Prioritising prevention: Case of seasonal influenza vaccination

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Prudence Whitehead
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1 Prioritising prevention: Case of seasonal influenza vaccination background briefing Access to high-quality healthcare is hailed across Europe as its central defining feature. European healthcare is also viewed as among the best in the world. However, current challenges linked to Europe s changing demographic situation as well as the continuing economic downturn have revealed the unsustainability and inefficiency of many aspects of the system. At a time when greater economies are urgently needed, cost-effective prevention accounts for less than 3% of total healthcare budgets in Europe. Clearly, if Europe wants to improve its public finances and the quality of life and wellbeing of its citizens, its traditional treatment-oriented system needs to shift focus towards health promotion and disease prevention. This requires encouraging healthier lifestyles and investing in immunisation. This background briefing, coinciding with the organisation of a Friends of Europe Café Crossfire debate entitled Healthcare in times of austerity: Boosting cost-effective prevention, reviews the challenges and opportunities for boosting prevention in healthcare by taking the example of the seasonal influenza vaccination. What are the social and economic costs of influenza? Seasonal influenza is an infectious, communicable viral disease occurring in regular, large or smaller, winter epidemics. It spreads easily from person to person, circulates worldwide and can affect anybody in any age group. Commonly neglected and confused with similar diseases (i.e. the common cold), influenza has a severe social and economic impact on society. Not only does it afflict approximately 1 in 10 Europeans every year, it can also bring the risk of complications, resulting in more severe illnesses and even premature death. According to the World Health Organisation (WHO), those most at risk of becoming seriously affected by influenza are the so called high risk groups : children younger than two years, older people (65 years or older) and those with chronic illnesses. Worldwide, these annual epidemics result in approximately three to five million cases of severe illness and about to deaths 1 ; 40,000 (moderate season) to 220,000 (severe season) of them in Europe. 2 From an economic point of view, seasonal influenza also exacts a heavy economic toll, costing US$ 6 million per inhabitants annually in countries like Germany or France 3 ; the hospital admissions of elderly patients during influenza epidemics cost over GBP 22 million annually in the UK alone. Moreover, the economic burden can also be seen, although difficult to measure, in terms of lost days of work and school, and productivity and growth losses. Paradoxically, seasonal influenza is also one of the best-known preventable diseases, and its social and economic costs are avoidable through vaccination. May 2013»

2 Why vaccinate? The two public health interventions that have had the greatest impact on the world's health are clean water and vaccines, according to the World Health Organisation (WHO) 4. Indeed, immunisation is one of the biggest health successes of the last century and helped to control many diseases, with some even being completely eliminated; smallpox, for example, was officially eradicated in 1979 thanks to a focused immunisation effort across the world. Vaccines against seasonal influenza have been available and in use for more than 60 years. As the virus frequently changes its antigenic composition, WHO s Global Influenza Surveillance Network 5 reviews the vaccine content every year and publishes recommendations on the composition of the seasonal influenza vaccine (currently: the three strains of influenza expected to be most prevalent) for the Northern and Southern Hemisphere. As a consequence, the process of manufacturing the influenza vaccine is very challenging, as it must be made anew each year. Moreover, an incorrect estimation of the number of doses to be produced might lead to either a shortage or wastage of vaccines. In collaboration with scientists and policymakers, WHO also develops a unified manufacturing, testing and regulatory approach towards influenza vaccines and supports member states efforts to develop "The two public health interventions that have had the greatest impact on the world's health are clean water and vaccines." The 2009 influenza pandemic : lessons learned prevention, control and surveillance strategies. In 2003, the World Health Assembly adopted Resolution to increase influenza vaccination coverage of all people at high risk, with the goal of at least 50% vaccination coverage of the older age groups of the world s population by 2006 and 75% by The effectiveness of the influenza vaccine is not easy to evaluate, as it differs from year to year due to its changing composition and varies according to the age or risk group. It has been estimated that the influenza vaccine can prevent 70% to 90% of cases of influenzaspecific illness in healthy adults under the age of 65. Amongst the elderly, the vaccine reduces severe illnesses and complications elderly is more limited. by up to 60%, and cuts the death rate by 80%. However, some research suggests that the effect on mortality amongst the While the effectiveness of seasonal influenza vaccination is estimated to be high, assessing its costeffectiveness is much more challenging. Considerable research has been done in this area and most studies agree that vaccination of the elderly (aged 65 years or over) is cost-effective, with the savings associated with avoided healthcare costs more than compensating for the cost of vaccination. However, the cost-effectiveness was more difficult to prove with other age groups and many researchers have found that in healthy adults aged 18 to 49 years vaccination was not cost-saving. During the 2009 H1N1 influenza pandemic (also known as swine flu), a novel strain of influenza infected over 33,000 throughout Europe. This episode offers a number of valuable lessons in how to respond to future outbreaks of influenza, including seasonal influenza: Containment is no longer a realistic strategy: the 21st-century world is so interconnected as to make containment impossible. Surveillance must be improved: monitoring systems failed to notice this new virus strain until a major outbreak occurred. Coordination is essential: many member states adopted different coping strategies. As a result of the lack of coordination, member states competed for vaccines, leading to a vaccine shortage and extortionate prices. The lessons on coordination and cooperation appear to have been effective already. The European Commission has developed a proposal for a voluntary mechanism for the joint procurement of vaccines in which the Commission would negotiate with pharmaceutical companies on behalf of member states. It is hoped that this proposal, if passed, will both speed up the approval of new vaccines and guarantee a basic level of equitable access to vaccines for those most at risk. May

