by Harry Goldhagen
First published October 9, 2002 by Medscape Infectious Diseases
I was talking with a friend of a friend the other night at a local tavern. She’s a third-year MD-PhD, intensely interested in all things medical, and she asked what I was writing about lately. Influenza, I said. Did she know that more people in the United States die from flu and pneumococcal pneumonia each year than from AIDS?
“You can’t compare them,” she exclaimed heatedly. “Those are old people who would have died soon anyway, people in their 70s and 80s, who are probably immunocompromised or on their way out. While people with AIDS are dying in their 30s. So many years lost!”
Perhaps it’s a function of getting older, but the opportunity to live to see another season seems like a good idea to me, no matter what the age. Especially when it’s so easy to accomplish with 2 relatively inexpensive vaccines. But I fear that this young student is not alone in her point of view. Even though an estimated 20,000 people a year, mostly 65 years and older, die from influenza,[1] this is still seen as an “old person’s” problem.
Certainly, my father’s doctor shares this viewpoint, at least at some level. When my father was deathly ill 2 winters ago, obviously falling into the high-risk category, we had to keep reminding his internist to get the vaccines. Only by the third visit that winter had he finally remembered to stock his office with pneumococcal vaccine.[2] And of course the flu vaccine was in short supply that year, and wasn’t easily available until December.
Despite the notion that these “older” people are going to die soon anyway, it has been shown that influenza vaccination is a cost-effective way to reduce mortality in the elderly. For instance, Gross and colleagues found in a 1995 meta-analysis that influenza vaccine reduced hospitalization by 50% and death by 68%.[3] (Surprisingly, there are very few published studies of mortality and influenza, at least that I can find on Medline.) And when looking strictly at costs (a very common way of looking at health nowadays, I hear), HMOs can improve the health of the elderly by vaccinating them for influenza for little additional expense. For example, Mullooly and coworkers[4] examined the costs of this intervention in the northwest region of the Kaiser Permanente HMO during the 1980s and found that the organization saved $6.11 per high-risk elderly person and $1.10 for any elderly person. It did cost them $4.82 for each non-high-risk elder, but the authors state, “Indirect benefits, such as prevention of suffering, incapacity, and lost wages, are likely to compensate for the small net cost of vaccinating non-high-risk elderly persons.”
Of course, the elderly are not the only ones at risk from influenza. According to the Centers for Disease Control and Prevention, other high-risk groups include children aged 1 year and younger; anyone with chronic disorders of the pulmonary or cardiovascular systems (including asthma); those who have required regular medical follow-up or hospitalization during the preceding year because of chronic metabolic diseases (including diabetes mellitus), renal dysfunction, hemoglobinopathies, or immunosuppression; children and adolescents who are receiving long-term aspirin therapy; and women who will be in the second or third trimester of pregnancy during the influenza season.[1] And the pneumococcal vaccine is recommended for anyone aged 65 years or older, as well as others at higher risk of invasive pneumococcal disease.[2]
But does vaccination significantly increase seniors’ length of life? I was unable to find a case-control study comparing vaccinated and nonvaccinated seniors that gives a sense of how many years are actually lost by forgoing influenza vaccine. This would need to be stratified by comorbidities or another measure of health, as was done in the Kaiser study (ie, high risk vs healthy). If anyone knows of such a published study, please let me know. Then I could answer that youngster, who expects anyone older than 65 to kick off imminently.
During this upcoming influenza season, let’s put aside the quote Osler is best known for, even if he didn’t say it: “Pneumonia is the old man’s friend.” Rather, let’s remember this more active approach to improving the health of the elderly:
One of two things happens after sixty, when old age takes a fellow by the hand. Either the rascal takes charge as general factotum, and you are in his grip body and soul; or you take him by the neck at the first encounter and after a good shaking make him go your way. [5]
So go ahead and grab that rascal by the neck. Vaccinate your patients for influenza and pneumococcal disease. It won’t be long before that senior is you!
References
- Prevention and control of influenza: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep. 2002;51(RR-03):1-31. Full text
- Prevention of pneumococcal disease: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep. 1997;46(RR-08):1-24. Full text
- Gross PA, Hermogenes AW, Sacks HS, Lau J, Levandowski RA. The efficacy of influenza vaccine in elderly persons. A meta-analysis and review of the literature. Ann Intern Med. 1995;123:518-527. Abstract
- Mullooly JP, Bennett MD, Hornbrook MC, et al. Influenza vaccination programs for elderly persons: cost-effectiveness in a health maintenance organization. Ann Intern Med. 1994;121:947-952. Abstract
- William Osler Quotes. Available at: https://www.gi-guy.com/william_osler_quotes.htm. Accessed October 1, 2002.
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