Influenza Vaccination: Challenges for Adolescent and College Healthcare

Allan L. Markus, MD, MS, MBA

Medscape Infectious Diseases.  2008; ?2008 Medscape
Posted 01/15/2008

Seasonal Influenza: Burden of Illness

According to the US Centers for Disease Control and Prevention, influenza and pneumonia combined were the eighth leading cause of death in the United States.[1] Furthermore, in a 1993 article by Sullivan and colleagues,[2] it was estimated that over 4.1 million people had excess respiratory illnesses due to influenza and that this translated to 16.6-17.9 million restricted activity work days. In a study by Molinari and colleagues,[3] they estimated that in 2003, the cost of caring for influenza in the United States alone would be $10.4 billion with another $16.3 billion in lost earnings and productivity -- with a total economic cost of $87 billion.

Seasonal Influenza: Clinical Presentation

Typically patients become infected with influenza by inhalation of respiratory droplets from another infected individual. There is a 1- to 4-day incubation period, and once sick, the patient can be infectious up to 10 days after the onset of symptoms. Typical symptoms include significant malaise, fever, body aches, headache, sore throat, and cough. Unlike common cold symptoms, rhinorrhea and sinus congestion are not as prominent symptoms. Clinical symptoms alone cannot either rule in or rule out the presence of influenza, and rapid testing is now available for both influenza A and B. Secondary bacterial infections are possible, including staphylococcal pneumonia, usually heralded by a rapid worsening of the pulmonary picture and fevers in a patient with previously diagnosed influenza. The influenza virus may also cause a primary viral pneumonia. Most patients recover from influenza with little or no residual problems, although the malaise may last for 2-4 weeks in some cases.[4]

Seasonal Influenza: Vaccine and Treatment Rates

Although there are studies that show ranges of efficacy that can be up to 70% to 90% depending on the year for the inactivated influenza vaccine, the vaccination rate in the general population is low
(only 48% in 2004).[5] Despite medication being available for those who are diagnosed with the flu, it has been estimated that only 15% of primary care physicians prescribe this medication for those with the flu, and more importantly, 24% who met the criteria did not receive the medication.[6]

Seasonal Influenza: Implications of Vaccination of Low-Risk Populations

Adolescents and college-age students represent groups that are not at high risk for serious disease or mortality, but because of their living and going to school in such close quarters, they can easily spread the infection. Although there are segments of this population that are at higher risk for severe infections, such as those with asthma, HIV, and those who are pregnant, the vast majority are healthy adults for whom there are little trial data to show clinical or economic benefit for mass influenza vaccination. Thus, with its low mortality in this younger population, making a case for universal vaccination of the adolescent and college-age population requires one to look beyond influenza's mortality potential.

Healthy Adults

There are a few studies, however, that have looked at the impact of vaccination of healthy adults. In one of the only placebo-controlled, randomized trials of 2375 healthy adults, vaccination when well matched (efficacy over 80%) provided protection against influenza-like illness, excess physician visits, and lost workdays by 34%, 42%, and 32%, respectively.[7] This came at an overall cost of $11 per person vaccinated for the healthy adult. The Advisory Committee on Immunization Practices has recently put out its 2007 update of its 2006 recommendations and stated that all healthy people, including school-aged children, who want to reduce their risk of becoming ill with influenza should be vaccinated.[8]

College-Age Students

College-age students do not get vaccinated as often as those who are older. Some studies have shown that vaccination is linked to individual health beliefs on susceptibility to influenza and a higher degree of fear about side effects, but also may be related to costs.[9,10] In her August 2007 article, Middleman[10] proposed more use of mandatory vaccinations in adolescents to improve vaccination rates for other vaccines. She noted, however, the potential backlash for making certain vaccinations mandatory. This may be especially true in cases in which the benefit for certain populations in terms of economic outcomes has not been conclusively shown. Developing new models to get messages on susceptibility, safety, and costs to students on influenza vaccination could be an important method to increase the number of students choosing to become vaccinated.

Seasonal Influenza: Novel Preparedness Approaches at Arizona State University

Arizona State University (ASU) is a 63,000-student university located in the greater Phoenix metropolitan area. Its largest campus is the Tempe campus, having 55,000 students who attend classes and with about 9000 living on campus. The Campus Health Service provides the primary healthcare services on the 55,000-student Tempe Campus and collaborates with its healthcare partners at the 3 other campus locations. ASU decided to partner with both a vaccine manufacturer (CSL Biotherapies) and an advertising agency (Hal Lewis Group) to improve messaging and increase the vaccination numbers on our campus.


ASU was approached by CSL Biotherapies with the concept of developing a more comprehensive program to distribute vaccine to students, faculty, and staff. We used a marketing theme called "Season Pass." The strategy for increasing vaccination rates was multifaceted:

  • Influenza vaccine distribution events: Campus Health Service held 2 week-long events at the Student Union. Timing was done during the peak period of student activity from 10:00 am to 2:00 pm.

  • Giveaway strategy: All students who received a vaccine received an ASU T-shirt that displayed the Season Pass logo and passed on the message to make the campus "Flu-less." Students also received a postage-paid postcard that they could send home to inform parents that they had received their flu shot.

  • Residence hall distribution: Nursing staff planned days to administer vaccine in the residential halls.

  • Campus signage and advertising campaign: ASU, in association with a professional branding and marketing team, developed signage and media advertising that included student newspapers and radio stations marketing the Season Pass campaign.


