With flu coverage historically low after COVID, sustaining influenza vaccination has become a test of health-system resilience. This report examines three themes: protecting and expanding influenza vaccine funding, sharpening the messaging and weighing new vaccine technology against the 75% coverage target, and lifting uptake among the sub-groups that matter most — pregnant women, children, people with chronic conditions and healthcare professionals.
Draft Report
Observations · Challenges · Strategies
6th LifeCourse Immunisation Summit, 2021–2022
Excellence in Pediatrics Institute × Vaccines Together
Topic 01
We must protect influenza vaccine budgets at a time when rates are historically low as a result of COVID measures. Influenza will return, and progress on influenza vaccine research was limited as prevalence dropped; it is essential that we protect and grow influenza vaccine programmes across Europe.
Protecting the increase in uptake of current influenza vaccines, and defending the rise in coverage rates, will be challenging. Cost plays a great part in the decision-making process, and some may question whether the 75% coverage target is still relevant or achievable.
A robust influenza vaccine strategy is essential to health-system resilience. We need to understand better the advantages of flu vaccination in limiting the use of hospital resources and care — through direct and community protection against hospitalisation each season — and highlight the positive impact of flu vaccines in protecting hospitals during winter.
It is very hard to fully estimate and communicate the cost within the full economic model of influenza vaccine strategies, leaving the programme open to being cut unless we improve surveillance and correctly present the preventative nature of current programmes in terms of health-system resources saved through vaccination.
We should be advocating a move towards fully funded flu vaccination programmes. To offer maximum protection and uptake each season, we must remove the payer/cost barrier and include flu vaccination as part of universal vaccination programmes in Europe.
Financial support for all ages is challenging when health resources and budgets are stretched post-COVID. Funding for the 18–50 age range will be hard to achieve in the short to medium term, and even if funded, other barriers to adult influenza vaccination need to be addressed — a specific challenge at country, or even more local, level.
We must learn lessons from COVID and use the established systems and processes for influenza. COVID infections, for instance, are registered in a central database and automatically categorised into risk groups, detailing whether a person has underlying diseases and whether they are vaccinated.
Some of the COVID response infrastructure was only temporary during the pandemic, as were the budget allocation and investment. While some overlap can be achieved to increase influenza vaccine uptake, much of the infrastructure and budget may be COVID-specific.
We must reach out to decision-makers to ensure that adequate funding for future flu seasons is included in national health budgets.
We need to be clear with policymakers that comprehensive investment in winter vaccines is not just for COVID. COVID does not remove the need for comprehensive, increased investment in national immunisation plans for respiratory infections, including influenza, pneumococcal pneumonia, RSV and pertussis.
Utilise the infrastructure that countries developed to keep records for COVID vaccination, and start keeping records for influenza vaccination, setting the national registry base for adult vaccination.
An HCP-led vaccine policy group looking at universal funding for influenza vaccines for at least the next two years.
Topic 02
We need to present influenza vaccines in the context of winter vaccines and healthy ageing. It is essential to communicate the benefits of the flu vaccine as part of winter protection, while also looking beyond flu towards protection against the cardiovascular complications of pneumonia.
Convincing people to vaccinate against influenza can be challenging when efficacy is arguably lower than that of the COVID vaccines. This will prove difficult when presenting influenza vaccines as part of the winter vaccines message.
We must understand the importance of messaging in sustaining and increasing influenza vaccine rates. Both the type and the nature of the messaging matter for the narrative we use; we must move away from saying "it's flu season" and instead connect it to the context of COVID and to protecting family members and the broader society.
We must move away from the "protect the system" messaging that worked so well during the pandemic, and instead present flu vaccines as an obvious healthy-lifestyle choice.
Making the most of the influenza vaccines we have is important at this stage. We need to vaccinate with the vaccine we have; current vaccines provide a certain degree of efficacy, safety and availability. There is no reason to switch to a modern influenza vaccine simply because it is an mRNA vaccine.