3 What is being done in the EU? Although member states retain their exclusive competence with regard to the definition of their health policy and the organisation and delivery of health services and medical care, coordinated action at the European level is needed to exchange information and control the risks of seasonal influenza, that as a communicable disease is a cross-border threat that no member state can tackle on its own. This is endorsed by article 168 of the Treaty on the functioning of the European Union, which states that Union action, which shall complement national policies, shall be directed towards improving public health, preventing human illness and diseases, and obviating sources of danger to physical and mental health. Such action shall cover the fight against the major health scourges, by promoting research into their causes, their transmission and their prevention, as well as health information and education, and monitoring, early warning of and combating serious cross-border threats to health. Key EU legislation: Network for the surveillance of seasonal influenza The European Commission Decision 2000/96/EC 7 of 22 December 1999 on the communicable diseases to be progressively covered by the Community network under Decision No 2119/98/EC 8 of the European Parliament and of the Council created the first network for the surveillance of seasonal influenza. It contributes to the fight against seasonal influenza by providing policymakers and healthcare professionals with timely and accurate data on outbreaks of the disease. The ECDC The European Centre for Disease Prevention and Control (ECDC) was established in 2005 by the Regulation (EC) No 851/ of the European Parliament and of the Council of 21 April 2004 with the aim to strengthen Europe s defences against infectious diseases. Based in Stockholm, Sweden, the Agency s mission is to monitor, identify, assess and communicate current and emerging threats to human health posed by infectious diseases across Europe, working in partnership with national health protection bodies. In the area of influenza, the ECDC s task is to monitor and assess the spread of influenza, to operate the Early Warning and Response System (EWRS) and to provide member states with scientific and technical expertise on seasonal influenza vaccination. "Union action, which shall complement national policies, shall be directed towards improving public health, preventing human illness and diseases, and obviating sources of danger to physical and mental health. European Parliament resolutions On 26 October 2005 and 14 June 2006 the European Parliament adopted resolutions entitled Strategy against an influenza pandemic 10 and Pandemic influenza preparedness and response planning in the European Community' 11 respectively, urging Member States to increase influenza vaccination rates to meet WHO recommendations. Both resolutions also emphasise the importance of communication and cooperation between EU institutions, member states and industry stakeholders in combating this threat to public health. Council Recommendation On 22 December 2009 the Council of the European Union issued a recommendation 12 in relation to immunisation against seasonal influenza, encouraging member states to: Adopt and implement national, regional or local action plans or policies to achieve 75% vaccination against seasonal influenza amongst the elderly (and, if possible, other at-risk groups, such as the chronically ill) by the winter of 2014/2015 or earlier. This should lead to higher vaccination rates in general and cover healthcare workers. Measure uptake in all risk groups and analyse reasons for non-vaccination. Foster awareness campaigns, training and exchange of information on the problem of seasonal influenza. Report to the European Commission on the implementation of the recommendations, especially on the coverage achieved amongst risk groups. The recommendation also invited the European Commission to continue to support research on seasonal influenza through the Research Framework Programme and to report to the Council on the implementation of the recommendation via an interim report to be released in 2013 and a final report to be issued by the end of What is the state of play on access and use of the vaccines? The latest findings of the ECDC and WHO on seasonal influenza vaccination in Europe give cause for considerable concern. Both organisations emphasise the fact that monitoring of vaccination uptake is frequently inadequate, making it difficult to obtain an accurate picture of coverage rates amongst the various population groups in Europe. For example, May »

