Kick-off meeting of new Working Group on:

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1 Kick-off meeting of new Working Group on: EFPC 2016 Conference, September 4-6, Riga, Latvia Clinic of Social and Family Medicine Department of Social Medicine, School of Medicine, University of Crete, Greece

2 Current state and general background info Interpreting current state, mapping needs to address challenges Health providers The patient Context Tools and behavioral change New challenge of migration, refugees, etc. Focus of Working Group and Action Plan

3 Diphtheria epidemic recorded in Eastern Europe with cases referred and 4000 deaths reported 1 Morbidity from diphtheria and pertussis seems to be stable in adult life 2 Booster doses for tetanus provides protection against tetanus, diphtheria and pertussis 1 WHO recommends a booster vaccination for tetanus-diphtheria (Td) every 10 years, with a vaccinated target 90% 2 1. National Foundation for Infectious Diseases, Bethesda, MD. Immunization: Supporting a Healthier Life Throughout the Lifespan - National Adult Immunization Awareness Week 2008 Campaign Kit. Accessed November 12, Michel JP, Chidiac C, Loebenstein BG, et al. Advocating Vaccination of Adults Aged 60 Years and Older in Western Europe: Statement by the Joint Vaccine Working Group of the European Union Geriatric Medicine Society and the International Association of Gerontology and Geriatrics European Region. REJUVENATION RESEARCH. 2009;12(2):

4 Usually it affects adults over 50 years old 1 The implication of tetanus is under 0.2/ 100,000 in EU of 15 members 2 Mortality 10% - 20% 4 In the USA, more deaths in people >60 years old from Diabetes People with tetanus may need special care in the hospital 3 Vaccination coverage in people >65 years old in France is 60.5% which is under the target of WHO at 90% 1 Vaccination coverage reduces as we grow older 5 In Greece the protection percentage in men >60 and women>30 is low 6 1. Michel JP, Chidiac C, Loebenstein BG, et al. Advocating Vaccination of Adults Aged 60 Years and Older in Western Europe: Statement by the Joint Vaccine Working Group of the European Union Geriatric Medicine Society and the International Association of Gerontology and Geriatrics European Region. REJUVENATION RESEARCH. 2009;12(2): European Centre for Disease Prevention and Control. Annual Epidemiological Report on Communicable Diseases in Europe Report on the Status of Communicable Diseases in the EU and EEA/EFTA Countries Executive Summary Accessed on November 12, National Foundation for Infectious Diseases, Bethesda, MD. Immunization: Supporting a Healthier Life Throughout the Lifespan - National Adult Immunization Awareness Week 2008 Campaign Kit. Accessed November 12, Plotkin S, Orenstein W, Offit P. Vaccines. 5th Edition. Saunders Elsevier. 5. Tetanus. VPD Surveillance Manual, 4th Edition, 2008: Chapter 16: Simeonidis et al, Eur J Epidemiol 2003

5 Pertussis (Whooping cough) is very infectious 3 The transmission is very high 2 Parents and grandparents constitute the source of infection to their children 2 According to data from Australia the pertussis imports are increased in babies until 6 months and people over 85 years old 2 A million cases are recorded annually in the USA between teenagers and adults 3 Pertussis may cause death in adults 2 1. National Foundation for Infectious Diseases, Bethesda, MD. Immunization: Supporting a Healthier Life Throughout the Lifespan - National Adult Immunization Awareness Week 2008 Campaign Kit. Accessed November 12, Michel JP, Chidiac C, Loebenstein BG, et al. Advocating Vaccination of Adults Aged 60 Years and Older in Western Europe: Statement by the Joint Vaccine Working Group of the European Union Geriatric Medicine Society and the International Association of Gerontology and Geriatrics European Region. REJUVENATION RESEARCH. 2009;12(2): Zimmerman RK, Middleton DB, Burns IT, et al. Routine vaccines across the life span, The Journal of Family Practice. 2007;56(2):S18-36.

