Rebuttal

I support universal influenza immunization because influenza is a serious public health problem. The influenza vaccine is safe and effective at preventing influenza; immunization of only high-risk populations has been largely ineffective; and we are unprepared for an influenza pandemic. I believe that it is reasonable to expect that a universal immunization program will protect vulnerable populations (e.g., children), improve coverage of high-risk populations, reduce community transmission, improve preparedness for a pandemic and perform all of this in a cost-effective manner. The Ontario program should be carefully evaluated to determine whether it achieves these objectives.

Dr. Demicheli views universal immunization from the narrow perspective of benefits for healthy adults. The real world of public health is not so simple. Dr. Demicheli ignores the potential additional benefits of protecting vulnerable populations, improving high-risk coverage, reducing community transmission and improving preparedness for a pandemic.

Dr. Demicheli agrees that the published results of studies of the cost-effectiveness of universal influenza immunization are equivocal. He makes an excellent point about “the impossibility of transferring economic evaluations from one social context to another.” In other words, conclusions from studies of cost-effectiveness conducted for British soldiers have very limited application to an Ontario public program.

Population immunization was one of the truly outstanding public health achievements of the 20th century. Immunization has proven itself, time and time again, to be safe, effective and efficient. Immunization has eradicated smallpox, eliminated polio from the western hemisphere and controlled many diseases including measles, rubella and diphtheria.

Despite this outstanding record of success, we are reluctant to exploit the full potential of immunization. We procrastinated for almost 20 years before adopting the pneumococcal vaccine, and we still do not have public health immunization programs against adolescent pertussis. Immunization is our best strategy against influenza, as even Dr. Demicheli concedes. But it won't work unless we use it.