Rarely does a virus become the topic of a Presidential campaign, but influenza won such a dubious honor during the 2004 election cycle when nationwide shortages of influenza vaccine sparked public outrage.1 Of course, truth and practical experience are more instructive than election-year hyperbole, as evidenced by local responses to the 2004-2005 influenza vaccine shortage.2 Influenza is not just a local problem, but a global one, and centuries of evolutionary adaptation have helped this virus turn into a formidable adversary. Influenza vaccine distribution and supply systems have been in disarray since 2000.3 There are too few influenza vaccine manufacturers and the seasonal shifts of the virus make prediction of possible circulating strains slow and cumbersome, thus causing the manufacturing of the vaccine to operate on a razor-thin time line and margin.4 Hopes for an uneventful supply situation were dashed for the 2005-2006 influenza season as early season supply problems mitigated the benefits of additional influenza vaccine manufacturers.5 Now our fingers are crossed for minimal supply disruptions during the 2006-2007 influenza prevention season.

This special issue of the Journal of Public Health Management and Practice allows prominent public health experts to describe from a practice perspective the annual ritual of influenza prevention. Despite the many challenges influenza presents, these experts offer viable solutions to many of the recurring influenza vaccine-related problems evidenced through practice and improvement based on lessons learned. The solutions they pose are not only doable but also affordable. The cost of inaction-of not doing what is necessary to fix the public health immunization services delivery system-is greater than the cost of needed action. These solutions demonstrate that it is not only just more money that public health needs but also a better system for delivering immunization services overall.

Ways to Improve the Process

The status quo is not working. Many practitioners believe that the main stumbling block is a lack of sufficient numbers of influenza vaccine manufacturers. But even as more manufacturers enter the market, we still have to grapple with an antiquated supply and distribution model and public education campaigns that have not proved to work effectively. The country is undergoing demographic shifts that are posing new and complex challenges to our outreach and education efforts to vaccinate more and more of the population. These shifts introduce additional economic stresses on financially strapped local agencies that lead community efforts to vaccinate many vulnerable and high-risk people within these populations. Public health's efforts must transform, adapt, and become sensitive to the range of different local demographic challenges and must be tailored to meet specific local needs. This is not necessarily the end of the road. The next problem may be a glitch in production or a sharp spike in the difficulties of immunizing hard-to-reach populations with underlying chronic conditions. The new Advisory Committee on Immunization Practices' expanded childhood influenza vaccination recommendations are a positive step toward addressing some of the barriers to improving the uptake of influenza vaccine.6

While there are many interventions that produce good outcomes, and wonderful anecdotes of a particular local health department (LHD) doing good work, we as a public health system are not doing our best because the system prevents us from doing so. LHDs and other community immunization providers have had to turn away patients because they lack influenza vaccine and cannot afford to lose money on unused doses year after year due to financially punitive nonreturn clauses in influenza vaccine contracts,7 and the reimbursement/administration rates they are paid by Medicare have only recently risen to reasonable levels.8

Cooperation across the partnerships

Influenza vaccines, unlike other vaccines, are not long-lasting and must be given annually. This is expensive. This expense is paired with the fact that 8.2 million of the 46 million uninsured Americans fall into one or more influenza high-risk categories.9 Quality of service to this population of uninsured persons and vaccine safety can be improved, but only by a fully engaged system, and that requires better cooperation and collaboration across the three levels of governmental public health, along with their private sector partners. If the focus is on outcomes, efficiencies, and cost-effectiveness, large gains in the quality of delivery of influenza vaccine and improved uptake by the public could be made across the entire system, not just in one state, an individual LHD jurisdiction, or by one vaccine manufacturer. Until we dedicate the means and resources to cover everyone who wants a dose of influenza vaccine, the distribution and supply system will remain complicated. And it is the current state of complexity and confusion that drives costs and negatively affects service quality and public health credibility, our messages, and uptake of influenza vaccine by the public.

The Annual American Medical Association/Centers for Disease Control and Prevention Influenza Summits bring together these partner organizations to work on the spectrum of influenza-related issues-production, storage and handling, distribution, and finance. The meetings highlight and discuss vulnerabilities at several points along the chain of influenza-prevention activities. As impressive as these meetings are, there remain unanswered questions every year. Will manufacturers produce enough vaccine? Will the circulating influenza strains match the vaccine strains? Will the season be severe and spike vaccine demand and produce spot shortages? How do we collectively respond to any of these emergencies? What can we learn from these recurring supply and distribution problems? Ultimately, there is a real question of authority-what can governmental public health do within a privately driven enterprise such as vaccine manufacturing? They can provide advice and be listened to for starters, and the annual Influenza Summit provides such a forum.

Implications for Preparedness

A sobering thought strikes when you consider the influenza vaccine supply and distribution problems of the past few years-the nation is definitely not very well prepared to deal with a pandemic strain of influenza. The inability to handle routine activities during an interpandemic season is a key indicator of that. This serves as a fitting and disturbing symbol of our vulnerability. The goal is to find influenza message models that individuals unconsciously follow-and we need to understand how that works if we want to vaccinate annually an ever-expanding group of people against influenza. And we need to understand how an emergency changes everything that all levels of public health have planned for.

We know that strange things happen when fear is added to the mix-that occurs in part because of a breakdown in normal channels of communication. If we have rock-solid community partnerships during the delivery of routine public health services, such as annual influenza vaccination clinics, then the communication channels are that much more robust and resistant to breakdowns during emergencies. These relationships need to be established well before an event takes place, not during an event. LHDs play a key role during emergencies because people look to their authority for help, support, and information. Learning these lessons from our previous influenza vaccine supply and distribution problems will help us predict and control these situations and can help save lives during future vaccine shortages or other public health emergencies.

Conclusions

Federal public health experts report that annually more than 36,000 individuals die from influenza-related complications and more than 200,000 are hospitalized with influenza-related conditions. As our population grows older and an increasing number of people have chronic health conditions, such as obesity, diabetes, arthritis, and hypertension, the number of high-risk persons needing influenza vaccine will only increase and become a bigger burden on our already top-heavy healthcare system.10

Since the late 1990s, influenza vaccination rates have not increased very much, even among healthcare workers.11,12 However, we must note that these national data could mask even worse local pockets of severely low influenza immunization rates. Influenza-related morbidity and mortality remain too high, and we have gained little ground on reducing racial and ethnic immunization rate disparities, despite concentrated education campaigns.13 Public health must revitalize its prevention efforts to avoid further slippage. These efforts need to be sustained and intensified so that access to and demand for influenza vaccine becomes more widespread, which could bring relief to our omnipresent influenza vaccine supply dilemmas.

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