Third European Influenza ConferenceVilamoura 14-17 September 2008

INCREASING THE OVERALL EPIDEMIC VACCINATION COVERAGE:

THE MACROEPIDEMIOLOGY OF INFLUENZA VACCINATION

David S. Fedsondfedson@wanadoo.fr

WHO Recommendations for Influenza Vaccination - 2005

• Raise awareness about influenza vaccination among health care workers and the public

• Increase vaccination coverage of all at-risk people (~ 25% of a country’s total population)

elderly people 50% by 2006 75% by 2010

Macroepidemiology of Influenza Vaccination Study Group

• Voluntary unfunded network of individuals in 73 countries

• Report on influenza vaccine distribution, recommendations and public reimbursement

Population % not in

Region 2006 MIVSG

North America, Europe 1,135 M 4

Latin America 562 12

Asia & Oceania 3,720 57

Middle East, Africa 1,111 82

World 6,500 49

National Recommendations in 71 Countries - 2005

• Virtually all countries recommend vaccinating elderly people (≥ 60 or 65 yrs) and those with cardiopulmonary and renal diseases, diabetes mellitus and immunocompromise

• A few countries vaccinate all people ≥ 50 yrs• Less agreement on pregnant women,household contacts

and children on aspirin • Several countries vaccinate children 6-24 mos (Austria,

Canada, Chile, Rep. of Korea, Taiwan and Mexico)• In 2008, US recommended vaccination up to 18 yrs

MIVSG 2007

Influenza Vaccination in 71 Countries, 1997-2005

/ 637

MIVSG 2007

Influenza Vaccination in 71 Countries, 2002-2005

/ 637

MIVSG 2007

Influenza Vaccination in 71 Vaccine-producing and Non producing Countries

2002-2005

/

Vaccine-producing

Non producing

637

MIV SG 2007

Influenza Vaccination in Countries With and Without Public Reimbursement

2002-2005

With reimbursement

No reimbursement

MIV SG 2007

Influenza Vaccination in Western Europe 1997-2002-2005

MIV SG 2007

Influenza Vaccination inMalta, 1997-2005

MIV SG 2007

Influenza Vaccination in Central and Eastern Europe 1997-2002-2005

GNI per capita ($), adjusted for PPP Vaccine doses distributed / 1000 pop.

MIV SG 2007

LuxembourgNorway

SwitzerlandIceland Ireland

DenmarkAustriaBelgium

Netherlands SwedenFinlandFrance

GermanyItaly

SpainGreeceCyprus

SloveniaCzech Rep.

PortugalMalta

HungarySlovak Rep.

EstoniaLithuania

PolandLatviaCroatia

Russian Fed.RomaniaBulgariaUkraineAlbaniaGeorgia

UzbekistanKyrgyz Rep.

Economic Development and Influenza Vaccination in Europe, 2005

MIV SG 2007

Influenza Vaccination in the Western Pacific, 1997-2002-2005

GNI per capita ($) adjusted for PPP

Vaccine doses distributed / 1000 population

MIV SG 2007

Economic Development and Influenza Vaccination in the

Western Pacific, 2005

JapanAustralia

SingaporeN. ZealandRep. Korea

Thailand

MIV SG 2007

Influenza Vaccination in the Americas 1997-2002-2005

(1)

GNI per capita ($) adjusted for PPP

Vaccine doses distributed / 1000 population

MIV SG 2007

ChileMexico

UruguayCosta Rica

BrazilColombiaPanama

VenezuelaPeru

El SalvadorGuatemala

EcuadorHonduras

Bolivia

Economic Development and Influenza Vaccination in Latin America, 2005

MIV SG 2007

Influenza Vaccination in Countries With Recommendations for Children

6-23 Months, 2003-2004-2005

MIVSG Findings on Influenza Vaccine Distribution

• Global distribution increased from

292 M doses in 2003 to >329 M doses in 2005• Great differences persist in vaccine distribution

among individual countries• A few countries increased distribution spectacularly

while others decreased distribution, often due to supply shortages

• Higher vaccine uptake in vaccine-producing countries and in those with public reimbursement

MIVSG Findings on Influenza Vaccine Distribution

• Recommendations for childen 6-23 months of age in seven countries did not lead to higher uptake overall (no surprise)

No information on vaccine use in specific age or high-risk groups

Despite remergence of H5N1 in 2003, most countries showed little change in distribution

between 2002 and 2005

Monitoring Influenza Vaccination Across Europe

• Currently most countries monitor vaccine uptake (especially in the elderly ) with methods unique to each country

• Possible methods for monitoring uptake across Europe- population surveys- vaccine distribution data (MIVSG)- physician information networks

• Other issues to be considered for cross-European monitoring- common set of variables - frequency of surveys- central coordination

What would be the purpose of establishing a cross-European system for monitoring of influenza vaccination?

Kroeneman M et al. Eurosurveill 2008; 13 (20): pii=18874.

Comparison of ESWI (2006) and MIVSG (2005) Vaccination Rates

Vaccination Rates (%)

ESWI ≥ 65 yrs ESWI ≥ 15 yrs MIVSG ≥ 15 yrs*

Germany 53.1 27.4 29.8UK 69.8 25.0 27.6Italy 65.6 24.4 18.6France 68.3 24.2 22.4Portugal 53.3 23.6 16.7Spain 71.1 21.8 27.9Austria 36.8 17.8 16.8Finland 63.1 16.2 18.5Poland 25.3 14.1 9.1Czech Rep.30.2 13.8 7.6Ireland 50.7 13.5 20.5

* MIVSG rates/total population adjusted to population ≥ 15 yrs

Influenza Vaccination in Spain

• Eligible population - 2006-2007current recommendations - 410 doses/1000 pop.

