Perspectives in Disease Prevention and Health Promotion Allegheny County 1986-87 Influenza Vaccination Program -- Pittsburgh, Pennsylvania

Over the last 10 years, the Allegheny County Health Department has promoted vaccination of all persons considered to be at high risk of complications and death following influenza infection (1). Vaccine coverage for institutionalized high-risk individuals has ranged from a low of 36% for the 1979-80 influenza season to 71% for the 1985-86 season. Until the 1986-87 season, coverage among noninstitutionalized individuals had not been determined.

For the 1986-87 season, the health department set a goal of 60% coverage for all high-risk groups. These groups include the 10,200 persons served by chronic-care facilities and the 210,000 persons who are over 65 years of age but do not require long-term care. The number of high-risk persons below 65 years of age in Allegheny County's general population of 1.4 million is unknown. To accomplish its goal, the health department offered free vaccine and technical support to all physicians, chronic-care facilities, and other medical providers who were willing to administer the vaccine free of charge.

All potential providers of influenza vaccine were sent copies of the recommendations of the Immunization Practices Advisory Committee (ACIP) on prevention and control of influenza (1). Participants received vaccine requisition forms and a supply of information statements on influenza and influenza vaccine, which describe the benefits and risks of influenza vaccination. These information statements are signed by vaccinees or their guardians to acknowledge their having understood the information and their consent to receive vaccine. The statements also provide a telephone number so vaccinees can report any significant illnesses that develop within 28 days after vaccination. These steps help in monitoring adverse events that occur during the influenza season. All providers, community groups, and clinics using influenza vaccine supplied by the health department were required to report on a regular basis the number of doses administered by their organization.

In July 1986, the health department sent promotional and educational materials to all physicians, hospitals, community health centers, senior citizen facilities, and other organizations dealing with high-risk and older persons. Local media were informed and encouraged to publicize the times and locations of the special health department and community clinics. Program staff kept the operating hours and locations of these clinics current so interested persons could be referred to a convenient clinic. The American Lung Association (ALA) of western Pennsylvania contributed significantly to the campaign by strongly recommending the vaccine to the individuals it serves who belong to high-risk groups and by distributing educational materials and information to professional organizations.

Well before the beginning of the 1986-87 influenza season, health department staff mailed letters to all nursing home directors and chronic-care facility administrators, recommending influenza vaccine for all residents. Consent was handled in several ways: competent patients signed the forms themselves, and legal guardians or their designees signed for patients unable to do so. Influenza vaccine provided to nursing homes was intended for residents only, and individual facilities were responsible for providing vaccine to their staff.

A limited number of doses of pneumococcal polysaccharide vaccine was also available. Because of cost constraints, pneumococcal vaccine was not sent to other providers but was administered free to high-risk patients attending health department clinics.

The vaccination program was evaluated at the end of the 1986-87 influenza season. Data revealed that 52,455 (92%) of the 57,140 doses of influenza vaccine available for distribution were administered. Thirty-four percent were given in health department clinics, and 43% were given in hospital outpatient departments, community clinics, and senior citizen facilities. The remainder were administered in chronic-care facilities (16%) and by private providers (7%). A total of 4,624 doses of pneumococcal vaccine were administered in health department clinics.

Of the 10,200 persons residing in nursing homes and chronic-care facilities, 8,529 (84%) received vaccine provided by the health department. Health department staff and the ALA conducted a special survey to evaluate vaccine coverage among persons 65 years of age and above who were not residing in chronic-care facilities. Thirty-two percent of the 533 persons aged 65 and over identified in a random sample of 400 households reported obtaining influenza vaccine during the 1986-87 influenza season. Fifty-seven percent of those vaccinated identified private physicians as their source of medical care and vaccine administration. Reported by: EJ Streiff, RN, MPH, J Prior, MPH, Allegheny County Health Dept, Pittsburgh, Pennsylvania; R David, Acting State Epidemiologist, Pennsylvania State Dept of Health. Div of Immunization, Center for Prevention Svcs; Influenza Br, Div of Viral Diseases, Respiratory Diseases Br, Div of Bacterial Diseases, Center for Infectious Diseases, CDC.

Editorial Note

Editorial Note: The 10-year effort to provide a high rate of influenza vaccine coverage to high-risk groups in Allegheny County illustrates several important points:

• While influenza vaccination programs should begin in November, promotional efforts should be initiated well before the influenza season. Motivational and programmatic materials should be mailed early in the summer to allow ample time for coordination. To anticipate resource needs, public health agencies should estimate the size of the target population well in advance.

• Program organizers should collaborate with volunteer organizations whose strong endorsements can influence both medical professionals and the public. This measure is especially important for reaching chronically ill persons under age 65, a large percentage of whom may be accessible only through private providers.

• After the campaign, the effectiveness of resource usage and vaccine coverage among specific risk groups should be evaluated. Influenza vaccination is the single most important measure in preventing influenza infection. Consequently, the ACIP recommends influenza vaccine for all high-risk persons 6 months of age or older and for their medical-care providers or household contacts, for children and teenagers receiving long-term aspirin therapy, and for other persons wishing to reduce their chances of acquiring influenza (1). The ACIP recommends that infection-control programs in chronic-care facilities set a goal of 80% vaccination rates for the residents.

In Allegheny County, the flexibility in providing consent for vaccination of residents of chronic-care facilities probably helped to exceed the 80% goal recommended by the ACIP. However, a household survey revealed that the vaccine coverage rate achieved outside chronic-care facilities was much lower than desired. This problem should be addressed by developing systematic approaches to influenza vaccination in physician's offices, clinics, and hospitals. These approaches should include vaccination not only for high-risk patients but also for medical personnel who have the potential to introduce influenza virus into high-risk hospital settings.

November is the optimal time for organized vaccination campaigns in chronic-care facilities, worksites, and other places where high-risk persons are routinely accessible. In addition, high-risk adults and children who do not reside in chronic-care facilities should be vaccinated during regular medical follow-ups in the fall, and those not scheduled for visits should be notified to come in for vaccination. When hospitalized high-risk adults and children are discharged between September and the time influenza activity declines in their community, physicians should provide vaccine at the time of discharge (1).

Since there is considerable overlap between the groups targeted to receive influenza vaccine and pneumococcal polysaccharide vaccine, public health authorities should consider offering both vaccines during an influenza campaign. Pneumococcal vaccine and influenza vaccine can be given at the same time at different sites without increased risk of side effects (1).

Because of cost considerations, Allegheny County was forced to restrict pneumococcal vaccination to high-risk patients attending health department clinics. However, since a single dose of pneumococcal vaccine confers lasting immunity for adults (2), even modest programs such as this should produce high vaccine coverage levels over time. Whenever resources permit, a candidate for influenza vaccine should be viewed as a candidate for pneumococcal vaccine, unless previously vaccinated (1). The cost of pneumococcal vaccine is reimbursable for eligible beneficiaries through Medicare, Part B.

References

1. Immunization Practices Advisory Committee. Prevention and control of influenza. MMWR 1987;36:373-80,385-7.

2. Immunization Practices Advisory Committee. Update: pneumococcal polysaccharide vaccine usage--United States. MMWR 1984;33:273-6, 281.

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