David Sinclair on the challenges of vaccinating adults

The International Longevity Centre-UK is an independent, non-partisan think-tank dedicated to addressing issues of longevity, ageing and population change.

#adultimmunisation @ilcuk @sinclairda

Immune ResponseVaccination in adults: What are the challenges? What are the solutions?

David Sinclair, International Longevity Centre – UK @ilcuk @sinclairda



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Interests

ILC-UK Report (Immune Response) funded via an unrestricted educational grant from Pfizer International Operations. SAATI report supported by Vaccines Europe. Commissioned by SAATI and supported financially by Pfizer.




In summary – Key messages

There is a strong evidence base to support a focus on immunisation as a lifecourse issue

But vaccination across the lifecourse does not get the attention it should

Policies can be patchy and inconsistent at a European level (and even within countries)

Policy makers should focus on breaking down the barriers to adult immunisation.



Working across Europe on adult vaccination

ILC-UK are a founding and leading member of SAATI (Supporting Active Ageing Through Immunisation)

SAATI aims to: Increase public and policy maker awareness of the need for adult vaccinations.

The SAATI partnership produced a consensus statement (2012)

In November 2013, SAATI published Adult vaccination: a key component of healthy ageing. The report is available on the ILC-UK website at www.ilcuk.org.uk

http://www.ilcuk.org.uk/




A focus on adults: Taking a life-course approach

With the exception of the seasonal influenza vaccine, many adults believe

that vaccination is relevant only for children, and awareness of adult

vaccines is low.

Perception of vaccines and vaccinations EVM Study Number 41039032.



IPD hits older and younger people

[See Adult Vaccination: A Key Component of Healthy Ageing]



As does influenza




Vaccine preventable disease has a big impact

Seasonal influenza: The UK reported a 2010-11 winter period more severe in terms of pressure on hospitals than during the 2009-10 pandemic winter. In 2012- 13, excess death rates were the highest since 2008-09, with peaks coinciding with influenza circulation [Public Health England. See Adult Vaccination: A Key Component of Healthy Ageing]

Pneumonia: UK and Slovakia have the highest reported mortality rates in Europe (25 per 100 000 population cases in 2005 and 2009). [See Adult Vaccination: A Key Component of Healthy Ageing]

http://www.flickr.com/photos/un_photo/5832685007/sizes/z/in/photostream/



Impact of vaccine preventable disease

Invasive pneumococcal disease: In 2005, the UK, as well as Belgium, Ireland and Sweden, reported rates of confirmed cases which approach or are greater than 10 per 100 000. There was a similar picture in 2009 with relatively high rates in the UK and in Belgium, Finland, Ireland, Sweden and Slovenia compared to the other countries reporting. Among the countries reporting high rates, the trend is relatively static in the UK. [See Adult Vaccination: A Key Component of Healthy Ageing]

Pertussis: the recent increase in pertussis notifications corresponds with the availability of enhanced diagnostic methods. Since 2006, there has been greater awareness and use of these testing methods, compared to previous years. [See Adult Vaccination: A Key Component of Healthy Ageing]



And there is evidence for vaccination of older adults

Cohort studies show that influenza vaccination provides substantial health benefits, including reduced hospitalisations, outpatient visits, mortality and antibiotics prescription among older people. [Nichol, as cited in Chlibek 2012. See Adult Vaccination: A Key Component of Healthy Ageing].

A vaccination programme for older people was shown to be effective on invasive pneumococcal disease (IPD) in the UK. Recent clinical studies also suggest vaccination with pneumococcal conjugate vaccines may provide a benefit in adults. [Jackson, as cited in Chlibek 2012. See Adult Vaccination: A Key Component of Healthy Ageing ].



Evidence for vaccination of older adults

The implementation of a herpes zoster vaccination programme for older people has the potential to improve their quality of life markedly by reducing the incidence and severity of the disease. One study, based on a randomised control trial, found a reduction in disease burden in older adults of 61% and a reduction of postherpetic neuralgia by 67%. [Oxman 2005, as cited in Chlibek 2012. See Adult Vaccination: A Key Component of Healthy Ageing]

http://www.flickr.com/photos/48039948@N02/6070071650/sizes/m/in/pool-92307085@N00/

Herpes zoster vaccine is not approved in Spain



We also know vaccination is cost effective

A systematic review of the relevant literature in English language on the cost-effectiveness evidence of immunisation for adults aged 50 years or over in all EU Member States was performed for the SAATI report published in November 2013.

