Influenza Vaccination in india - Pediatrician's Perspective, May 2016
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Transcript of Influenza Vaccination in india - Pediatrician's Perspective, May 2016
Influenza vaccination in IndiaA Pediatrician’s Perspective
Dr Gaurav Gupta,Pediatrician,
Member AAP, IAP,Charak Clinics, Mohali
21 May 2016
Conflict of Interest
• Received grants from various vaccine manufacturers including – - Sanofi Pasteur– - GSK– - Abbott(Manufacturers of different Influenza vaccines)
Overview
• Influenza – is it really that big a problem – Indian Children?
• Influenza vaccine – Indian Data• Whom, how & when to vaccinate ?
CASEAlisha is a 7-year-old girl brought to your
Clinic by her mother, who tells you her daughter “suddenly came down with a bad cold.” She reports that “Alisha was fine when she went to bed” but in the morning suddenly became ill with vomiting, a dry cough, sore throat, and high fever.
WHAT DO YOU THINK IS THIS??
Often misunderstood and underestimated, Influenza is not just “a bad cold”!
Annual influenza epidemics
Influenza pandemics: exceptional epidemiological events
occurring every few decades(11–36 years)
CLINICAL FEATURES & CASE DEFINITION
JAMA 2000; 284 (13): 1740
Laboratory Confirmation required for epidemiological purposes only
Influenza can also present as croup, bronchiolitis, pneumonia, febrile disease mimicking bacterial sepsis
Can predispose to bacterial infections (otitis media, pneumonia, bronchiolitis)
Global Burden of Influenza in Children
05/01/2023 www.thelancet.com. Published online November 11, 20117
……concluded that, in 2008, 90 million cases of influenza occurred among children < 5
20 million cases of ALRI, one million cases of severe ALRI and
28,000-111,500 deaths
Influenza incidence in children < 5 year is ~ 3 times higher in developing as compared to developed countries
Incidence per 1,000 children/yr (95% CI)Mortality rate %
(95% CI)Influenza Influenza acute
LRIInfluenza severe
ALRI
Developing countries 154 (84-275) 35 (22-55) 1.7 (1.1-2.5) 2.96 (0.79-5.13)
Industrialised countries 55 (28-106) 12 (7.5-18) 1.2 (0.9-1.7) 0.17 (0.08-0.26)
28,000–111,500 deaths in 2008, 99% in developing countries.
Nair et al. The Lancet, Volume 378, Issue 9807, Pages 1917 - 1930, 3 December 2011
Influenza is a common cause of pediatric medical visits
• In Thailand in 2004, 23% of 1092 febrile outpatients were influenza positive by PCR1
• In Vietnam during 2006-07, national surveillance reported that 19% of 11,082 febrile outpatients had lab-confirmed influenza infection by PCR3
• In Cambodia during 2006-08, 4,233 febrile pediatric outpatients were screened by PCR and 27.7% were influenza positive4
• In China during 2008-10, 1,472 febrile pediatric outpatients were screened by PCR and 30.9% were positive (Type A 13.3%, Type B 6.8%, pH1N1 10.8%)5
1. Simmerman JM et al. The Cost of Influenza in Thailand. Vaccine 24 (2006) 4417–44262. Brooks, A et al. Influenza is a Major Contributor to Childhood Pneumonia in a Tropical Developing Country. PIDJ. Vol 29, Number 3, March 2009
3. Nguyen, HT et al. National influenza surveillance in Vietnam. Vaccine 28(2010) 398-402.4. Blair, PJ et al. Influenza epidemiology in patients with acute fever in Cambodia. Epidemiol. Infect 138 (2101) 199-209.
5. Pen, J et al. The Epidemiology and Etiology of Influenza-Like Illness in Chinese Children From 2008 to 2010. Journal of Medical Virology 84:672–678 (2012)
05/01/20239
Have we made any progress towards Prevention?
Multisite Influenza surveillance Network & Improved Influenza Detection
05/01/202310
Pune (NIV),Kasauli (CRI)Mumbai (Haffkins Institute)
WHO National Influenza Center s(as of April 2011)
10 cities data suggests 14% of the total samples sent were Influenza positive
05/01/202311
A(H1N1) in India, 2009-15*Time period
May 2009-Dec 2009
Jan 2010-Dec 2010
Jan 2011-Dec 2011
Jan 2012-Dec 2012
Jan 2013-Dec 2013
Jan 2014-Dec 2014
Jan 2015-Feb 2015*
Cases 27236 20604 603 5044 5253 937 18,105
Deaths 981 1763 75 405 699 238 1,005
Mortality ratio
3.60% 8.55% 12.44% 8.03% 13.31% 25.40% 5.75 %
• Data till February 27, 2015 (Source: Office of the Director, Emergency Medical Relief, Directorate General of Health Services, Government of India, New Delhi.)
https://flutrackers.com/forum/forum/india/seasonal-flu-2009-2014-including-h1n1-pandemic-2009-ai/721670-india-influenza-2015-2-868-media-reported-fatalities/page6
• http://www.japi.org/april_2015/08_ua_h1n1_revisited_after_six.html
ARE WE
SEEING TIP OF THE ICEBERG?
