Can routine offering of influenza vaccination in office-based settings reduce racial and ethnic disparities in adult influenza vaccination?

BACKGROUND: Influenza vaccination remains below the federally targeted levels outlined in Healthy People 2020. Compared to non-Hispanic whites, racial and ethnic minorities are less likely to be vaccinated for influenza, despite being at increased risk for influenza-related complications and death. Also, vaccinated minorities are more likely to receive influenza vaccinations in office-based settings and less likely to use non-medical vaccination locations compared to non-Hispanic white vaccine users. OBJECTIVE: To assess the number of "missed opportunities" for influenza vaccination in office-based settings by race and ethnicity and the magnitude of potential vaccine uptake and reductions in racial and ethnic disparities in influenza vaccination if these "missed opportunities" were eliminated. DESIGN: National cross-sectional Internet survey administered between March 4 and March 14, 2010 in the United States. PARTICIPANTS: Non-Hispanic black, Hispanic and non-Hispanic white adults living in the United States (N = 3,418). MAIN MEASURES: We collected data on influenza vaccination, frequency and timing of healthcare visits, and self-reported compliance with a potential provider recommendation for vaccination during the 2009-2010 influenza season. "Missed opportunities" for seasonal influenza vaccination in office-based settings were defined as the number of unvaccinated respondents who reported at least one healthcare visit in the Fall and Winter of 2009-2010 and indicated their willingness to get vaccinated if a healthcare provider strongly recommended it. "Potential vaccine uptake" was defined as the sum of actual vaccine uptake and "missed opportunities." KEY RESULTS: The frequency of "missed opportunities" for influenza vaccination in office-based settings was significantly higher among racial and ethnic minorities than non-Hispanic whites. Eliminating these "missed opportunities" could have cut racial and ethnic disparities in influenza vaccination by roughly one half. CONCLUSIONS: Improved office-based practices regarding influenza vaccination could significantly impact Healthy People 2020 goals by increasing influenza vaccine uptake and reducing corresponding racial and ethnic disparities.

Immunogenicity and safety of an intradermal boosting strategy for vaccination against influenza in lung transplant recipients.

The immunogenicity of influenza vaccine is suboptimal in lung transplant recipients. Use of a booster dose and vaccine delivery by the intradermal rather than intramuscular route may improve response. We prospectively evaluated the immunogenicity and safety of a 2-dose boosting strategy of influenza vaccine. Sixty lung transplant recipients received a standard intramuscular injection of the 2006-2007 inactivated influenza vaccine, followed 4 weeks later by an intradermal booster of the same vaccine. Immunogenicity was assessed by measurement of geometric mean titer of antibodies after both the intramuscular injection and the intradermal booster. Vaccine response was defined as 4-fold or higher increase of antibody titers to at least one vaccine antigen. Thirty-eight out of 60 patients (63%) had a response after intramuscular vaccination. Geometric mean titers increased for all three vaccine antigens following the first dose (p < 0.001). However, no significant increases in titer were observed after the booster dose for all three antigens. Among nonresponders, 3/22 (13.6%) additional patients responded after the intradermal booster (p = 0.14). The use of basiliximab was associated with a positive response (p = 0.024). After a single standard dose of influenza vaccine, a booster dose given by intradermal injection did not significantly improve vaccine immunogenicity in lung transplant recipients.

Influenza vaccination in immunocompromised patients: efficacy and safety.

Yearly administration of the influenza vaccine is the main strategy to prevent influenza in immunocompromised patients. Here, we reviewed the recent literature regarding the clinical significance of the influenza virus infection, as well as the immunogenicity and safety of the influenza vaccine in HIV‑infected individuals, solid-organ and stem-cell transplant recipients and patients receiving biological agents. Epidemiological data produced during the 2009 influenza pandemic have confirmed that immunocompromised patients remain at high risk of influenza-associated complications, namely viral and bacterial pneumonia, hospitalization and even death. The immunogenicity of the influenza vaccine is overall reduced in immunocompromised patients, although a significant clinical protection from influenza is expected to be obtained with vaccination. Influenza vaccination is safe in immunocompromised patients. The efficacy of novel strategies to improve the immunogenicity to the vaccine, such as the use of adjuvanted vaccines, boosting doses and intradermal vaccination, needs to be validated in appropriately powered clinical trials.

