Wednesday, November 4, 2009

The Flu Shot Truck

Last week I wrote a piece regarding the controversy regarding vaccines and autism, which seems timely given the recent release of vaccine against the H1N1 "swine flu." But worries about vaccine safety are not the only reasons why people don't get their shots. One is a fear of needles, which is my own personal albatross. While it doesn’t faze me in the slightest to take a finely honed 14 gauge tubular piece of stainless steel and ram it into whichever body cavity seems appropriate at the time, the thought of an infinitely smaller 27 gauge butterfly piercing my own this hide is simply excruciating (I’m getting woozy just thinking abut it).

While this is the kind of thing one in the medical profession hopes to keep to themselves, several years ago my aichmophobia (fear of needles or pointed things) became a very public event. During my tenure as Director of Health at the Kansas Department of Health and Environment, we were having a flu shot clinic for state employees. As the down-to-earth, ground-level leader that I was, I walked among the staff, encouraging the troops and eating the cookies set out for the patients without actually doing any work. (This is called “management.”) One of the public relations folks decided it would be a good idea to take a picture of me, the State Health Guy, getting his shot as well.

Mind you, this totally irrational crazy psychiatric needle thing is not something I share on a regular basis. So I looked for an intellectual, yet remarkably cool, way out. I kept stressing that as of yet, I was not in a high-risk group, so I didn’t want the resource wasted on me when it could be used for someone more deserving. That one was pretty good, I thought. Altruistic, willing to risk his own health for that of others. But they still wanted to get a photo, so we reached a compromise. It would look like I was getting the shot, but the needle would be capped and we would rotate just enough so that nobody could see the needle cap. That way it would look real, but we’d still be saving the dose for someone else. (Still holding that “public service” line, too.)

So I rolled up my sleeve, turned three-quarters to the left, put on my requisite public servant smile, and felt the pressure against my arm. Hard. Really hard. I guess you should push hard to make it look right. The photo over, I turned around to see the nurse put the bare needle into the red sharps box.

I don’t remember a whole lot after that. I remember saying “You gave me a SHOT?”, and my eyes must have opened wide because suddenly my peripheral field of vision extended from Salina to Venus. Then I was in a wheelchair, and I was asked if I wanted to lie down. I refused. Leaders don’t lie down. They do, however, sit quietly, pant loudly, become pale and diaphoretic, and experience a full blown panic attack, the last one of which I experienced when I had to ride a roller coaster in order to impress my soon Bride-to-Be (Note to son: Dad’s not going on Space Mountain this year. Or ever).

The following year, when I went to visit the flu clinic, no shots were offered. Apparently I began hyperventilating simply walking in the door, and was directed immediately to a cot without any prior conversation.

While influenza vaccination is currently on everyone’s mind, it is only a small piece of the overall picture of immunization. Vaccination rates in this nation are not what they should be. We have national targets for immunization rates; The Healthy People 2010 Project of the United States Centers for Disease Control suggests that by the end of the decade, 80% of children should receive the minimum recommended vaccine series prior to school entry, and 90% of those adults and children at risk should receive influenza and pneumonia vaccine. (For the record, the minimum recommended vaccines for children as measured by the CDC’s National Immunization Survey is the “4:3:1:3:3” series consisting of 4 doses of diptheria, tetanus, and pertussis vaccine; 3 doses of polio vaccine; 1 doss of measles, mumps, and rubella vaccine; 3 doses of Haemophilus influenza B vaccine; and 3 doses of hepatitis B immunization.) There are also additional childhood immunizations advised to provide further protection, including those for pneumonia, chickenpox, and hepatitis A. Young women may also benefit from administration of human papilloma virus (HPV) vaccine in an effort to prevent cervical cancer.

While these are goals, they do not necessarily equate to complete protection for the population. To achieve population immunity (also known as “herd immunity,” the phenomena where protection a given segment of the population prevents disease in the group as a whole…and probably why everyone instantly understands why airline cabins are also called ‘cattle cars”), an immunization rate of 95% should be our aim (no “shot” pun intended).

Kansas had been especially concerned with childhood immunization rates, and for some time I was pleased to be part of a project known as Immunize Kansas Kids. It’s an undertaking to find out what factors make an immunization program successful in local communities and the state as a whole. While Kansas had been making solid progress in raising our immunization rates, there was still a long way to go to reach our own goal of 90% coverage for the recommended childhood vaccines.

What we found...much to our chagrin, I think…is that there is no easy answer. Some of us thought that state financing of all childhood vaccines was the key, but there is no good link between the way vaccines are financed on a statewide basis and immunization rates. Another thought was that a high reliance of the local public health department (as opposed to within physician’s offices) for vaccination depressed immunization rates, but some of our counties with the highest rates are those without any local physician. Maybe it was a function of geography and transport, but rural areas generally show higher rates than urban ones. A statewide electronic immunization registry was felt by some to be the solution, but while it makes the immunization process more accurate and consistent it doesn’t bring children in the door for shots. Access to care is likely a factor as well, but it’s hard to tell exactly how that plays out in the context of the other factors described. Of course, one of the problems with any study of this kind is that the people to talk to are those who don’t get their kids immunized on time. But since the children don’t get immunized, those families don’t appear on any record until they have to get the shots just before school, two to three years after the optimal window for care.

One thing that seems to be missing from the discussion is the potential role of prehospital EMS services in immunizing the community. While you could argue that doing preventive primary care is not part of the mission of EMS (and I’d argue back at you that any health care professional should morally be concerned with preventing the very suffering that employs you), logistically EMS is ideally suited for immunization efforts, especially in rural areas where "down time" between calls are often prolonged and where it's not cost-effective to run large-scale vaccination clinics. EMS fixed costs such as the unit, the crew, and the station are constant, and previously non-productive time can now be used as an enhanced community resource, an expanded demonstration of paramedic abilty, and even a potential driver of revenue.

That being said, the idea of EMS services, especially those that are fire-based, giving immunizations is not a new one. Many fire stations dispense flu and pneumonia shots to elders every year during the late fall. It’s a community service, there’s cash and/or Medicare reimbursement involved, you never have to leave the comfort of your work “home,” and immunizing adults plays to the comfort level of EMS staff.

But just think of what impact one could make in children, which is our real target population. The mobility of EMS equipment and expertise means that the vaccines can be taken to where the children are, including disadvantaged parts of the community or labor camps in rural areas. EMS is often not perceived as intrusive or punitive in the same fashion as law enforcement, so access to children of migrants or those here under other circumstances may be enhanced. (While the issue of immigration is beyond this discussion, I do agree with Arkansas Gov. Mike Huckabee who noted, in a debate about immigration reform during the last Presidential campaign, that this nation should be above punishing the children for the sins of the father.)

I would suspect that local health departments would be more than willing to work with EMS staff to expand the outreach of their immunization programs, and may in many cases be able to provide supplies and materials, or even reimbursement for services, using their own federally and state funded resources intended for those in need. Participating in such efforts also gives EMS crews more comfort in assessing and caring for children, which can only benefit the total skill set of the paramedic. Importantly, the increased level of visibility that comes with this level of community involvement reinforces the need for support of EMS services at a time when fiscal considerations are putting the industry at risk.

I hope that EMS services will use the opportunities presented by immunization efforts during this year’s influenza outbreak to expand their reach to the full spectrum of immunizations. Just don’t ask me to come by that day. And if you do, have the cot ready.

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