6 BOI Score No. of cases No. of cases Vaccine efficacy (%) - 95%CI Efficacy of Zostavax in reducing the incidence of herpes zoster Zostavax significantly reduced the number of PHN cases Vaccination reduces the burden of illness of HZ and the number of PHN cases n=642 p<0.001 CI: % -51.3% n=315 Placebo Zostavax n=19,276 n=19,270 No of cases: 38,546 n= % n=27 Placebo Zostavax n=19,276 n=19,270 Zostavax decreased the incidence of HZ & PHN and reduced burden of illness (BOI) Efficacy of Zostavax in reducing the burden of illness of herpes zoster 5.68 Placebo n=19,276 p<0.001 CI: % -61.1% 2.21 Zostavax n=19,270 No of doses: One subcutaneous injection of 0.5ml of zoster vaccine Duration of study: Nov 1998 Apr 2004 Duration of follow-up: Median 3.12 years p<0.001 CI: % Shingles prevention study 1. Miller E., Marshall R., Vudien J. Epidemiology, outcome and control of varicellazoster infection. Rev Med Microbiol 1993;4: Oxman MN, Levin NJ, Johnson GR, et al. A Vaccine to Prevent Herpes Zoster and Postherpetic Neuralgia in Older Adults. N Engl J Med.2005;352: Scott FT, Leedham-Green ME, Barrett-Muir WY et al. A study of shingles and the development of postherpetic neuralgia in East London. J Med Virol 2003;70 Suppl 1:S24-S Oxman MN. Clinical manifestations of herpes zoster. In: Arvin AM, Gershon AA, eds. Varicella zoster virus: virology and clinical management. Cambridge, England: Cambridge University Press, 2000: DeMelker H, Berbers G, Hahne S, et al. The epidemiology of varicella and herpes zoster in the Netherlands: Implications of varicella zoster virus vaccination. JVAC : 1-7.

7 Aging affects as much as pathetic and energetic immunization 1 Innate immunity Non pathogen-specific Immune response to infection Adaptive immunity Pathogen-specific With aging, the immune system operates weakly 1 Cellular components of the immune responses 3 B cell T cell T cell Macrophage The number and/ or the functions of the immune cells are affected 2 Natural Killer Cell Neutrophil Natural Killer Cell Antibodies CD4+ T cell CD8+ T cell 1. Aspinall R, Giudice GD, Effros RB, et al. Challenges for vaccination in the elderly. Immunity & Ageing. 2007;4:9. 2. Kumar R, Burns EA. Age-related decline in immunity: implications for vaccine responsiveness. Expert Rev Vaccines 2008;7: Cytokines in cancer pathogenesis and cancer therapy. Nature reviews cancer

8 Example: Vaccination hesitancy A lot of work to be done still on improving uptake and overall coverage! Various initiatives right now: Vaccine uptake in under 19s NICE quality standard Draft for consultation September 2016 An estimated 3 million children and young people aged 18 months to 18 years may have missed either their first or second MMR vaccination. The potential exposure of so many children and young people to the measles virus means that there is a risk of a large outbreak. Measles can lead to serious complications and can be fatal.

9 Education in students and health care workers in vaccination issues Participation of healthcare workers in sorting vaccination during the visit in the practice Vaccination in special population groups (teenagers, pregnant women, soldiers, workers and physicians) and Vaccination of vulnerable groups: uninsured and immigrants, refugees relevant projects (e.g., EUR-HUMAN lessons) as contrasted and compared to: Vaccination and participation of local government and NGOs

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11 Canadian study of large sample (patients and providers, surveys and focus groups) focusing on four vaccine-preventable diseases and vaccines (diphtheria-tetanuspertussis, zoster, pneumococcus and influenza). Positive attitudes towards vaccines paralleled concern about the burden of illness and confidence in the vaccines, with providers being more aware of disease burden and confident in vaccine effectiveness than the public. Barriers and facilitators to improved vaccine coverage in adults, such as trustmistrust of health authorities, pharmaceutical companies and national recommendations, autonomy versus the public good and logistical issues (such as insufficient time and lack of vaccination status tracking), were identified by both the public and providers. MacDougall et al. (2015) The challenge of vaccinating adult: attitudes and beliefs of the Canadian public and healthcare providers. BMJOpen, 5:e doi: /bmjopen

12 HCWs constitute a priority group for immunization (e.g., H1N1) Nevertheless, low vaccination rates have been documented (e.g., influenza pandemic) and are associated with the onset of nosocomial cases and outbreaks HCWs, health-care institutions, and public health bodies have the moral obligation to protect vulnerable patients and therefore weigh the benefits of mandatory vaccination. A particular challenge at a time of austerity. Maltezou and Tsakiris. (2011) Vaccination of health-care workers against influenza: our obligation to protect patients. Influenza Other Respir Viruses Nov;5(6): doi: /j x. Epub 2011 Mar 21. Maltezou and Lionis (2015) The financial crisis and the expected effects on vaccinations in Europe: a literature review. Infect Dis (Lond) Jul;47(7): doi: / Epub 2015 Mar 5. 12

13 Mandatory vaccination for certain diseases in certain groups (influenza, measles, mumps, rubella, hepatitis B, pertussis, varicella). Mandatory vaccination has been adopted by very few countries and for very limited indications. There are significant immunity gaps among HCWs against VPDs in Europe Measles example Eliminating measles by 2010 has not been accomplished Stronger recommendations and higher vaccination coverage against measles in healthcare workers could contribute to eliminate measles in the general population. Recent work indicates that self-reported rates vary greatly (5.8% %) Mandatory vaccinations were supported by 65.1% of 1,807 respondents, with wide differences by disease. Multiple logistic regression analysis revealed higher rates of acceptance of mandatory vaccination in physicians compared with other HCW categories.

