Influenza nearing epidemic levels in the US

By Debra Watson
22 December 2003

Influenza outbreaks continue to progress across the United States with the disease widespread in 36 US states, up from 24 in early December. The Centers for Disease Control now characterize the flu outbreak as a likely epidemic.

The official count for child flu deaths has more than doubled from last week, from 20 to 42. With three months left in the flu season, stocks of vaccine are already depleted. Parents in Western states, where the flu season first took hold, are traveling hundreds of miles in search of vaccine for their children. At least 11 children have already died in Colorado from respiratory complications related to the flu, and some US schools have been forced to shut down because so many students are sick.

The federal Department of Health and Human Services (HHS) has begun distributing an additional 100,000 doses of vaccine to health care providers in the US. An additional 375,000 are to be purchased in Europe. Because the current process used to manufacture flu vaccine includes a mandatory incubation period, none of the three US companies that make vaccines can manufacture more doses in time for this flu season.

HHS and the US Centers for Disease Control (CDC) knew vaccine makers had cut the number of doses produced for the 2003-2004 to 83 million doses, down 12 million doses from the previous year, doing nothing to ensure ample supplies in anticipation of heavy demand. The half-million new doses distributed by HHS are a drop in the bucket, and it is becoming increasing clear that there will be little protection for the population at large if the outbreak develops into a full-blown epidemic. The high-risk categories the CDC normally recommends for vaccination includes an estimated 185 million people.

HHS has also announced plans to distribute another 150,000 children’s doses in January. This is little comfort for worried parents in states across the US who are learning too late that this year’s predominant flu strain seems to be hitting children very hard. Children under eight who are getting their first vaccine must take it in two doses spaced a month apart, putting further strain on vaccine stocks.

For hundreds of thousands of US families, the traditional holiday season is being overshadowed by influenza concerns. Instead of scrambling for gifts, this year many parents are racing the clock to find the last doses of vaccine. Some are being forced to fork over $65 to $75 for a flu nasal spray for their children. Most parents won’t find that either as only 4 million doses of FluMist were manufactured. It costs three to four times more than the traditional flu shot, and most insurance companies do not cover the expense.

The flu season hit in early October in the Western US. Last week, 200 people lined up for flu shots at the Clark County, Nevada, Health District. The state had ordered a record 29,000 doses but received only 16,000. By Friday, December 12, the Las Vegas Review—Journal reported one area hospital was seeing two to three times more children than on a normal day, “the vast majority complaining of flu-like symptoms.” Nevada State epidemiologist Dr. Randall Todd said that 10 percent of patients seen by doctors were complaining of influenza-like symptoms, up from 6 percent reported during the peak of the flu season last year.

The CDC reported deaths as a whole from influenza hovering near epidemic levels. By early December at least 20 children had died from encephalopathy and other complications of the flu. On December 18, PBS News Hour reported that 40 percent of 7,800 influenza cases in Colorado were among children under five. One doctor said cases of influenza were the highest she had seen in 20 years.

Early warnings ignored

Despite a dramatic rise in the percentage of flu cases of the more virulent type-A influenza over the past dozen years, the government has done nothing to develop a coherent vaccination plan for what should be a largely preventable disease.

Though an investigation of an unusual number of child deaths in a Michigan influenza outbreak last winter is ongoing, the government made no provision to ensure vaccination of the general population, including healthy toddlers and schoolchildren. Normally, only very young children have a death rate from influenza comparable to that of the elderly. Up to this year, flu cases among people over 65 resulted in 90 percent of all deaths from influenza in any given year.

The CDC routinely recommends that adults over 50, children 6 months to 23 months, anyone with a chronic illness and anyone who interacts with or cares for at-risk individuals get flu shot every year. Pre-school and school-age children are not included, although they are a prime vector for flu as their immune systems are not fully developed. Because the disease spreads through droplets from coughing or sneezing, congregation at nurseries and schools increases the opportunity for the infection to spread. The past few years have seen indications of increased influenza illness and death among children under 21.

However, recommendation that a particular population get vaccinated means little. Unacceptable levels of illness and large numbers of preventable deaths each year are accepted by the authorities as perfectly normal. The federal government takes no responsibility for the serious public health task of protecting the population from influenza epidemics. Every year, on average more than 100,000 people are hospitalized and 36,000 mostly elderly people die in the US as a result of complications from the flu.

Disease prevention and treatment in the US are subordinated to the profit drive of huge pharmaceutical companies, Wall Street investors and business entrepreneurs, with the federal government unwilling to allocate funding for basic vaccination programs.

Public health versus private profit

Despite the threat to public health posed by such a deadly communicable disease, less than 10 percent of vaccine in any given year is purchased by government entities. The patchwork of state, county and other local health authorities organizing vaccination campaigns is simply not designed to ensure full or even major vaccination needs.

In America, the responsibility to pay for shots, and a doctor or health care provider to administer them, falls completely on the individual family. Even when programs are available at public health clinics or at special vaccination venues in malls and supermarkets, the over 40 million US citizens who have no health care coverage must pay up to $20 for the shots.

