By LAURAN NEERGAARD
AP Medical Writer

WASHINGTON (AP) Starting next week, it's time to line up for flu vaccine again, and this year some Americans will get to choose a squirt up the nose instead of a shot in the arm.

But the new nasal-spray vaccine, called FluMist, will cost well more than twice as much as a shot. It also cannot be used by those who need protection against influenza the most: babies and toddlers, people 50 or older and those with asthma or other chronic illnesses.

Still, FluMist's expected advertising blitz could generate new interest in flu protection at a pivotal time. Specialists say far too few Americans get vaccinated, including healthy people who may not be at risk of dying but spread around influenza's misery.

In addition, fearing a winter return of the deadly new SARS virus, the World Health Organization is urging more flu vaccination. While flu vaccine won't prevent SARS, both diseases have similar symptoms, and WHO contends that holding down the number of serious influenza cases will mean less chance of doctors mistaking flu for SARS.

The U.S. Centers for Disease Control and Prevention doesn't want to make that connection, cautioning that other respiratory viruses circulate during the winter that could be confused with SARS, too.

There's reason enough to get flu vaccine, stresses CDC's Dr. Scott Harper: Influenza kills 36,000 Americans in an average year, hospitalizes 114,000 and infects up to 20 percent of the population.

Roughly 70 million people get a flu vaccination every year, less than half the number especially urged to get it, Harper laments. Among the highest-risk patients, only a third of adults with asthma are vaccinated, and fewer than two-thirds of the elderly, even though flu shots are free under Medicare.

Vaccine experts think that's partly due to complacency the last two flu seasons have been mild and partly due to two years of manufacturing delays that had doctors rationing the season's earliest inoculations.

The manufacturing problems appear solved: CDC says plenty, 85.5 million doses, are becoming available, and early-October inoculations are open to everyone.

For the complacent, ``it would be very unusual to have three mild seasons in a row,'' warns Dr. William Schaffner of the National Foundation for Infectious Diseases.

The following high-risk people need flu shots, CDC says:

Everyone over age 50.

Anyone with chronic medical conditions such as heart or lung disorders including asthma, diabetes, kidney disease or weak immune systems.

Children aged 6 months to 2 years.

Residents of nursing homes or other long-term care facilities.

Women who will be more than three months pregnant during the flu season.

Children of any age on long-term aspirin therapy.

Caregivers of high-risk people need vaccination as well.

FluMist, the new nasal spray, is an option for healthy people ages 5 to 49.

FluMist's maker and marketer, MedImmune Inc. and Wyeth Vaccines, hope to sell 5 million doses in this first season of sales. Even for the healthy, flu's misery is a major disruption, they argue, that causes 70 million missed workdays and 38 million missed schooldays a year.

But FluMist has an average wholesale price of $46 a dose not counting the cost of administering the spray, which could add at least another $10. A flu shot typically costs $15 to $20.

Most healthy people pay for flu vaccine out-of-pocket at walk-in programs offered by drugstores or employers. Patients hoping for insurance coverage will have to check with their carriers; some have agreed to cover FluMist, sometimes with higher co-pays, although Wyeth won't reveal how many.

Why is FluMist only for the healthy? First, FluMist is made of live but weakened flu virus considered too risky for people with compromised immune systems; the shot is made of killed virus. The spray's safety hasn't been proved in older people or those with chronic illnesses. As for youngsters, a study found those under 5 were at increased risk of suffering asthma-like attacks after FluMist had been squirted up their noses.

For the healthy, FluMist's convenience likely will prove attractive and whatever it takes, getting more people protected is the goal, says Schaffner, preventive medicine chairman at Vanderbilt University.

``I would hope that 10 years from now, we are recommending annual influenza immunization for everybody,'' he says.

(Copyright 2003 by The Associated Press. All Rights Reserved.)