Virosome-Formulated Plasmodium falciparum AMA-1 & CSP Derived Peptides as Malaria Vaccine: Randomized Phase 1b Trial in Semi-Immune Adults & Children.

Background: This trial was conducted to evaluate the safety and immunogenicity of two virosome formulated malaria peptidomimetics derived from Plasmodium falciparum AMA-1 and CSP in malaria semi-immune adults and children.Methods: The design was a prospective randomized, double-blind, controlled, age-deescalating study with two immunizations. 10 adults and 40 children (aged 5-9 years) living in a malaria endemic area were immunized with PEV3B or virosomal influenza vaccine Inflexal (R) V on day 0 and 90.Results: No serious or severe adverse events (AEs) related to the vaccines were observed. The only local solicited AE reported was pain at injection site, which affected more children in the Inflexal (R) V group compared to the PEV3B group (p = 0.014). In the PEV3B group, IgG ELISA endpoint titers specific for the AMA-1 and CSP peptide antigens were significantly higher for most time points compared to the Inflexal (R) V control group. Across all time points after first immunization the average ratio of endpoint titers to baseline values in PEV3B subjects ranged from 4 to 15 in adults and from 4 to 66 in children. As an exploratory outcome, we found that the incidence rate of clinical malaria episodes in children vaccinees was half the rate of the control children between study days 30 and 365 (0.0035 episodes per day at risk for PEV3B vs. 0.0069 for Inflexal (R) V; RR = 0.50 [95%-CI: 0.29-0.88], p = 0.02).Conclusion: These findings provide a strong basis for the further development of multivalent virosomal malaria peptide vaccines.

Differences in pandemic influenza vaccination policies for pregnant women in Europe.

BACKGROUND: An important component of the policy to deal with the H1N1 pandemic in 2009 was to develop and implement vaccination. Since pregnant women were found to be at particular risk of severe morbidity and mortality, the World Health Organization and the European Centers for Disease Control advised vaccinating pregnant women, regardless of trimester of pregnancy. This study reports a survey of vaccination policies for pregnant women in European countries. METHODS: Questionnaires were sent to European competent authorities of 27 countries via the European Medicines Agency and to leaders of registries of European Surveillance of Congenital Anomalies in 21 countries. RESULTS: Replies were received for 24 out of 32 European countries of which 20 had an official pandemic vaccination policy. These 20 countries all had a policy targeting pregnant women. For two of the four countries without official pandemic vaccination policies, some vaccination of pregnant women took place. In 12 out of 20 countries the policy was to vaccinate only second and third trimester pregnant women and in 8 out of 20 countries the policy was to vaccinate pregnant women regardless of trimester of pregnancy. Seven different vaccines were used for pregnant women, of which four contained adjuvants. Few countries had mechanisms to monitor the number of vaccinations given specifically to pregnant women over time. Vaccination uptake varied. CONCLUSIONS: Differences in pandemic vaccination policy and practice might relate to variation in perception of vaccine efficacy and safety, operational issues related to vaccine manufacturing and procurement, and vaccination campaign systems. Increased monitoring of pandemic influenza vaccine coverage of pregnant women is recommended to enable evaluation of the vaccine safety in pregnancy and pandemic vaccination campaign effectiveness.

