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DataWatch

Americans’ Responses To The 2004 Influenza Vaccine Shortage

Abstract

 
Polling taken during the 2004 influenza vaccine shortage found a high level of public concern but no consensus on who should be responsible for solving the problem. A substantial minority questioned whether the vaccine should be reserved for high-risk groups, while a majority thought that care providers should be responsible for allocating it. Many people did not seek vaccination for reasons beyond the shortage, including concerns about safety and efficacy and the perceived low risk from influenza. Although some have suggested that this might have been a successful case of health care rationing, it might not be generalizable to shortages of vaccines for other diseases.

Published reports show substantial success in reserving the more limited vaccine supply for high-risk groups. To date, 35 percent of people in these groups have received the vaccine, in comparison with 4 percent of nonpriority adults (ages 18–64). However, among high-risk groups the proportion receiving vaccination in the 2004–05 season was down when compared with reports from the prior season. In 2003–04, 68 percent of those age sixty-five and older, 43 percent of adults with chronic high-risk conditions, and 49 percent of health care workers with patient contact received the vaccine. In this season through November 2004, the reported comparable figures were all lower (51 percent for the elderly 19 percent for those with chronic illness, and 34 percent for health care workers).³ To date, this experience suggests a reversal in the improving vaccination trends for seniors. The percentage of this group reporting receiving a flu vaccine had steadily risen, from 31 percent in 1989 to 68 percent in 2003.⁴

Although the existing supply of vaccine has been reserved for high-priority groups, a recent study showed that a substantial minority of these groups tried to get the influenza vaccine this season and were unable to obtain it. It showed that 37 percent of seniors and 54 percent of those with chronic illnesses were unable to get the vaccine when they tried. Also, studies showed that many people in the high-priority groups who did not try to get vaccinated did not try because of their perception of a shortage this year.⁵

How did the American public respond to this major shortage of vaccine in 2004, and what are the implications for potential events in the future? Using results from a survey conducted by the Harvard School of Public Health and four other national opinion surveys conducted by media organizations, the authors address five issues: (1) How concerned was the public about this major shortage of flu vaccine? (2) Who do they believe was responsible for the shortage? (3) In the future, who should be principally responsible for ensuring that there is an adequate supply of vaccine? (4) Who should decide how the vaccine should be allocated in a shortage, and was the current allocation system seen as fair and equitable? (5) What does the public believe about the seriousness of influenza as an illness, the effectiveness of the vaccine, and its safety, including the safety of an imported vaccine? How might these perceptions affect demand for the vaccine in the future? Would we expect similar effects if there were shortages of other types of vaccine during a widespread epidemic?

Data Sources And Methods

Top Data Sources And Methods Study Results Discussion And Conclusions NOTES

 
The data presented here are mainly derived from a survey designed by researchers at the Harvard School of Public Health. Telephone interviews were conducted by International Communications Research (ICR) between 29 October and 9 November 2004. The questionnaire was administered to adults age eighteen and older, selected using a fully replicated, stratified, single-stage, random-digit-dialing sample of households nationally. A total of 1,227 adults completed interviews. This group included an oversample of parents with children ages 6–23 months. A total of 249 interviews with this group were completed.⁶

The data were weighted to account for the disproportionate probability of household selection attributable to multiple telephone lines and the probability associated with the random selection of an individual household member. In addition, the data were weighted by age, sex, race/ethnicity, education, region, census division, and metropolitan status to be nationally representative.⁷

When interpreting these findings, one should recognize that all surveys are subject to sampling error. Results might differ from what would be obtained if the whole U.S. adult population had been interviewed. The size of this error varies with the number of people surveyed and the magnitude of differences in the responses to each question. The sample error for 1,227 respondents is plus or minus three percentage points.