4 Health at a glance: Europe Vaccination rates for influenza, population aged 65 and over, 2010 (or nearest year) Trends in vaccination rates for influenza, population aged 65 and over, (or nearest year) Source: OECD Health Data 2012, Health at a Glance: Europe May

5 The Netherlands: a successful story 14 According to Ted van Essen, adviser to the Dutch Health Council, several reasons can explain the high rates of influenza vaccination in the Netherlands: one professional held accountable: the general practitioner (GP) with a patient list system a national electronic medical records system that allows physicians and healthcare workers (HCW) to identify names and addresses of all at-risk patients, (i.e., 30% of the population) free vaccinations for at-risk patients a guaranteed fee for GPs who administer the vaccine centralised government purchasing of vaccines easy paperwork for the GP and convenient vaccination hours including evenings in certain cases for patients a simple campaign based on a postcard invitation-with-flyer from the GP systematic feedback to evaluate effort and results just one third of member states gather comparable data regarding the levels of vaccine uptake by the chronically ill and by healthcare workers 13, even though vaccination of the latter group is known to play a significant role in reducing the spread of seasonal influenza. from getting vaccinated and the countries with the lowest coverage in Europe are those that spend the least on subsidising seasonal flu vaccination. Finally, access to immunisation is still limited in some regions and countries, primary those with low-income economies. Moreover, it is observed that overall seasonal influenza vaccination rates remain low across the EU (see page 4). Of particular concern is the fact that so far only the Netherlands (see above) has achieved the target of 75% coverage amongst the elderly; the majority of member states, in particular from Central and Eastern Europe, do not appear likely to reach this target by the specified deadline of 2014 /2015. WHO has highlighted that the reasons behind the relatively low uptake of this vaccine across the EU are multifactorial and multidimensional. There is a lack of knowledge and misinformation (antivaccination internet campaigns) about the vaccines and many unfounded fears about the vaccine s safety and its side effects, as well as lack of confidence in its effectiveness and lack of trust in the advice from public health officials. Also, some medical practitioners do not recommend the influenza vaccination to their patients. On the other hand, costs are one major factor in preventing many What still needs to be done? "Overall seasonal influenza vaccination rates remain low across the EU. So far only the Netherlands has achieved the target of 75% coverage amongst the elderly. In view of the relatively low number of people availing of the seasonal influenza vaccination, the coverage of this vaccine needs to be greatly expanded if the social and economic costs of influenza in the EU are to be reduced. However, this will not be possible to achieve until more importance is given to disease prevention in budgetary terms and prevention is perceived as an investment that yields a considerable rate of return. Given the complex nature of the challenges surrounding the influenza vaccination, stimulating cooperation and engaging in an open debate among all stakeholders policymakers, industry representatives, healthcare professionals and citizens will be essential in achieving success. Public awareness campaigns and professional training should play an important role in any attempt to increase vaccination rates. Informing people of the benefits of influenza vaccination and dispelling May »

