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Flu shots all around! But is it the best way?

April 18, 2010

Courtesy: Daryl Campbell

Lying in bed, wrapped in a comforter, fists clenched. Your teeth are chattering, your body is sore, your head is pounding. You feel horrible, and yet a loved one is trying to do the most unthinkable thing – they want your blanket.

No, you can’t have it! I’m freezing! you say.

Come on, it’ll make you feel better. You have a fever, they respond.

Having the flu is a universal experience. But for some, it is much worse than a runny nose and a couple of days off work. Visits to the doctor, the emergency department, or even death can all come as a result of the viral infection. The seasonal illness is so common that the government of Ontario decided to try a new approach to fighting it, a Universal Influenza Immunization Plan. The program was implemented in 2000 and set out to provide influenza vaccination for all Ontario residents over the age of six months.

Most governments, if they are fortunate enough to have an influenza vaccination program, use what is called a targeted approach. In targeted programs, the influenza vaccine is provided to people whose health would be seriously at risk if they got the flu. This usually includes small children, the elderly, or people with chronic health problems like diabetes, cancer, or lung disease.

There are a number of reasons why a universal plan should be better than a targeted plan: it should save money from people not missing work, unclog busy hospitals during flu season, and lead to reductions in the spread of the disease. As with any theory in science and medicine, it’s better to back it up with some data. Ontario’s adoption of a universal program provided a testing ground for the world’s scientists to work out the effects of giving the vaccine to everyone.

It’s been 10 years since the universal plan’s introduction, but a number of questions still linger.

The most obvious; is it even working? Well, it depends on who you ask.

A new study released in the Public Library of Science Medicine journal called Economic Appraisal of Ontario’s Universal Influenza Immunization Program: A Cost-Utility Analysislooked at what the impact of influenza would have been in Ontario if it had continued with the targeted approach it had in place before 2000. The researchers estimated that the universal approach prevented 111 deaths, 28% less than if Ontario had continued with a targeted strategy. They also found a 61% reduction of the flu, or 34,541 cases.

Another study reported in the journal Global Public Health called Time for an ecosystem approach to public health? Lessons from two infectious disease outbreaks in Canada found that the universal plan “does not appear to have reduced laboratory-diagnosed cases of flu.” The researchers said that 109 people out of every 100,000 got the flu when Ontario used a targeted approach, but 164 out of every 100,000 got it after the policy shift.

While the overall impact of the universal plan is still up in the air, the vaccine’s effectiveness for helping some people is well known.

David Hutton is a PhD candidate from Stanford University. He researches the cost-effectiveness of pandemic influenza and other health programs.

“From what I can tell it’s definitely effective and cost-effective to vaccinate young children and the elderly. I think everyone agrees you get health benefits if you vaccinate anyone, or at least you don’t hurt people,” said Hutton.

Hutton said the confusion over the universal health program comes when you try to figure out how it is affecting people outside of the high risk groups.

“That’s the tricky part, because if you’re talking about flu vaccinations sometimes people are thinking about the elderly. And for the elderly it definitely is a mortality issue. But for vaccinating healthy working-aged adults it’s definitely more of a quality of life issue,” he said.

When a medical tool affects quality of life, it is an effect on how healthy you feel, and your ability to do the things you want to do. So having the flu, and the sore, achy, sick feeling you get, detracts from your quality of life. It’s an issue of being sick – morbidity – rather than dying – mortality.

“For the most part I would say the vaccination of health working adults is something that’s going to affect morbidity versus mortality,” said Hutton.

“So I get a vaccine, and then I don’t get sick, so I don’t have to stay in bed for a week and have a fever and so forth. But it’s not likely that I would have died if I didn’t get the influenza vaccination. So we need a way to think about how bad that morbidity is, and compare that to other things,” he said.

We often think of the flu vaccine as something that saves lives. This is definitely true for the high risk groups. But the universal vaccination plan provides vaccine to healthy adults, where targeted plans don’t.

But here’s the thing – according to the new PLoS study, the universal influenza plan costs double the targeted plan; $40 million dollars a year compared to $20 million. If it’s a matter of getting sick, what is that really worth?

“I think it would be more important to think about, well, how much are we really willing to spend to avoid someone being sick for a couple of days? And then think about how else we would want to spend our money. And are there better things that we would want to spend our money on?” said Hutton.

That’s where these questions get really tricky. Yes, it has been shown that the universal influenza immunization plan is better than our previous targeted plan at preventing illness. The PLoS study which was comparing the two programs even found the new approach to be more cost effective than the old one. But the new way of doing it, and the old way of doing it, aren’t the only ways it can be done.