Study Results

Top Data Sources And Methods Study Results Discussion And Conclusions NOTES

 
Was the public aware of the influenza vaccine shortage, and whom did they blame for it? The public was aware of the shortage of influenza vaccine. The majority of respondents believed that their community was experiencing a shortage of influenza vaccine (66 percent), and six in ten of those were concerned about the shortage (31 percent very concerned, 31 percent somewhat concerned).⁸ In a survey taken after the shortfall was announced, 43 percent of respondents said that they were following the news story very closely. This is greater than the percentage who said that they were following stories about drug safety after the recall of the drug Vioxx, Elizabeth Edwards’ diagnosis of breast cancer, and reports of a vaccine that could protect women from cervical cancer.⁹

The public did not hold any one group responsible for the shortage of influenza vaccine (Exhibit 1). Nearly 40 percent blamed vaccine manufacturers and pharmaceutical companies, and nearly 30 percent blamed federal government public health agencies. The public was much less likely to blame state and local governments, people getting vaccinated who are not at high risk, health plans and insurers, or physician organizations.¹⁰ Similarly, other polling found that nearly 40 percent of respondents thought that "the vaccine manufacturer that had problems with the safety of its facility" was most at fault, one-third thought that a federal health agency was most at fault, and 26 percent said that they did not know who was at fault (Exhibit 1).¹¹ In a third poll, only one in three Americans said that the Bush administration was to blame.¹² Of note, a survey taken at the time of the influenza vaccine shortage found that confidence in the CDC and the U.S. Food and Drug Administration (FDA) remained high.¹³

The vaccine allocation system. The survey asked about respondents’ views of the CDC’s vaccine allocation guidelines. Although respondents were generally supportive of reserving the vaccine for those at the highest health risk, the survey found a sizable proportion believing that the responsibility for allocating the vaccine should not lie with the CDC. Respondents were far more likely to say that individual doctors and nurses should decide who receives it; many fewer thought that a government agency should have this responsibility (Exhibit 2). In addition, there was much skepticism among the public about how this allocation system would work in reality. Only 14 percent reported being very confident that "government agencies, together with the vaccine industry" would assure that the limited supply of vaccine would be distributed fairly. Two-thirds of respondents believed that wealthy or influential people would be able to get the vaccine even if they were not in a high-risk group (Exhibit 2).¹⁵

How would the public have preferred that the scarce vaccine be allocated? After being told that there was a limited supply of the influenza vaccine, respondents were asked what would be the best way to distribute the vaccine fairly. Slightly more than half said that the vaccine should be reserved for high-risk groups, one-third believed that doctors and nurses should decide who should get the vaccine, and 4 percent thought that the vaccine should be given to anyone who wants it until it is gone (Exhibit 2).

The survey also gave respondents the following scenario: "Some people who are not at a high risk for getting a serious case of influenza as defined by the CDC have been trying to get the flu vaccine." Respondents were then asked which came closer to their view: "These people should not be allowed to get the vaccine because there are people who need it more than they do, or these people should be able to get the vaccine because they themselves are the best judge of how much they need it." About two-thirds responded that those who are not at high risk should not be allowed to get the vaccine (Exhibit 2). Among those, 58 percent believed that the doctors who give the vaccines should be responsible for ensuring this; one-fifth thought that local health authorities should have this responsibility, and approximately equal proportions said that the CDC (10 percent) or the people themselves (9 percent) should be responsible.

Knowledge of influenza and the flu vaccine. In understanding the public’s reaction to the flu vaccine shortage, it is important to examine beliefs about the seriousness of influenza and the safety and efficacy of the vaccine. The survey asked the public about their knowledge of influenza, the effectiveness of the vaccine and other preventive measures that they could take to avoid becoming ill with influenza, and worries about side effects from the vaccine.

The public underestimated the severity of influenza as an illness (Exhibit 3). When asked to estimate the number of Americans who die each year from influenza, 27 percent of respondents cited less than 1,000; one-third cited 1,000–19,999; just about a tenth cited 20,000–39,999; and approximately one-quarter said that they did not know.¹⁸ The CDC estimates that influenza accounts for approximately 36,000 deaths each year.¹⁹

When asked specifically about the 2004–05 flu vaccine, only 30 percent believed that it would be very effective at preventing people from getting influenza. Also, although the risk of serious side effects from the vaccine has been shown to be very low, a minority reported concerns about side effects. One-fifth said that it was very likely that a person who got the vaccine would experience at least one of the following side effects: fever or extreme tiredness, getting influenza or a serious illness, or death.²¹ There were no significant differences in concerns about side effects between Americans in high-risk groups and those who were not at high risk for serious complications from influenza (data not shown).

