Public Health Feature - March 2010
Tex Med. 2010;106(3):39-43.
By Crystal Conde
Last September, Carol J. Baker, MD, of Houston, found out that she had been appointed chair of the Centers for Disease Control and Prevention's (CDC's) Advisory Committee on Immunization Practices (ACIP) by U.S. Secretary of Health and Human Services Kathleen Sebelius.
"I was surprised to be nominated," Dr. Baker said. "I'm excited to be appointed as chair of ACIP, and I want to ensure vaccine policy decisions continue to be based on scientific evidence, not on misinformation, emotion, or political pressure."
Dr. Baker is one of 15 ACIP members, all of whom are experts in fields associated with immunization. ACIP's role is to provide advice that will lead to reduced incidence of vaccine-preventable diseases in the United States and an increase in the safe use of vaccines. The committee develops written recommendations for the routine administration of vaccines to children and adults. Recommendations include age for vaccine administration, number of doses and dosing interval, and precautions and contraindications.
Among her responsibilities as ACIP chair, Dr. Baker leads the committee's annual three meetings and represents ACIP at federal advisory meetings, including the National Vaccine Advisory Committee and the Board of Scientific Councilors to CDC.
Dr. Baker is the executive director of the Texas Children's Hospital Center for Vaccine Awareness and Research and a professor of pediatrics and molecular virology and microbiology at Baylor College of Medicine. She served as head of Baylor's section on infectious diseases for 25 years. She's also the Texas Children's Hospital Foundation chair in Pediatric Infectious Diseases.
She says her background in immunization research and education helped prepare her for her leadership role in ACIP. Her research interests entail pediatric infectious diseases, group B streptococcal infections, maternal immunization research, and vaccine policy.
Dr. Baker is a past president and current member of the board of directors of the National Foundation for Infectious Diseases (NFID), a nonprofit organization dedicated to educating the public and health care professionals about the causes, treatment, and prevention of infectious diseases. Her work with NFID, combined with her experience as associate editor of the 2000, 2003, 2006, and 2009 editions of Red Book , published by the American Academy of Pediatrics (AAP), opened her eyes to the many challenges facing primary care physicians who vaccinate, she says. As associate editor, she reviews infectious disease and immunization policies and guidelines.
Dr. Baker was an official liaison to ACIP from 2002 to 2005. She became a member of the committee in 2006. She will hold her post as chair of ACIP through 2012.
Texas Medicine : What do you hope to accomplish as chair of ACIP?
Dr. Baker: I want to emphasize to the public, especially to parents, that vaccine-preventable diseases are bad. Vaccination is good. The public tends to distrust anything tied to the government, like vaccines. I want to communicate with the public and build parents' confidence in vaccine safety.
As a doctor, I treat people still afflicted with vaccine-preventable diseases. Sometimes these diseases are fatal. People need to realize some of these diseases will come back if they don't continue to follow the recommendations and immunization guidelines of ACIP, AAP, the American Academy of Family Physicians (AAFP), the American College of Obstetricians and Gynecologists, and others. ACIP works in conjunction with these organizations and others to make sure our recommendations and policies are consistent with theirs.
Texas Medicine : Texas has made a lot of progress in increasing its childhood vaccination rates. What are some strategies that would help the state continue this trend and improve vaccination rates among adolescents and adults?
Dr. Baker: I think Texas Medical Association's Be Wise - Immunize SM program has contributed to increasing statewide vaccination rates. The work continues for TMA, the Texas Department of State Health Services (DSHS), local health departments, and all the people who educate and encourage people to get vaccinated, as well as those who provide vaccinations for the uninsured.
I think school immunization laws have played a major role in rising immunization rates among children, too. I'm confident the state will see vaccination rates for the tetanus, diphtheria, and acellular pertussis (Tdap) vaccine booster and the meningococcal conjugate vaccine climb above 40 percent among adolescents. Those vaccines had been recommended for all adolescents since 2006 and 2007, respectively. Last year, DSHS began requiring these immunizations for children entering seventh grade.
It's important physicians communicate with their legislators about the importance of school-based vaccine laws. If we have new vaccines that fit into our schedule for toddlers, children, and adolescents, I think they should be added to school immunization requirements as CDC recommends them.
Texas Medicine : In the past, physicians have voiced concern to TMA that they haven't received their seasonal flu vaccine in a timely manner or in the quantity they needed. What types of vaccine distribution models might help improve the delivery of seasonal flu vaccine? Can anything be done to ramp up production volume?
Dr. Baker: We learned from the H1N1 flu pandemic experience that vaccine manufacturers can ramp up production volume. The pace at which vaccine can be developed, however, has limits right now, because vaccine strains grow in eggs. Egg-free vaccines are coming in the near future, and that will speed up the process and hopefully aid physicians in getting their vaccine orders more quickly.
One of the problems now is vaccine distributors send flu vaccine to retailers first. I'm not sure that will change anytime soon. Office-based practitioners are often the last to receive their supplies of flu vaccine.
I urge physicians to be patient and to remember that they have plenty of time to vaccinate their patients. It's not too late to immunize patients against flu in December, January, or February. (See " Survey: Physicians Frustrated by Seasonal Flu Vaccine Distribution .")
Texas Medicine : The H1N1 outbreak put vaccine research and delivery to the test. In what ways was the effort to develop the H1N1 vaccine and distribute it to physicians successful? What lessons can public health officials and physicians take away from this effort?