Cost-effectiveness studies were found for 4 of the 7 key vaccine-preventable diseases in the report: herpes zoster, influenza, IPD and pneumonia. [See Adult Vaccination: A Key Component of Healthy Ageing]

For these 4 diseases, studies were found for 13 EU nations that show immunisation is likely to provide a cost-effective strategy for those aged 50 years or over. [See Adult Vaccination: A Key Component of Healthy Ageing]



And there could be significant “invest to save” return for policymakers: The SAATI/Dutch study

For the 7 vaccine preventable conditions, an estimated 34,528 infectious disease cases would be avoided over a 50 year period. Approximately 5,782 premature deaths avoided over the same period.

The amount of lost working days prevented over the same period was put at 127,480. Health cost savings projected to reach 6.6 million euros

Lifetime tax contributions from implementing adult vaccination amounted to 537 million over the remaining life years of the cohort. [See Adult Vaccination: A Key Component of Healthy Ageing]



The SAATI/Dutch study

Based on the investment costs of vaccinating those aged 50 in the year 2012, the benefit-cost ratio suggests that every 1 euro invested would result in 4.02 euros over the lifetime of the cohort.




The challenges: Why are we worried?

There seems a reluctance to take firmer action to improve standards of adult immunisation in Europe.

Adult vaccination remains an underused public health strategy to promote healthy ageing.

Few EU countries operate a comprehensive adult immunisation schedule. Countries often recommend vaccination to at-risk groups, whilst age-based recommendations – which allow individuals to self-assess their status – are not applied for all vaccine preventable diseases.

Adult vaccination coverage rates are often low and vary across European countries. They are also significantly lower than early childhood vaccination rates. In addition, Central and Eastern European countries often perform less well than Western Europe in terms of uptake results.



Why doesn’t adult immunisation get the attention it should?

Gaps in access to the vaccines and reimbursement; Limited awareness of infectious diseases and vaccines in the

population of all age groups; Gaps in the promotion of adult vaccination schedules by public

health authorities; Limited leadership from healthcare professionals in recommending

vaccination; Inconsistent monitoring and surveillance systems.



Up-take varies by country




European Adult National Recommendations and Reimbursement of PCV13Last Updated 20th March 2014

Russia

Turkey

Romania

Poland

SlovakiaCzech Rep.

Hungary

Bulgaria

Ukraine

Lithuania

CroatiaB &H Serbia

Latvia

Estonia

Slovenia

Belarus

Funded Age

Private

Not Funded AgeFunded RiskNot Funded Risk

Germany

Italy

AustriaSwitzerland

France

SpainPortugal

IrelandUK

Denmark

Belgium

Netherlands

Greece

Norway

Sweden Finland

Israel

*Choice: HCP chooses PPV alone or PCV>PPV

**Considered extremely niche recommendation, therefore ‘Private’ no risk recommendation



Variable guidelines/difficult to access information

Finland 65+Italy varies, 50-65Check Spain, varies, little or no age onlyHungary 50+Bulgaria 50+Estonia 50+Lithuania 50+Poland 50+




How can the consumer be confident of the science of immunisation if policy makers cant agree on recommendation?



Improving life-course vaccination

What can we do?



Possible Solutions

Focus on prevention as better than cure Review incentives to vaccination Raise awareness among consumers A greater role for employers A bigger role for insurers Ensuring vaccination is accessible Nudging people towards vaccination Vaccinate health and care professionals More research European Health and Vaccination Platform at EU level



Prevention is better than cure

“Vaccination can provide cost-effective protection against a host of diseases throughout life, but remains an underused public-health strategy in adults for the promotion of healthy ageing”. [Michel, J. -P., Gusmano, M., Blank, P.R. and Philp, Ian. (2010) Vaccination and healthy ageing : how to make life-course vaccination a successful public health strategy. European Geriatric Medicine, Vol.1 (No.3). pp. 155-165. ISSN 18787649]

Vaccination can play a significant preventative role, alongside other forms of prevention such as screening, in proactively preventing diseases and health ills before they occur, rather than reacting to them afterwards, with drugs and other forms of treatment.

ILC-UK recommends

Healthcare professionals undertaking health check-ups of older people should check whether their patients are up to date with their vaccines.



