“Every interaction you have …should be an opportunity to discuss and offer influenza vaccination”. Health service perspectives on influenza vaccination promotion and delivery to Aboriginal families living in New South Wales, Australia

Source: Rowe SL, Leder K, Perrett KP, et al. Maternal vaccination and infant influenza and pertussis. Pediatrics. 2021;148(3): e2021051076; doi.10.1542/peds.2021-051076Investigators from multiple institutions in Australia conducted a population-level inception cohort study to assess the effectiveness of maternal influenza and pertussis vaccination during pregnancy in preventing these diseases in their children during the first 6 months of life. For the study, they abstracted data from the Victorian Perinatal Data Collection (VPDC) on women whose pregnancies ended between September 2015 and December 2017. The VPDC includes information on all live births and stillbirths in Victoria, Australia, including demographic and clinical data related to pregnancy and birth. In addition, whether the mother received influenza and/or pertussis vaccine at any time during pregnancy is recorded. Data from multiple databases were reviewed to identify laboratory-confirmed cases of influenza and pertussis in infants <6 months old during the study period and record ED visits, hospital admissions, and deaths from influenza and pertussis. Information from these databases and VPDC were linked to identify mother-infant dyads.The primary study outcomes were laboratory-confirmed cases of influenza and pertussis in infants born to mothers included in the study, and secondary outcomes included cases of severe disease, defined as ED visit, hospitalization, or death from influenza or pertussis in study infants. Poisson regression was used to calculate the relative risk (RR) for influenza and pertussis in infants of mothers vaccinated during pregnancy vs not vaccinated, after adjusting for multiple confounders. Results were stratified in infants <2 months old, and those 2 to <6 months of age. Vaccine effectiveness (VE) of maternal immunization in preventing childhood illness was estimated as (1-RR) × 100.Data were analyzed on 186,962 mother-infant dyads. Overall, 45.9% of study women were vaccinated against influenza during pregnancy and 68.5% against pertussis. There were 185,404 and 184,194 infants, respectively, included in influenza and pertussis vaccination analyzes. The risk of influenza was significantly reduced in children whose mothers were vaccinated, both among children <2 months old (RR, 0.44; 95% CI, 0.25, 0.77), and in those 2 to <6 months of age (RR, 0.64; 95% CI, 0.42, 0.98), with VE estimated as 56.1% (95% CI, 23.3%, 74.9%) and 35.7% (95% CI, 2.2%, 57.7%), respectively. Maternal vaccination reduced the risk of pertussis in infants <2 months old (RR, 0.20; 95% CI, 0.06, 0.63), with an estimated VE of 80.1% (95% CI, 37.1%, 93.7%), but no significant effect was noted among infants 2 to <6 months old (RR, 0.68; 95% CI, 0.33, 1.39). Maternal pertussis immunization reduced the risk of severe pertussis in infants <2 months old (RR, 0.38; 95% CI, 0.16, 0.94). There were no significant effects from maternal vaccination on severe cases of pertussis in children 2 to <6 months old or on influenza among children <6 months old.The authors conclude that maternal vaccination during pregnancy reduces the risk of influenza and pertussis in infants <2 months old.Dr Brady has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.The goal of maternal immunization is to provide infants with passive antibodies prior to their first dose of vaccines. In a previous study, Baxter et al1 noted that maternal Tdap during pregnancy significantly reduced pertussis risk during the entire first year of life (See AAP Grand Rounds. 2017;38[2]:15.)1 In the current study, which included infants born at ≥30 weeks’ gestation, this benefit was most notable only in infants <2 months. In contrast, Baxter et al1 enrolled only infants born at ≥37 weeks’ gestation, allowing more time for antibody transfer after maternal Tdap receipt (usually between 27–36 weeks’ gestation).2As demonstrated by the results of the current study, maternal vaccination during pregnancy also reduces the infant’s risk for influenza during the first 6 months of life. Tdap and influenza vaccination rates during pregnancy, however, remain suboptimal.3 To assess influenza and Tdap vaccination coverage among women pregnant during the 2020–21 influenza season, the Centers for Disease Control and Prevention (CDC) conducted a survey during April 2021.4 Among 1,795 survey respondents who were pregnant anytime during October 2020–January 2021, 54.5% reported receiving an influenza vaccine before or during pregnancy. Among 729 respondents, 53.5% reported receiving Tdap during pregnancy. Unfortunately, receipt of both influenza and Tdap vaccines was reported by only 30.7% of women.COVID-19 vaccines also are recommended for all pregnant women.5 Providers need to take every opportunity to recommend these vaccines for their pregnant patients.Vaccination of pregnant women with Tdap, influenza, and COVID-19 vaccines is safe and protects the mother and her young infant.As influenza vaccines are approved only for infants ≥6 months of age, the 6-month duration of immunity conferred by maternal influenza vaccination provides further support for maternal immunization.

