Universal Influenza Vaccination Recommendations:
Local Health Department Perspectives
Geoffrey R. Swain and James Ransom
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M
odern vaccines—including influenza vaccine—provide
a uniquely powerful and cost-effective way to prevent
deadly communicable diseases from spreading.
Unfortunately, since the last decade of the 20th century,
influenza vaccine supply and distribution problems have steadily
grown worse in the United States. Supply disruptions such as
delayed deliveries or shortages have occurred in 5 of the last 6
years, hindering efforts to combat a disease that every year kills
about 36,000 people and sends more than 200,000 to hospital.
Universal influenza recommendations may be one means of
resolving our nation’s recurring influenza vaccine supply and
distribution crises.
KEY WORDS: influenza, local health departments, universal
vaccination, vaccine distribution, vaccine supply
During the influenza vaccine shortage of 2004–2005,
local, state, and federal governmental public health
agencies and vaccine manufacturers collaborated in
an unprecedented effort to share vaccine distribution
information.1–3 This effort was an important step, but
we need to go further. As a nation, we should move to-
ward a clear recommendation for an annual influenza
vaccination for everyone aged 6 months and older. Uni-
versal influenza vaccination would decrease the num-
ber and severity of influenza cases, save lives, and
lessen the impact of influenza on the healthcare system
and economy.4 By increasing demand, universal vac-
cination would be expected to build production and
distribution capacity.
Universal vaccination would not end the vagaries of
vaccine strain production based on egg-based technol-
ogy because there are many variables in this equation
(eg, production, manufacturing, distribution, adminis-
tration of vaccines, market forces).5–7 However, it is es-
sential that we address each variable and make every
J Public Health Management Practice, 2006, 12(4), 317–320
C 2006 Lippincott Williams & Wilkins, Inc.
effort to get to the point where the promise of influenza
vaccine can be made good on in interpandemic periods,
and where we could vaccinate everyone, quickly, in the
event of an influenza pandemic.
If well accepted, a universal vaccination recommen-
dation would provide more stability for vaccine man-
ufacturers, thereby significantly reducing annual fluc-
tuations in demand on the basis of how many cases
of influenza-like illness appear early in the season.
This stability for manufacturers would likely result in
both higher and more stable supplies of vaccine, which
would in turn minimize the confusion of yearly, and
sometimes mid-season, changes in recommendations
that public health leaders must make because supplies
are currently so difficult to predict. Additional bene-
fits would result from the extensive public education
that will be needed to achieve universal vaccination.
People will better understand how vaccines work and
why protecting themselves with annual influenza shots
will also help protect people to whom they might unin-
tentionally transmit the virus—their families, friends,
clients, and coworkers.
Our current system produces mixed messages—
encouraging everyone to get an annual influenza shot,
but having complex risk-based recommendations that
shift with supply forecasts. This article will discuss per-
spectives of local health departments (LHDs), since per-
spectives of private practitioners have been discussed
and detailed elsewhere.8
Minimizing future influenza vaccine supply
disruptions—both for interpandemic influenza and
for pandemic preparedness—is crucial to public
Corresponding author: James Ransom, MPH, National Association of County and
City Health Officials, 1100 17th St NW, Second Floor, Washington, DC 20036
(e-mail: jransom@naccho.org).
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Geoffrey R. Swain, MD, MPH, Associate Medical Director, City of Milwaukee Health
Department, and Center Scientist, Center for Urban Population Health, Milwaukee,
Wisconsin; and Associate Professor, Department of Family Medicine, University of
Wisconsin School of Medicine and Public Health, Madison, Wisconsin.
James Ransom, MPH, Senior Analyst, Immunization Project, National Association of
County and City Health Officials, Washington, DC.
317
318 ❘ Journal of Public Health Management and Practice
health’s mission. However, the manufacturing and
distribution of influenza vaccine is controlled by the
private sector. Even though the public sector accounts
for a best-guess estimate of 15 percent of all doses
purchased and administered,9 local public health is
expected to be responsible for local mass vaccination
in the event of a pandemic. At the same time, local
public health has no solid support from state and
federal agencies for assuring adequate vaccine supply.