Not everyone that dies with an influenza-like illness is tested for influenza;
Influenza-associated deaths are often a result of complications secondary to underlying medical problems, which may be missed.
jan - mar 2008
apr-jun 2008
july-sept 2008
oct 2008-dec 2008
jan to march 2009
apr to june 2009
july to sept 2009
Oct 2009 to dec 2009
Jan to march 2010
Apr to june 2010
july to sept 2010
Oct 2010 to dec 2010
Jan to march 2011
Apr to June 2011
0
50
100
150
200
250
Incidence of ILI from our center
What do we understand?
With very limited data there’s enough reason to believe that the magnitude of the problem is much higher in developing countries including India as compared to the developed
countries
05/01/202314
15
Clinical effectiveness of Influenza Vaccine
Clinical effectiveness of
TIV (450 subjects)
Vaccinated cohortN=150
Followed upN=137
Fully vaccinatedN=106
Partially vaccinatedN=31
Unvaccinated cohortN=300
Followed upN=282
16
Fully vaccinated Vs UnvaccinatedOutcome Fully
Vaccinated cohort (%)
Unvaccinated cohort (%)
Relative Risk
p-value 95% CI
UV 2.8 38.7 0.0987 0.0001 0.032-0.304
ARI 8.5 16.7 0.5478 0.0832 0.277-1.082
ILI 0.9 35.5 0.0357 0.0009 0.005-0.253
Ab. 0.9 6.4 0.1558 0.0686 0.021-1.152
Conclusion
• Flu vaccine is effective in reducing ILI & unscheduled visits to doctor.
• No effect of partial vaccination
• Vaccine effectiveness studies have found VE of 60-85% in children < 5 yrs age when vaccine strains match well with circulating strains
• Limited data indicate additional protection of unvaccinated household and community contacts by immunization of children
Sage working group: Background Paper on Influenza Vaccines and Immunization. April 2012
SAGE Data- Protection against influenza
Evidence of effectiveness in children younger than 3 years
www.thelancet.com/infection Vol 11 January 2011
9 m- 3y: 66% VE against any influenza, 84% against influenza A < 2 years, VE 66% against any influenza, 79% against influenza A
Assessment of effectiveness
of influenza vaccination by comparing the
proportions of laboratory-confirmed
influenza A and B infections in fully vaccinated and
unvaccinated children a prospective cohort study
Impact of Vaccination In Pre-school And School-going Children
05/01/2023
1.Neuzil KM et al Pediatr Infect Dis J, 2001: 20:733-40. Heikkinen T et al.Influenza vaccination in the prevention of acute otitis media in children: Am J Dis Child 1991;45:445-8 Pediatric Infect Disease J 2006:25;5;401-404 New England J Med 2000; 342:225-31 Principi N et al. socioeconomic impact of influenza on healthy children and their families Pediatr Infect Dis J 2003; 22:S2007-10.20
Studies confirm effectiveness of Influenza vaccination in Pre-School
Children
Studies confirm Influenza vaccination in School-Going Children to be:
• Not only effective in reducing the sufferings
• But also a Cost Saving proposition
Reduction in Influenza related morbidity
Direct & Indirect benefits of Vaccination
WHOM TO VACCINATE???
Vaccine recommendations by authorities
Ideally, all
individuals
should have the
opportunity to be
vaccinated
Priority should
be given to high
risk population
including
children between
6-23 months
• All those
aged over 6
months in a
clinical at-
risk group
• Only in all
high risk
children
>6 months
• Universal
Vaccination
of all children
from the age
of 6 months.
• Special
attention for
children upto
60 months
• Routine
influenza
vaccination is
recommended
for all persons
aged ≥6 months
*CEVAG: Central European Advisory Grouphttp://www.who.int/docstore/wer/pdf/2002/wer7728.pdf Accessed on 2/08/2010
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr59e0729a1.htm?s_cid=rr59e0729a1_e Accessed on 2/08/2010http://www.sehd.scot.nhs.uk/cmo/CMO(2010)14.pdf Accessed on 2/08/2010
http://www.biomedcentral.com/content/pdf/1471-2334-10-168.pdf. Accessed on 2/08/2010
*
Annual influenza vaccine is widely recommended for children above 6 months globally, including WHO
IAP Position Paper (2013) Points Out :
Amongst pediatric population, apart from children with chronic medical conditions , children below 2 years of age
should be considered a target group for influenza immunization because of a high burden of severe disease in
this group.