New evidence strengthens policy to vaccinate healthcare workers

Pregnant women and infants <6months are at increased risk of severe influenza but can receive protection through influenza vaccination administered during pregnancy. Since influenza vaccination and virus transmission are seasonal in the United States, the calendar timing of pregnancy could impact the opportunity for influenza vaccination and risk of influenza for pregnant women and their infants. Using data on laboratory-confirmed influenza-associated hospitalizations from 2005/06 to 2022/23 (excluding the 2009/10 and 2020/21 seasons), we assessed the risk of hospitalization by influenza season timing and by pregnancy start and infant birth months. We then used 2022/23 influenza vaccination coverage data, and the weekly number of influenza positive specimens identified from 2005/06 to 2022/23 (excluding 2009/10 and 2020/21), to quantify how the opportunity for seasonal influenza vaccination and risk of influenza exposure varied with pregnancy and birth timing. We found that pregnancy start and infant birth months with the greatest hospitalization risk varied between seasons. In seasons peaking before the second week in January, the greatest percentage of hospitalizations occurred among pregnancies beginning March-June with births in October-December. In seasons peaking later, the greatest percentage occurred among pregnancies beginning May-August with births in November-January. Opportunities for protection through maternal vaccination also varied between pregnant women and infants who were most at risk for influenza. Most pregnant women at risk of influenza had an opportunity for current season vaccination during or before pregnancy (93-98% depending on season timing). However, only 17-54% of infants at risk had an opportunity for current season protection as many were born before most influenza vaccines were administered. Our results highlight heterogeneity in influenza vaccination opportunity and risk of influenza and severe disease among pregnant women and young infants and could inform strategies to increase vaccine-mediated protection in those at greatest risk.

Influenza vaccine in children with asthma: Why no progress?

Even though the efficacy of pneumococcal vaccine against invasive pneumococcal infections and other closely related infections has been established, its use in the United States is only one quarter of that of influenza vaccine. The simultaneous administration of the two vaccines could be expected to raise the coverage of pneumococcal vaccination to a considerable degree. There is a paucity of data regarding the reactions associated with the simultaneous administration of pneumococcal and influenza vaccines. All persons aged 65 years or older living in 29 administrative districts in Northern Finland were offered influenza vaccine alone or influenza and pneumococcal vaccines. A total of 9336 persons (49.6% of the target population) accepted vaccination: 4581 persons born in odd years received influenza vaccine, and 4755 persons born in even years received influenza and pneumococcal vaccines. Local reactions were recorded in a diary by vaccines on the day of vaccination and for 4 days afterward according to the following scale: no reaction, mild reaction, strong reaction, and disabling reaction. The participants who felt feverish were asked to measure and record their temperature. Ninety-three percent of those vaccinated returned the diary. No serious reactions were observed. The incidence of local reactions was 284 per 1000 vaccinations in the influenza-vaccinated group and 441 per 1000 vaccinations in the influenza-pneumococcal-vaccinated group, a difference of 157 (95% confidence interval, 137 to 176), and that of fever (temperature, at least 37.5 degrees C) was 10 and 24 per 1000, respectively, for a difference of 14 (95% confidence interval, 9 to 19). The frequency of local reactions decreased with advancing age. Because the adverse reactions to the pneumococcal and influenza vaccines when given together were mild, we conclude that the simultaneous administration of the two vaccines to the elderly population, irrespective of age, is safe.