For those with coverage, many basic health plans do not cover such routine immunizations. Health Maintenance Organizations (HMOs) do little to promote the annual flu shots. Though HMOs claim to cover vaccines, a recent survey found that only a small percentage of children insured by these plans actually got the vaccine.

Some health plans have agreed to pay for FluMist, but others have no plans to pay the higher cost to protect children not vaccinated before the shots ran out.

Pharmaceutical companies and vaccines

Complicating the picture is the questionable efficacy of the vaccine formulation produced this year. One of the three components of the vaccine may be at best only 40 percent effective in protecting against the increasingly predominant Fujian-type virus. According to CDC Director Dr. Julie Gerberding, the H3N2 Fujian strain is turning up in three out of four cases cultured so far this year.

Thirty-five years ago there were 30 companies in the US producing vaccine, but that number has dropped to only three. For some childhood vaccines, there is only one supplier in the country. Several times in recent years, this has led to shortages of vaccines, including basic childhood vaccines.

This contraction in vaccine production was one of the factors leading to the miscall on formulating this year’s vaccine. Even though evidence from last year’s season argued for inclusion of specific H3N2 Fujian protection when the new flu formula was finalized in March, the decision was made to go with last year’s formula, hoping the A/Panama component would offer some protection against the newer strain. The CDC claimed the risk of changing production would lead to delays or even the failure of at least one of the private companies. They point out that only two companies are still making the flu shot and there were serious manufacturing delays in recent years.

Despite some hand-wringing by Democratic politicians, no one is seriously suggesting the government take responsibility for producing and distributing the vaccine. Such a program would run counter to the free-market mantra of the Bush administration and pose a threat to profits for the private health care industry.

Unlike expensive AIDS drugs, it is not the high cost, but rather the low profit margin of vaccines that has reduced the number of pharmaceutical companies willing to produce them. Since they make only pennies on the dollar, they would rather shift their efforts to marketing expensive designer drugs that yield high profits. Many pharmaceutical companies have dropped out of flu vaccine production altogether.

This year the pharmaceutical company Wyeth stopped production of flu vaccine delivered by injection, and began marketing the expensive nasal vaccine made by MedImmune. MedImmune spent $50 million for ad campaigns to doctors and the general public to advertise its new vaccine, focusing on its painless delivery system. Since the vaccine uses a live virus it is considered suitable only for healthy individuals outside the CDC’s high-risk groups. Thus recipients of Medicare, the elderly and disabled, who have been reimbursed for flu shot costs since 1993, cannot be administered the nasal spray.

Chaos in the health care system

The Trust for America’s Health (TFAH) recently released a report examining the allocation of $1.7 billion in federal funds in 2002 and 2003 through the new Public Health Security and Bioterrorism Preparedness Act. The TFAH report uncovered a deterioration of public health entities in the US, despite federal funding, as state after state faces near bankruptcy. They found 33 states cut public health funds from 2002 to 2003. Six states, including Michigan, Massachusetts, Montana, Alaska, Missouri and Oklahoma, cut their budgets by more than 10 percent.

The report states, “Only 13 states have a plan (complete or draft form) for responding to the emergence of a flu outbreak, which is viewed by health officials as potentially more devastating than a bioterrorism attack.” It calls influenza “the forgotten epidemic,” and points to the Spanish flu that killed 30 million people worldwide in 1918, including over half a million in the US.

According to the report, “The CDC does not require each state to submitted influenza strategy to the agency for analysis and approval, and has yet to release a national plan for federal response to pandemic flu.” In fact, influenza is not even a reportable disease, which means the CDC uses estimates based on various sources to track its spread and mortality rate.

The report notes several examples of public health cutbacks resulting from state budget crises. These include:

* In California, state public health laboratories could lose from 16 to 20 percent of their state funding in fiscal year 2004 and the laboratory that serves the city of Oakland, as well as contracts to do testing for other counties, may shut down completely.

* The Alabama Department of Public Health plans to lay off 250 people by the end of the year, close regional labs and curtail its flu vaccination purchase and free flu shot program.

* In Larimar County in Colorado, one of the states hardest hit in this year’s flu season, $100,000 in federal money was added to the county health budget but $700,000 was eliminated due to state cuts.

From epidemic to pandemic

The chaos surrounding the current US influenza outbreak underscores the fact that the capitalist market system is unable to deal with the complexities of a modern urban society. A health epidemic in any country in the world could quickly spread to a world pandemic.

If health care workers in one of the most advanced capitalist countries are prevented from effectively fighting even common influenza by the vagaries of the market, what chances are there for tackling more deadly emerging diseases?

The AIDS epidemic, recent outbreaks of West Nile virus, and the SARS epidemic last March brought the international character of infectious disease to the attention of millions. While US health care workers come up against the dictates of the pharmaceutical and health care profiteers, international collaboration by scientists and clinicians is subordinated to the geopolitical interests of individual nations. Medical workers are already pointing to an unacceptable divide that leaves poor countries at a severe disadvantage in accessing influenza vaccine.