polysaccharide vaccine—that is, the assurance factor for its efficacy—is high. This vaccine has also been judged most useful for the elderly in terms of cost-effectiveness and has been recommended for all elderly persons by the Centers for Disease Control as well as the American College of Physicians.11,40,42,53

The committee thus recommends that 23-valent vaccine be given to all elderly persons, particularly those 65 years of age or older. Because antibodies resulting from vaccine are long-lasting, the vaccine will only need to be given once to most persons. It should be strongly considered for anyone 50 years of age or older with underlying disease (e.g., a heart condition). Revaccination should be considered for elderly persons who received only 14-valent vaccine. Medicare Part B currently pays for the vaccine and the costs of administration, but there has been little promotion of this benefit and many are unaware of its existence.

Because pneumococcal vaccine is less effective in immunosuppressed persons, the committee urges that more immunogenic vaccines be developed. (The conjugated H. influenza vaccine currently available could be used as the prototype.) There is also a great need for more education of physicians, public health agencies, and the elderly themselves regarding the benefits of pneumococcal vaccine. Medicare should promote the vaccine more actively (an individual's Medicare card could indicate whether he or she had received the vaccine), and industry and government should promote or conduct research aimed at improving the existing versions. There should also be incentives provided by third-party payers for persons to be immunized. Giving vaccine on entry to long-term care or at the time of discharge from a hospital are other ways to increase the vaccine's use.

INFLUENZA

Influenza, a respiratory infection caused by any of the strains of the antigenically variable influenza A and B viruses, is one of the major risk factors for the elderly. Influenza epidemics occur every year, usually during the winter months. Estimates of the costs of such epidemics cite staggering figures derived from medical costs, hospitalizations, loss of productivity, and mortality.30,31,54 Household survey data suggest that influenza leads all other illness categories in terms of restricted activity and bed days,1 whereas viral surveys have demonstrated that the elderly consistently have the highest hospitalization and death rates from influenza of any population group.3,5,6,7,13,20,33,41 Even in winters with ''limited" influenza activity, there are more



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