Influenza in children – Diagnosis, treatment and prevention

Background: The burden of influenza on children is substantial. Although mortality rates are low, the incidence of influenza is highest in children, among whom also complications are frequent. A more accurate recognition of influenza in children could enable the rational use of antiviral drugs and help to avoid unnecessary courses of antibiotics. Limited data exists on the efficacy of oseltamivir treatment and the trivalent inactivated influenza vaccine (TIV) in children. Aims and methods: We sought for signs and symptoms that could help clinicians to diagnose influenza on clinical grounds in a case-control study in children <13 years of age. We further assessed the feasibility of different diagnostics methods during the early stage of the illness in children aged 1-3 years. The efficacy of early oseltamivir treatment (started <24h from the onset of symptoms) was evaluated in a randomized controlled trial (RCT) conducted in children 1-3 years of age, and the effectiveness of TIV to prevent laboratory-confirmed influenza was determined in a prospective, observational cohort study conducted among children aged 9 months to 3 years of age. Results: Fever was the only symptom predicting influenza in children. The sensitivity of conventionally used laboratory methods to detect influenza during the first 24h of illness was 92%. The sensitivity of the influenza rapid test in the same setting was 90% for influenza A and 25% for influenza B. Early oseltamivir treatment shortened the duration of the illness in children with influenza A by 3.5-4.0 days, but no efficacy was observed against influenza B. The effectiveness of TIV was 84% against the wellmatched influenza A, while no effectiveness against the mismatched influenza B was observed. Conclusions: Laboratory diagnostics are needed for a reliable diagnosis of influenza in children and were found sensitive already during the early stage of the illness. Early oseltamivir treatment was highly effective against influenza A, but no efficacy was seen against influenza B. TIV is effective also in young children if a good match between the vaccine and circulating strain is achieved.

Evaluación del programa de vigilancia centinela de influenza y otros virus respiratorios 1997- 2007 Colombia

La influenza es una entidad clínica, que es causada por los virus de la influenza A, B y C del género Influenza. El virus de la influenza A se clasifica en subtipos, con base en 2 antígenos de superficie: la hemaglutinina y la neuraminidasa. La respuesta inmune frente a estos antígenos (especialmente frente a la hemaglutinina), disminuye la probabilidad de infección, así como la severidad del cuadro clínico. La intención de este trabajo es describir el funcionamiento del programa de vigilancia centinela de influenza y otros virus respiratorios en Colombia, que permite identificar en que medida se alcanza la finalidad de esta actividad y que dificultades en general afectan su funcionamiento.

Cost-benefit evaluation of routine influenza immunisation in people 65-74 years of age

OBJECTIVES: To determine the cost-effectiveness of influenza vaccination in people aged 65-74 years in the absence of co-morbidity. DESIGN: Primary research: randomised controlled trial. SETTING: Primary care. PARTICIPANTS: People without risk factors for influenza or contraindications to vaccination were identified from 20 general practitioner (GP) practices in Liverpool in September 1999 and invited to participate in the study. There were 5875/9727 (60.4%) people aged 65-74 years identified as potentially eligible and, of these, 729 (12%) were randomised. INTERVENTION: Participants were randomised to receive either influenza vaccine or placebo (ratio 3:1), with all individuals receiving pneumococcal vaccine unless administered in the previous 10 years. Of the 729 people randomised, 552 received vaccine and 177 received placebo; 726 individuals were administered pneumococcal vaccine. MAIN OUTCOME MEASURES AND METHODOLOGY OF ECONOMIC EVALUATION: GP attendance with influenza-like illness (ILI) or pneumonia (primary outcome measure); or any respiratory symptoms; hospitalisation with a respiratory illness; death; participant self-reported ILI; quality of life (QoL) measures at 2, 4 and 6 months post-study vaccination; adverse reactions 3 days after vaccination. A cost-effectiveness analysis was undertaken to identify the incremental cost associated with the avoidance of episodes of influenza in the vaccination population and an impact model was used to extrapolate the cost-effectiveness results obtained from the trial to assess their generalisability throughout the NHS. RESULTS: In England and Wales, weekly consultations for influenza and ILI remained at baseline levels (less than 50 per 100,000 population) until week 50/1999 and then increased rapidly, peaking during week 2/2000 with a rate of 231/100,000. This rate fell within the range of 'higher than expected seasonal activity' of 200-400/100,000. Rates then quickly declined, returning to baseline levels by week 5/2000. The predominant circulating strain during this period was influenza A (H3N2). Five (0.9%) people in the vaccine group were diagnosed by their GP with an ILI compared to two (1.1%) in the placebo group [relative risk (RR), 0.8; 95% confidence interval (CI) = 0.16 to 4.1]. No participants were diagnosed with pneumonia by their GP and there were no hospitalisations for respiratory illness in either group. Significantly fewer vaccinated individuals self-reported a single ILI (4.6% vs 8.9%, RR, 0.51; 95% CI for RR, 0.28 to 0.96). There was no significant difference in any of the QoL measurements over time between the two groups. Reported systemic side-effects showed no significant differences between groups. Local side-effects occurred with a significantly increased incidence in the vaccine group (11.3% vs 5.1%, p = 0.02). Each GP consultation avoided by vaccination was estimated from trial data to generate a net NHS cost of 174 pounds. CONCLUSIONS: No difference was seen between groups for the primary outcome measure, although the trial was underpowered to demonstrate a true difference. Vaccination had no significant effect on any of the QoL measures used, although vaccinated individuals were less likely to self-report ILI. The analysis did not suggest that influenza vaccination in healthy people aged 65-74 years would lead to lower NHS costs. Future research should look at ways to maximise vaccine uptake in people at greatest risk from influenza and also the level of vaccine protection afforded to people from different age and socio-economic populations.

