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Third European Influenza Conference
Vilamoura 14-17 September 2008
INCREASING THE OVERALL EPIDEMIC
VACCINATION COVERAGE:
THE MACROEPIDEMIOLOGY OF
INFLUENZA VACCINATION
David S. Fedson
[email protected]
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
Influenza Vaccination in 71
Influenza vaccination in 56 countries, 1997-2005
Countries, 1997-2005
Malta
Canada
Rep. of Korea
Japan
USA
Germ any
Spain
Belgium
U.K.
Australia
Netherlands
Luxem bourg
Latvia
France
Iceland
New Zealand
Sw itzerland
Hong Kong SAR
Ireland
Israel
Italy
Finland
Greece
Russian Fed.
Taiw an
Austria
Croatia
Portugal
Sw eden
Hungary
El Salvador
Chile
Slovenia
Denm ark
Norw ay
Slovak Rep.
Costa Rica
Mexico
Brazil
Rom ania
Poland
Argentina
Czech Rep.
Uruguay
Lithuania
Bulgaria
Singapore
Colom bia
Estonia
Turkey
Serbia/Monten.
Ukraine
Algeria
Om an
Moldova
South Africa
China
Jordan
Iran
Panam a
Thailand
Equador
Venezuela
Uzbekistan
Guatem ala
Peru
Albania
Egypt
Bolivia
Georgia
Kyrgyz Rep.
303
84
84
76
70
65
61
56
51
50
46
40
34
27
26
25
22
21
19
16
14
12
11
8
7
6
5
4
4
2
2
1
1
1
0
50
201
195
185
183
181
178
168
167
162
162
160
153
150
148
147
140
139
139
138
136
131
130
129
127
123
113
102
94
100
239
238
227
223
/
345
336
457
637
255
1997
2005
150
200
250
300
350
400
Doses of influenza vaccine distributed / 1000 population
450
MIVSG 2007
Influenza Vaccination in 71
Influenza vaccination in 56 countries, 2002-2005
Countries, 2002-2005
Malta
Canada
Rep Korea
Japan
USA
Germ any
Spain
Belgium
UK
Australia
Netherlands
Luxem bourg
Latvia
France
Iceland
N. Zealand
Sw itzerland
Hong Kong SAR
Ireland
Israel
Italy
Finland
Greece
Russian Fed.
Taiw an
Austria
Croatia
Portugal
Sw eden
Hungary
El Salvador
Chile
Slovenia
Denm ark
Norw ay
Slovak Rep.
Costa Rica
Mexico
Brazil
Rom ania
Poland
Argentina
Czech Rep.
Uruguay
Lithuania
Bulgaria
Singapore
Colom bia
Estonia
Turkey
Serbia/Monten
Ukraine
Algeria
Om an
Moldova
South Africa
China
Jordan
Iran
Panam a
Thailand
Equador
Venezuela
Uzbekistan
Guatem ala
Peru
Albania
Egypt
Bolivia
Georgia
Kyrgyz Rep.
303
65
56
51
50
46
40
34
27
26
25
22
21
19
16
14
12
11
8
7
6
5
4
4
2
2
1
1
1
0
50
84
84
76
70
201
195
185
183
181
178
168
167
162
162
160
153
150
148
147
140
139
139
138
136
131
130
129
127
123
113
102
94
239
238
227
223
/
345
336
437
637
255
61
2002
2005
100
150
200
250
300
350
Doses of influenza vaccine distributed / 1000 population
400
450
MIVSG 2007
Influenza Vaccination in 71 Vaccineproducing and Non producing Countries
2002-2005
Influenza vaccination in 56 countries,
2002-2005
Canada
Japan
USA
Germany
U.K.
Australia
Netherlands
France
Italy
183
160
Russian Fed.
Hungary
Romania
China
Malta
Korea
Belgium
Spain
Luxembourg
Iceland
N. Zealand
Switzerland
Ireland
Latvia
Finland
Greece
HongKong
Taiwan
Austria
Croatia
Portugal
Sweden
Chile
Slovenia
Denmark
Israel
Norway
Slovak Rep.
