. I really don’t understand why physicians aren’t first priority for receiving the flu vaccine. We know who is high risk and who is not. In my office we have received many calls this past month from patients who were very upset that they could not find the vaccine. Many of these people were very high risk and should not be at the mercy of a flawed vaccine distribution system.

While I’m still on my soapbox, I have one more issue I’d like to address. Many physicians aren’t even giving vaccines anymore. That’s because we lose money on almost every vaccine we give. First, we have to buy the vaccine from a distributor or from the manufacturer. (That’s another issue; I actually have to do comparison shopping to find the best rate for vaccines. What a waste of time!) We have to pay for the vaccine when we buy it, and if it expires generally we eat the cost. We have to pay for the syringe, needle, alcohol pads, gauze and bandaids. We have to pay someone to administer the vaccine, then someone to bill the insurance company. Then we wait for a check. Here are some examples of the what I paid (vaccine only) and was reimbursed in 2005:

Chickenpox vaccine: cost of vaccine-$77 reimbursement-$66.82 to $78.86
Hepatitis B vaccine (adult): cost of vaccine-$60 reimbursement-$41.25 to $52
MMR: cost of vaccine-$42.15 reimbursement-$38.05 to $43.64

We also bill for administration of the vaccine, and received anywhere from $0 to $14.40 ($6 on average).

Can you blame some physicians for not administering vaccines?

Several vaccines have recently been approved, and there are a few on the horizon. Following are some of the more important ones you may be hearing about.

Menactra is a new vaccine for meningococcal infection approved for persons aged 11-55. The CDC now recommends routine vaccination of adolescents at ages 11-12, before high school entry, or college freshmen living in dormitories (whichever comes first).

Meningococcal disease is rare, but consequences of infection can be (and often are) devastating. Meningococcal infection can cause meningitis, sepsis (widespread infection in the blood) and other milder illnesses. It is most common in infants under one year, but also peaks in adolescents, who tend to have more serious long term consequences (including death). Prior to Menactra, the American Academy of Pediatrics recommended another vaccine (Menomune) for high-risk children and college freshmen. Unfortunately, immunity with Menomune wanes after 3 years, after which a booster is required. The new Menactra is similarly effective to the older vaccine, but will confer a much longer immunity. At this time the vaccine is too new to know if and when a booster will be required.

Adacel and Boostrix are new diphtheria/tetanus/pertussis vaccines for older children and adults. Pertussis (also known as whooping cough) has been increasing and is at a 40 year high. This is especially true in adolescents and adults, who often are sick and coughing for many weeks. Infants, however, have a high risk of dying from the disease. Infants are most commonly exposed by family members and caregivers. There have even been pertussis outbreaks traced to healthcare workers in doctor’s offices!

All infants receive the pertussis vaccine as part of the DTP at ages 2, 4, 6 and 18 months. Previously the last booster was given prior to kindergarten. After age 7 the risk and side effects of the vaccine were considered too dangerous. These new vaccines are designed for older children and adults, and appear to have a safety profile comparable to the dT (tetanus booster) which is what is usually given.

Adacel is approved for ages 11-64, and Boostrix for ages 10-18. Otherwise there does not appear to be a significant difference between the two. Both are approved for a single dose only, with no recommendations for a booster at this time. Right now adolescents aged 11-12 are being targeted for this vaccine, but it should be considered for anyone who is due for a tetanus booster.

A new vaccine for HPV called Gardasil is expected to be available within the year. High-risk strains of HPV (Human Papilloma Virus) have been shown to cause cervical cancer. This vaccine prevents cervical cancers and pre-cancers in clinical trials. It has also been shown to prevent infection with the virus. This vaccine will initially be given primarily to adolescent girls, since it should be given prior to women becoming sexually active (HPV is sexually transmitted). It is unknown how long it will be effective, but it is expected to last 5-10 years (after which presumably a booster would be given). Whether boys should receive the vaccine is also unknown. Studies are currently being conducted with men also.

We are fortunate to have several new vaccines available to protect us. I hope you all consider these vaccines, especially for adolescents, but also for adults. Finally, I’d like to leave you all with some links to reliable information about vaccines.

www.vaccine.org -- Allied Vaccine Group
http://www.cdc.gov/vaccines/ -- CDC’s National Immunization Program
www.cispimmunize.org -- American Academy of Pediatric’s Immunization info
www.immunize.org -- Immunization Action Coalition
www.vaccineinformation.org
www.immunizationinfo.org -- Nat’l Network for Immunization Info
www.hhs.gov/nvpo -- US gov’t National Vaccine Program Office
www.vaccine.chop.edu -- Vaccine ed at the Children’s Hospital of Philadelphia

To your good health,
Jasmine Moghissi, MD