To the Editor: Each year, approximately 2 million Muslims travel from all over the world to participate in hajj. Approximately 22,000 pilgrims travel from the United Kingdom to Makkah, Saudi Arabia; of those, approximately 1,000 pilgrims reside in the east end of London. In the past, infectious diseases research conducted during these pilgrimages focused on meningococcal disease because of outbreaks associated with the hajj. Since 2000, the dates of the hajj have been moved back into the winter season; this time change could lead to a seasonal increase in outbreaks of respiratory infections caused by influenza and other viruses. From 1991 to 1992, influenza A was a common cause of respiratory infection in pilgrims tested in Makkah (1). However, the incidence rate of influenza among pilgrims from Europe is not well-known. A previous study of influenzalike illness among pilgrims from Pakistan reported rates of 36% in influenza-vaccinated pilgrims and 62% in influenza-nonvaccinated pilgrims; these results were based on clinical endpoints without microbiologic confirmation (2). We assessed the risk for influenza infection among a cohort of pilgrims from the east end of London who participated in the hajj in 2003. From December 2002 to January 2003, we enrolled 115 participants who planned to take part in hajj in 2003. The study was approved by the North London Multicentre Research Ethics Committee and the Trustees of East London Mosque. Informed consent was obtained through appropriate translators. All participants attended the East London Mosque, Whitechapel, London; 30 were vaccinated with influenza vaccine (A/New Caledonia/20/99 [H1N1]-like strain, A /Moscow/10/99 [H3N2]-like strain, B/Sichuan/379/99-like strain). Venous blood samples were collected, and questionnaires were completed before the participants departed for the hajj and within 2–3 weeks of their return in February to March 2003. Tests for influenza A and B were conducted by using hemagglutination inhibition against the following influenza antigens: A/NewCalidonia/20/99, A/Wuhan/371/91, A/Sydney/5/97, A/Panama/2007/99, B/Sichuan/379/99, and B/Harbin/7/94. A diagnosis of influenza was made based on seroconversion with at least a fourfold rise in antibody titer. Based on seroconversion, the influenza attack rate among all pilgrims was 38% (44/115). The attack rate was 30% among the vaccinated and 41% among the nonvaccinated participants (Table) (odds ratio for influenza in vaccinees = 0.61, p = 0.28). Of the 44 patients, 42 (37%) were infected with influenza A H3N2; 1 had influenza A H1N1, and 1 had influenza B infection. Six influenza A H3N2 patients were dually infected; two patients seroconverted to A H1N1, and four patients seroconverted to influenza B. Nearly half (21/44) of the patients with influenza received a course of antimicrobial drugs while on the hajj compared with 38% (27/71) of those who did not seroconvert. The attack rate in the vaccinated patients was lower than the rate in nonvaccinated patients, which is consistent with some protective effect of the influenza vaccine. Table Seroconversion and respiratory symptoms due to influenza infection and vaccination status among U.K. pilgrims Even though blood was collected from five convalescing patients within 3 weeks of their return from the hajj, some of the patients may have acquired influenza B infection immediately after their return to the United Kingdom, as it was the main strain circulating in the United Kingdom in late February to March 2003. Many pilgrims from throughout the world, some of whom may carry H3N2 drift variants, mingle closely during the hajj. This type of exposure increases the risk for worldwide spread of new drift variants and other contagious respiratory diseases (3). Given the potential for the high influenza attack rate documented in this study, all pilgrims, regardless of age, should be offered influenza vaccination before they travel on the hajj during winter months. On-site testing for influenza should be available to medical services in Makkah (and countries of origin), and treatment with a neuraminidase inhibitor should be offered to persons who test positive and have been symptomatic for <48 hours (4). This treatment should lessen the transmission risk to pilgrims during the crowded events during travel and on their return home (5). When pilgrims return from the hajj, physicians should be informed that pilgrims may bring back new drift variants of influenza; physicians should consider the diagnosis and treat persons at risk and their close contacts (4).

Influenza and pneumococcal vaccination in chronic obstructive pulmonary disease (COPD)

Influenza update: Activity on the rise

Pregnant women and infants are at high risk for severe influenza and many countries, including France, recommend annual influenza immunization during pregnancy. We aimed to estimate influenza vaccination and refusal rates and assess associated factors among pregnant women during the 2015–16 season in France. We used data from a national representative sample of women who gave birth in March 2016 and were interviewed before hospital discharge (N = 11,752). In the multivariable analysis, robust Poisson regression models were used to study associations with maternal characteristics and prenatal care characteristics. Influenza vaccine coverage among pregnant women was 7.4% (95% confidence interval [CI]: 6.9–7.9). Only 24.9% (95% CI: 24.2–25.7) of women said that they received a care provider proposal for vaccination and 70.4% (95% CI: 68.7–72.0) of these declined it. Vaccine uptake was associated with low parity (prevalence ratio [PR] = 2.1; 95% CI: 1.4–3.2 for parity 0 vs ≥ 3), high educational level (PR = 2.5; 95% CI: 2.0–3.2), healthcare occupation during pregnancy (PR = 1.8; 95% CI: 1.5–2.1) and preexisting conditions at risk for influenza (PR = 1.7; 95% CI: 1.3–2.2). Women were more frequently vaccinated when their main care provider was a general practitioner. Multiparae women and those with medium or low educational level were significantly more likely than others to decline influenza vaccine after a provider proposal. Influenza vaccine coverage is very low in France, mainly because of infrequent care provider proposals and also frequent women’s refusals. Effective interventions should be designed to promote vaccination among medical professionals and reduce vaccine hesitancy among pregnant women.

