European Influenza Vaccination: Goals already reached and obstacles that still remain Patricia R. Blank University of Zurich and Basel, Switzerland

Overview Facing the challenges and opportunities of influenza vaccination coverage rates in Europe – Current vaccination coverage in EU countries – Recommendations Implemented by which countries? Vaccine policies – Vaccination campaigns Which countries have organised them? – Barriers and driving factors towards influenza vaccination

The main challenges of influenza vaccination In general populations – By increasing disease awareness – By increasing vaccination acceptability In the elderly and most vulnerable populations – By ensuring effective immune response – In order to reduce morbidity and mortality To increase vaccination coverage rates To increase protection

Recommendations in Europe Age-based – Everyone above a defined age limit – Generally above 65 years of age Risk-based – Everyone under the age-defined limit suffering from underlying/chronic illnesses Patients with cardiovascular, respiratory, metabolic and/or renal disease and the immune-compromised Health care workers – Recommended in several EU countries

Goals of health authorities World Health Organisation 75% for the elderly and all people at high risk by 2014/15 European Parliament adapted and supported (2009) 1.WHO. WHO recommends influenza vaccine composition for Northern Hemisphere Available at 2.(P6_TA(2005)0406) 3.Council recommendation of 22 December 2009 on seasonal influenza vacci- nation (Text with EEA relevance) (2009/1019/EU). Off J Eur Union Centers for Disease Control and Prevention. Morb Mortal Wkly Rep 2007; 56(37): 953–9  Individual countries can set their own schedules and conditions for vaccination  Vaccination rates vary considerably across Europe

Influenza vaccine coverage rates are still insufficient USA 1 Europe 2 Australia (range of 11 countries) 2009 Elderly (≥65 years)68 %16% - 78%78% High-risk adults (18-65 years) 36% (18-49) 45 % (all 50-64) 11% - 54%40 % Children (0-18 years)40%NA8% General population40% 9.5% % (14 years +) 24% 1.MMWR - Interim Results: State-Specific Seasonal Influenza Vaccination Coverage --- United States, August January Blank PR et al, J Infect Jun;58(6): Sanofi Pasteur: country estimations (One Page Market Map)

Vaccine coverage rates vary considerably across Europe Blank et al. J Infect Jun;58(6):

Official vaccination recommendations across EU countries GBRNLDFRAESPITAIRLBELDEUCHEFINSWEPRTCZESVKPOLBGR 50+ * Some Region s * 65+ Chronic Disease Sufferers incl. children School-age children (all) 3M- 12Y Children < 3 y.o. (all) 3M- 12Y Healthcare professionals Pregnant women *Recommendation/ reimbursement with lower priority than 65+ Blank et al, unpublished data, 2010

Implemented policy elements among European countries differ considerably No Yes VCR, vaccination coverage rates; HA, Health Authority; NVIG, National Vaccine Industry Group; GP, general practitioners; HC, Health centre a)regionally restricted; b) reimbursement with lower priority than 65+; c) some information available; d) not uniformly implemented; e) GP consult fee or nurse fee; f) Past years Blank et al, unpublished data, 2010

Numbers of implemented policy items vary between countries Blank et al, unpublished data, 2010

Policies linked to higher VCR HCW financial incentive % reimbursement of vaccine Patients receive personal letter for free flu vaccine Awareness campaigns: radio and tv Awareness campaigns: flyers in medical waiting rooms Awareness campaigns: website for public Awareness campaigns: press/ media conference National objectives Monitoring VCR HCW have objective to achieve in high risk groups* HCW financial incentive % reimbursement of vaccine Patients receive personal letter/voucher for free flu vaccine Yellow: Positive correlation of stand-alone policy, Spearman's rho ρ (p-value < 0.05); Green: Positive correlation of two policies, ρ (p-value < 0.05) *nationally or regionally Blank et al, unpublished data, 2010

Corner stones for successful implementation of influenza vaccination Definition of VCR objectives Monitoring and analysing annual VCR Conducting annual vaccination campaigns Awareness and information to the public  Broad communication campaigns to educate the public on  Severity of influenza  Safety profile and benefits of the vaccine Critical role of HCW  Specific education is needed  Awareness of the disease  Financial incentives Free access to vaccine are significant ways to ensure proper vaccination uptake

Considerable gap between target vs. reality VCR (%) Error bars: 95% confidence intervals Blank et al. J Infect Jun;58(6):

Driving factors for vaccination General population (11 countries, 2007/08)* Awareness of the seriousness of influenza55% Advise from family doctor/ nurse53% Avoid transmission to family members/ friends39% Because of their age36% Are not in very good health26% To prevent interruption of professional activities21% It is required/ indicated for the job10% Because the media attention on avian flu9% 1.Education on the seriousness of the disease 2.Pro-active HCW identifying the at-risk population * Among those vaccinated Blank et al. J Infect Jun;58(6):