≥ 65 yrs - 41% < 65 yrs HR - 16 % healthy contacts - 36%

ACIP-like guidelines - 610 doses/1000 pop.Vaccine 2007; 25: 3249-53.

vaccine distribution in 2005 - 233 doses/1000 pop.

• Vaccination coverage - 2003 ≥ 65 yrs - 63.7% Eur J Public Health 2007;17:272-7.

< 65 yr HR - 30.5% Infection 2006; 34: 135-41.

HCWs - 19.7%

Influenza Vaccination in Spain

• Vaccination effectiveness - 65 yrs, 2002-2005

- 24 deaths (all causes) / 100,000 / week

- 14% of deaths prevented by vaccination

- 239 vaccinations prevented one death (144-1748) Vaccine 2007; 25: 6699-707.

• Cost effectiveness - 50-64 yrs

- third party payor - € 14,919 / QALY; € 9731 / LYG

- societal perspective - € 4149/ QALY; € 2706 / LYG

Vaccine 2007; 25: 6900-10.

Five Reasons Why People Choose to Receive Influenza Vaccine

• Doctor/nurse recommended it 47 %• Not in very good health 47 %• Protects against influenza 39 %• Don’t want to infect others 23 %• It’s free and recommended 22 %

Influenza Vaccine Supply Task Force presentation at the WHO/SEARO Workshop on Strengthing NCIPs in Pandemic Influenza Preparedness, 26-28 March 2008

Physician Recommendation and

Influenza Vaccination - US, 1988

Patient Physician PercentAttitude Recommendation Vaccinated

Positive Yes 87Negative Yes 70

Positive No 8Negative No 7

MMWR 1988; 37: 657-61.

Hospitalization and Death Among People Discharged from Hospital During the Flu Vaccination Season in Manitoba, 1982-83

Hospitalized during

flu season (%)

Died in hospital during flu season (%)

Age group (yrs)

% total population P & I

All resp. conditions P & I

All resp. conditions

25-44 3 11 19 65 74

45-64 3 32 31 82 63

65-74 6 39 44 62 67

≥ 75 12 45 46 66 66

Fedson DS et al. Ann Intern Med 1992; 116: 550-5.

Improving the Delivery of Seasonal Influenza Vaccine Across Europe

• Focus on improving individual national vaccination programs, not on cross-European efforts

- consistent year-to-year monitoring- administrative features associated with higher vaccination rates, not individual patient characteristics- reimbursement

A rising tide does not necessarily lift all boats

• New targets for improving vaccine delivery- individuals at risk - hospital discharge programs- populations - childhood vaccination

Western EuropeAustria Michael KunzeBelgium Rene SnackenCyprus Chrystalla HadjianastassiouDenmark Ann E. OttosenFinland Rose-Marie OlanderFranceJean-Marie CohenGermany Peter WutzlerGreece Andreas ConstantopoulosIceland Thorolfur GudnasonIrelandJoan O’DonnellItaly Isabella DonatelliMalta Tanya MelilloLuxembourg Claude P. MullerNetherlands Ted van EssenNorway Lars HaaheimPortugal Helena Rebelo de Andrade Spain Agustin PortelaSweden Ake OrtqvistSwitzerland Mark Witschi United Kingdom Jane Leese

Eastern Mediterranean and AfricaAlgeria Fawzi DerrarEgypt Mostafa OrkhanIran Abdoul reza EsteghamatiJordan Ali Muhaidat

Oman Salah Al AwaidySouth Africa Barry D. Schoub

Central and South AmericaArgentina Vilma SavyBolivia Raul ArtegaBrazil Joao Toniolo-NetoChile Leonardo MaggiColombia Enrique GutierrezCosta Rica Maritza Morena SinglerDominican Rep Jose Brea del CastilloEcuador Greta MignoEl Salvador Suarez CastanedaGuatemala Adib RodriguezPanama Xavier SaezPeru Gordito ChaparroUruguay Homero BagnuloVenezuela Jaime Torres

Western PacificAustralia Alan HampsonChina not identifiedHong Kong SAR Christina MawJapan Kosaku UchidaNew Zealand Lance JenningsRep. of Korea Woo-Joo KimSingapore Chan Kwai PengTaiwan Shu-fong Chen

Southeast Asia Thailand Piyanit Tharmaphornpilas

Central and Eastern EuropeAlbania Miriam Xibinaku

Bosnia & Herz. Prof. PuvacicBulgaria Mira Kojouharova

Croatia Ira Gjenero-Margan

Czech Rep. Eva VitkovaEstonia Olga Sadikova

Georgia L. Jabidze

Hungary Zsuzsanna Molnar

Israel I tamar Grotto

Kyrgyz Republic Kalia Kasymbekova

Latvia Inga VelickoIrina Lucenko

Lithuania Arvydas Ambrozaitis

Macedonia Blaze Nikolovski

Moldova Peter G. ScofertsaMontenegro Dragan Lausevic

Poland Lidia BrydakRomania Viorel Alexndrescu

Russian Fed. Larisa Rudenko

Serbia Mila Vucic-Jankovic

Slovak Rep. Zuzana Kristufkova

Slovenia Maja Socan

Turkey Selim Badur

Ukraine Anna V. Moiseeva

Uzbekistan Dilorom Tursunova

North AmericaCanada Theresa Tam

Mexico Augustin Lara Esqueda

United States Greg Wallace

AcknowledgementMIV Study Group Investigators

MIVSG 2007

Influenza Vaccination of Elderly and High-risk People