14 Healthcare providers Primary care providers Other specialties providing care outside standard PHC settings The patient the citizen the community Contextual factors, organizational settings, policy decisions and action plans

15 The environment Health authorities Other stakeholders Lay opinion Economic conditions Physicians The clinical setting Medical contract Motives or other factors facilitating behavior change Clients/ patients Pharmacists Nurses

16 Theory of planned behaviour Health beliefs model Motivational interviewing Behavioral Beliefs Attitude toward the behaviour Normative Beliefs Subjective Norm Intention Behaviour Control Beliefs Perceived behavioral control Actual behavioral control Copyright 2006 Icek Ajken

17 Percent Objective: reduce irrational prescribing of OTC medicines in general practice Intervention: 1-day training programme; poster presentation; visits of trained professionals to the workplace; reminders and s (4-week follow-up) Result: Reduced median intention scores in the intervention groups. High overall acceptance and perceived practicality of the programme by GPs. 100 A patient visiting you health centre is asking you to prescribe him medicines he has already purchased from the pharmacy, without a prescription. What do you do? Prescribe it Prescribe it (and give advice on the risks associated with the medicine Prescribe it (for the last time; and give advice on the risks associated with the medicine) Desired behaviour change Do not prescribe it Lionis C, et al. BMC Fam Pract Feb 17;15:34. 0 Before intervention Intervention group After intervention

18 Document experiences and establish a baseline for an overview of issues in practice Additional issues given challenges from population with undocumented health records and/or false reporting (e.g., refugees, irregular immigrants and migrant workers going through multiple countries, etc.) Need to implement shared decision-making Need to interact with bodies, associations, fellow colleagues in other countries, other professions, etc. on the basis of established rationale aiming for a unified approach

19 Establish the baseline and present and discuss related activities of Immunize Europe, WHO, Vaccines Europe, etc. Currently, there are multiple forums of exchange with relatively poor dissemination, visibility or interaction with primary care professionals Room for improvement between public health and primary care interaction to better inform policy makers

20 Establish timeline of activities and team and start building ties with similar groups across professional board Ensure all professions in primary care team work are represented and on board (opportunistic immunisation/vaccination) Aim for initial mapping of efforts public health perspective and primary care perspective for Porto 2017 Aim for outline of unified approach and/or Position Paper Crete 2018

21 Child (e.g., in hotspot or short-term centre) has significant vaccine side effect (e.g., anaphylaxis or rare yet well documented idiosyncratic side effect); parents are reluctant to vaccinate other children, themselves, elderly family members Narratives and practical advice on interaction and impact assessment of such events in (for example) tight knit communities

22 Pandemic flu mitigation, example of unlikely tools and means: Serious video games (SVGs) - an innovative tool that may serve public health, control spreading of infectious diseases and increase vaccination uptake SVG are particularly appropriate for infections transmitted diseases as behaviors are key determinants for control and preventive measures SVG may be a promising tool for promoting vaccination and an opportunity to describe and associate other preventive measures according to a disease Ohannessian et al. (2016) A systematic review of serious video games used for vaccination. Vaccine, Vol 34, Issue 38, p

23 1. Simply reassure the patient about vaccination vaccination 2. Utilise motivational interviewing or other behaviour change approach 3. Ask advice/support to other healthcare practitioners 4. Both answers 2 and 3

24 Baseline Questionnaire and probing Share findings Reach out and hold session to map activities Overview of online courses, educational and training material Awareness material, infographic and other resources Overview of events and workshops related to vaccines and immunisation, as well as community activities Best practice tracker and map of parallel activities from other bodies, organisations, etc.

25 A meeting place where experiences and ideas can be exchanged Identify commonalities and essential differences in priorities and contexts Develop a common approach and provide key messages and information to inform decision-makers and policy decisions across Europe and globally Contact details Survey will stay open, s to be sent to all participants to generate final mailing list elena.petelos@med.uoc.gr lionis@galinos.med.uoc.gr