Reasons against vaccination among non- vaccinated population General population (11 countries, 2007/08)* Don‘t think they are likely to catch the flu39% Have never considered it34% Have not received advice from family doctor31% It is not a serious enough illness22% I am too young to be vaccinated19% I do not think the vaccine is effective enough17% I though about it but I did not end up getting vaccinated17% My pharmacist has never recommended it 14% I do not like injections/ needles13% 1.Lack of education on the disease and the vaccine 2.Lack of adequate advice from HCWs 3.Lack of pro-active reminding systems 4.Vaccination acceptability * Among those never vaccinated Blank et al. J Infect Jun;58(6):

Options encouraging vaccination against influenza General population (11 countries, 2007/08)* If family doctor/ nurse recommended it55% More information on the efficacy of the vaccine 28% More information on the tolerance of the vaccine24% Vaccination at work 24% Because of travelling to regions with high risk of influenza 24% If it were cheaper/ reimbursed/ free24% If knowledge about the disease would be better24% If there were other ways of administering the vaccine20% 1.Pro-active HCW 2.Information on efficacy / tolerance of the vaccine 3.Adequate funding in place 4.Vaccination acceptability * Regardless of vaccination status Blank et al. J Infect Jun;58(6):

Significant costs associated with influenza Total annual costs of influenza outbreaks vary between $1 - $6 million per 100,000 inhabitants (France, Germany and USA) – Hospitalisation costs – lost productivity from missed work days and lost lives Annual indirect costs account for: – 82% of total influenza costs in Germany – 80–90% of the total influenza costs in France – 88% of the total influenza costs in the USA 1. World Health Organization. Wkly Epidemiol Rec 2005; 33: 279– Molinari NM. Vaccine 2007; 25: 5086– Kressin BW, Hallauer JF. Deutsches Ärzteblatt 1999; 96: B275–B Levy E. Pharmacoeconomics 1996; 9: 62– Weycker D, et al. Vaccine 2005;23:1284–1293 Significant Costs Associated with Influenza – USA, 2005 Indirect costs represent the majority of the total economic burden of influenza

The increase of vaccine use in the European Union (EU) would result in an important reduction of influenza burden Increasing vaccine use across all EU-25 countries so that a 100% coverage rate of the target at-risk population could be achieved Current coverage of at-risk population 35.4% coverage100% coverage Number vaccinated79,054,065223,442,807 Number of cases of influenza18,391,57711,172,140 PCP visits for treatment of influenza5,119,9593,158,794 Hospital admission3,075,9112,279,169 Excess deaths133,54265,005 Ryan J, et al. Vaccine 2006; 24: 6812–6822.[121] ~ - 7 M ~ - 2 M ~ - 0,8 M ~ - 70 K

Summary Influenza vaccine coverage rates among recommended groups are well below the WHO goals Implementation of appropriate vaccination policies can positively influence uptake rates Patients do not appreciate the severity of influenza disease, and the benefits of vaccination Corner stones for successful implementation of influenza vaccination Definition of VCR objectives Monitoring and analyzing annual VCR Conducting annual vaccination campaigns Awareness and information to the public Critical role of HCW Free access to vaccine 19

Conclusion Several factors would encourage vaccination and break down obstacles to immunisation – Physician recommendation – Perception of the disease and the vaccine – Trust in the vaccine – Official recommendations Activating the correct drivers and dealing with vaccination barriers should stimulate influenza vaccine uptake  Applying multiple strategies may sustain high immunisation rates

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Acknowledgement Thomas D. Szucs and Matthias Schwenkglenks, Institute of Pharamaceutical Medicine, University of Basel Sandrine Samson and Christophe Ladreyt, SPMSD, Lyon Angus Nicoll, ECDC, Stockholm The European Vaccine Manufacturers group which supported the influenza study via an educational grant, Bruxelles

Which factors can predict influenza vaccinations? Socioeconomic factors associated with influenza vaccination analyzed by multivariate analyses Qualitative presentation of statistically significant odds ratios adjusted for all other listed factors per country FranceGermanyItalyUnited Kingdom SpainAustriaCzech Republic FinlandIrelandPolandPortugal Belonging to risk group* Gender (Male) Size of household: 2 vs 1 person/s ≥ 3 vs 1 person/s Size of town: 2nd smallest vs smallest category 2nd largest vs smallest category Largest vs smallest category Level of education: Secondary vs primary Tertiary vs primary Household income : Middle to lowest category Highest to lowest category Positive predictor;Negative predictor;Factor with no significant odds ratio;Not applicable * Includes persons aged ≥ 65 years, or suffering of chronic illness, or working in medical field Endrich MM et al, Vaccine Jun 19;27(30):