REPORT TO THE PRESIDENT

REGARDING CURRENT
SEASONAL INFLUENZA POLICY
An executive policy briefing by the Office of Science
and Technology Policy
Emma Cammann, Ngozi Okaru, Neha Shah, Breanna Walsh
Spring 2015

Executive Summary:
Seasonal influenza annually infects between 5 to 20 percent of the
United States population. Many severe instances of influenza occur in
high-risk populations, resulting in higher rates of hospitalization and
death due to complications during infection. Complications requiring
hospitalization burden the U.S. economy by billions of dollars annually.
High-risk populations include adults aged 65 and older, children under
the age of 5, people with chronic health conditions, and pregnant
women. Recommended goals include modifying vaccine strategies and
limiting antiviral treatment for these high-risk populations. To
implement these goals, future policy should work to promote
vaccination modifications and antiviral treatment for these populations.
In addition, education about vaccine treatment should focus on the
target populations that fall into the high-risk category. To measure the
successes of these strategies, observational studies and interviews can
then be done to measure the policy's effects on these populations.
Future policy should concentrate on minimizing the number of
complications, hospitalizations, and deaths due to influenza, especially
in these high-risk populations.

TABLE OF CONTENTS
Article I.
Problem Statement..
.1
Article II.
Background
..1-3
Section
Section
Section
Section

II.1
II.2
II.3
II.4

Influenza Virus
Influenza Vaccine
Influenza Antiviral Treatments
Defining High-Risk Populations

(a) Adults Ages 65 and Over

(b) Children Under the Age of 5
(c) People with Chronic Health Conditions
(d) Pregnant Women

Article III. Economic

Justification..3
Article IV. Recommended
Goals...3-4
Section IV.1
Promote the implementation of targeted
vaccination strategies among high-risk populations.
Section IV.2
The use of antiviral medications should be
reserved for high-risk populations and heavily regulated
for treatment of seasonal influenza.
Section IV.3
Improve educational outreach and
awareness campaigns regarding seasonal influenza in
high-risk populations.

Article V.
Recommended Implementation
Strategies..5-7
Section V.1

Vaccine Policy Specific Recommendations

(a) Adults over the age of 65

(b) Children Under the Age of 5
(c) People with Chronic Health Conditions
(d) Pregnant Women

Section V.2
Antiviral Policy Specific Recommendations
Section V.3
Education Outreach Specific
Recommendations
(a) Adults aged 65 and older
(b) Pregnant Women
(c) Parents of children Aged 2 to 5
(d) People with Chronic Health Conditions

Article VI. Recommendations for Measuring

Success.7
Article VII. Conclusion
...8

PROBLEM STATEMENT

Seasonal influenza is a contagious, respiratory illness caused by a virus

that infects between 5 and 20 percent of the United States population
each year.1

Figure 1. As many as 1 in 5 U.S. citizens are infected with influenza

annually.
In the U.S., an estimated 200,000 hospitalizations and 36,000 deaths
occur annually due to complications related to the virus.2 In other
words, nearly 1 in 1600 people are hospitalized with influenza-related
complications, while almost 1 in 9000 people die of these
complications. Populations at high-risk of hospitalization and death
include:
Older adults, specifically those age 65 and older
Children, specifically those under the age of 5
People with chronic health conditions, including asthma,
diabetes, and heart disease
Pregnant women
While universal vaccination of all U.S. residents against seasonal
influenza is currently recommended by the Centers for Disease Control
and Prevention(CDC), it is neither an economically nor politically
feasible plan of action. For this reason, influenza policy should be
focused on preventing severe cases of influenza that lead to
complications, hospitalizations, and deaths, particularly within the
demographic groups listed above. Using targeted vaccination,
education, and treatment methods, this policy aims to lower the
current rate of influenza infection in the United States, while also
maintaining tenets of fiscal responsibility and medical autonomy.

1 U.S. Department of Health and Human Services, Seasonal Flu

2 U.S. Department of Health and Human Services, Seasonal Flu and Rothberg, et al., 2008
1

Article VIII. BACKGROUND

Section VIII.1 Influenza Virus
The influenza virus attacks the respiratory tract, with symptoms
including fever, chills, dry cough, and body aches.3 Complications,
such as pneumonia, bronchitis, asthma attacks, sinus infections, and
ear infections commonly develop in high-risk populations, which can
lead to hospitalization and death. The influenza virus also changes
rapidly; therefore, different strains circulate throughout the population
each year.4 It is for this reason that new vaccines must be
manufactured annually.