Incentivising vaccination

An exercise performed by a focus group participant looked at the variation between PCTs in terms of adult vaccination take up. They found that the top five PCTs all had local incentives in place whilst none of the bottom five did [Immune Response]

“Perhaps an incentive of £20 pounds to the GP for vaccinating would be successful, but would it be in the public interest and would the public trust this type of approach?” ILC-UK Focus group participant

Small cash incentives improve HepB vaccination rates among injecting drug users [April 2014: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)60196-3/abstract]



An informed consumer

“Carers should be targeted with information about adult vaccination.”

“We should use travel vaccination clinics and general health checks as an opportunity to inform adults about vaccination more generally.”

“It can be difficult for consumers to find out what the UK immunisation guidelines are. Not many people are going to delve into the Green book. There should be a simplified check list for those aged over 18.”

ILC-UK Focus group participants



The role for employers?

The Government and the private sector are increasingly interested in how we extend working lives. A fear of a skill shortage and an ageing society means that employers and Government are going to have to look for ways to support us in the workplace for longer.

But there have been few initiatives in the private sector which have considered the case for adult vaccination of staff.

Yet the vaccination of older workers against for example, the flu could not only be cost-effective (reducing the number of days lost due to ill health) for employers, but could also contribute to a healthier workforce. Similarly getting shingles whilst still in the workplace can pull people out of the workforce for very long periods.



A greater role for insurance?

Some health insurers provide incentives for individuals to join a gym. Putting in place similar incentives to vaccinate may prove useful.

The Affordable Care Act in the US will providing preventative vaccination to those in individual health plans

One focus group participant argued that there is demand from some insurance consumers for life and health insurance to become more integrated and centred around the policyholder. Such a change may result in the industry needing to reinvent its offer to meet the demands of this new consumer. And vaccination might form part of this offer.



Making vaccination more accessible. A greater role for pharmacy?

ILC-UK believe that it is vital to expand the range of settings which provide vaccination to include, for example, community pharmacies.



Nudging people towards vaccination

Nudge:Thaler and Sunstein (2008)

Suggests that individuals’ actions and decisions don’t result simply from a rational overview of external circumstances.

Instead they are equally likely to be based on systems of habitual behaviour based on learned traits and biases.

How might we “nudge” vaccination? • The use of ‘declination forms’ by health

services and employers could encourage employees to think twice about turning down vaccination.

• Play on the strong sense of civic duty which might encourage vaccination to protect others, particularly if advised to do so by their physicians.

• Creating a social norm of adult vaccination (beyond flu) through investment in communications.

• Research should be commissioned to explore what messages are most likely to result in greater uptake of adult vaccinations.



Vaccination of Health and Social Care professionals

“When I was doing the rounds as a nurse, teams used to come around and offer vaccination to myself and other healthcare workers. But some members of staff still refused.” ILC-UK Focus group participant

Last year, just 45.6% of UK health and social care workers were vaccinated against flu. [Immune Response: ILC-UK]

Levels of vaccination of healthcare professionals varies significantly by NHS Trust. In 2011, some trusts achieve almost 95% coverage of staff whilst others only achieved around 5% of staff vaccinated against seasonal flu. [Immune Response: ILC-UK]



A need to know more

There is limited research which explores adult vaccination. Where it does exist it is dominated by research on influenza.

The WHO Global Vaccines Action plan urged Governments to “Encourage and support research on vaccines and vaccination issues”. It is important that the Government continues to support such research.[http://www.who.int/immunization/global_vaccine_action_plan/en/]

ILC-UK recommends: The Government, industry and other research funders should ensure there is adequate research on the potential and efficacy of adult vaccination.



What did SAATI recommend?





The challenges of advocacy? For discussion

At a European level health is a national competence At an developing world level the focus remains on childhood

immunisation There are few “champions” There is limited expertise outside industry/industry funded

organisations There is a perception of industry lobbying There is limited funding for advocacy in this area There are other priorities in Adults/older adults work The UK does relatively well so it is difficult to point to better

uptake/practice Last year’s flu efficacy issues are a challenge and an

opportunity Disease specific groups are interested but they have many

priorities



In summary – Key messages

There is a strong evidence base to support a focus on immunisation as a lifecourse issue

But vaccination across the lifecourse does not get the attention it should

Policies can be patchy and inconsistent at a European level (and even within countries)

Policy makers should focus on breaking down the barriers to adult immunisation.



References (reports available at www.ilcuk.org.uk)



Many thanks

David SinclairDirectorInternational Longevity [email protected]: @ilcuk and @sinclairda

mailto:[email protected]