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UniversalInfluenzaVaccinationRecommendations:Local Health Department Perspectives
Geoffrey R. Swain and James Ransom
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odern vaccines—including influenza vaccine—providea uniquely powerful and cost-effective way to preventdeadly communicable diseases from spreading.Unfortunately, since the last decade of the 20th century,influenza vaccine supply and distribution problems have steadilygrown worse in the United States. Supply disruptions such asdelayed deliveries or shortages have occurred in 5 of the last 6years, hindering efforts to combat a disease that every year killsabout 36,000 people and sends more than 200,000 to hospital.Universal influenza recommendations may be one means ofresolving our nation’s recurring influenza vaccine supply anddistribution crises.
KEY WORDS:
influenza, local health departments, universalvaccination, vaccine distribution, vaccine supply
During the influenza vaccine shortage of 2004–2005,local, state, and federal governmental public healthagencies and vaccine manufacturers collaborated inan unprecedented effort to share vaccine distributioninformation.
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This effort was an important step, butwe need to go further. As a nation, we should move to-ward a clear recommendation for an annual influenzavaccinationforeveryoneaged6monthsandolder.Uni-versal influenza vaccination would decrease the num- ber and severity of influenza cases, save lives, andlessentheimpactofinfluenzaonthehealthcaresystemand economy.
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By increasing demand, universal vac-cination would be expected to build production anddistribution capacity.Universalvaccinationwouldnotendthevagariesof vaccine strain production based on egg-based technol-ogy because there are many variables in this equation(eg, production, manufacturing, distribution, adminis-tration of vaccines, market forces).
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However, it is es-sential that we address each variable and make every
J Public Health Management Practice 
, 2006, 12(4), 317–320
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2006 Lippincott Williams & Wilkins, Inc.
efforttogettothepointwherethepromiseofinfluenzavaccinecanbemadegoodonininterpandemicperiods,andwherewecouldvaccinateeveryone,quickly,intheevent of an influenza pandemic.If well accepted, a universal vaccination recommen-dation would provide more stability for vaccine man-ufacturers, thereby significantly reducing annual fluc-tuations in demand on the basis of how many casesof influenza-like illness appear early in the season.This stability for manufacturers would likely result in bothhigherandmorestablesuppliesofvaccine,whichwould in turn minimize the confusion of yearly, andsometimes mid-season, changes in recommendationsthat public health leaders must make because suppliesare currently so difficult to predict. Additional bene-fits would result from the extensive public educationthat will be needed to achieve universal vaccination.People will better understand how vaccines work andwhyprotectingthemselveswithannualinfluenzashotswillalsohelpprotectpeopletowhomtheymightunin-tentionally transmit the virus—their families, friends,clients, and coworkers.Our current system produces mixed messages—encouraging everyone to get an annual influenza shot, but having complex risk-based recommendations thatshiftwithsupplyforecasts.Thisarticlewilldiscussper-spectivesoflocalhealthdepartments(LHDs),sinceper-spectives of private practitioners have been discussedand detailed elsewhere.
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Minimizing future influenza vaccine supplydisruptions—both for interpandemic influenza andfor pandemic preparedness—is crucial to public
Corresponding author: James Ransom, MPH, National Association of County andCity Health Officials, 1100 17th St NW, Second Floor, Washington, DC 20036(e-mail: jransom@naccho.org).
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Geoffrey R. Swain, MD, MPH,
Associate Medical Director, City of Milwaukee HealthDepartment, and Center Scientist, Center for Urban Population Health, Milwaukee,Wisconsin; and Associate Professor, Department of Family Medicine, University ofWisconsin School of Medicine and Public Health, Madison, Wisconsin.
James Ransom, MPH,
Senior Analyst, Immunization Project, National Association ofCounty and City Health Officials, Washington, DC.
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Journal of Public Health Management and Practice
health’s mission. However, the manufacturing anddistribution of influenza vaccine is controlled by theprivate sector. Even though the public sector accountsfor a best-guess estimate of 15 percent of all dosespurchased and administered,
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local public health isexpected to be responsible for local mass vaccinationin the event of a pandemic. At the same time, localpublic health has no solid support from state andfederal agencies for assuring adequate vaccine supply.In addition, the nation does not have adequate publicsector infrastructure for adult immunizations, and thisgap cripples LHDs’ efforts to develop organizationalcapacity and infrastructure to vaccinate hard-to-reachhigh-priority adults and their contacts annually. Thisdiffers tremendously from the childhood vaccinationplatform,wheregovernmentalpublichealthpurchasesa bulk quantity of those childhood doses through thevaccines for children (VFC) program.
