While a nationwide push for vaccination against swine and seasonal flu has led to long lines for shots, another vaccine against a common and deadly flu complication - pneumonia - hasn't gotten to many of the people most at risk.
Most babies get the pneumococcal vaccine, but only two-thirds of seniors, who generally are the hardest hit by flu each year, get their recommended dose. And vaccines get to only one-third of older children and adults with health problems such as heart or lung disease or diabetes who have had a hard time with swine flu, according to the federal Centers for Disease Control and Prevention.
"We have a window of opportunity because there may be another wave of H1N1 influenza and seasonal flu season hasn't started yet," said Dr. Deborah L. Wexler, executive director of the Immunization Action Coalition, which provides information to doctors and advocates for vaccines. "A huge number of people should be getting the vaccine who aren't getting it. If you can protect yourself from something that could kill you, why would you not?"
Public health officials say the pneumonia vaccine suffers from a lack of advertising and that many doctors might not know which of their patients should have the vaccine. Sometimes the recommendations change. The CDC, for example, recently began advising that adult smokers and people with asthma get vaccinated.
But because flu season lasts until May and more outbreaks are likely, some of those officials, including the top ranks at the CDC, have begun talking about the pneumonia vaccine, which they say could save thousands of lives a year and prevent debilitating effects of severe illness in many more.
Bacterial pneumonia is closely linked to flu, and in past outbreaks many of those who have died have also had such a lung infection. The CDC says early data show that this pandemic may be similar. A recent study found that at least one-third of those who died of swine flu also had a kind of vaccine-preventable pneumonia.
The vaccine also can prevent some other bacterial infections, including bloodstream infections and meningitis, which infects the tissues and fluids around the brain and spinal cord. In general, about one in 20 people who get bacterial pneumonia die, and three in 10 who get meningitis die.
Doses of the pneumococcal conjugate vaccine are given to babies at 2, 4, 6 and 12 to 15 months as part of their series of vaccinations and are required by area school districts. Also called PCV7 or Prevnar, it protects against seven strains of the most common Streptococcus pneumoniae bacteria. A new vaccine was recently approved that would ward off 13 strains.
The CDC recommends that those ages 2 to 64 with health problems and seniors 65 and older get a dose of a different version, the pneumococcal polysaccharide vaccine. Also called PPSV23 or Pneumovax, it protects against 23 strains of bacteria. Typically, one shot is sufficient.
Kira Driscoll of Highlandtown will be one of those who gets the vaccination. Her mother, April Driscoll, will see to it. Kira is 2 months old and recently got her first Prevnar shot in her leg.
"It makes sense to get it," Driscoll said from Dr. Ralph S. Brown's office at Sinai Hospital. "I'd rather her be protected with vaccines. In general, it's good to get vaccines. My husband and I have gotten our flu shots."
But some in public health say that after the first three doses given to most babies, and to a slightly lesser extent 12- to 15-month-olds, doctors are inconsistent about vaccinations for other at-risk patients.
Another problem is that vaccination is not effective against all pneumonia. It can only protect against certain strains of S. pneumoniae, and there are about 100. It can't protect against viral pneumonia or staph infections. And not all vaccines are 100 percent effective, which is why the CDC recommends that those who have gotten flu shots also get a pneumonia vaccine. Pneumonia can also strike those who don't have the flu.
At Sinai, Dr. Susan V. Lipton, a pediatric infectious disease specialist, says kids with cancer, HIV, diabetes or chronic lung disease are some of those who have been getting the vaccine since the 1970s and 1980s, when the first type was licensed.
Lipton said doctors have to be more conscious of the recommendations for older kids.
"I personally feel that we pediatricians have gotten sloppy about using Pneumovax appropriately since the pneumococcal conjugate vaccine [for babies] was introduced [in 2000] and has proven so effective," she said. "Since the most common complications of H1N1 or any influenza are bacterial superinfection ... and much of pneumococcal disease is now preventable, of course we should be targeting high-risk children."
She said doctors also need to be aggressive about vaccinating those with bad cases of asthma and even some obese patients, who have had trouble managing swine flu, though the CDC hasn't targeted this population.
As for adults, St. Joseph Medical Center began a novel program to survey all its inpatients in 2004 to see who might need the pneumonia vaccine, as well as flu shots. In the past year, officials have vaccinated almost 1,100 people for pneumonia, up from nearly 900 the previous year.
Dr. Linda Adler, who specializes in hospital medicine at St. Joseph, said most patients get their vaccines after they recover from whatever illness brought them to the hospital and before they're discharged. Over the years, she said, the program has become smoothly integrated into doctors' and nurses' routines.
Few object when the vaccine is offered, she said, but she believes that many adults have not been vaccinated because no one offered it. Many do not have regular doctors, and some have doctors who offer only flu shots, because that's what their patients demand after hearing about flu outbreaks and vaccine shortages. But, "I don't remember ever hearing anything about Pneumovax in the news," she said.
Some area health departments have been offering the pneumonia vaccine along with the flu vaccines at clinics in health and senior centers this fall; others have not.
Yet, both the flu and pneumonia vaccines are important, Adler said. For those who survive, the illness can be life-altering. They can "spiral" from the flu to pneumonia to infections in their blood and elsewhere. Many elderly people who recover are no longer as functional and independent as they were. And while not all suffer from the kind of bacterial pneumonia that the vaccine covers, it is the most common type.
"If you get the vaccines, you can stop the flu and much of the pneumonia," she said. "In medicine, we deal with the most common problems first, and that's what this is. It's the low-hanging fruit. ... And we have a window, a lull in [flu] infections, where we can concentrate on vaccinating more people."
Who should get the pneumonia vaccine?
Pneumococcal polysaccharide vaccine is recommended for:
* Those 65 and older.
* Those ages 2 to 64 with certain underlying health conditions. Smokers and people with asthma were recently added.
Pneumococcal conjugate vaccine is recommended for:
* Children under 2 in a series of four doses at 2, 4, 6 and 12-15 months.
* Children ages 2-4 who have missed shots at those intervals.
* Children 2-4 with certain health conditions, especially those that affect the immune system.