Canada Outdoes U.S. on Flu Vaccine Policy

We have all seen pictures on the news of people waiting in long lines to get their flu shots this year; many of us were not able to get one before the supply ran out. Because the Canadians have taught us a thing or two about how to run a national health insurance system, we decided to look to our neighbors north of the border to see how they handle their flu shots. We found that the Canadian government, particularly the Ontario Ministry of Health, has implemented innovative strategies to ensure that its residents are protected from the flu, and we would do well to learn from their example. We pay three times as much for each shot and vaccinate a much lower percentage of our high-risk population.

Influenza viruses cause annual winter epidemics leading to an estimated 36,000 deaths in the United States each year. Annually, influenza is also responsible for hundreds of thousands of hospitalizations, tens of millions of workdays lost, and costs the U.S. economy tens to hundreds of billions of dollars.

Simple hand-washing and covering your mouth when you cough or sneeze can limit spread of the disease, but the disease can also be prevented by two different vaccines. One is a shot, the inactivated vaccine. The other, available this year for the first time, is squirted into the nostrils and is a live vaccine. They are both about 70% effective and both must be given every year because immunity wanes quickly and the virus changes over time. Both vaccines have the same viruses in them, and the composition of each year’s vaccine is based on the published recommendations of the World Health Organization’s Global Influenza Surveillance Network. The nasal vaccine can only be given to healthy people between the ages of 5 and 49 and can’t be given to pregnant women, while the shot can be given to almost anyone over 6 months old.

Vaccination is “strongly recommended” by the U.S. Advisory Committee on Immunization Practices (ACIP) for everyone who is considered high-risk for influenza-related complications or death. High-risk people include those 65 years of age or older, in nursing homes, or with heart or lung diseases like asthma, kidney diseases, problems with their immune systems, blood problems like sickle cell disease, diabetes, and pregnant women. People who could give high-risk people the flu, like their household contacts and health care workers, are also “strongly recommended” to get the vaccine. A flu shot is also available and encouraged by ACIP for anyone else who wants it.

In the United States, the influenza vaccine supply is produced completely by private manufacturers who independently determine the amount of vaccine produced each year based on demand during the previous flu season. For five years prior to this flu season, there has been an overproduction of vaccine, resulting in doses being discarded and money lost to manufacturers. Last year, 95 million doses were made and 12 million discarded, so only 83 million doses were manufactured this year. The media also portrayed this season as especially severe, when in actuality it simply started earlier and has already peaked in many places. We also don’t know if more children died this year from the flu because we simply don’t have accurate numbers from past years. The misperception of a particularly bad flu season led to increased demand for the vaccine, which — combined with manufacturers making fewer doses — resulted in the current shortage of influenza vaccine. Predictably, manufacturers and distributors exploited the situation by raising their prices. Health departments usually pay about $8 wholesale per shot, but as the season progressed and supplies dwindled, some states, such as Georgia and Colorado, were paying $16.50 per shot.

Even without these problems, vaccination coverage rates have been dismal historically. There are approximately 185 million people in the United States who fall into the “strongly recommended” group, but only 70-75 million people are vaccinated each year, including people who are not high-risk. That’s a total of one-fourth of the roughly 292 million people in the U.S. The highest coverage is among the elderly, with 64% of people 65 or older receiving vaccinations in the winter of 2000-2001, and 83% of people in nursing homes vaccinated in 1998. There is considerable racial disparity, however, with 70% of white people 65 or older vaccinated in 2001-2002, but only 52% of non-Hispanic African Americans and 47% of Hispanics vaccinated. Younger people in high-risk groups fare even worse, with 29% of high-risk 18-64 year olds and only 10-25% of pediatric asthmatics vaccinated. Clearly, we are not adequately reaching the high-risk people, and with the decentralized system in place in the U.S., it is difficult to redistribute vaccines appropriately. This year, low-risk people were the recipients of a large enough number of vaccinations that we ran out of vaccines before some high-risk people could get their shots.

The situation in Canada is considerably different. It has a National Health Insurance program that covers everyone in the country and enables the country to act as a large buying unit. The vaccine is purchased by the federal government for a negotiated price, which is $2.68 per dose in U.S. dollars this year, or one-third what U.S. health departments usually pay. Unfortunately, the recently passed Medicare drug reform in the U.S. specifically prohibits negotiating drug prices. The amount of vaccine purchased in Canada is based on requests from the provinces, and was 10.4 million doses this year. The government is not concerned about over-ordering since the manufacturers have agreed to take back for credit up to 5% of their product, if necessary. The vaccines are then distributed to the provincial governments, who mount impressive media campaigns about flu shots, including TV and radio ads, posters on public transportation, information in workplaces, and hotlines to find the nearest clinic. The provinces also have centralized redistribution systems to handle local shortages if necessary. This year in the U.S., there were areas that had completely run out of vaccine but still had unvaccinated high-risk people, while other places had extra vaccine left over. In Canada, the extra vaccine could have been moved easily to areas of shortage, but in the U.S. we have no way of redistributing those shots, or even knowing where they are.

One Canadian province, Ontario, has gone still further. Rather than just targeting high-risk populations, it concluded that the greatest public health benefit would be derived from vaccinating everyone without contraindications because many high-risk people contract the flu from low-risk people. Therefore, for the past four years, the province has offered free influenza vaccination to all residents over 6 months old. Based on previous years’ experiences, it purchased about 6 million doses this year, enough to vaccinate 50% of the entire population. As of early January 2004, Ontario had already administered 5.5 million doses. Despite including low-risk people, the province is still remarkably successful at reaching their high-risk populations. Last year Ontario vaccinated 77% of people 65 or older (compared with 64% in the U.S.), 48% of people aged 16-65 with chronic medical conditions (29% in the U.S.), and 95% of people in long-term care facilities (83% in the U.S.). The program, including vaccine price and an intensive media campaign, is expected to cost 22.6 million U.S. dollars. The program seems here to stay as the Ministry of Health has committed to free universal influenza vaccination and approximately 80% of Ontario residents approve of the program.

Some steps are already being taken to improve flu vaccination in the U.S., such as the expanded recommendation for routine flu shots for all children aged 6 to 23 months beginning next winter. In addition, Secretary Tommy Thompson of the Department of Health and Human Services has requested $100 million from Congress in the 2004 budget to finance research to develop adequate influenza vaccine supply in case of a major outbreak. This money has not yet been appropriated, however, so it is unclear if the program will ever see the light of day. However, given the failures of the U.S. system, it is in our best interest to institute parts of the Ontario plan. Critical components of the Canadian policy that bear emulating include centralized price negotiation, purchasing, distribution, and redistribution if necessary. To reassure manufacturers, the government must guarantee to purchase a minimum number of vaccines. If our government could negotiate a price equivalent to the Canadians’ (and because of our larger size we should actually do better), we could have bought three times the amount of vaccine we bought this year for the same amount of money, thus eliminating the shortage. The other lesson to be learned from Ontario is to conduct a massive media campaign targeting both the public and health care practitioners to decrease racial disparities and increase the coverage of our high-risk citizens and our population as a whole.