Costa Rica
Mexico
El Salvador
Argentina
Brazil
Poland
Czech Rep.
Uruguay
Lithuania
Bulgaria
Singapore
Colombia
Estonia
Turkey
Ser&Monten
Ukraine
Moldova
South Africa
Jordan
Panama
Thailand
Equador
Venezuela
Guatemala
Peru
Albania
Egypt
Uzbekistan
Bolivia
Georgia
Kyrgyz Rep.
65
56
51
50
46
40
34
30
26
21
19
14
11
8
7
6
4
4
2
2
2
1
1
1
0
50
255
303
350
Vaccine-producing
148
136
84
16
201
227
223
274
181
178
168
162
158
153
150
149
147
140
139
139
138
130
129
127
127
123
113
102
94
92
90
84
76
195
/
238
233
637
437
Non producing
61
2002
2005
100
150
200
250
300
350
400
Do s e s o f in flu e n za v a c c in e d is trib u te d / 1 0 0 0 p o p u la tio n
450
MIVSG 2007
Influenza Vaccination in Countries With
and Without Public Reimbursement
2002-2005
Influenza vaccination in 56 countries, 1997-2003
Malta
Canada
Japan
United States
Germany
Belgium
Spain
U.K.
Australia
Netherlands
France
New Zealand
Switzerland
Ireland
Italy
Finland
Greece
Hong Kong SAR
Taiwan
Croatia
Portugal
Sweden
Chile
Slovenia
Denmark
Israel
Norway
Slovak Rep.
Mexico
Argentina
Brazil
Romania
Czech Rep.
Uruguay
Serbia&Montenegro
Ukraine
Rep. of Korea
Latvia
Iceland
Russian Fed.
Austria
Hungary
Costa Rica
El Salvador
Poland
Lithuania
Bulgaria
Singapore
Colombia
Estonia
Turkey
Moldova
South Africa
China
Jordan
Panama
Thailand
Equador
Venezuea
Guatemala
Peru
Albania
Egypt
Uzbekistan
Bolivia
Georgia
Kyrgyz Rep.
303
65
94
90
84
84
21
16
14
11
8
7
6
4
4
2
2
2
1
1
1
0
201
255
With reimbursement
61
30
26
56
51
50
46
40
34
183
178
168
162
160
153
150
149
147
139
139
138
130
129
127
127
123
113
238
233
227
223
637
350
76
102
92
148
140
136
336
185
181
No reimbursement
19
1997
2005
50
100
150
200
250
300
350
400
D oses of influenza vaccine distributed / 1000 population
450
MIV SG 2007
Influenza Vaccination in Western Europe
1997-2002-2005
Germany
255
Belgium
238
Spain
233
U.K.
227
The Netherlands
201
Luxembourg
195
France
183
Iceland
181
Switzerland
168
Ireland
162
Italy
160
Finland
153
Greece
150
Austria
140
Portugal
1997
2002
2005
139
Sweden
138
Denmark
127
Norway
123
0
50
100
150
200
Doses of influenza vaccine distributed / 1000 population
250
300
MIV SG 2007
Influenza Vaccination in
Malta, 1997-2005
637 135 124 134 84 75 56 60 68
1997
68
1998
60
1999
56
2000
75
2001
84
2002
134
2003
124
2004
135
2005
637
0
50
100
150
200
250
300
350
400
450
500
550
Doses of influenza vaccine distributed / 1000 population
600
650
MIV SG 2007
Influenza Vaccination in Central and
Eastern Europe 1997-2002-2005
Latvia
Israel
Russ. Fed
Croatia
Hungary
Slovenia
Slovak Rep.
Romania
Poland
Czech Rep.