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Local Public Health Department Perspective
The National Association of County and City HealthOfficials (NACCHO) surveys LHDs every influenzaseason.Collectively,LHDsarenotsatisfiedwithfederaleffortstowardaddressingthechronicinfluenzavaccinesupply crises.
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Understanding the reasons for frus-trations at the local level is fundamental to planningan effective strategy toward implementing universalrecommendations.Many LHDs are concerned that the federal govern-ment and vaccine manufacturers are failing to keep acloseeyeonthethreatfromcontinuedinfluenzavaccinesupply disruptions. In response to years of influenzavaccine supply disruptions, many communities havedeveloped their own reallocation and sharing schemestobetterredistributescarcedosesofvaccine.
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Thesuc-cesses of these activities have resulted from strategiccommunity partnerships formed between LHDs, pri-vate healthcare providers, nursing homes and otherlong-term-care facilities, hospitals, community healthcenters,pharmacies,andotherentitiesthatprovideim-munizationservicestothecommunity.However,LHDsfacilitate vaccine reallocation among these providersusing20th-centurytools.Theydeterminewhohashowmanydosesofvaccinebymakingphonecallsandtheyrecordtheresultsonsimplespreadsheets.Eventually,intheeventofaninfluenzapandemic,wewillneedasafe,sturdy, and reliable 21st-century system to confront it.
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The VFC helps families by providing free vaccines to doctorswho serve eligible children and is administered at the nationallevel by the CDC through the National Immunization Program.The CDC contracts with vaccine manufacturers to buy vaccinesat reduced rates.
Routine use of state electronic vaccination databaseswould be a natural starting point to include adultimmunizations.Regarding emergency preparedness in general,LHDsareanincreasinglyimportantpartofournationalsecurity and readiness interests. But to the extent thatpublic health preparedness includes the ability to de-ployeitherpreexposureorpostexposuremassvaccina-tion,theendresultisthatthelinchpinofourreadinessisinthehandsofprivatecompanies,whoseprimarymis-sion is not to protect the public’s health but to improveshareholder value. It is imperative to take every op-portunitytosolidifysuppliesandimprovedistributionchannels of influenza and other life-saving vaccines.This may take a multipronged approach that could in-clude increased public-private partnerships, targetedgovernemental regulation, secondary vaccine markets,federal purchase of additional doses, and last—not theleast—increasing demand through a universal recom-mendation for influenza vaccine.
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Case Study: Milwaukee
Many LHDs have historically provided substantial di-rect service delivery of influenza vaccine administra-tion.Morerecently,someoftheseLHDs,liketheCityof MilwaukeeHealthDepartment(MHD),havepartneredwith local mass vaccinators to provide most influenzavaccine in their communities. In Milwaukee, the MHDhaspartneredwiththelocalVisitingNurseAssociation(VNA), and the VNA holds a large number of publicinfluenza vaccine clinics at multiple sites distributedthroughout the area. The MHD helps assure that sitesserving underserved populations are included in theVNA’sclinicschedule,andhelpstheVNAadvertiseitsclinicdates,times,andlocations.TheMHD’sroleindi-rect influenza vaccine administration has thus recently been limited to vaccine for high-priority homeboundindividuals (for whom MHD nurses make home visitsto provide vaccine), and some influenza vaccine provi-sion for individuals presenting to the MHD’s routinechildhood immunization clinics.WhiletheMHDhasinvestedsubstantialenergyandresourcesinpreparednessissuesingeneralandinpan-demicpreparednessspecifically,ithasnotyet—assomeother LHDs have done
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—used annual influenza vac-cine administration as a vehicle to test and exercise itspandemic-scale mass vaccination capabilities.
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The NACCHO Influenza Vaccine Reallocation Database is anonline collection of voluntary vaccine reallocation plans to helppublichealthagenciesandtheircommunitypartnersshareinfor-mation on influenza vaccine supplies. This database is a collec-tion of critical local contingency plans that can help direct other jurisdictions in their efforts to prepare for supply disruptions.