Is influenza vaccination cost effective for healthy people between ages 65 and 74 years? A randomised controlled trial

The aim of this study was to determine the cost effectiveness of influenza vaccination for healthy people aged 65-74 years living in the UK. People without risk factors for influenza (chronic heart, lung or renal disease, diabetic, immuno-suppressed or those living in an institution) were identified from 20 general practitioner (GP) practices in Liverpool in September 1999. 729/5875 (12.4%) eligible individuals were recruited and randomised to receive either influenza vaccine or placebo (ratio 3: 1)! with all participants receiving 23-valent-pneumococcal polysaccharide vaccine unless already administered. The primary analysis was the frequency of influenza as recorded by a GP diagnosis of pneumonia or influenza like illness. In 2000, the UK vaccination policy was changed with influenza vaccine becoming available. for all people aged 65 years and over irrespective of risk. As a consequence of this policy change. the study had to be fundamentally restructured and only results obtained over a one rather than the originally planned two-year randomised controlled trial framework were used. Results from 1999/2000 demonstrated no significant difference between groups for the primary outcome (relative risk 0.8, 95%, CI 0.16-4.1). In addition. there were no deaths or hospitalisations for influenza associated respiratory illness in either group. The subsequent analysis. using both national and local sources of evidence, estimated the following cost effectiveness indicators: (1) incremental NHS cost per GP consultation avoided = pound2000; (2) incremental NHS cost per hospital admission avoided = pound61,000: (3) incremental NHS cost per death avoided = pound1.900.000 and (4) incremental NHS cost per QALY gained = pound304,000. The analysis suggested that influenza vaccination in this Population would not be cost effective. (C) 2004 Elsevier Ltd. All rights reserved.

Influenza virus vaccination in kidney transplant recipients: serum antibody response to different immunosuppressive drugs

Introduction: This study prospectively accessed the immune response to the inactivated influenza vaccine in renal transplant recipients receiving either azathioprine or mycophenolate mofetil (MMF). Side effects were investigated. Methods: Sixty-nine patients received one dose of inactivated trivalent influenza vaccine. Antihemagglutinin (HI) antibody response against each strain was measured before and one to six months after vaccination. Results: Geometric mean HI antibody titers for H1N1 and H3N2 strains increased from 2.57 and 2.44 to 13.45 (p = 0.001) and 7.20 (p < 0.001), respectively. Pre- and post-vaccination protection rates for H1N1 and H3N2 increased from 8.7% to 49.3% (p < 0.001); and 36.3% (p < 0.001) and seroconversion rates were 36% and 25.3%, respectively. There was no response to influenza B. The use of MMF reduced the H1N1 and H3N2 protection rates and the seroconversion rate for the H1N1 strain when compared with the use of azathioprine, and subjects transplanted less than 87 months also had inferior antibody response. Adverse events were mild and there were no change on renal function post-vaccination. Conclusion: Renal transplant patients vaccinated against influenza responded with antibody production for in. uenza A virus strains, but not for in. uenza B. Use of MMF and shorter time from transplantation decreased the immune response to the vaccine.