6 anxiety about the safety of the vaccine is important. The role of the media, including social media, in getting the right message (based on scientific evidence and testimonials) to the public is key in strengthening and restoring public trust in vaccination. Involving family doctors and pharmacists in raising awareness and distribution of the vaccine is also a must and providing them with economic incentives could be considered. If these campaigns are to be effective, influenza vaccination needs to be more accessible for all citizens, and in particular high risk groups. Measures should include flexibility with regard to the vaccination hours and subsidisation of vaccines aimed at reducing or even eliminating personal costs. environment that allows the pharmaceutical industry to unfold its R&D potential and boost incremental innovation in the effort to improve current vaccines. Finally, the EU should play a key role in identifying and assessing the risks of the disease and its spread, in providing member states with scientific and technical expertise and in monitoring the vaccination coverage among member states. The EU can also coordinate member states immunisation programmes and policies, encourage the exchange of information and best practices, stimulate investment and innovation and possibly be the main negotiator with pharmaceutical companies. Awareness campaigns should also be combined with an increased effectiveness of the vaccines: European and national legislators should create an End notes 1 World Health Organization, Influenza Factsheet, ( 2 European Commission, Citizens' summary Seasonal Flu Vaccination ( 3 WHO Position Paper, Releve Epidemiologique, Hebdomadaire, No. 33, August Plotkin S, Orenstein W,, and Offit P,.Vaccines, 5 th ed. Saunders, WHO Global Influenza Surveillance Network (GISN): /96/EC: Commission Decision of 22 December 1999 on the communicable diseases to be progressively covered by the Community network under Decision No 2119/98/EC of the European Parliament and of the Council (notified under document number C(1999) 4015) ( 8 Decision No 2119/98/EC of the European Parliament and of the Council of 24 September 1998 setting up a network for the epidemiological surveillance and control of communicable diseases in the Community ( 9 Regulation (EC) No 851/2004 ( 10 European Parliament resolution on the strategy against an influenza pandemic, Wednesday, 26 October 2005 Strasbourg ( 11 European Parliament resolution on pandemic influenza preparedness and response planning in the European Community (2006/2062(INI)) ( 12 Council of the European Union, Council Recommendation of 22 December 2009 on Seasonal Influenza Vaccination, Official Journal of the European Union, O Flanagan, D., Cotter, S., and Mereckiene, J. Seasonal influenza vaccination in Europe: vaccination policy and vaccination coverage.summary of VENICE surveys ( 14 European Scientific Working group on Influenza, The First European Influenza Summit ( May

7 Further reading Friends of Europe. Why Health is Crucial to European Recovery, 2012: Portals/13/Documents/Reports/2012/FoE_Report_Health_2012.pdf Debating Europe, Health in the EU: Themed Week, ( Council of the European Union, Council Recommendation of 22 December 2009 on Seasonal Influenza Vaccination, Official Journal of the European Union, European Centre for Disease Control and Prevention: seasonal_influenza/key_messages/pages/key_message_3.aspx World Health Organization, Influenza (Seasonal), Fact Sheet No. 11, World Health Organization, Influenza Vaccines, WHO Position Paper, Releve Epidemiologique, Hebdomadaire, No. 33, August World Health Organization, Draft Global Vaccination Action Plan, ( pdf_files/wha65/a65_22-en.pdf) World Health Organization, Regional Office for Europe. Vaccines and Immunization, ( Organisation for Economic Co-operation and Development, Influenza Vaccination for Older People, Health at a Glance: Europe 2012, OECD Publishing, health_glance_2012_en.pdf May »

8 Authors Shada Islam Head of Policy at Friends of Europe Tel: +32 (0) Danuta Slusarska Project Executive at Friends of Europe Danuta.slusarska@friendsofeurope.org Tel: +32 (0) Louise Smyth Project Assistant at Friends of Europe Louise.smyth@friendsofeurope.org Tel: +32 (0) Friends of Europe is a leading European think-tank that aims to stimulate thinking on the future of the EU. For more than a decade our contribution has been the confrontation of ideas that is vital to policymaking and to encouraging wider involvement in Europe's future. Contact us: 4, Rue de la Science, B-1000 Brussels - Belgium Bibliothèque Solvay - Parc Léopold, Rue Belliard 137, 1040 Brussels - Belgium Tel.: +32 (0) Fax: +32 (0) info@friendsofeurope.org May

Perspectives from regions: successes and challenges in promoting seasonal influenza vaccine usage in the EU

Perspectives from regions: successes and challenges in promoting seasonal influenza vaccine usage in the EU N. Safrany European Commission Pr. A. Nicoll ECDC 2 nd WHO GAP mtg 12-14 July 2011 Background