 
Universal Influenza Vaccination Recommendations
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The move from being a mass provider of influenzavaccine to partnering with a community-based agency(VNA, in Milwaukee’s case) for provision of influenzavaccine was a local policy decision. A substantialchange in recommendations regarding who shouldreceive influenza vaccine (ie, a universal recommen-dation) would spur the MHD to review that policydecision. The MHD would need to discuss the advan-tages and disadvantages of wading back into the massvaccinator role. The pros include potentially improvedemergencypreparedness;theconsincludequestionsof whether government should take over what the pri-vate sector seems to be doing well, and questions of what services the MHD would
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provide as a resultof investing staff resources into substantially increasedinfluenza vaccine administration.However,thisdoesnotargueagainstauniversalrec-ommendation. In fact, universal recommendation ornot, optimal emergency preparedness as it relates tomass vaccination may require LHDs such as the MHDto strengthen their partnerships with private entities,community-based vaccinators such as the VNA, andothers. The fundamental issue at the moment is sup-ply: it does very little good for the MHD to be pre-pared, either alone or in partnership, to vaccinate theentire 600,000-person population of Milwaukee if theamount of vaccine supply available is nowhere nearthat required to do it. To the extent that a universal rec-ommendation would stimulate increased productioncapacity and thus stabilize and optimize supply of in-fluenza vaccine during interpandemic periods, capac-ityandsupplywouldalsobelikelygreaterintheeventof a pandemic. Thus, a universal recommendation— by increasing supply—would also support the MHD’sotherpreparednesseffortsandpartnershipstobemoreeffective when needed.
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Benefits, Implementation Issues,and Other Options
Auniversalrecommendationforinfluenzavaccinecan-not be quickly or easily implemented. Although in-fluenza vaccination is quite cost-effective, finance andreimbursement questions would need to be workedout. Strengthened public-private partnerships would be needed to assure that adequate resources are avail-able for vaccination. A great deal of public educationwouldalsoberequired.Thegeneralpublicwouldneedtounderstandthattheriskfactorshavenotgoneaway;certain people would still be at greater risk of compli-cations and/or death from influenza, and it would re-maintruethatthosehighest-riskpersonswouldstillbefirst priority in the event of a vaccine shortage duringinterpandemic periods.However,ifthegeneralpubliccangrasptheconceptsstated above and simultaneously understand that eachperson is a potential influenza transmitter, and that thehealth of 
all
of us, in this case, depends in large part onthehealthof 
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ofus,thenwewillhavemadesubstan-tialstridesinincreasingandsolidifyingthedemandforinfluenzavaccine,whichwillinturnprovidemanufac-turers with what they need to increase and solidify thesupply.There are some other alternatives to increase supplyandimprovedistribution,someofwhichcouldbeusedeither separately from or in conjunction with a univer-sal recommendation. For example, the CDC could actasavaccinedistributorforstateandlocalhealthdepart-ments, and for others in the private sector as well. Inthis scenario, the CDC could order a guaranteed num- ber of vaccine doses from each available manufacturer,and LHDs and others would order vaccine from theCDC at a pooled price. In addition to providing stabledemandtosupportastablesupply,ifonemanufacturerexperienced difficulties in production, no LHD would be caught without vaccine, since the CDC would stillhave supply from the others. In effect, the CDC couldfunction as the clearinghouse at the national level thatLHDs frequently serve now locally.Furthermore, it may make sense to initiate demon-stration projects in several geographic areas. Particu-larly for interpandemic influenza, it makes intuitivesense that higher levels of vaccine uptake will resultinhigherlevelsof“herdimmunity,”andthuslowerat-tackratesevenamongtheunvaccinated.ThedatafromMilwaukeetwodecadesagoshowthisclearlytobetruefor measles attack rates and measles-mumps-rubellavaccine completion rates.
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Influenza might not be-have in the same way; specific demonstration projectsshowing universal vaccination associated with lowerinfluenza attack rates among the unvaccinated mayhelp to provide the data needed to support a uni-versalinfluenzavaccinationrecommendation—anditsimplementation—nationwide.
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Conclusions
Universalinfluenzarecommendationspresentnewob-stacles and new opportunities for overcoming danger-ouslimitationsinour currentinfluenzavaccinesupplyand distribution situation. These limitations, thoughadmittedly not entirely or directly caused by low sup-ply, have forced LHDs to experiment with novel waysto connect their communities with life-saving vaccine.However, reactive responses such as improvised ra-tioning do not necessarily equate with effective plan-ning.Futuresuccesswilldependontheirabilitytohaveadequateandreliablesuppliesofinfluenzavaccine,and
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