In the 2006-2007 season, ASU ran a number of employee flu clinics and distributed vaccine through our health center and the Student Union to students. Nine hundred twenty-seven vaccines were distributed to students, and 1416 were distributed to employees for a total of 2343 doses of vaccination.

During the fall 2007 season, using the new methodology above, 2049 students were vaccinated and 1931 employees were vaccinated, for a total of 3980 vaccinations distributed (Figure). These results occurred despite an increase in price from $10/vaccination in 2006 to $18/vaccination for students and $20/vaccination for employees in 2007.


Influenza vaccine administration at Arizona State University, autumn 2006 to winter 2007 vs autumn 2007.



Influenza can be a debilitating disease on a college campus. With influenza's potential for a high infectivity rate, the close living and teaching areas in colleges, and the traditionally lower rates of annual vaccination of the population, colleges and universities can be particularly vulnerable to influenza outbreaks on their campuses. Although it does not have a high mortality rate, the costs in missed classes, lack of academic performance, and potential for nonretention of students who miss too much class make this a serious concern for both college health center directors and university officials.

We believe that instituting programs, such as the ones described here that improved our vaccine distribution by 41% in 1 year, will have a positive effect on these outcomes. Although not studied, we know that a number of students and employees when exposed to the repetitive messaging of the Season Pass campaign went to their own physicians and obtained their influenza vaccination from their primary care providers.

We did not design this program to study differences in the outcomes of academic performance or retention for the university, but this could be an important future area for research. The annual variability in the antigenic drift in the flu virus and how well the vaccine "matches" with the flu strain that ultimately comes to the ASU campus are important but uncontrollable variables in containing an influenza outbreak on our campus during the 2007-2008 season.

Plans for future events include planning a vaccination event during parents' weekend. We know from other studies that parents can have a strong influence on students' likelihood of obtaining vaccinations.[12] Although we did enlist some student volunteers, we will need to have a stronger presence of student workers to relay the messages on the importance of vaccination to reduce influenza-like illness, missed workdays, and physician visits. Future studies will need to include an economic analysis of running a similar campaign and the potential academic impact on college students' performance and retention.

In conclusion, we believe that convenient timing/location of vaccination events, giveaways that are directed at the college-age population, and having information that directly addresses influenza vaccination myths can all be used to improve vaccination rates in this population. Collaborations between colleges and industry partners may be one method of improving vaccination rates on college campuses.


  1. Centers for Disease Control and Prevention. 2004 vital statistics. Available at: Accessed January 8, 2008.
  2. Sullivan KM, Monto AS, Longini IM Jr. Estimates of the US health impact of influenza. Am J Public Health. 1993;83:1712-1716. Abstract
  3. Molinari NA, Ortega-Sanchez IR, Messonnier ML, et al. The annual impact of seasonal influenza: measuring disease burdens and costs. Vaccine. 2007;25:5086-5096. Abstract
  4. Demicheli V, Rivetti D, Deeks JJ, Jefferson TO. Vaccines for preventing influenza in healthy adults. Cochrane Database Syst Rev. 2004.
  5. Linder JA, Chan JC, Bates DW. Appropriateness of antiviral prescribing for influenza in primary care: a retrospective analysis. J Clin Pharm Ther. 2006;31:245-252. Abstract
  6. Bridges CB, Thompson WW, Meltzer MI, et al. Effectiveness and cost-benefit of influenza vaccination of healthy working adults: a randomized controlled trial. JAMA. 2000;284:1655-1663. Abstract
  7. Centers for Disease Control and Prevention. Recommendations and guidelines: Advisory Committee on Vaccination Practices (ACIP). January 7, 2008. Available at: Accessed January 8, 2008.
  8. Keenan H, Campbell J, Evans PH. Influenza vaccination in patients with asthma: why is the uptake so low? Br J Gen Pract. 2007;57:359-363.
  9. Steiner M, Vermeulen LC, Mullahy J, Hayney MS. Factors influencing decisions regarding influenza vaccination and treatment: a survey of healthcare workers. Infect Control Hosp Epidemiol. 2002;23:625-627. Abstract
  10. Middleman A. New adolescent vaccination recommendations and how to make them 'stick.' Curr Opin Pediatr. 2007;19:411-416.
  11. Fiore AE, Shay DK, Haber P, et al. Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices, 2007. MMWR Morbid Mortal Wkly Rep. 2007;56(RR06):1-54.
  12. Zimet GD, Mays RM, Sturm LA, Ravert AA, Perkins SM, Juliar BE. Parental attitudes about sexually transmitted infection vaccination for their adolescent children. Arch Pediatr Adolesc Med. 2005;159:132-137. Abstract

I would like to acknowledge the efforts of Carrie Jankowski, RN, Eric Anger, PharmD, and Donna Estabrook, Assistant Director of Operations, who coordinated the flu vaccination effort at ASU; Vice President Dr. James Rund and Associate Dean Dr. Martha Christiansen who gave us administrative support; and Marie Mazur of CSL Biotherapies and Lisa McCloskey from the Hal Lewis Group who both supported our efforts at ASU.

Allan L. Markus, MD, MS, MBA, Clinical Associate Professor of Medicine, University of Arizona College of Medicine, Tucson, Arizona; Director of Health Services, Arizona State University, Tempe, Arizona

Allan L. Markus, MD, MS, MBA, has disclosed no relevant financial relationships.