Section VIII.2 Influenza Vaccine

The seasonal influenza vaccine is the most effective method for
preventing both the infection and spread of the influenza virus.5 In the
United States, an estimated 3 million medical visits and 90,000
hospitalizations were averted by use of the influenza vaccine during
the 2013-2014 influenza season.6 There are two major types of
vaccine: the live attenuated influenza virus vaccine (LAIV), a nasal
spray, and the injectable inactivated influenza virus vaccine (IIV),
which does not contain any live virus.7

Section VIII.3 Influenza Antiviral Treatments

Antiviral medications were first utilized and recommended for cases of
pandemic influenza, rather than seasonal bouts.8 Currently, antivirals
are used to shorten the duration and severity of influenza symptoms in
cases detected within 48 hours of infection.9 However, influenza is a
rapidly evolving virus. While antiviral drugs are widely effective now,
evidence suggests that some influenza strains have already become
resistant to oseltamivir (Tamiflu).10 Just as widespread antibiotic use
has perpetuated antibiotic-resistant bacteria strains, widespread
antiviral use could give rise to antiviral-resistant forms of influenza.

3 Mayo Foundation for Medical Education and Research, Influenza

4 Mayo Foundation for Medical Education and Research, Influenza
5 Reed, et al., 2014
6 Reed, et al., 2014
7 Centers for Disease Control and Prevention, Inactivated Influenza Vaccine.
8 World Health Organization, 2010
9 Centers for Disease Control and Prevention, "Use of Antivirals."
10 Centers for Disease Control and Prevention, "Antiviral Drug Resistance
2

Section VIII.4 Defining High-Risk Populations

(a) Adults aged 65 and over. This age group has increasingly
high hospitalization rates; moreover, the mortality rate for
people above the age of 85 is sixteen times greater than those
who are between 65-69 years of age.11
(b) Children under the age of 5. Each year, an average of 20,000
children of this age are hospitalized due to complications related
to influenza.12 Children are at higher risk for developing severe
influenza primarily due to weakened immune systems. In
addition, infected children are often responsible for many adult
influenza infections.
(c) People with chronic health conditions. People suffering from
chronic health conditions such as asthma, diabetes, and heart
disease are at a higher risk for influenza complications and thus
have higher rates of hospitalization and death.13 In addition,
people ages 45-64 with preexisting medical conditions have an
equivalent risk of influenza-related complications to that of those
aged 65 and older.14
(d) Pregnant women. Pregnant women are at an especially high
risk of contracting influenza due to immune system changes.15 In
addition, expectant mothers are more likely to have
cardiopulmonary complications during influenza season, leading
to long-term hospitalization and expensive procedures. This fact
is of particular importance because there was only a 40.7%
reported vaccination rate among pregnant women during the
2013-14 influenza season.16

Article IX.

ECONOMIC JUSTIFICATION

There needs to be a heightened effort to decrease the death rate due

to seasonal influenza. Deaths are often prefaced by hospitalizations;
therefore, prevention and treatment should be stressed for populations
that have high hospitalization rates. Hospitalization is one of the most
expensive impacts of seasonal influenza, as influenza-related medical
expenses cost taxpayers billions of dollars each year (e.g. influenza-

11 Rothberg, et al., 2008

12 Centers for Disease Control and Prevention, Children, the Flu, and the Flu Vaccine
13 Rothberg, et al., 2008
14 Rothberg, et al., 2008
15 Flannery, et al., 2015
16 Rothberg, et al., 2008
3

related medical expenses alone cost $10.4 billion dollars in 2003). 17 It

follows that a decrease in the number of hospitalizations would also
alleviate some of the economic burden currently associated with
influenza. In order to do this, public health policy should strive to
prevent severe influenza in people with a high risk of hospitalization.
Table 1. Influenza related expenses are detrimental to the U.S.
economy. The following data show the most recent calculations of the
economic burden of influenza.
ECONOMIC BURDEN OF INFLUENZA
Average influenza-related hospitalization cost
$6,90018
Number of influenza-related hospitalized days
3.1 million*
Total influenza related medical expenses
$10.4
billion*
Average work hours lost by parents due to children with
73 hours19
influenza
Total economic burden of influenza
$87.1
billion*
20
*

Article X.