Lithuania
Bulgaria
Estonia
Turkey
Serbia/Montenegro
Ukraine
Moldova
Uzbekistan
6
Albania 2
Georgia 1
Kyrgyz Rep. 1
0
160
113
76
56
51
34
139
136
129
185
148
84
65
40
27
26
21
1997
2002
2005
50
100
150
Doses of influenza vaccine distributed / 1000 population
200
MIV SG 2007
Economic Development and Influenza
Vaccination in Europe, 2005
L u xLuxembourg
e m b o u rg
N o rw a y
Norway
Switzerland
Ic e l a n dIceland
Ire l a n d
Ireland
D e n m a rk
Denmark
Au s tri a
Austria
B elgium
Belgium
N e th e rl a n d s
Netherlands
Sweden
Sweden
Fi n l a n d
Finland
Fra n c e
France
G e rm a n y
Germany
Ita l y
Italy
Spain
Spain
G re e c e
Greece
Cy p ru s
Cyprus
Slov enia
Slovenia
Cz e c h R e p .
Czech Rep.
P o rtu g a l
Portugal
M a l ta
Malta
H u n g a ry
Hungary
Slov ak R ep.
Slovak Rep.
E s to n i a
Estonia
L i th u a n i a
Lithuania
Poland
Poland
L a tv i a
Latvia
Cro a ti a
Croatia
R u s s i a n Fe d .
Russian Fed.
R om ania
Romania
B u l g a ri a
Bulgaria
U k ra i n e
Ukraine
Al b a n i a
Albania
G e o rg i a
Georgia
U z b e k i s ta n
Uzbekistan
K y rg y z R e p .
Kyrgyz Rep.
S w i tz e rl a n d
70000
60000
50000
40000
30000
20000
10000
GNI per capita ($), adjusted for PPP
0
0
MIV SG 2007
100
200
300
400
500
600
700
Vaccine doses distributed / 1000 pop.
Influenza Vaccination in the
Western Pacific, 1997-2002-2005
Rep. of Korea
336
Japan
303
Australia
223
New Zealand
178
Hong Kong SAR
149
Taiwan
147
Singapore
1997
50
2002
China
2005
16
0
50
100
150
200
250
300
Doses of influenza vaccine distributed / 1000 population
350
MIV SG 2007
Economic Development and
Influenza Vaccination in the
Western Pacific, 2005
Japan
Au s t r a l i a
Sin g a p o re
N . Z ealand
R e p . Ko re a
Th a ila n d
40000
30000
20000
10000
Japan
Australia
Singapore
N. Zealand
Rep. Korea
Thailand
0
0
100
200
Vaccine doses
distributed / 1000
population
GNI per capita ($)
adjusted for PPP
MIV SG 2007
300
400
Influenza Vaccination in the Americas
1997-2002-2005
Canada
United States
El Salvador
Chile
(1)
Costa Rica
Mexico
Argentina
Brazil
Uruguay
Colombia
Panama
11
Equador 7
Venezuea 6
Guatemala 4
Peru 4
Bolivia 1
0
350
274
131
130
102
94
90
84
61
46
1997
2002
2005
50
100
150
200
250
Doses of influenza vaccine distributed / 1000 population
300
350
MIV SG 2007
Economic Development and Influenza
Vaccination in Latin America, 2005
Chile
Mexico
Uruguay
Costa Rica
Brazil
Colombia
Panama
Venezuela
Peru
El Salvador
Guatemala
Ecuador
Honduras
Bolivia
Ch i l e
M ex ico
U ru g u a y
Co s ta R i c a
B ra z il
Co l o m b i a
Panam a
Ve n e z u e l a
Pe ru
El Salv ador
G u a te m a l a
Ecuador
H o n d u ra s
B oliv ia
14000
12000
10000
8000
6000
4000
2000
0
0
20
40
60
80
100
120
Vaccine doses distributed /
1000 population
GNI per capita ($)
adjusted for PPP
MIV SG 2007
140
Influenza Vaccination in Countries With
Recommendations for Children
6-23 Months, 2003-2004-2005
Canada
350
Rep. of Korea
336
United States
274
Taiwan
147
Austria
140
Chile
2003
2004
130
Mexico
2005
94
0
50
100
150
200
250
300
350
Doses of influenza vaccine distributed / 1000 population
MIV SG 2007
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
29.8
UK
69.8
25.0
27.6
Italy
65.6
24.4
18.6
France
68.3
24.2
22.4
Portugal
53.3
23.6
16.7
Spain
71.1
21.8
27.9
Austria
36.8
17.8
16.8
Finland
63.1
16.2
18.5
Poland
25.3
14.1
9.1
Czech Rep.
