Wednesday, February 07, 2018

ECDC: Low Uptake Of Flu Vaccine In Europe Jeopardizes Pandemic Preparedness


`Selling' the public on the idea that they need to get a flu shot every year has not been easy, complicated by years (like this one) with low vaccine effectiveness (VE), `scare tactics' used by the anti-vaccine crowd and social media, inconsistent public health policies around the world, and a low acceptance among many healthcare workers.
While far from perfect, most years the flu vaccine provides moderate protection (50%-60%) against currently circulating flu viruses. Less so for the elderly, but even when it fails to prevent flu, it may help moderate its impact (see CID Journal: Flu Vaccine Reduces Severe Outcomes in Hospitalized Patients).
Unfortunately, the vaccine does not prevent other respiratory infections (adenovirus, rhinovirus, parainfluenza, etc.) and so many people who get the jab fall ill with one of these  and believe the vaccine `failed' them.
While we've seen an increase in flu vaccine uptake in the United States in recent years, the same cannot be said for Europe, where vaccination rates have actually declined. 
And that presents a problem not only for the public's health during seasonal epidemics, but also for pandemic planners who need to see annual vaccine usage go up in order for pharmaceutical companies to afford to build and maintain the capacity needed to produce adequate supplies of emergency vaccine during a pandemic. 
Trying to produce (and deploy) billions of pandemic jabs over a short period of time from an industry that is set up to produce less than a billion doses each year is a recipe for failure.
And while there are `estimates' of reserve production capacity reaching into the billions of doses over a year's time, similar production goals during the 2009 H1N1 pandemic were badly missed (see H7N9 Vaccine Realities).

These estimates also assume a `best case scenario'.  One where:
  1. The pandemic influenza strain will grow in eggs as well as the seasonal strain;
  2. The supply of eggs for vaccine development is not impacted by the pandemic strain;
  3. Fifteen micrograms of antigen is sufficient for an effective vaccine dose without adjuvant; and
  4. There would be a sufficient supply of vials, syringes, etc. and functioning transport networks to deploy and dispense the vaccine

A lot of  things would have to go exceedingly well to meet the demand during a pandemic, assuming we actually have the manufacturing capacity required. 

Last week the journal Vaccine published a WHO sponsored study on the decline of flu vaccine uptake in Europe, and the potential impact that could have on global flu vaccine production capacity.
How close are countries of the WHO European Region to achieving the goal of vaccinating 75% of key risk groups against influenza? Results from national surveys on seasonal influenza vaccination programmes, 2008/2009 to 2014/2015
Pernille Jorgensena Jolita Mereckieneb Suzanne Cotterb Kari Johansenc Svetla Tsolovac Caroline Browna


Despite policy recommendations, influenza vaccination uptake remains suboptimal. Low levels of vaccination is not only a missed opportunity for preventing influenza in vulnerable groups, but could negatively affect pandemic preparedness. Improved understanding of barriers to influenza vaccination is needed to increase uptake and reverse negative trends. Furthermore, implementation of vaccination coverage monitoring is critical for assessing performance and impact of the programmes.
(Continue . . . .)
Unfortunately, convincing people that they should get a flu shot every year in order to prop up the vaccine industry so they can produce sufficient vaccine during a future emergency is a tough sell to an increasingly skeptical public.
But unless governments around the world decide take on that responsibility, the private sector is the only game in town. 
Improving the effectiveness of the seasonal flu vaccine would certainly help, as the incentive to get a highly effective jab is much greater than a `moderately' effective shot. Two low VE years out of the last 4 seasons haven't helped the vaccine's reputation.

Below you'll find an ECDC press release on the above study, after which I'll return with a final thought.

Low uptake of seasonal influenza vaccination in Europe may jeopardise capacity to protect people in next pandemic
press release
7 Feb 2018
Fewer than one third of older people are vaccinated in half the countries surveyed
Influenza vaccination coverage among high-risk groups has dropped in the European Region over the last seven years, and half the countries report a decrease in the number of vaccine doses available. These are the results of the first comprehensive overview of seasonal influenza vaccine coverage in the European Region of the World Health Organization (WHO) between 2008/09 and 2014/15, conducted by the European Centre for Disease Prevention and Control (ECDC) and the WHO Regional Office for Europe. Low uptake of seasonal influenza vaccination in Europe jeopardises the capacity to protect people during annual epidemics and the next pandemic, the two organisations warn.

