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Influenza - History, Vaccination, and Public Health

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“Influenza is an acute contagious respiratory illness caused by infection with an influenza virus.”

(HPSC, 2015)

Influenza History

• 1918-19 Spanish Flu – killed 50m worldwide. American soldiers sought protection through wearing protective gauze masks

• 1957-58 Asian Flu - Nobody aged 40 or under has immunity because strain has not circulated in humans since 1968.

Influenza History

• 1968-69 Hong Kong Flu – originated in Hong Kong and killed 34,000 people in UK. Prevention took place through the wearing of surgical face masks.

(Colin Parish, 2007)

History in Ireland• 1916-23 influenza killed 20,000 out of a 4m

population

- Proportional to that of other EU countries

• Outbreak of Spanish Flu in Ireland brought back by returning soldiers

• Accentuated by intense political activism eg being imprisoned (several thousand republican activism) and victory parades such as one for Great War in Dublin in early 1919

(John Dorney, 2013)

• Viral cause not identified until 1930

• One of the epidemics clearest effects was to expose the flawed structure of the public health system

History in Ireland contd.

Modern system of global communication, steamships and railways provided conditions for easily and speedy spread of virus

(Phillips and Killingray, 2003)

1970’s outbreak

• Vaccinations in place to deal with threat of 1968 Hong Kong influenza but no vaccination to deal with new virus

(Irish Independent, 1976)

• Media campaigns were used to warn people from visiting people in hospitals

(Aine Mitchell, 2010)

• 1976- time of crippling recession in Ireland which brought a halt to modernisation of health services

Vaccination or not

Anti-influenza vaccinations for members of An Garda Síochána

No. of Patients

Number who received the vaccination 208Number who did not receive the vaccination 8252Number who reported sick on account of influenza (having received the vaccination) 34Number of days absent (having received the vaccination) 148Number who reported sick on account of Influenza (having not received the vaccination) 1592Number of days absent (having not received the vaccination) 8573

• Preventative vaccinations were available but only in moderation during 1976 swine flu threat (Corish Dail Debates Vol 288, 1976)

(Aine Mitchell, 2010)

Infectious disease such as influenza was very common in the early part of the century, it is now however much more rare.

This is as a result of the implementation of specific vaccinations against certain diseases.

CDC ‘Take 3’ Actions to fight the flu.

1.Take time to get the flu vaccine

2.Take everyday preventative actions to

stop the spread of germs

3.Take flu antiviral drugs if your

Doctor prescribes them

Everyone is at risk100 million people infected every year

in Northern Hemisphere*

1:10 adults 1:3 children 10,000-40,000 deaths in the USA

13

Summary influenza/ILI general outbreaks in health care facilities/residential institutions by HSE area; 2013/2014 flu

season

14

HSE-areaNo. of

outbreaksTotal no.

illTotal no.

hospitalised

Total no.

dead

Total no. lab

confirmed

Total no. lab investigated

East 23 431 26 13 94 167Midlands 2 10 0 1 5 6Midwest 4 41 23 0 13 4

Northeast 6 90 12 0 18 28Northwest 4 30 11 0 14 17Southeast 7 154 11 6 26 43

South 9 103 18 7 2 5West 3 40 2 1 12 19

  58 899 103 28 184 289

*Source CIDR data

Influenza Vaccine• 2014-2015 seasonal flu vaccine

• Trivalent containing antigens from two type A and

one type B virus strains

• 2014/2015 A/California/7/2009 (H1N1)pdm09-like virus, A/Texas/50/2012 (H3N2)-like virus, a B/Massachusetts/2/2012-like virus

• Cultured in Eggs or cell based

• Inactivated Vaccine

• No Thimerosal

• No adjuvants

• Quadrivalent vaccines available

• Live attenuated vaccine, intranasal vaccine used in UK to vaccinate children

Influenza Vaccine• Vaccine given at onset of winter season every year

• Licenced for > 6months of age

• Given by I.M injection, thigh or deltoid muscle

• Antibodies take 10-14 days to develop

Suitable for most people

Contraindicated

• Anaphylaxis to previous dose or it constituents (other that ovalbumin)

Precautions

• Acute severe febrile illness defer

• Egg allergy- if confirmed egg anaphylaxis or egg allergy can be given influenza vaccine with ovalbumin content <0.1micrograms per dose

• Children 12-23mths separate from PCV by one week

Influenza vaccine Side effects

• Soreness redness at vaccination site in 1/3 of people

• Fever,Malaise and myalgia 6-12hrs after immunisation and lasts for about 48hrs

• Guillain barre syndrome rare, risks of GBS are higher following influenza like illness

• Anaphylaxis rare

• Injected influenza vaccine ‘inactivated’ cannot cause influenza

Who should get the Influenza vaccine?

Everyone!

Anyone who does not want to get influenza!

Influenza vaccine recommended for persons who are at increased risk of influenza complications

• Greater than 50yrs

• Chronic illness, heart disease,liver disease,resp disease, diabetes

• Immunosuppression due to disease or treatment

• Conditions that compromise respiratory function

• Downs syndrome

• Children with moderate to severe neurodevelopment disorder

• Morbid obesity BMI . 40

• Residents of nursing homes or long stay facilities

Influenza vaccine recommended for Pregnant women

• All pregnant women at any stage of pregnancy

• Pregnancy increases risk of complications from influenza because of alterations in heart rate lung capacity and immunological function

• Immunisation could prevent 1-2 hospitalisations per 1000 pregnant women

• It is inactivated vaccine so very safe in pregnancy

ECDC council recommendation on Seasonal influenza vaccination (2009/2010/EU)

• Targets of Council recommendation

• Reach 75% vaccination coverage of Older age groups by 2014-15

• This target of 75% should, if possible be extended to the risk group of people with chronic conditions

• Member states are also encouraged to improve vaccination coverage among healthcare workers

Vaccine European New Integrated Collaboration Effort ‘VENICE’

On December 2013 the VENICE III project started.