RECOMMENDED GOALS

Section X.1
Promote the implementation of targeted
vaccination strategies among high-risk populations.
Children and the elderly are vaccinated at increased levels in
comparison to the rest of the population; however, the administered
vaccines may not be of optimum
efficacy. Additionally, there is low vaccine uptake among those with
chronic health conditions and pregnant women.21

17 Molina, et al., 2007

18 Milenkovic, Agency for Healthcare Research and Quality, 2006.
19 Centers for Disease Control and Prevention, Treating Childrens Flu Illness Costly
20 Molina, et al., 2007
21 Centers for Disease Control and Prevention, "Pregnant Women and Flu Vaccination and Centers for
Disease Control and Prevention, "Influenza Vaccination Information for Health Care Workers."

Figure 2. Influenza vaccine doses distributed in the United

States, by season. The number of influenza vaccine doses
distributed steadily increased until 2011, after the 2009 H1N1
pandemic, but then fell.

Section X.2
The use of antiviral medications should be
reserved for high-risk populations and heavily regulated
for treatment of seasonal influenza.
Widespread use of antiviral drugs is predicted to give rise to antiviral
resistant strains of influenza.22 If high-risk populations become infected
with such strains, rates of hospitalization, complication, and death will
skyrocket.

Section X.3
Improve educational outreach and
awareness campaigns regarding seasonal influenza in
high-risk populations.
Despite the CDCs extensive education efforts, it remains difficult for
members of high-risk populations to find demographic-specific
influenza information. Given that education is an incredibly costeffective method of reducing the burden of disease, more steps should
be made to address these high-risk populations through this method.23

22 Hayden and Menno, 2011

23 Mitic, et al., 2012
5

Article XI. RECOMMENDED IMPLEMENTATION

STRATEGIES
Section XI.1

Vaccine Policy Specific Recommendations:

(a) Adults over the age of 65:

A high dose variation of the trivalent seasonal influenza
vaccine should be administered. Due to the weakening of the
immune system over time, older adults require a more
powerful dose of the vaccine.24 The use of the high dose
vaccine is predicted to eliminate 22,567 influenza-related
hospitalizations and 5423 influenza-related deaths, resulting
in total economic savings of $154 million.25
(b) Children under the age of 5:
The Live Attenuated Influenza Vaccine (LAIV) should be used
for vaccination of children ages 2 to 5. While the LAIV costs
an additional $7.72 per vaccination, LAIV use has a total net
cost savings of $45.80 per vaccinated child, as there are
fewer influenza-related hospitalizations and lost productivity
hours for parents.26
Children between the ages of 6 months and 2 years should
receive either the LAIV or the Inactivated Influenza Vaccine
(IIV), as recommended by a pediatrician.27
Those living in a household with immunosuppressed persons
should receive the IIV.28
Children with a history of respiratory illness,
immunosuppressive conditions or wheezing should be
administered the IIV, regardless of age.29
First-time recipients of the influenza vaccine should receive
two doses of the vaccine within the span of four weeks.30
(c) Persons with chronic health conditions:
This population should be granted a recommendation and
offer of vaccination at the time of prescription pick-up, while
also receiving increased education and the option of
vaccination from their healthcare provider during regularly
scheduled appointments.
24 DiazGranados, et al., 2015
25 Chit, et al., 2014
26 Luce, et al., 2008
27 Belshe, et al., 2007
28 Immunization Action Coalition, "Ask the Experts: Diseases & Vaccines-Influenza."
29 Belshe, et al., 2007
30 Centers for Disease Control and Prevention, Recommended Immunization Schedules
6

Since different chronic health problems have different

implications, the distinction between using the LAIV vs. IIV
vaccines be left up to healthcare providers.

(d) Pregnant women:

Influenza vaccines should become a standard component of
prenatal care and vaccination should be made available at
OB-GYN practices. Additionally, vaccination of expectant
mothers is also the leading mode of influenza prevention in
infants under the age of 6 months.31
Since the immune systems of pregnant women are partially
suppressed, pregnant women and people who live in close
contact with pregnant women should receive the IIV.32

Section XI.2

Antiviral Policy Specific Recommendations:

In cases of pandemic influenza, antiviral medications should

be made available to all persons, with priority given to highrisk individuals.
In cases of seasonal influenza, antivirals should only be
administered to members of high-risk populations, in an effort
to preemptively combat drug resistance.
Antiviral medications should be made readily accessible to
high-risk individuals, as these medications are most effective
if administered within 48 hours of infection.33 Primary care
physicians should be able to prescribe antivirals to these
individuals via telecommunication appointments.