BackgroundThe aims of this study were: a) to evaluate attitudes and practices of health care workers (HCWs) towards influenza vaccination and their opinion regarding a vaccination promotion toolkit; b) to estimate hospital HCWs’ influenza vaccination coverage rates (VC).MethodsThe Bambino Gesù Children’s Hospital (OPBG) is an academic hospital in Italy. Since 2009, free influenza vaccination is offered to HCWs during working hours. In October-December 2013, a communication campaign based on a standardized toolkit was conducted. In December 2013, we performed a cross-sectional survey in a sample of hospital wards, based on a self-administered questionnaire including participants’ characteristics; self-reported influenza vaccination history; reasons for vaccination or missed vaccination; opinion regarding the toolkit. Multivariable logistic analysis was used to assess independent predictors of influenza vaccination status. Annual VC for years 2009–2013 was estimated by using the number of seasonal influenza vaccine doses administered to HCWs as numerator, and the number of hospital HCWs as denominator.ResultsOut of 191 HCWs who participated in the survey, 35.6 % reported at least one influenza vaccination during their life; 6.8 % adhered to annual revaccination. Years of service and professional category were significantly and independently associated with vaccination (adjusted-OR: 2.4 for > 10 years of service, compared to < 5 years of service; adjusted-OR: 2.6 for physicians compared to nurses). Patient protection was the main reported reason for vaccination (34.3 %); considering influenza a mild disease was the main reason for non-vaccination (36.9 %); poor vaccine effectiveness was the main reason for missed annual revaccination (28.8 %). Overall, 75 % of respondents saw at least one promotion tool; 65.6 % of them found the information useful. Hospital VC decreased from 30 % in 2009, to 5 % in 2012. In 2013, VC was 14 %.ConclusionsSatisfactory influenza VC in HCWs is hard to achieve. In 2013, along with the toolkit implementation, we observed an increase in HCWs’ vaccination coverage, nevertheless, it remained unsatisfactory. Tailored information strategies targeting nurses and recently employed HCWs should be implemented. Institution of declination statements, adding influenza vaccination to financial incentive systems, or vaccination requirements should also be considered to increase influenza VC among HCWs.

Background While influenza vaccination is known to positively impact health equity, vaccination recommendations vary by country and may not always optimize equity considerations. For example, while the US recommends vaccination for everyone aged ≥6 months, the UK’s recommendations are limited to adults aged ≥65 years, those aged &amp;lt; 65 years at higher risk, and specific age groups of children. This pilot study measured the health equity-related impact of broader UK vaccination recommendations. Methods Data availability determined that this analysis focused on adults aged ≥50 years in England. Health equity impact was assessed by Index of Multiple Deprivation Quintiles (IMDQ) and age (50–64, ≥65 and ≥50 years). Influenza risk and prevented cases were estimated using influenza hospital admission rates, vaccination effectiveness and coverage (flu season 2022/23). An exploratory analysis was conducted assuming extension of UK national guidance to all ≥50-year-olds with equal vaccine uptake in 50–64-year-olds as in ≥65-year-olds. Results This study estimated vaccination currently prevents ∼80% of all preventable cases in ≥65-year-olds vs. 47% in 50–64-year-olds. Influenza risk is highest in IMDQ1 (most deprived group) across age and vaccination status. Influenza prevention from vaccination of 50–64-year-olds (coverage ∼50%) in England is greatest in IMDQ1 (16% of all preventable cases prevented vs. 4% in IMDQ5, least deprived) (Table 1). Assuming extension of UK national guidance to all ≥50-year-olds with similar coverage to ≥65-year-olds (∼80%) may prevent ∼26% of preventable cases in IMDQ1 and ∼8% in IMDQ5 (Tables 1−3). Conclusion Expanding influenza vaccination to other age groups can help increase health equity by improved influenza prevention. Greater vaccination coverage would enable the highest reduction in cases, especially in the most socially disadvantaged groups. Funding: GSK Disclosures Eliana Biundo, MSc, GSK: Employee|GSK: Stocks/Bonds (Private Company) Victoria G. Soares, MBA, GSK: Advisor/consultant Irshaad Jansen, MSc, GSK: Employee|GSK: Stocks/Bonds (Private Company) Tomas Mrkvan, PhD, GSK: Employee|GSK: Stocks/Bonds (Private Company)