“Vaccination is the most effective measure to prevent severe disease caused by influenza. However, according to our research, influenza vaccination uptake has been steadily declining in a number of countries in the European Region”, says Dr Zsuzsanna Jakab, WHO Regional Director for Europe. “This is of serious concern now for people at higher risk of severe consequences, especially older people, and in the future potentially for the entire population, as the production of pandemic vaccines is closely linked to seasonal vaccine use. I urge European countries to increase vaccination coverage to hit the goal of 75% uptake among older and other at-risk people.”
“All European Union Member States have signed up to the goal of reaching 75% uptake among older people and other vulnerable groups; however, these targets are not being reached”, says Dr Andrea Ammon, Director of ECDC. “ECDC is committed to further work with Member States in support of their efforts to control seasonal influenza”, she continues.

The overview appears in a peer-reviewed scientific article published in Vaccine in January 2018 , based on data from the Vaccine European New Integrated Collaboration Effort (VENICE III) and WHO surveys. As the 2017/18 influenza season peaks in western Europe, a number of countries have seen a rapid increase in severe cases and, according to EuroMOMO, the organisation for European monitoring of excess mortality for public health action, some are reporting excess mortality among the elderly.
Older people at higher risk of death from influenza

WHO and partners estimate that over 44 000 people die annually of respiratory diseases associated with seasonal influenza in the WHO European Region, out of a total of up to 650 000 global deaths.

According to annual surveys funded by ECDC and WHO, although 34 000 (over 75%) of these deaths in Europe are among people aged 65 years or above, vaccine uptake remains low in this group. Half the countries in the WHO European Region are vaccinating fewer than one in three older people.

As for the other at-risk groups: 

vaccination was generally recommended for people with chronic illnesses; however, coverage was below 40% in most countries;

  • almost all countries recommended influenza vaccination for health-care workers, but the majority reported influenza vaccine uptake as being as low as 40%;
  • in total, 90% of countries had vaccine recommendations for pregnant women in 2014/2015, compared with 40% before the 2009 A(H1N1) pandemic; however, coverage overall was low, with half the countries reporting uptake below 10%;
  • fewer than half the countries, most of them in eastern Europe, recommended influenza vaccination for young children; vaccination coverage ranged from less than 1% to 80%.
Vaccine shortages and declining demand behind low coverage

There are a number of context-specific factors influencing vaccination uptake. In the lower-resourced countries of the Region, where influenza may not be considered a high-priority disease, low coverage is a consequence of limited vaccine procurement.

Where vaccines are more widely available, uptake has been low or dropping for reasons ranging from complacency and lack of confidence in vaccines and health authorities, to lack of recommendations by health-care workers or access-related barriers, including out-of-pocket costs.

To address vaccination gaps effectively, it is necessary to understand the multiple barriers to vaccination, including:

  • rights, regulations and accessibility, availability and convenience of vaccination services;
  • social and cultural norms, values and support;
  • individual motivation, values, attitudes, knowledge and skills.

The quest for a universal flu vaccine - one that you might only have to take once in your lifetime (or more likely, every few years) - gets a lot of attention, and a lot of money thrown at it. And while that is indeed a laudable goal, and could potentially save many lives - if successful - it would (over time) reduce the need for a robust global flu vaccine production capacity. 
What happens if a pandemic virus that evades that vaccine emerges, after production capacity is decreased, is something I've not seen discussed.
By that time we may have moved completely to cell-based or recombinant vaccines, making rapid production feasible. But it is something that will need to be figured out, should a universal vaccine prove successful.

Meanwhile, and probably for at least the next 5 years, we have to deal with the flu vaccine technology, and manufacturing capacity, we have right now.  And during a severe influenza pandemic, neither are likely to perform as well as we'd like.