Section XI.3
Education Outreach Specific
Recommendations:
(a) Adults aged 65 and older:
As the use of the Internet and social media campaigns is less
effective in reaching this demographic, the more traditional
methods of spreading influenza awareness should continue to
be utilized. These methods include flyers, televisions
advertisements, PSAs, newspaper articles, and physician
recommendations.
(b) Pregnant women:
As this demographic tends to be more involved in social
media, platforms such as Pinterest, Facebook, Twitter and
Instagram can be utilized as educational tools.
31 Takeda, 2015.
32 Immunization Action Coalition, "Ask the Experts: Diseases & Vaccines-Influenza."
33 Centers for Disease Control and Prevention, "Use of Antivirals."
7

Considering that over one-quarter of expectant mothers do

not receive vaccination recommendations, OB-GYNs should
also be encouraged to remind their patients about the
importance of prenatal vaccination.

(c) Parents of children aged 2 to 5:

This demographic often overlaps with pregnant women;
therefore, social media campaigns can still be utilized as
educational tools.
Additionally, pediatricians and daycare centers should be
encouraged to promote influenza awareness through direct
conversations, emails, and pamphlets.
(d) People with chronic health conditions:
This demographic can be taught and reminded of influenza
prevention techniques while receiving other medical care.
Specifically, both verbal and written vaccination reminders
should be given out at the time of regular prescription.

Article XII. RECOMMENDATIONS FOR

MEASURING SUCCESS
Using data collected by public health workers and documented in
hospital records, a variety of metrics need to be collected. With the
overarching goal of reducing the number of hospitalizations and deaths
due to seasonal influenza, the most useful measures will be the rates
of hospitalization for influenza-related illness and the number of deaths
caused by influenza-related complications. Complete medical
histories, which include vaccination, education, and treatment history
should be taken for all patients hospitalized with influenza-related
illness.

Through observational studies, the CDC uses influenzasensitive diagnostic tests to measure vaccine effectiveness.34
To measure the success of the aforementioned
recommendations, data on the number of hospitalizations and
deaths among both vaccinated and unvaccinated high-risk
individuals should be collected from hospital records.
The number of influenza-related hospitalizations and deaths
among high-risk individuals should be collected from hospital
records, along with history of antiviral prescription. After
three years, the data should be analyzed, leading to either
reinforcement or reevaluation of influenza treatment policy.

34 Centers for Disease Control and Prevention, "Vaccine Effectiveness."

8

Influenza-related educational material effectiveness has been

tested by self-report telephone interviews.35 People who fall
into the category of high-risk for influenza-related
hospitalizations could be polled to check if vaccination rates
have increased in this population due to educational
materials.

After three years, the data should be compiled and analyzed, leading
to either reinforcement or reevaluation of the proposed policy. If there
is no change in hospitalization or mortality rates due to influenza, yet
cost savings have been successful, the new policy should be
maintained.

Article XIII. CONCLUSION

Through a comprehensive policy that targets high-risk populations,
including adults age 65 and older, children under the age of 5,
pregnant women, people with pre-existing health conditions, and
health care workers, the burden of influenza-related hospitalizations
can be drastically reduced- saving lives in an economically feasible
manner. It is imperative to successfully manage severe cases of
influenza in high-risk populations, as these cases are responsible for
the largest portion of the economic burden of influenza and can
frequently lead to death.

Implement
targeted
Vaccination
Strategies

Make vaccine
35 Armstrong,
1999.
recommendatio
ns demographic
specific

Development of
new seasonal
influenza policy

Implementation
of new seasonal
influenza policy

Limit the use of

antivirals
influenza
medication to
high-risk
patients and
pandemic
situations

Increase the
presence of
demographic
specific
influenza
education

Increase
vaccine
availibity for
high-risk 9
populations

Use social
media to target
younger
demographics

Reevaluation of
seasonal
influenza policy

Use existing
healthcare
services to
target people
with preexisting
condtions

Figure 3. Overview of proposed plan of action. Purple indicates a

process that should be continued on a yearly basis and white indicates
the changes that will be implemented with this specific policy
statement.

10

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14