30.2
13.8
7.6
Ireland
50.7
13.5
20.5
* MIVSG rates/total population adjusted to population ≥ 15 yrs
Influenza Vaccination in Spain
• Eligible population - 2006-2007
current 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%
< 65 yr HR - 30.5%
HCWs
- 19.7%
Eur J Public Health 2007;17:272-7.
Infection 2006; 34: 135-41.
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
Not in very good health
Protects against influenza
Don’t want to infect others
It’s free and recommended
47 %
47 %
39 %
23 %
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
Attitude
Physician
Recommendation
Percent
Vaccinated
Positive
Negative
Yes
Yes
87
70
Positive
Negative
No
No
8
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 (%)
Age group
% total
(yrs)
population
Died in hospital during
flu season (%)
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
12 
45
46
66
66
≥ 75
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
Acknowledgement
MIV Study Group Investigators
Central and Eastern Europe
Albania
Miriam Xibinaku
Bosnia & Herz. Prof. Puvacic
Bulgaria
Mira Kojouharova
Croatia
Ira Gjenero-Margan
Czech Rep.
Eva Vitkova
Estonia
Olga Sadikova
Georgia
L. Jabidze
Hungary
Zsuzsanna Molnar
Israel I
tamar Grotto
Kyrgyz Republic Kalia Kasymbekova
Latvia
Inga Velicko
Irina Lucenko
Lithuania
Arvydas Ambrozaitis
Macedonia
Blaze Nikolovski
Moldova
Peter G. Scofertsa
Montenegro
Dragan Lausevic
Poland
Lidia Brydak
Romania
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 America
Canada
Mexico
United States
Theresa Tam
Augustin Lara Esqueda
Greg Wallace
Western Europe
Central and South America
Austria
Michael Kunze
Belgium
Rene Snacken
Cyprus
Chrystalla Hadjianastassiou
Denmark
Ann E. Ottosen
Finland
Rose-Marie Olander
FranceJean-Marie Cohen
Germany
Peter Wutzler
Greece
Andreas Constantopoulos
Iceland
Thorolfur Gudnason
IrelandJoan O’Donnell
Italy
Isabella Donatelli
Malta
Tanya Melillo
Luxembourg
Claude P. Muller
Netherlands
Ted van Essen
Norway
Lars Haaheim
Portugal
Helena Rebelo de Andrade
Spain
Agustin Portela
Sweden
Ake Ortqvist
Switzerland
Mark Witschi
Argentina
Bolivia
Brazil
Chile
Colombia
Costa Rica
Dominican Rep
Ecuador
El Salvador
Guatemala
Panama
Peru
Uruguay
Venezuela
United Kingdom
Jane Leese
Eastern Mediterranean and Africa
Algeria
Egypt
Iran
Jordan
Oman
South Africa
Fawzi Derrar
Mostafa Orkhan
Abdoul reza Esteghamati
Ali Muhaidat
Salah Al Awaidy
Barry D. Schoub
Vilma Savy
Raul Artega
Joao Toniolo-Neto
Leonardo Maggi
Enrique Gutierrez
Maritza Morena Singler
Jose Brea del Castillo
Greta Migno
Suarez Castaneda
Adib Rodriguez
Xavier Saez
Gordito Chaparro
Homero Bagnulo
Jaime Torres
Western Pacific
Australia
Alan Hampson
China
not identified
Hong Kong SAR Christina Maw
Japan
Kosaku Uchida
New Zealand
Lance Jennings
Rep. of Korea
Woo-Joo Kim
Singapore
Chan Kwai Peng
Taiwan
Shu-fong Chen
Southeast Asia
Thailand
Piyanit Tharmaphornpilas
MIVSG 2007
Influenza Vaccination of
Elderly and High-risk People