Predictors of adherence to influenza vaccination for healthcare workers from a teaching hospital: a study in the prepandemic era

Introduction: Even before the 2009 pandemics, influenza in healthcare workers (HCW) was a known threat to patient safety, while Influenza vaccine coverage in the same group was generally low. Identification of predictors for HCW adherence to Influenza vaccination has challenged infection control committees. Methods: Our group conducted a cross-sectional survey in December 2007, interviewing 125 HCWs from a teaching hospital to identify adherence predictors for Influenza vaccination. The outcomes of interest were: A - adherence to the 2007 vaccination campaign; B - adherence to at least three yearly campaigns in the past five years. Demographic and professional data were assessed through univariate and multivariate analysis. Results: of the HCWs interviewed, 43.2% were vaccinated against Influenza in 2007. However, only 34.3% of HCWs working in healthcare for more than five years had adhered to at least three of the last five vaccination campaigns. Multivariate analysis showed that working in a pediatric unit (OR = 7.35, 95% I = 1.90-28.44, p = 0.004) and number of years in the job (OR = 1.32, 95%CI = 1.00-1.74, p = 0.049) were significant predictors of adherence to the 2007 campaign. Physicians returned the worst outcome performances in A (OR = 0.40, 95%CI = 0.16-0.97, p = 0.04) and B (OR = 0.17, 95%CI = 0.05-0.60, p = 0.006). Conclusions: Strategies to improve adherence to Influenza vaccination should focus on physicians and newly-recruited HCWs. New studies are required to assess the impact of the recent Influenza A pandemics on HCW-directed immunization policies.

Fatores associados à vacinação contra influenza em idosos em município do Sudeste do Brasil

OBJETIVO: Mesmo gratuita e disponível no Brasil desde 1999, a cobertura vacinal contra a influenza ainda é inadequada em diversos municípios do País. O objetivo da pesquisa foi estimar a cobertura vacinal e identificar fatores relacionados à vacinação contra a influenza em idosos. MÉTODOS: Realizou-se inquérito domiciliar em amostra aleatória sistemática (N=365) da população urbana maior de 60 anos em Botucatu, São Paulo. Foi aplicado modelo de regressão logística múltipla, cuja variável dependente foi ter sido vacinado em 2002. Foram testadas no modelo as covariáveis: sexo, idade, socioeconômicas (renda per capita, número de pessoas por cômodo, escolaridade, estado civil, ocupação, tempo de moradia), antecedentes mórbidos, de internação, hábito de fumar, sintomas respiratórios nos últimos 15 dias e atividades comunitárias (trabalho voluntário, atividades no bairro, igreja). RESULTADOS: Registrou-se cobertura vacinal de 63,2% (IC 95%: 58,3-68,2). Foi observado menor percentual de vacinados entre os idosos na faixa etária de 60 a 64 anos. As variáveis que se mostraram associadas à vacinação e permaneceram no modelo final foram: idade (OR=1,09 por ano; IC 95%: 1,06-1,13); hipertensão arterial (OR=1,92; IC 95%: 1,18-3,13); inserção em atividades na comunidade (OR=1,63; IC 95%: 1,01-2,65). A vacinação em portadores de doenças crônicas não atingiu níveis adequados conforme esperado para este grupo de risco, com exceção dos hipertensos. A participação em atividades comunitárias e sociais foi relacionada com o estado vacinal. CONCLUSÕES: Condições socioeconômicas, hábitos e idade não restringiram o acesso à campanha vacinal. Por outro lado, campanhas específicas, endereçadas a indivíduos da faixa de 60 a 64 anos, podem ampliar a cobertura da vacinação.