Greg Zaric is the Canada Research Chair in Health Care Management Science and an Associate Professor at the University of Western Ontario. He said looking at how much you get for your money is a good way of comparing programs,

“It gives you a very powerful way of thinking about priorities within your healthcare system,” said Zaric.

“The argument is that if the total budget for healthcare is limited, then you can’t have everything you want within healthcare. So you can look at these cost-effectiveness ratios to start assigning priorities to different drugs or different technologies,” said Zaric.

Even if the comparisons works, Zaric said it doesn’t always sit well with the public.

“I think there is a certain amount of suspicion of anything that is done that looks as though it is done to save money at the expense of health,” said Zaric.

Zaric is right, people don’t likes the idea letting others get sick just to pinch pennies – but the issue is more complex than that. The universal influenza plan may be better than what we had, but that doesn’t mean it’s necessarily the best option for using the roughly $20 million a year.

So what else is there?

Hutton thinks he has an idea of where we should be looking, and pointing our needles.

“I’m in my mid-30’s and I’ve got a bunch of friends who are now having kids. And it’s funny, my friends are now a lot sicker than they used to be now that they’ve got kids and the kids are spreading the disease to them,” said Hutton.

“…Most studies think that most of the transmission of the flu virus occurs in children and other people who are in high contact with others. Kids are typically referred to as super-spreaders; they don’t wash their hands, they rub their hands all over their faces, they cough on other people and stuff. So if there’s a group to target in order to reduce the spread of the disease it’s probably children,” said Hutton.

The idea of targeting kids, in addition to the high risk groups, is gaining traction. One of the big reasons is because when a child gets sick, parents or other caretakers might have to stay home from work. The PLoS study found that vaccinating children leads to big decreases in influenza rates for everyone else.

“Models of seasonal and pandemic influenza have explored the impact of targeting interventions, such as vaccination, to children of pre-school and school age to limit transmission of infection and observed disease reductions in the wider community,” said the report.

Ira Longini, a professor of biostatistics at the University of Washington delivered a presentation that said models of the effects of vaccinating children “suggest that influenza vaccination of school-age children leads to significant reductions in influenza health burdens among other population groups as a result of decreased exposure to and transmission of influenza viruses.”

The old targeted influenza plan used in Ontario didn’t provide vaccines to children, except for those with underlying health problems. A new approach, targeting children, healthcare workers, and other people who are likely to be heavy transmitters of influenza might provide many of the benefits of the universal program. It also might even be more cost-efficient.

Another way to approach the problem is to accept the fact that you might get the annual sniffles, but realize Ontario could use the money in a different way. Zaric explained one of the big benefits of using cost-effectiveness as a bench-mark is that it allows us to compare programs that don’t seem at all related.

Hutton, the PhD candidate from Stanford, said we can use a measure of health called a quality adjusted life year to find better ways to promote health.

“You could even say, let’s use those same metrics in terms of how many dollars we are willing to spend to get a QALY and apply that to things like transportation programs,” said Hutton.

“So if we were going to put in more guard rails on highways and things like that. How many dollars are we spending to put in those guardrails, and how many motor vehicle accidents are we going to prevent with that. And so how many broken bones are we going to prevent? Those are QALYs. And how many deaths are we going to prevent?” said Hutton.

“I think the purpose of doing a lot of these cost-effectiveness analyses should be to be able to help you make those kinds of judgments about, do we spend money on health care? Do we spend it on education? Do we spend it on other social services and things like that? We’ve got a lot of choices about how we can spend our money, and although people say my health is priceless, it really isn’t. You know, you are willing to trade off things for your health,” said Hutton.

There are reasons to stick with the universal influenza immunization plan, however. One of the major considerations is a concept called herd immunity.

“If everyone except for one person has been vaccinated, then that one last person doesn’t have to worry about anything because no one else is going to have the disease and be able to spread it,” said Hutton.

“Or if a sufficient number of people in the entire population are vaccinated then if an infected person comes into that community they just won’t be able to spread it to enough people to be able to sustain the transmission of the virus,” said Hutton.

The other main reason is that, as far as health programs go, vaccination is pretty cheap, especially when compared against intensive care units and MRIs.

But science is all about testing new ideas to find out what works. Zaric said that when the data comes back, it’s important to keep what works and drop what doesn’t.

“We should be evaluating the data on everything that we’re doing, and making sure that it is the most effective use of resources and that it does compare favorably with other things that we do.”


Sander B, Kwong JC, Bauch CT, Maetzel A, McGeer A, Raboud JM, & Krahn M (2010). Economic appraisal of Ontario’s Universal Influenza Immunization Program: a cost-utility analysis. PLoS medicine, 7 (4) PMID: 20386727

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