In addition, the nation does not have adequate public
sector infrastructure for adult immunizations, and this
gap cripples LHDs’ efforts to develop organizational
capacity and infrastructure to vaccinate hard-to-reach
high-priority adults and their contacts annually. This
differs tremendously from the childhood vaccination
platform, where governmental public health purchases
a bulk quantity of those childhood doses through the
vaccines for children (VFC) program.∗
● Local Public Health Department Perspective
The National Association of County and City Health
Officials (NACCHO) surveys LHDs every influenza
season. Collectively, LHDs are not satisfied with federal
efforts toward addressing the chronic influenza vaccine
supply crises.10,11 Understanding the reasons for frus-
trations at the local level is fundamental to planning
an effective strategy toward implementing universal
recommendations.
Many LHDs are concerned that the federal govern-
ment and vaccine manufacturers are failing to keep a
close eye on the threat from continued influenza vaccine
supply disruptions. In response to years of influenza
vaccine supply disruptions, many communities have
developed their own reallocation and sharing schemes
to better redistribute scarce doses of vaccine.12 The suc-
cesses of these activities have resulted from strategic
community partnerships formed between LHDs, pri-
vate healthcare providers, nursing homes and other
long-term-care facilities, hospitals, community health
centers, pharmacies, and other entities that provide im-
munization services to the community. However, LHDs
facilitate vaccine reallocation among these providers
using 20th-century tools. They determine who has how
many doses of vaccine by making phone calls and they
record the results on simple spreadsheets. Eventually, in
the event of an influenza pandemic, we will need a safe,
sturdy, and reliable 21st-century system to confront it.
∗
The VFC helps families by providing free vaccines to doctors
who serve eligible children and is administered at the national
level by the CDC through the National Immunization Program.
The CDC contracts with vaccine manufacturers to buy vaccines
at reduced rates.
Routine use of state electronic vaccination databases
would be a natural starting point to include adult
immunizations.
Regarding emergency preparedness in general,
LHDs are an increasingly important part of our national
security and readiness interests. But to the extent that
public health preparedness includes the ability to de-
ploy either preexposure or postexposure mass vaccina-
tion, the end result is that the linchpin of our readiness is
in the hands of private companies, whose primary mis-
sion is not to protect the public’s health but to improve
shareholder value. It is imperative to take every op-
portunity to solidify supplies and improve distribution
channels of influenza and other life-saving vaccines.
This may take a multipronged approach that could in-
clude increased public-private partnerships, targeted
governemental regulation, secondary vaccine markets,
federal purchase of additional doses, and last—not the
least—increasing demand through a universal recom-
mendation for influenza vaccine.
● Case Study: Milwaukee
Many LHDs have historically provided substantial di-
rect service delivery of influenza vaccine administra-
tion. More recently, some of these LHDs, like the City of
Milwaukee Health Department (MHD), have partnered
with local mass vaccinators to provide most influenza
vaccine in their communities. In Milwaukee, the MHD
has partnered with the local Visiting Nurse Association
(VNA), and the VNA holds a large number of public
influenza vaccine clinics at multiple sites distributed
throughout the area. The MHD helps assure that sites
serving underserved populations are included in the
VNA’s clinic schedule, and helps the VNA advertise its
clinic dates, times, and locations. The MHD’s role in di-
rect influenza vaccine administration has thus recently
been limited to vaccine for high-priority homebound
individuals (for whom MHD nurses make home visits
to provide vaccine), and some influenza vaccine provi-
sion for individuals presenting to the MHD’s routine
childhood immunization clinics.
While the MHD has invested substantial energy and
resources in preparedness issues in general and in pan-
demic preparedness specifically, it has not yet—as some
other LHDs have done∗ —used annual influenza vac-
cine administration as a vehicle to test and exercise its
pandemic-scale mass vaccination capabilities.
∗
The NACCHO Influenza Vaccine Reallocation Database is an
online collection of voluntary vaccine reallocation plans to help
public health agencies and their community partners share infor-
mation on influenza vaccine supplies. This database is a collec-
tion of critical local contingency plans that can help direct other
jurisdictions in their efforts to prepare for supply disruptions.

The move from being a mass provider of influenza
vaccine to partnering with a community-based agency
(VNA, in Milwaukee’s case) for provision of influenza
vaccine was a local policy decision. A substantial
change in recommendations regarding who should
receive influenza vaccine (ie, a universal recommen-
dation) would spur the MHD to review that policy
decision. The MHD would need to discuss the advan-
tages and disadvantages of wading back into the mass
vaccinator role. The pros include potentially improved
emergency preparedness; the cons include questions of
whether government should take over what the pri-
vate sector seems to be doing well, and questions of
what services the MHD would not provide as a result
of investing staff resources into substantially increased
influenza vaccine administration.
