ACP: Making the most of opportunities to get people immunized

acp-logoA guest column by the American College of Physicians, exclusive to

It seems to begin earlier and earlier each year — displays are up in stores in late July, newspaper and radio ads start appearing in August, and the media reports on it before the kids even go back to school. Yes, flu vaccine season is in full motion. Last year I shared with you a few pointers to increase your practice’s immunization rate. This year I would like to add some more helpful tips and discuss some common barriers to vaccinating your patients.

One of the hassles of flu vaccine season is the increased volume of phone calls from patients who want to know “is the flu vaccine in?” as well as when we will give it. This ties up our phone lines for patients who are calling for other reasons, such as appointments. Like many offices, ours has a computerized phone system that greets callers and triages their calls (“press 1,” etc.).

During flu vaccine season, we record a message for the automated attendant that tells patients all they need to know about flu vaccine availability, allowing them to hang up right away instead of waiting for a receptionist. Another method is to add a “press 1 for information on flu vaccines” to your options. If you have an electronic health record with a patient portal or electronic messaging capability (or even an old-fashioned website), you can post the information there as well and encourage patients to check there instead of calling.

Our office has standing orders that allow the medical assistants to administer flu vaccine to all patients unless they have a medical contraindication or don’t want it. It’s worth the extra effort to educate your staff on what constitutes a medical contraindication. Some of the concerns most frequently raised by patients have to do with illnesses and other treatments. Unless a patient has a moderate or severe illness (with or without fever), they can be immunized. Therefore, patients with cold symptoms who are mildly ill can get the vaccine. Patients on antibiotics can be immunized, assuming they are not moderately to severely ill. Patients who have a history of severe reaction to egg protein should not be immunized without physician involvement and special precautions, but others with history of “egg allergy” may be able to receive the vaccine. The CDC has guidelines on how to approach this.

A recurring theme is that we not miss opportunities to get people immunized. If a patient with a mild cold doesn’t get a flu vaccine today, how likely is it that they will get the vaccine later in the season? Another area where we must be mindful of missed opportunities is in the timing of the vaccine. In my neighborhood, chain drug stores offer flu vaccine in July. The decline over time of vaccine effectiveness, especially in elderly persons, is a concern. If there is significant decline in titers six months after a patient receives vaccine, then those July and August “early birds” may not be protected by January or February, when influenza activity may be high. The studies are not clear on this phenomenon, but if possible, waiting until September or October makes sense. However, if patients pass up a chance for vaccine in late summer and never get to it in the fall or early winter, they may be better off receiving it early than not at all.

Another barrier to a successful vaccination program is misinformation or misunderstanding about the vaccine. You cannot get influenza from the inactivated (injected) flu vaccine, period. The incidence of reactions to the vaccine that could be described as “getting sick from the vaccine” is low in studies. Unfortunately, some of the erroneous information comes from clinicians, as we have learned from efforts to immunize physicians and nurses and the reasons some decline flu vaccine. The less than perfect success rate of flu vaccine in preventing influenza often comes up as an excuse to not get immunized, as if a 60% prevention rate means that it’s not worth getting the vaccine. The last time I checked, 60% prevention is better than 0% prevention, which is what skipping the vaccine gets you. Seatbelts don’t prevent injury or death 100% of the time either, but that doesn’t mean that we should not wear them.

Occasionally, thimerosal is mentioned as a reason for not getting immunized. Thimerosal is a popular whipping boy among the junk scientists, even though there is significant evidence that shows no adverse effects from the use of this compound, which is used to prevent bacterial growth in multidose vials. If you’re not able to convince your patient that Jenny McCarthy is wrong, be aware that most single dose vials or prefilled syringes are thimerosal-free.

A source of growing confusion among physicians is the increased number of flu vaccine options. In addition to “live” and “inactivated” we have trivalent, quadrivalent, and high potency to choose from. The Advisory Committee on Immunization Practices (ACIP) recommendation statement discusses the available products but it does not recommend one type over another, based on available research.

If you want to learn more about this, ACP has an Immunization Portal with a variety of tools to help physicians to improve their immunization rates (not just for influenza) that includes a mobile app, patient information materials, and links to other resources.

One of the most powerful ways to immunize yourself against the naysayers and fear mongers is for you to set an example and make sure that you get your flu vaccine every year. Unless you are under the age of six months, there is no excuse for you not to.

Yul Ejnes is an internal medicine physician and a past chair, board of regents, American College of Physicians. His statements do not necessarily reflect official policies of ACP.

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