Dr. Baker: From a manufacturing point of view, the H1N1 flu vaccine effort was successful. All the vaccine was made, and the approval process that often involves a lot of bureaucracy and paperwork went more quickly. The manufacturing process for the H1N1 vaccine was identical to that of the seasonal flu vaccine. I think the public misunderstood that we were dealing with a new virus, not a new vaccine.
Physicians and public health professionals learned some good lessons from this latest pandemic. One is that we need better methods of preparing vaccines. Cell-free, egg-free vaccine that could protect against all strains of flu - those circulating and those in the future - is coming.
We also learned the H1N1 pandemic media coverage increased people's flu awareness. The media overall did a good job of informing the public about H1N1 and seasonal flu. People now have a better respect for influenza and how to protect themselves.
Texas Medicine : It's more common now for physicians, especially those who vaccinate children, to get a lot of questions and concerns from parents regarding vaccine safety. What can busy physicians do to address parental apprehension while striving to ensure all their patients get vaccinated?
Dr. Baker: I think vaccines have been a victim of their own success. I grew up seeing my classmates contract and even die from polio. Many people have never seen the effects of polio or other vaccine-preventable diseases. To reinforce the importance of vaccination as a public health intervention I coauthored a book, Vaccine Preventable Disease: The Forgotten Story . It contains a collection of 17 stories from families whose loved ones died from or became ill from a vaccine-preventable disease. The book seeks to educate families about the importance of protecting children through vaccines and to dispel the myth that vaccine-preventable diseases are merely relics of the past.
I congratulate pediatricians and family physicians for working so hard to ensure patients receive immunizations according to the schedule. I appreciate their efforts. I know more parents have questions about vaccine safety.
The first thing doctors, nurses, and pharmacists need to do is educate themselves. Next, these professionals need to provide their patients with educational materials, especially when parents have questions about new vaccines. I've found that most parents with questions are educated and will read the literature you provide them.
DSHS has free vaccine safety resources that can be shared with parents on its Web site. Texas Children's Hospital also has vaccine information for parents online. Physicians can download TMA's Be Wise - Immunize Physician Toolkit for Children [ PDF ] and Be Wise - Immunize Physician Toolkit for Adolescents [ PDF ], which both contain vaccine safety information.
Texas Medicine : Many physicians face challenges when it comes to purchasing newer, more expensive vaccines; paying for storage and administration; and covering overhead costs. What are some methods physicians can employ to avoid having to cut back or eliminate certain vaccines?
Dr. Baker: This is a significant problem that unfortunately won't go away and could get worse. Pediatricians and family physicians outlay a great amount of money for child and adolescent immunizations.
Fixing the vaccine-financing problem is a priority for the American Medical Association, AAP, and AAFP. At the federal level, the National Vaccine Program Office is responsible for ensuring collaboration among the many federal agencies involved in vaccine and immunization activities. That group, along with the Institute of Medicine, has published a vaccine-financing plan.
Vaccines are so inexpensive when compared with our treatment interventions. From my personal point of view, I would encourage legislative leaders to provide all vaccines free of charge and to reimburse all vaccinators for the cost of vaccine storage and administration. That's my dream and my political statement.
Crystal Conde can be reached by telephone at (800) 880-1300, ext. 1385, or (512) 370-1385; by fax at (512) 370-1629; or by e-mail at Crystal Conde .
Survey: Physicians Frustrated by Flu Vaccine Distribution
A Texas Medical Association and Texas Pediatric Society (TPS) survey shows that 71 percent of physician respondents weren't able to meet their patients' demand for seasonal influenza vaccine for the 2009-10 season. Findings illustrate physicians' frustration with having to wait for flu vaccine while vaccine distributors ship to large retailers and pharmacies first.
TMA and TPS conducted the 2009-2010 Seasonal Flu Vaccine Survey in January to collect information on physicians' experiences with ordering seasonal flu vaccine. Members of TMA and TPS expressed concern about the slow delivery and insufficient supply of vaccine early in the flu season. TMA and TPS plan to use the information from the survey to tailor resources to aid physicians in ensuring their patients receive influenza vaccine.
The Ad Hoc Seasonal Influenza Workgroup reviewed the following survey results at the TMA Winter Conference in January:
- 94 percent of respondents ordered vaccine;
- 46 percent either received no vaccine or an incomplete order;
- 83 percent referred some or all of their patients to another vaccine provider;
- Respondents reported referring patients most often to a pharmacy, local public health office, or grocery store; and
- The majority of respondents - 71 percent - weren't able to meet their patients' demand for vaccine.
The Ad Hoc Seasonal Influenza Workgroup is made up of seven TMA member physicians. Pediatrician Jason V. Terk, MD, a member of the workgroup and of the TMA Council on Public Health, said it's "clearly wrong when retailers get influenza vaccine supply weeks before physicians."
Workgroup member Scot R. Morris, MD, a Brownwood pediatrician and a member of TMA's Committee on Child and Adolescent Health, says adequate flu vaccine supply is important to the preservation of the medical home.
"The health professionals on the front lines doing the work of immunizing should get the vaccine first," he said. "It's frustrating to physicians when they order flu vaccine and don't receive enough of it or don't get it in a timely manner."
TMA and TPS e-mailed invitations to participate in the Web survey to 10,000 Texas physicians who practice internal medicine, family medicine, pediatrics, and obstetrics and gynecology. The organizations received responses from 408 physicians, or 4 percent of those invited to participate.
Survey findings show that physicians living in rural areas with populations less than 10,000 were least likely to receive enough vaccine to meet patient demand. Only 20 percent of doctors who practice in rural areas reported getting adequate flu vaccine supply. Physicians in Tarrant County reported the highest percentage - 42 percent - for receiving enough vaccine to meet patient demand.
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