Go figure, I’ve been in a holiday mood lately and with things slowing down at work there is extra time to catch up on some seasonal episodes of my favorite shows. Last night was NCIS season 11 episode 11: “Homesick”. The story line is that a severe respiratory disease is affecting the children of military personnel around the DC area. As the team works with the Centers for Disease Control and Prevention (CDC) to identify the source of the infection, Dr. Mallard, the NCIS Medical Examiner, calls Gibbs to notify him of the first fatality. When Gibbs asks which of the children has died, Mallard replies
When it comes to infectious diseases, the old are just as vulnerable as the young.
Camera then pans to an ashen-skinned, gray-haired male lying in an open body bag. Who knows where thoughts come from; but, that single line from a fictional show set forward an internal tirade revolving around the real price American’s pay each year due to two (mostly) preventable illnesses, influenza and pneumonia. The price is paid in terms of hospitalization costs, lost days of productivity, and, in the worst of cases, with loss of life.
The price paid
No clear statistics are available with regard to the cost America pays due to workers sick with the flu or pneumonia. However, using diagnosis data from patients that seek professional medical treatment and some BLS averages, the Agency for Healthcare Research and Quality (AHRQ) estimates that America spends $87 billion a year on medical care (a direct cost) while workers lose 70 million days of work for approximately $9.5 billion in lost wages.
Together, influenza and pneumonia are the eighth leading cause of death in the U.S. across all age groups claiming 55,227 lives in 2014, the latest year reported by the CDC. With 44,836/55,227 deaths in persons age 65 and older, clearly the elderly make up the majority (81%) of influenza and pneumonia fatalities. There are physiologic and environmental reasons that cause the elderly to have a significantly higher influenza and pneumonia incidence and mortality rate than younger populations.
A person’s physiology and environment are two of the three key factors that epidemiologists examine when studying disease. In the Epidemiology Triangle three factors are necessary for disease to spread: a susceptible host, a conducive environment, and an external disease-agent. To stop the spread of a disease one need only to remove one of the three factors. One “host” factor that is easily influenced is that of immunity via vaccination.
The CDC recommends that all persons over age 6 months be immunized against the flu. People over age 65, all health care workers with face-to-face patient contact, as well as others that may be susceptible to flu are considered to be at increased risk and are strongly suggested to receive an annual vaccination. Yearly vaccination for influenza is required because different strains of the flu afflict the U.S. as the disease migrates. World-wide teams of epidemiological and public health specialist make educated guesses of the top four strains likely to hit the U.S. Those strains provide the basis used in the formulary of each year’s flu vaccine production run. Historically, the flu vaccine has a 50-60% success rate at preventing the flu. Even why the exact strain in the vaccine is wrong, studies show that people immunized have 57% fewer hospital admissions and report milder symptoms than the full blown flu. Further, Fireman et al, (2009) estimates that 1 life is saved for every 4,000 people vaccinated against the flu.
The pneumonia or pneumococcal vaccine is really two separate vaccinations that are given at least a year apart. The two vaccinations provide protection against 36 disease-causing strains of pneumococcal bacteria as well as providing some protection against bacterial meningitis. For most, the vaccines provide lifetime immunity. Some people may be at higher risk of immunologic compromise and require a “booster” every so often. Patients, especially those over age 50, or with compromised immune systems, should follow the recommendation of their primary care physician or seek guidance at the local health department.
Both the influenza and pneumococcal vaccine are covered 100% for people receiving Medicare part B. The Vaccines for Children (VFC) program allows eligible children up to age 19 to also receive the vaccinations free of charge. As well, private insurance companies and employer-health programs are required to cover vaccinations as a provision of the Affordable Care Act (ACA).
Immunization rates are rising
It is difficult to contribute the rise in immunization use to a single cause. Whether it is due to public education, insurance coverage, or wide-spread availability; the number of adults receiving annual influenza vaccinations has been rising. In 2004 the vaccination rate was 35.9%. The percentage of adults receiving the annual flu shot in 2015 was only 48.5%, even though vaccinations are covered since 2010.
Has the increased use of immunizations made a difference?
The CDC reports that deaths from influenza and pneumonia have been dropping by approximately 3.8% a year since 1999. This roughly corresponds with the increased rate of vaccination. It is easy to surmise that increased use of vaccines is attributable to a lower number of deaths from flu and pneumonia each year but vaccination is only a part of the picture. Improvements in treatment, institutional policy changes, and prevention via environmental controls have also worked to decrease the infection and death rate.
Does the cost of flu and pneumonia vaccination outweigh the costs and risks associated with becoming ill?
For working adults, considering that the average U.S. worker misses 3 days of work when catching the flu and makes $17/hr the comparison of $408 in lost wages against a $7.24 – $35.75 flu vaccine is easy. Even looking at population-size numbers and using the most expensive ($35.75) vaccine, the value of immunization is clear considering that there are 159.5 million U.S. workers it would cost $5.7 billion to immunize compared to $9.5 billion in lost wages. This doesn’t even account for additional costs of care for which America spends approximately $4 billion a year. Things get tricky when comparing the cost for pneumonia vaccines which are more expensive and generally given to older people.
It is easy to compare the monetary cost involved with prevention of influenza and pneumonia. Providing the flu shot and pneumonia vaccine has the ability to save billions of dollars a year but it is saving 26,000 lives or more a year that really matters, especially when the majority are as vulnerable as the elderly and children.
What can be done?
Everyone over age 6 months is encouraged to receive an annual influenza vaccination. Vaccination is strongly encouraged for healthcare workers, people with increased risk, and people living with persons that are immuno-compromised. Administration of the influenza is safe, covered by insurance, and some versions don’t require an injection. Remember that insurance companies may place limitations on where the vaccine can be obtained so out-of-pocket cost may be incurred if using an out-of-network provider.
Healthcare providers should obtain an influenza vaccination annually and be extra vigilant in hand washing. Employers should encourage sick workers to stay home – not only will the employee recover sooner, they will not be spreading diseases to fellow workers, customers, and patients. Patients at increased risk and everyone over age 65 should be offered influenza and pneumococcal vaccine when visiting the ED, outpatient clinic, dialysis unit, or lab.
At-home caregivers should certainly receive immunizations as close, prolonged contact increases the risk of spreading flu and pneumonia; especially to patients with decreased mobility. Family members/care givers should arrange for in-house immunization services for persons that are confined to the home.