Flu Near You     I’ve pondered for years whether to open Pandora’s Box about all that the doctor’s office does to prepare for your flu vaccine, and until this year, I’ve resisted the urge to whine about the challenges.

My father was always one to say, “Don’t bring me a problem without also bringing some of the solution,” and I’ve adopted his wise advice over the years.  I’ve never written about the complexities of the work we do to get ready for flu vaccines because I have yet to come up with any meaningful solutions to simplify or improve the challenges it creates.

I changed my mind this season because understanding the process of vaccine development and distribution is critical to becoming an educated health care consumer, and it IS part of the solution to improved vaccination rates.  I want my patients and their parents to understand the why and how of what goes on behind the scenes to prevent influenza.  Because there is an improved vaccine this year, smart parents in the carpool line will be the ones who know to ask, “Did your child get the 4-strain or the 3-strain vaccine?”

In the year before you arrive for your flu vaccine, experts have to predict which strains are going to circulate the following year, and then manufacturer the vaccine.  As science gets better, so do vaccines.  We now can protect against four different strains of the influenza virus with this year’s vaccine (although both 3-strain and 4-strain vaccine are available.)

The two main types of vaccine, inactivated ‘shot’ and live-attenuated ‘nose drops,’ are recommended for just about everyone older than six months, with a somewhat complex “if/then” algorithms to determine who should receive which vaccine.  While it’s complex, helping parents choose which vaccine is not as challenging as making sure I have it to administer.

Problem #1  Give Me Your Best Guess A Year In Advance.  In the winter (while our kids are busy with strep throat and gastroenteritis,) doctors have to ‘pre-book’ their flu vaccine supply for the following year.   Manufacturers need to know how much vaccine to make and doctors want to ensure that they receive enough vaccine to protect patients so planning ahead seems logical, but there are no guarantees.  Just because I want 100 doses of vaccine doesn’t mean I’ll get them.  It also doesn’t mean that they will be delivered when I want them either.  Many doctors pre-book their estimated vaccine needs with a variety of manufacturers hoping to ensure an adequate delivery, but every year, it feels a bit like the lottery.

• How much will my practice grow in a year requiring that I buy more supply?
• Will the children who are eligible to receive nasal vaccine this year all choose it over the shot?
• How many parents will take advantage of the convenience offer and get vaccinated at the same time their child does?

Problem #2  Commit to the Vaccines You Want, But Choices May Change.  This season, the pre-bookable vaccines included live-attenuated FluMist  (which contains the four strains predicted to circulate in the US this winter), and also a choice between the 3-strain and 4-strain injectable shot.  What should my practice buy?

• Will parents balk at the 4-strain as a ‘new’ vaccine and only accept the 3-strain shot?  (Better get some of both)
• Will the health insurers pay the increased cost for the 4-strain vaccine or will they ask parents to pay for it?
• Will the 4-strain shot receive FDA approval for use in the 6-month to 3 year olds so that I should order enough for them? (The answer turned out to be YES, but the FDA was still processing their decision when pre-booking took place.)

It’s a real dilemma guessing a year in advance what patients will choose in order to have adequate supply but not waste vaccine that could be used to prevent this awful disease in someone else.  When we say, “First come, first served… ” we want to have on hand whatever vaccine your child will want to receive, but it’s very possible, given how we must guess a year in advance, that she will have to settle for the second choice.

Our practice made the commitment with pre-booking to order enough 4-strain vaccine to protect the patients in the practice and the parents who have taken advantage of our offer to vaccinate them as a convenience.  We can only hope that we receive the doses ordered in a timely fashion and in the quantity we reserved to serve everyone’s need.

Problem #3  Distribution Dilemmas.   One of the most frustrating parts of being the little guy, (and many pediatricians feel this way) is that the delivery of vaccines seems very unfair.  Parents often point out that the local pharmacy is advertising Flu vaccines (along with a 20% discount coupon!) when the pediatrician’s office has not yet received its first shipment.   We are allowed to request a shipment amount and date of delivery, but again, no guarantees. Last year, Partners in Pediatrics received its first shipment of vaccine with only one vial (ten doses) of vaccine, and it arrived in a ridiculously big 18-inch cooler-box.  A week later, we received another with 20 infant doses of vaccine in an equally giant cooler.  A week after that, part of the nasal vaccine shipment arrived.  Vaccine delivery that seems to have no rhyme or reason creates a huge challenge in planning for flu vaccine visits.

Problem #4   When To Get Your Vaccine.  Our office is all about streamlined efficiency.  Depending on which flu vaccine is recommended for your child, there is an ideal window of time to receive the vaccine so that the body produces the most antibodies to last throughout the flu season.  For children who receive the nasal vaccine, it can be given as early as late summer because those antibodies last MUCH longer than flu shot antibodies.  Children who receive the shot should ideally be vaccinated in October or November in order to have the highest antibody levels for the ensuing months of flu season.  The CDC has recommended that vaccine be given as soon as it’s available, but this advice is probably based on the large number of people who need to be vaccinated in a limited window of time.  Science suggests the wise should wait for the ideal window in the late autumn months.

As you begin to see some of the challenges that doctor’s face in order to immunize against influenza, it’s important to remember that our system works pretty well, in spite of my grumbling.  Case in point:  remember when the new H1N1 virus emerged on the scene?  The virus was identified in the summer and by the fall, a vaccine was produced and distributed to doctors and clinics in record time.  Parents were well educated on this new virus and vaccinated their families.  Many people were protected by the vaccine, and a true pandemic did not really occur.

It’s important to remember (because the media isn’t running feature stories on flu or the importance of getting vaccinated right now) that just by reading this far into the article, you’re now smarter than the average bear!  You now know more about what happens behind the scenes at your doctor’s office to insure that your child is protected. So pledge today with the CDC guys to protect your family.  Call and make time to get vaccinated if you haven’t done so already.

Click some of the links in the text of this blog if you would like a more detailed explanation than this space will allow.  Teach other parents some of what you’ve learned.  Lastly, join us in tracking the virus this season by downloading the Flu Near You app.  You can donate your experience data and help Boston Children’s Hospital track and understand the spread of flu in children and families all over the United States.

Gayle Schrier Smith, MD

(Strong Believer That An Ounce of Prevention Is Worth A Pound of Cure!)

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