Willingness to receive an imported flu vaccine. To ease the vaccine shortage, the U.S. Department of Health and Human Services (HHS) announced that it would purchase up to four million doses of the vaccine from Germany.²² This vaccine, Fluarix (manufactured by GlaxoSmithKline), is fully approved for use in Germany; however, it is not approved for general use in the United States and is therefore considered investigational for legal purposes. After being told that the vaccine was considered investigational, respondents were asked about their willingness to receive it if no other vaccine were available. More than half said that they would be willing to take it if no other vaccine were available (Exhibit 4). However, after respondents were told that they would have to sign a waiver stating that they were aware that the imported vaccine was considered investigational, their willingness to receive the vaccine decreased more than ten percentage points. Among African Americans, willingness to receive the imported vaccine decreased from 54 percent to 34 percent when they were told they would have to sign a waiver (data not shown). Overall, 15 percent reported being very worried about either the safety or the efficacy of the imported vaccine (data not shown).²³ Similarly, a survey taken after HHS announced plans to import the influenza vaccine from Germany found that 36 percent of Americans would feel safe receiving this vaccine (Exhibit 4).²⁴

Top Data Sources And Methods Study Results Discussion And Conclusions NOTES

Second, it is important to realize that many Americans who are at high risk for serious complications from influenza have not sought the vaccine for many reasons, in addition to the announced shortage. These reasons include concerns about the vaccine’s effectiveness and safety, as well as perceptions of being at low risk for influenza (Exhibit 3). Reducing the number of flu deaths each year will require broader public understanding that the vaccine is generally safe and effective and that more than 30,000 people die each year from the effects of influenza. Health officials and health care providers, including private physicians and nurses, need to continue their educational efforts emphasizing the need for these groups and the general public to get vaccinated. Although this is the strategy that the government should follow during future influenza seasons, it may be difficult to convince the general public that there will be an ample supply of the vaccine after this year’s shortage.²⁶

In addition, receiving an imported vaccine that is labeled as investigational raises serious concerns about safety among many Americans. Public health authorities and health care workers will need to explain that imported vaccines have been fully tested in other countries for both safety and effectiveness. Otherwise, it is likely that a substantial share of adults at high health risk will refuse to take such a vaccine if it is offered. Our results suggest that this is of particular concern among African Americans, who have a historical concern about experimentation by public health authorities.²⁷

Finally, it has been suggested that the recent flu vaccine shortage provided a successful experiment in health care rationing.²⁸ Our survey suggests that these results may not be generalizable to other situations. Even in the case of influenza, a disease perceived by most of the public as relatively benign, four in ten respondents did not believe that the vaccine should be reserved for high-risk groups. The willingness of many Americans to go along with the vaccine allocation system this year may have been a result of a mild influenza season or of believing that influenza is not a serious illness, that the vaccine is not effective, or that there was a risk of serious side effects from the vaccine. However, the U.S. experience might be very different in the case of a disease that is perceived to be highly lethal and highly contagious, and for which the public believes there is an effective vaccine. Surveys taken immediately prior to the Iraq war found that the public would be willing to take the smallpox vaccine—even when they were told that there is a considerable risk of serious side effects—and that Americans wanted the vaccine to be available to the general public rather than being reserved for health care workers.²⁹ This suggests that in these instances the demand for the vaccine might make it much more difficult for physicians and public health officials to ration a limited supply based on categories of health risk.

Editor's Notes

 
Catherine DesRoches (cdesroch{at}hsph.harvard.edu) is a research scientist at the Harvard School of Public Health in Boston, Massachusetts. Bob Blendon is a professor of health policy and political analysis there. John Benson is managing director of the Harvard Opinion Research Program.

This work was supported by a cooperative agreement with the U.S. Centers for Disease Control and Prevention to provide technical assistance for public health communication by monitoring the response of the general public to public health threats.

NOTES

Top Data Sources And Methods Study Results Discussion And Conclusions NOTES

 