05/01/2023VM VASHISHTHA, A KALRA AND P CHOUDHURY; INDIAN
PEDIATRICS VOLUME 50__SEPTEMBER 15, 201323
Recent Ministry of Health Recommendation:
http://mohfw.gov.in/showfile.php?lid=3069
When to vaccinate?
INTERNATIONAL SURVEILLANCE NETWORK
VACCINE MANUFACTURER
M A M J J A S O N D J FF M
Process of Influenza Recommendations and Vaccine Availability
WHO(Northern hemisphere)
PRODUCTION
WHO(Southern hemisphere)
PRODUCTION
Chalumeau HP. Vaccine manufacture at the time of a pandemic influenza. European journal of epidemiology1994;10: 487-490
WHO recommendations
• In most of the countries using influenza vaccine, the vaccination starts before the onset of peak influenza season, with the latest available strain of vaccine
WHO Influenza Vaccine Recommendations
Influenza Activity And Peaks
05/01/2023
Data source: FluNet (www.who.int/flunet), Global Influenza Surveillance Network (GISN) 29
Trends in influenza circulation in India
Influenza virus circulation
peaks in June-August
IAP recommendations 2013
05/01/2023
INDIAN PEDIATRICS VOLUME 50__SEPTEMBER 15, 201330
Vaccination Schedules
* 2 doses at least 1 month apart for children receiving vaccine for the first time
Age group Dosage (im/sc) No. of doses
6-35 months 0.25 ml 1 or 2*
3-8 years 0.5 ml 1 or 2*
> 9 years 0.5 ml 1
IAP recommendation
Vaccine type Composition Immunogen
icityReactogen
icityWhole-virus
(no longer used)
Whole virus +++ +++
Split virionSurface,
nucleocapsid & matrix proteins
+++ ++
Subunit Surface proteins ++ ++
Virosomal Surface proteins & virosomes ++ +
Adjuvanted Surface proteins & adjuvant +++ ++
Nasal Live attenuated +++ +++ (Low) ++ (Medium) +++ (High)
Differences between Influenza vaccines
Amorij JP. Pharm Res. 2008;25(6):1256-1273.
Good Immunogenicity and tolerability
01/05/2023 Split Vs Subunit Dr SS | 33
http://www.ifpma.org/resources/influenza-vaccines/influenza-vaccines/about-influenza-vaccine.html
Types of Inactivated Influenza Vaccines
01/05/2023 Split Vs Subunit Dr SS | 34
• The vaccine effectiveness for the split virion influenza vaccine was 77.8% (CI 58.5%-90.3%) for subunit vaccine was 44.3% (CI -11%-70.9%)
Findings
01/05/2023 Split Vs Subunit Dr SS Kim YK et al. 2013
• The proportion of subjects with HI titers ≥40 for H1N1; H3N2 and B viruses were higher in children receiving split virus vaccine.
• The proportions of seroconversion for H1N1, H3N2 and B viruses were also higher in subjects receiving the split virus vaccine.
• The overall local reactions were similar in both vaccine types. 35
Exciting Future ahead ?
QUADRIVALENT LIVE INFLUENZA VACCINE
FDA NEWS RELEASEFor Immediate Release: Feb. 29, 2012FDA approves first quadrivalent vaccine to prevent seasonal influenzaThe first quadrivalent live attenuated vaccine to prevent seasonal influenza has been approved by FDA. FluMist Quadrivalent (MedImmune), will be available for the 2013-2014 flu season. This too will be administered as a nasal spray. The vaccine is indicated for individuals ages 2 years through 49 years. FluMist Quadrivalent will contain 2 strains of influenza A and 2 strains of influenza B. Including a second influenza B strain improves the odds of protection against whichever B strain is circulating.
http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm294057.htm
Scientists made the vaccine by fusing key proteins of the flu virus, made synthetically by genetic engineering technology, with a bacterial protein called ferritin that can automatically assemble itself into “nanoparticles” smaller than the virus. The flu proteins, which stick out from the ferritin like the spikes on a sea mine, stimulate immunity against the virus.
Nature (2013) doi:10.1038/nature12202Received 28 August 2012 Accepted 18 April 2013 Published online 22 May 2013
Newer VaccinesDriven by Science or Commerce?
1st J & K State Medical Science Congress. 21st May 2016
ASCOM, Sidhra
• US and Europe- Health of people is State's responsibility.- Include (almost) every vaccine in NIP – Hepatitis A, Varicella, Rota, PCV, HPV etc.
• India– People's health is Personal responsibility.– Health & disease prevention is not in human
control, it is God/ Fate
Summary: Reasons for Expanded Pediatric Influenza Vaccination
High disease burden exists in India
Children are at increased risk for serious complications
Children play an important role in transmission in the community
The long-term experience with influenza vaccine, confirms its effectiveness and excellent tolerability
IAP points out that children below 2 years of age should be considered a target group for influenza immunization
Recent MOH guidelines highlight that vaccination is desirable in children between 6m -8years of age
05/01/2023
41