New-technology flu vaccines hold promise, but they are not certain to succeed and may be some way off. We must build on where we are as a starting point. The 75% target is optimistic in Europe but must remain the goal; current flu vaccine efficacy and effectiveness in protecting the elderly against hospitalisation and mortality are not yet robust enough.
There is a need to improve flu vaccine effectiveness in the long term. We are now used to COVID vaccines with 90% effectiveness, whereas flu vaccine efficacy is between 40–60% or even lower. New vaccine technology offers a chance to improve targeting, bringing vaccines closer to the actual circulating variants.
mRNA vaccine technology offers an opportunity, but even with mRNA the problem remains that haemagglutinin, the immunodominant protein, still changes — so it would still have to be an annual vaccine. That said, we could delay the decision on the vaccine strain by three or four months, because of the production timeline.
Create and disseminate a "health package" for adults and the elderly on health maintenance. Emphasis must also be given to the suitability of the vaccine for patients with chronic conditions.
Investment in clear, accurate and consistent public health messages, building the social and economic case for greater investment in sustained influenza campaigns. This is as much about health and social-care capacity as anything else.
Working to improve vaccine efficiency and the possibility of developing new influenza vaccines that can be adapted to be more effective each flu season.
Extensive training of HCPs and nurses is needed to understand the mechanisms and the pros and cons of the various vaccine technologies, providing HCPs with the latest vaccine information to build trust and advocate the use of seasonal influenza vaccines.
Topic 03
We must reinforce and keep communicating the importance of influenza vaccines for pregnant women — "one shot, two lives." Vaccinating pregnant women leads to more than a 30% reduction in infant hospitalisation, and children younger than six months of age are in fact at the highest risk of hospitalisation.
Most HCPs advocate flu vaccination for pregnant women, but uptake is very variable — in many cases only 30–40% are vaccinated — highlighting a need to communicate better both the importance and the potential risk of not being vaccinated against influenza during pregnancy.
The importance of vaccinating children. We need to target the highest-risk children, who could face complications if they catch flu and who fall into a risk group. But children are very effective flu spreaders, and we need to keep prevalence low to protect the elderly and the vulnerable adult at-risk group. Vaccinating children also keeps parents in the workplace and brings wider community-transmission benefits.
Governments have been reluctant to mobilise the argument that children should be vaccinated against COVID to protect the elderly — but that is a big part of why we vaccinate children against influenza. We also need to communicate the actual flu burden in children more effectively: studies have shown that somewhere between 0.5% and 10% of all children will seek medical advice per season.
Focusing on vaccinating those with underlying health conditions. There is an opportunity to build on the number of people with chronic conditions who were quick to have the COVID-19 vaccine.
Flu is often seen, even by those in at-risk groups, as a minor risk to health — even though it can have significant implications for the individual, as well as for the demand on hospital resources each winter.
Flu vaccination of HCPs. One issue is healthcare workers who have no intention of taking the flu vaccine; most hospitals manage somewhere between 60% and 80% of their staff. More substantial incentives, or mandatory vaccination, are needed to increase coverage among HCPs.
COVID has demonstrated that mandatory vaccination for HCPs is a very divisive issue. Given the historically lower efficacy rates of flu vaccines, it would be a very difficult policy to implement. An alternative is to increase HCP education on the impact of unvaccinated HCPs.
Flu vaccine education for HCPs and target groups — pregnant women in this case — is vital. We need to keep investing in vaccine education and continue it throughout HCPs' careers and people's lives. Targeted communication and social media strategies are required to engage women in influenza vaccine uptake.
Communicate the importance of children as asymptomatic spreaders of influenza and the risks to the whole family, especially the elderly.
Understand the different factors that may influence uptake, and look at potential clinical indicators within the risk groups. Some people decide for themselves, even though the GP system says they are eligible. Reach marginalised communities and groups with the help of their community healthcare professionals.
An awareness campaign is needed to highlight the risk of catching flu among at-risk groups, drawing attention to the often-overlooked personal risks of catching flu if you are in a risk group.