1. "U.S. to Import Flu Vaccine," Medicine and Health (13 December 2004): 5.
2. U.S. Centers for Disease Control and Prevention, "Interim Influenza Vaccination Recommendations, 2004–05 Season," 22 December 2004, www.cdc.gov/flu/protect/whoshouldget.htm (1 March 2005).
3. "Estimated Influenza Vaccination Coverage among Adults and Children—United States, September 1–November 30, 2004," Morbidity and Mortality Weekly Report 53, no. 49 (2004): 1147–1153.
4. National Center for Health Statistics, Health, United States, 2004, with Chartbook on Trends in the Health of Americans (Hyattsville, Md.: NCHS, 2004), 81.
5. "Experiences with Obtaining Influenza Vaccination among Persons in Priority Groups during a Vaccine Shortage—United States, October–November, 2004," Morbidity and Mortality Weekly Report 53, no. 49 (2004): 1153–1155.
6. Harvard School of Public Health/International Communications Research flu vaccine survey, 29 October–9 November 2004 (Storrs, Conn.: Roper Center for Public Opinion Research, 2004).
7. The study was conducted as part of an omnibus survey; therefore, the data are not collected in a way that allows for the calculation of the response rate. However, studies have indicated that when the results from a survey with a long field period and a high response rate are compared with a survey with a field time that is similar to the Harvard School of Public Health survey, few statistically significant differences are observed between responses from the two surveys when the data are statistically reweighted. Pew Research Center for the People and the Press, "Polls Face Growing Resistance, but Still Respresentative: Survey Experiment Shows," 2004, people-press.org/reports/display.php3?ReportID=211 (19 March 2005); S. Keeter et al., "Consequences of Reducing Nonresponse in a National Telephone Survey," Public Opinion Quarterly 64, no. 2 (2000): 125–148[Abstract]; and R. Curtin, S. Presser, and E. Singer, "The Effects of Response Rate Changes on the Index of Consumer Sentiment," Public Opinion Quarterly 64, no. 4 (2000): 413–428.[Abstract]
8. Harvard School of Public Health/ICR flu vaccine survey.
9. Henry J. Kaiser Family Foundation/Harvard School of Public Health poll, 2–5 December 2004 (Roper Center, 2004). Elizabeth Edwards is the wife of John Edwards, the 2004 Democratic candidate for vice president.
10. Harvard School of Public Health/ICR flu vaccine survey.
11. That survey specifically asked about the CDC, the Food and Drug Administration, and the U.S.Department of Health and Human Services. Wall Street Journal/Harris Interactive health care poll, 14–16 December 2004, www.harrisinteractive.com/news/newsletters/wsjhealthnews/WSJOnline_HI_Health-carePoll2004vol3_iss25.pdf (19 March 2005).
12. ABC News/Washington Post poll, 18–20 October 2004 (Roper Center, 2004).
13. Harris poll, 20–25 October 2004, www.harrisinteractive.com/harris_poll/index.asp?PID=524 (5 January 2005).
14. Harvard School of Public Health/ICR flu vaccine survey.
15. Ibid.
16. F. Katayama, "Sickening Prices," CNN.com, www.cnn.com/2004/US/10/13/flu.shot.prices/index.html (1 March 2005).
17. Harvard School of Public Health/ICR flu vaccine survey.
18. Ibid.
19. "Experiences with Influenza-Like Illness and Attitudes regarding Influenza Prevention—United States, 2003–04 Influenza Season," Morbidity and Mortality Weekly Report 53, no. 49 (2004): 1156–1158.
20. CDC, "Key Facts about the Flu: How to Prevent the Flu and What to Do If You Get Sick," 10 November 2004, www.cdc.gov/flu/keyfacts.htm (7 January 2005); and Harvard School of Public Health flu survey.
21. CDC, "Vaccine Side Effects," 11 May 2004, www.cdc.gov/nip/vacsafe/concerns/side-effects.htm#flu (7 January 2005); and Harvard School of Public Health/ICR flu vaccine survey.
22. "U.S. to Import Flu Vaccine," Medicine and Health (13 December 2004).
23. Harvard School of Public Health/ICR flu vaccine survey.
24. Wall Street Journal/Harris Interactive health care poll.
25. S.L. Knobler et al., eds., The Threat of Pandemic Influenza: Are We Ready? (Washington: National Academies Press, 2004).
26. "New England Pushes to Find Takers for Flu Shots," Boston Globe, 12 January 2005.
27. R.D. Lasker, Redefining Readiness: Terrorism Planning through the Eyes of the Public (New York: New York Academy of Medicine, 2004).
28. T.H. Lee, "Rationing Influenza Vaccine," New England Journal of Medicine 351, no. 23 (2004): 2365–2366.[Free Full Text]
29. R.J. Blendon et al., "The Public and the Smallpox Threat," New England Journal of Medicine 348, no. 5 (2003): 426–432[Abstract/Free Full Text]; and Lasker, Redefining Readiness.

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