Eventos adversos após vacinação contra influenza em idosos, Distrito de Campinas, SP, 2000

Há poucos dados sistematizados sobre eventos adversos da vacina contra influenza no Brasil. Este trabalho visou identificar estes eventos em população acima de 60 anos que compareceu à Campanha Nacional de Vacinação do Idoso, em Distrito de Campinas, SP, em 2000. Foi realizada entrevista para relato de sintomas gerais e locais, com nexo temporal após a aplicação do imunobiológico, em amostra aleatória sistemática da população (n=206). Registraram-se 20,38% (IC 14,87-25,88) dos indivíduos com um ou mais sintomas, sendo a dor no local da vacina, a mais freqüente 12,6% (IC 8,09-17,15). Ajustou-se um modelo de regressão logística múltipla, tendo como variável dependente, a ocorrência de pelo menos um evento adverso. A variável independente que se mostrou associada às reações adversas foi o sexo (feminino) (OR=5,89 e IC 2,08-16,68). Os achados deste estudo reafirmam a pequena reatogenicidade da vacina contra a influenza.

Influenza among the elderly in the Americas: A consensus statement

Influenza exacts a heavy burden on the elderly, a segment of the population that is estimated to experience rapid growth in the near future. In the past decade most developed and several developing countries have recommended influenza vaccination for those > 65 years of age. The World Health Organization (WHO) set a goal of 75% influenza vaccination coverage among the elderly by 2010, but it was not achieved. In 2011, the Technical Advisory Group at the Pan American Health Organization, Regional Office of WHO for the Americas, reiterated the influenza vaccine recommendation for older adults. Relatively little information has been compiled on the immunological aspect of aging or on reducing its impact, information particularly relevant for clinicians and gerontologist with firsthand experience confronting its effects. To fill this data gap, in 2012 the Americas Health Foundation (Washington, D.C., United States) and the nonprofit, Fighting Infectious Diseases in Emerging Countries (Miami, Florida, United States), convened a panel of Latin American clinicians and gerontologists with expertise in influenza to discuss key issues and develop a consensus statement. The major recommendations were to improve influenza surveillance throughout Latin America so that its impact can be quantified; and to conduct laboratory confirmation of influenza for all patients who have flu-like symptoms and are frail, immunosuppressed, have comorbidities, are respiratory compromised, or have been admitted to a hospital. The panel also noted that: since evidence for antivirals in the elderly is unclear, their use should be handled on a case-by-case basis; despite decreased immunological response, influenza vaccination in older adults is still crucial; indirect immunization strategies should be encouraged; and traditional infection control measures are essential in long-term care facilities.

Fighting Misconceptions to Improve Compliance with Influenza Vaccination among Health Care Workers: An Educational Project

The compliance with influenza vaccination is poor among health care workers (HCWs) due to misconceptions about safety and effectiveness of influenza vaccine. We proposed an educational prospective study to demonstrate to HCWs that influenza vaccine is safe and that other respiratory viruses (RV) are the cause of respiratory symptoms in the months following influenza vaccination. 398 HCWs were surveyed for adverse events (AE) occurring within 48 h of vaccination. AE were reported by 30% of the HCWs. No severe AE was observed. A subset of 337 HCWs was followed up during four months, twice a week, for the detection of respiratory symptoms. RV was diagnosed by direct immunofluorescent assay (DFA) and real time PCR in symptomatic HCWs. Influenza A was detected in five episodes of respiratory symptoms (5.3%) and other RV in 26 (27.9%) episodes. The incidence density of influenza and other RV was 4.3 and 10.8 episodes per 100 HCW-month, respectively. The educational nature of the present study may persuade HCWs to develop a more positive attitude to influenza vaccination.