• The main change, from the previous VENICE I and II projects, is that the VENICE network is going to move into an official ECDC Vaccine Preventable Diseases network, with experts appointed as competent bodies of each member state.

The activities of the first two-year project mainly focus on:

• Seasonal influenza vaccination programmes,

• Quality of vaccine coverage data,

• Countries immunization schedules, plan of priorities for introduction and implementation of new vaccinations, roadmap for sharing and improving data, methodology and resources among the National Immunisation Technical Advisory Groups of EU/EEA countries.(17-02-2014)

Impact on Public Policies - Europe

• Influenza viruses always changing

• Strains monitored by WHO surveillance laboratories

• WHO recommends strains for inclusion in seasonal flu vaccine every year

• Seasonal flu vaccine formulated to ‘match’ circulating strains

Why annual vaccination?

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Influenza vaccine recommended for those likely to transmit influenza to a person at high risk for influenza complications

• Health Care workers, for their own protection and protection of patients

• Household contacts of at risk persons

• Out of home care givers to at risk persons

HCWs frequently implicated as the source of influenza transmission in health care settings Employees continue to work while sick with influenza Unvaccinated workers who are not sick can still spread the virus

Benefits of influenza vaccination of HCWs: Reduce risk of outbreaks in health care facilities Decrease staff illness and absenteeism Reduce costs resulting from loss of productivity

HCW and vaccination Why are we concerned?

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Reported seasonal influenza vaccination coverage among health care workers in 12 EU/EEA Member States

Romania

Netherlands*

England

Scotla

nd

Northern

Ireland

Wales

Hungary

Portugal

France

Germany**

Spain

Ireland

Slovenia

Norway

Poland0

10

20

30

40

50

60

70

80

90

100

2008-09 2009-10 2010-11 2011-12

Vacc

inati

on c

over

age

(%)

United Kingdom

27

28

Uptake seasonal influenza vaccine (%) among hospital staff,

by category & season (2011/2012, 2012/2013, 2013/2014)

Note: numbers of hospitals participating varied by season, 2011-2012 (n= 41), 2012-2013 (n=35) and 2013-2014 (n=46)

Reasons for not getting influenza vaccine among Irish HCWs (n= 92), 2006

Perceived low risk

Only good for elderly people

I don’t get the flu/rarely sick

I don’t need it

Problems with Vaccine / Injection / Side-effects

Problems with awareness / access

Other reason

0 10 20 30 40 50 60 70 80

70

14

21

35

13

10

8

Percentage (%)

Rea

son

fo

r n

on

-vac

cin

atio

n

29

Influenza & Public Health“Public Health refers to all organised measures (whether public or private) to prevent disease, promote health, and prolong life among the population as a whole”

- Assessment and monitoring

- Public Policy

- Access

*Vaccination and control of infectious diseases*

World Health Organization, 2015

CDC ‘Take 3’ Actions to fight the flu.

1.Take time to get the flu vaccine

2.Take everyday preventative actions to

stop the spread of germs

3.Take flu antiviral drugs if your

Doctor prescribes them

Disease Prevention

Health Promotion/Education

HPSC Monitor/Assessment

The Department of Public Health

GPs

Lab samples

Shared on communal Computerised Infectious Disease Reporting (CIDR)

Outbreak = Department of Public Health contact hospital/nursing home (etc.) with outbreak advise

e.g. Isolation, restrict visiting.

Influenza & Public Policy

• Health Information and Quality Authority (HIQA) & HPSC ‘Guidelines on influenza outbreaks’

• HSE ‘Guidelines for infection prevention and control management of a patient with suspect/probable/confirmed influenza’

• National Immunisation Advisory Committee (NIAC) recommendations for seasonal influenza vaccination (Campaigns)

Access

References

• Centres for disease control and infection (2015) available online at: http://www.cdc.gov/flu/about/disease/index.htm accessed 17th April 2015

• Corish Dail Debate (1976), Volume 288

• Dorney, J (2013) available online at: http://www.theirishstory.com/2013/05/16/ireland-and-the-great-flu-epidemic-of-1918/#.VTjSRhtFDX4 accessed 12th April

• Health Protection Surveillance Centre (2015) available online at: https://www.hpsc.ie/A-Z/Respiratory/Influenza/SeasonalInfluenza/Factsheets/File,12960,en.pdf accessed 15th April 2015

• Irish Independent (1976) Getting ready for swine flu, (5)

• Mitchell, A (2010) available online at: http://www.ucd.ie/ibp/MADissertations2009/Mitchell.pdf accessed 12th April

• Parish, C (2007) Pandemic Influenza: a daunting challenge for health services, Nursing Centre, V 31 (38)

• Phillips, H & Killingray, D (2003) The Spanish influenza pandemic of 1918-19:new pserpectives, London, Routledge

References

• http://www.cdc.gov/flu/protect/preventing.htm

• http//www.eswi.org/library/bulletins/0499-4.html.

• CDC. MMWR. 2001;50(RR-04)1-46.

• National Immunisation Guidelines for Ireland 2014

• *Health care workers in GPs practice

• Source VENICE survey ; http://venice.cineca.org/

• HPSC;http://www.hpsc.ie/A-Z/Respiratory/Influenza/SeasonalInfluenza/Vaccination/

• Mereckiene J et al. Euro Surveill. 2007;12(12).