Dose sparing influenza vaccine

Although the flu vaccine shortage is constantly in the news, public officials have not addressed the issue as to whether or not dose-sparing measures are effective and safe.

Since the publication of the following article in the New England Journal of Medicine in 2004, I have given 1/5 of the usual dose of influenza vaccine intradermally, rather than intramuscularly.

http://nejm.highwire.org/cgi/content/full/351/22/2295

My non-scientific impression, based on years of practicing the art of medicine, is that it works.

I have convinced many patients who have never taken flu vaccine before to take the plunge, based on several pieces of med-info.

1. The immune response is determined largely by cells within the skin, so let's give it in the skin.

2. This is an 'off-label' use of the vaccine. Being 'off-label' simply means that the FDA has not given official approval to the use of the medication in this manner. The doctor and patient make a joint decision as to whether the benefit outweighs the risk under the circumstances. The patient is always fully informed and always makes the final decision, but I don't offer the vaccine any other way.

3. I believe you are performing a patriotic service by taking the vaccine in this manner. I give it the same way to myself, my family, and my staff. If everyone did the same thing, we would have five times as many doses as we have now. If/when we have a pandemic, there will be a shortage, and you have paved the way to increase the supply.

4. Put an ice cube on your forearm until the underlying skin is blanched. That's where I make the injection. The ice makes the difference between minimal discomfort and essentially no discomfort. Itching from simple piercing of the skin is eliminated. Because the dose is so small, systemic side effects may be reduced.

5. Take the vaccine now. When we have a pandemic you will already have proved that you can tolerate the vaccine and won't be reluctant to take it again. Because we will run out of medicine during a pandemic, those who hesitate may not have a second chance.

6. The article published in the New England Journal strongly suggests (as do articles published subsequently) that the immunogenicity derived from intradermal administration of a smaller dose is as great or greater than what is achieved by traditional means.

It angers me that health departments and drug stores get the vaccine when I, as a primary care physician, cannot get any. Between the interference of the federal government in medicine, and the retaliation I've experienced from the state of Texas for exposing corrupt power-mongers, the government has put me out of business.

Shirley Pigott MD