Conference Coverage

European experts envy U.S. pediatric flu vaccination approach



– When American physicians think about health care in Europe, what typically comes to mind are government-funded, single-payer national health services with cradle-to-grave coverage of essential services, a strong public health bent, and perhaps some queuing.

Dr. Hanna Nohynek, chief physician in the infectious diseases control and vaccinations unit of the National Institute for Health and Welfare in Helsinki, Finland Bruce Jancin/MDedge News

Dr. Hanna Nohynek

So it may come as a surprise to learn that only 8 of 29 European countries recommend seasonal influenza vaccination for children and adolescents. And such powerhouses as Germany, France, Spain, Italy, and the Scandinavian countries are not among those eight, which consist of Finland, the United Kingdom, Poland, and smaller countries.

“It’s complicated. There is no common strategic approach,” Hanna Nohynek, MD, PhD, observed at a session on childhood immunization against flu held during the annual meeting of the European Society for Paediatric Infectious Diseases.

“In real life, influenza coverage among [European] children is either not known or quite low. Impact assessments in children are done in only a few countries,” said Dr. Nohynek, chief physician in the infectious diseases control and vaccinations unit of the National Institute for Health and Welfare in Helsinki, Finland.

“The only country doing as well coverage-wise as the U.S. is the U.K., with rates of 50%-65%. In Finland it’s less than 40%,” according to Dr. Nohynek.

“We have 28 countries today in the E.U. [European Union], and we have 28 different recommendations in Europe. So where do we go from here? It’s really not easy,” observed session cochair Alberticus Osterhaus, DVM, PhD, emeritus professor of virology at Erasmus University in Rotterdam, the Netherlands.

For all the oft-cited shortcomings of health care in the United States, the American approach to pediatric influenza vaccination is the envy of most European pediatric infectious disease specialists. That’s why Jon S. Abramson, MD, a former chair of the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices (ACIP), was invited to explain how the U.S. strategy was accomplished.

The U.S. approach

The current U.S. policy, implemented in 2010, is to recommend an annual flu shot for all persons older than 6 months of age.

Dr. Jon S. Abramson, former chair of the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices, and former chair of the department of pediatrics at Wake Forest University, Winston-Salem, N.C Bruce Jancin/MDedge News

Dr. Jon S. Abramson

“It was a stepwise, risk-based, data-driven approach,” explained Dr. Abramson, former chair of the department of pediatrics at Wake Forest University in Winston-Salem, N.C.

Influenza vaccination has been part of the U.S. public health program since 1960. Children aged 6-23 months, as well as their household contacts and women who will be pregnant during flu season, were added in 2004. In 2006, the flu vaccine recommendation was expanded to include children aged 6-59 months as a result of persuasive data showing that the rate of flu-associated hospitalizations and deaths in children up to 4 years old was second only to the rate in the elderly population.

The rationale for expanding the recommendation to include all school-age children and adolescents stemmed from evidence that the highest average flu-related illness rate in the United States was in that age group, which confirmed that schools are a powerful vector for the spread of influenza. Vaccinating this age-group also was seen as having an indirect benefit for their household contacts.

The current policy of recommending vaccination of everyone over age 6 months was adopted because it checked off a lot of boxes: “It’s a single recommendation, easy to apply; it eliminates the need to look for indications and risk factors; it increases vaccination coverage rates; annual vaccination is safe and effective; and flu-related morbidity and mortality occur in all age groups,” Dr. Abramson continued.

The rate of influenza vaccine coverage in pregnant women has improved over time from less than 15% to about 50%. To place that in perspective, however, the rate in Argentina is 95%, the pediatrician noted.

“We’re doing better in children than we are in adults in terms of seasonal coverage rates,” he added. “In 2015, it was 59%, versus 42% in adults.”

Dr. Abramson said there remains some skepticism in the United States regarding the effectiveness of flu vaccines in preventing flu-related illness. That’s because of the difficulty in communicating that vaccine effectiveness varies from year to year, sometimes substantially, depending upon two factors: the transmission characteristics of the circulating strains and how well the vaccines match up against those strains.

“I think we have to learn to live with that. I don’t think we’ll see a universal flu vaccine that we can give once every 10 years,” he said.

“The bottom line is, even if a vaccine is only 50% efficacious overall, we’re still impacting huge numbers,” the pediatrician added.

Dr. Abramson cited a CDC estimate that, for the 2012-2013 season, where the vaccine was 49% efficacious, the result of vaccination was 6.6 million fewer cases of influenza-associated illnesses nationally, 3.2 million fewer flu-associated medical visits, and 79,000 hospitalizations avoided.

“I think we have a fairly good program in the United States. We’re doing well in children. We certainly could be doing better. Not having FluMist for the past 2 seasons probably hurt us some,” according to Dr. Abramson.


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