However, this does not argue against a universal rec-
ommendation. In fact, universal recommendation or
not, optimal emergency preparedness as it relates to
mass vaccination may require LHDs such as the MHD
to strengthen their partnerships with private entities,
community-based vaccinators such as the VNA, and
others. The fundamental issue at the moment is sup-
ply: it does very little good for the MHD to be pre-
pared, either alone or in partnership, to vaccinate the
entire 600,000-person population of Milwaukee if the
amount of vaccine supply available is nowhere near
that required to do it. To the extent that a universal rec-
ommendation would stimulate increased production
capacity and thus stabilize and optimize supply of in-
fluenza vaccine during interpandemic periods, capac-
ity and supply would also be likely greater in the event
of a pandemic. Thus, a universal recommendation—
by increasing supply—would also support the MHD’s
other preparedness efforts and partnerships to be more
effective when needed.
● Benefits, Implementation Issues,
and Other Options
A universal recommendation for influenza vaccine can-
not be quickly or easily implemented. Although in-
fluenza vaccination is quite cost-effective, finance and
reimbursement questions would need to be worked
out. Strengthened public-private partnerships would
be needed to assure that adequate resources are avail-
able for vaccination. A great deal of public education
would also be required. The general public would need
to understand that the risk factors have not gone away;
certain people would still be at greater risk of compli-
cations and/or death from influenza, and it would re-
main true that those highest-risk persons would still be
first priority in the event of a vaccine shortage during
interpandemic periods.
Universal Influenza Vaccination Recommendations ❘ 319
However, if the general public can grasp the concepts
stated above and simultaneously understand that each
person is a potential influenza transmitter, and that the
health of all of us, in this case, depends in large part on
the health of each of us, then we will have made substan-
tial strides in increasing and solidifying the demand for
influenza vaccine, which will in turn provide manufac-
turers with what they need to increase and solidify the
supply.
There are some other alternatives to increase supply
and improve distribution, some of which could be used
either separately from or in conjunction with a univer-
sal recommendation. For example, the CDC could act
as a vaccine distributor for state and local health depart-
ments, and for others in the private sector as well. In
this scenario, the CDC could order a guaranteed num-
ber of vaccine doses from each available manufacturer,
and LHDs and others would order vaccine from the
CDC at a pooled price. In addition to providing stable
demand to support a stable supply, if one manufacturer
experienced difficulties in production, no LHD would
be caught without vaccine, since the CDC would still
have supply from the others. In effect, the CDC could
function as the clearinghouse at the national level that
LHDs frequently serve now locally.
Furthermore, it may make sense to initiate demon-
stration projects in several geographic areas. Particu-
larly for interpandemic influenza, it makes intuitive
sense that higher levels of vaccine uptake will result
in higher levels of “herd immunity,” and thus lower at-
tack rates even among the unvaccinated. The data from
Milwaukee two decades ago show this clearly to be true
for measles attack rates and measles-mumps-rubella
vaccine completion rates.13 Influenza might not be-
have in the same way; specific demonstration projects
showing universal vaccination associated with lower
influenza attack rates among the unvaccinated may
help to provide the data needed to support a uni-
versal influenza vaccination recommendation—and its
implementation—nationwide.
● Conclusions
Universal influenza recommendations present new ob-
stacles and new opportunities for overcoming danger-
ous limitations in our current influenza vaccine supply
and distribution situation. These limitations, though
admittedly not entirely or directly caused by low sup-
ply, have forced LHDs to experiment with novel ways
to connect their communities with life-saving vaccine.
However, reactive responses such as improvised ra-
tioning do not necessarily equate with effective plan-
ning. Future success will depend on their ability to have
adequate and reliable supplies of influenza vaccine, and
320 ❘ Journal of Public Health Management and Practice
increasing demand through a universal recommenda-
tion is one strategy toward that end. If LHDs are ex-
pected to be central and key figures in responding to a
pandemic scenario, then the expansion of production
of influenza vaccine doses may be one key to ensuring
that the necessary supply and distribution capacity is
built in over time.
Universal recommendations could help governmen-
tal public health to transcend a crisis mode of function-
ing and to more effectively address long-term system
problems and challenges. Such a monumental change
may require increased and innovative public-private
partnerships. It may even require re-imagining a pub-
lic health service and public health practice on the ba-
sis of principles of vaccines as public utilities and not
as commodities. It will certainly require collective re-
sponsibilities and full cooperation on the part of all the
partners—including political partners—in deliberative
planning, providing technical assistance, and, most im-
portant, the creation of an infrastructure and network
of resource support to sustain it.
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