1. Third European Influenza Conference Vilamoura 14-17 September 2008 INCREASING THE OVERALL EPIDEMIC VACCINATION COVERAGE: THE MACROEPIDEMIOLOGY OF INFLUENZA VACCINATION David S. Fedson dfedson@wanadoo.fr

2. 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

3. 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 2006MIVSG 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

4. 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

5. MIVSG 2007 Influenza Vaccination in 71 Countries, 1997-2005 / 637

6. MIVSG 2007 Influenza Vaccination in 71 Countries, 2002-2005 / 637

7. MIVSG 2007 Influenza Vaccination in 71 Vaccine- producing and Non producing Countries 2002-2005 / Vaccine-producing Non producing 637

8. MIV SG 2007 Influenza Vaccination in Countries With and Without Public Reimbursement 2002-2005 With reimbursement No reimbursement

9. MIV SG 2007 Influenza Vaccination in Western Europe 1997-2002-2005

10. MIV SG 2007 Influenza Vaccination in Malta, 1997-2005

11. MIV SG 2007 Influenza Vaccination in Central and Eastern Europe 1997-2002-2005

12. GNI per capita ($), adjusted for PPPVaccine doses distributed / 1000 pop. MIV SG 2007 Luxembourg Norway Switzerland Iceland Ireland Denmark Austria Belgium Netherlands Sweden Finland France Germany Italy Spain Greece Cyprus Slovenia Czech Rep. Portugal Malta Hungary Slovak Rep. Estonia Lithuania Poland Latvia Croatia Russian Fed. Romania Bulgaria Ukraine Albania Georgia Uzbekistan Kyrgyz Rep. Economic Development and Influenza Vaccination in Europe, 2005

13. MIV SG 2007 Influenza Vaccination in the Western Pacific, 1997-2002-2005

14. GNI per capita ($) adjusted for PPP Vaccine doses distributed / 1000 population MIV SG 2007 Economic Development and Influenza Vaccination in the Western Pacific, 2005 Japan Australia Singapore N. Zealand Rep. Korea Thailand

15. MIV SG 2007 Influenza Vaccination in the Americas 1997-2002-2005 (1)

16. GNI per capita ($) adjusted for PPP Vaccine doses distributed / 1000 population MIV SG 2007 Chile Mexico Uruguay Costa Rica Brazil Colombia Panama Venezuela Peru El Salvador Guatemala Ecuador Honduras Bolivia Economic Development and Influenza Vaccination in Latin America, 2005

17. MIV SG 2007 Influenza Vaccination in Countries With Recommendations for Children 6-23 Months, 2003-2004-2005

18. 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

19. 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

20. 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.

21. Comparison of ESWI (2006) and MIVSG (2005) Vaccination Rates Vaccination Rates (%) ESWI ≥ 65 yrs ESWI ≥ 15 yrs MIVSG ≥ 15 yrs* Germany53.127.429.8 UK69.825.027.6 Italy65.624.418.6 France68.324.222.4 Portugal53.323.616.7 Spain71.121.827.9 Austria36.817.816.8 Finland63.116.218.5 Poland25.314.1 9.1 Czech Rep.30.213.8 7.6 Ireland50.713.520.5 * MIVSG rates/total population adjusted to population ≥ 15 yrs

22. 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% Eur J Public Health 2007;17:272-7. < 65 yr HR - 30.5% Infection 2006; 34: 135-41. HCWs - 19.7%

23. 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.

24. Five Reasons Why People Choose to Receive Influenza Vaccine Doctor/nurse recommended it 47 % Not in very good health 47 % Protects against influenza 39 % Don’t want to infect others 23 % It’s free and recommended 22 % Influenza Vaccine Supply Task Force presentation at the WHO/SEARO Workshop on Strengthing NCIPs in Pandemic Influenza Preparedness, 26-28 March 2008

25. Physician Recommendation and Influenza Vaccination - US, 1988 Patient Physician Percent AttitudeRecommendation Vaccinated Positive Yes 87 Negative Yes 70 Positive No 8 Negative No 7 MMWR 1988; 37: 657-61.

26. Hospitalization and Death Among People Discharged from Hospital During the Flu Vaccination Season in Manitoba, 1982-83 Hospitalized during flu season (%) Died in hospital during flu season (%) Age group (yrs) % total population P & I All resp. conditions P & I All resp. conditions 25-44 3  11196574 45-64 3  32318263 65-74 6  39446267 ≥ 75 12  454666 Fedson DS et al. Ann Intern Med 1992; 116: 550-5.

27. 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

28. Western Europe AustriaMichael Kunze BelgiumRene Snacken CyprusChrystalla Hadjianastassiou DenmarkAnn E. Ottosen FinlandRose-Marie Olander FranceJean-Marie Cohen GermanyPeter Wutzler GreeceAndreas Constantopoulos IcelandThorolfur Gudnason IrelandJoan O’Donnell ItalyIsabella Donatelli MaltaTanya Melillo LuxembourgClaude P. Muller NetherlandsTed van Essen NorwayLars Haaheim PortugalHelena Rebelo de Andrade SpainAgustin Portela SwedenAke Ortqvist SwitzerlandMark Witschi United KingdomJane Leese Eastern Mediterranean and Africa Algeria Fawzi Derrar EgyptMostafa Orkhan IranAbdoul reza Esteghamati Jordan Ali Muhaidat OmanSalah Al Awaidy South AfricaBarry D. Schoub Central and South America ArgentinaVilma Savy BoliviaRaul Artega BrazilJoao Toniolo-Neto ChileLeonardo Maggi ColombiaEnrique Gutierrez Costa RicaMaritza Morena Singler Dominican RepJose Brea del Castillo EcuadorGreta Migno El SalvadorSuarez Castaneda GuatemalaAdib Rodriguez PanamaXavier Saez PeruGordito Chaparro UruguayHomero Bagnulo VenezuelaJaime Torres Western Pacific AustraliaAlan Hampson Chinanot identified Hong Kong SARChristina Maw JapanKosaku Uchida New ZealandLance Jennings Rep. of KoreaWoo-Joo Kim SingaporeChan Kwai Peng TaiwanShu-fong Chen Southeast Asia ThailandPiyanit Tharmaphornpilas Central and Eastern Europe AlbaniaMiriam Xibinaku Bosnia & Herz. Prof. Puvacic BulgariaMira Kojouharova CroatiaIra Gjenero-Margan Czech Rep.Eva Vitkova EstoniaOlga Sadikova GeorgiaL. Jabidze HungaryZsuzsanna Molnar IsraelItamar Grotto Kyrgyz RepublicKalia Kasymbekova LatviaInga Velicko Irina Lucenko LithuaniaArvydas Ambrozaitis MacedoniaBlaze Nikolovski MoldovaPeter G. Scofertsa MontenegroDragan Lausevic PolandLidia Brydak RomaniaViorel Alexndrescu Russian Fed.Larisa Rudenko SerbiaMila Vucic-Jankovic Slovak Rep.Zuzana Kristufkova SloveniaMaja Socan TurkeySelim Badur UkraineAnna V. Moiseeva UzbekistanDilorom Tursunova North America CanadaTheresa Tam MexicoAugustin Lara Esqueda United StatesGreg Wallace Acknowledgement MIV Study Group Investigators MIVSG 2007

30. Influenza Vaccination of Elderly and High-risk People