Influenza and pneumococcal vaccination and risk of stroke or transient ischaemic attack—Matched case control study

IntroductionVaccinating pregnant women with influenza vaccine and tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap) can reduce influenza and pertussis risk for themselves and their infants.MethodsSurveillance data were analyzed to ascertain influenza-associated hospitalization among pregnant women and infant hospitalization and death associated with influenza and pertussis. An Internet panel survey was conducted during March 27–April 8, 2019, among women aged 18–49 years who reported being pregnant any time since August 1, 2018. Influenza vaccination before or during pregnancy was assessed among respondents with known influenza vaccination status who were pregnant any time during October 2018–January 2019 (2,097). Tdap receipt during pregnancy was assessed among respondents with known Tdap status who reported a live birth by their survey date (817).ResultsFrom 2010–11 to 2017–18, pregnant women accounted for 24%–34% of influenza-associated hospitalizations per season among females aged 15–44 years. From 2010 to 2017, a total of 3,928 pertussis-related hospitalizations were reported among infants aged <2 months (annual range = 262–743). Maternal influenza and Tdap vaccination coverage rates reported as of April 2019 were 53.7% and 54.9%, respectively. Among women whose health care providers offered vaccination or provided referrals, 65.7% received influenza vaccine and 70.5% received Tdap. The most commonly reported reasons for nonvaccination were believing the vaccine is not effective (influenza; 17.6%) and not knowing that vaccination is needed during each pregnancy (Tdap; 37.9%), followed by safety concerns for the infant (influenza =15.9%; Tdap = 17.1%).Conclusions and Implications for Public Health PracticeMany pregnant women do not receive the vaccines recommended to protect themselves and their infants, even when vaccination is offered. CDC and provider organizations’ resources are available to help providers convey strong, specific recommendations for influenza and Tdap vaccination that are responsive to pregnant women’s concerns.

Currently in the U.S., approximately 7 million children (9.4%) have asthma (1), making it the most prevalent serious chronic illness among U.S. children.Clinically, the association of viral respiratory infections and asthma exacerbations has been understood for decades.More recently, infections with particular viruses have been identified as being particularly risky: respiratory syncytial virus, rhinovirus, and influenza virus are notable examples.In the spring of 2009, a new influenza virus (A(H1N1)pdm09 [2009 H1N1]) with pandemic potential was isolated from patients in the U.S. and around the world (2).Early data indicated that certain comorbid medical conditions increased the risk for hospitalization and intensive care unit admission (3).Persons with asthma appeared to bear a disproportionate risk, and local and state health departments along with Centers for Disease Control and Prevention (CDC) developed and disseminated guidance early in the outbreak for persons with asthma and their health care providers.Early diagnosis and use of antiviral medication, along with public health practices like self-distancing and hand-washing, were emphasized.Persons with comorbid conditions (including asthma) were prioritized to receive vaccine once it became available.These recommendations, however, were more re-iterations of existing practices and policies rather than de novo interventions.As was consistent with previous recommendations, vaccination of persons with asthma was to prevent influenza because of the risk of increased disease severity, rather than increased risk of becoming infected with influenza virus.Analysis of existing data did not, at that point in time, support (nor refute) an increased risk of infection among persons with asthma.In this issue of American Journal of Respiratory and Critical Care Medicine, Kloepfer and co-authors demonstrated an increased risk of infection with 2009 H1N1 influenza virus among persons with asthma.The opportunity to collect the data to demonstrate this finding was serendipitous: the authors had a well-planned, ongoing study of viral respiratory infection and asthma at the time the fall wave of the 2009 outbreak arrived in their locale.

Effectiveness of seasonal influenza vaccination in community-dwelling elderly people: an individual participant data meta-analysis of test-negative design case-control studies