Australia had an unusually early and initially severe flu season this year with more than 210,000 reported cases, which could foretell that a serious outbreak is on its way to the northern hemisphere where winter is just around the corner. The timing and impact of flu is unpredictable and varies from year to year, but to prepare for what might come this year, 25 million people in England will be offered free vaccines by the NHS – the largest safeguarding attempt the country has ever seen.
England hasn’t had an epidemic since 2010-11, when swine flu came back, but still some 5,500 people were hospitalised last year and there were nearly 1,700 deaths as a result from flu-related complications. Flu kills an average of 8,000 people in England every year and can be particularly serious in very young children, pregnant women, adults aged 65 and over and those with health problems because they tend to have weaker immune systems.
For the first time, all children will be given a nasal spray in primary schools, which will help them immunise against the four virus strains contained in the vaccine. Last year, 60.8 per cent of school children were vaccinated but Public Health England (PHE) hopes the needle-free vaccine will protect another 600,000 children this season.
“The original thought behind the vaccination programme was to protect more vulnerable people. It’s not that flu is a particularly serious illness in primary school children, it is all around this idea that they are the breeding ground,” says Jonathan Ball, professor of molecular virology at the University of Nottingham. Children are considered ‘super spreaders’ because they don’t always wash their hands or do not use tissues properly. As a result, they could put their family and other people around them at greater risk of infection.
PHE started rolling out a children’s vaccination programme in 2013 – first to children aged two, three and four and then up to 13-year-olds – and has been seeing some promising results. Initial findings showed that even two years after launching the programme, more than half (56.8 per cent) of children in primary schools, or rather their parents, took up the free offer. Handing out the vaccine to children while they are at school makes it much more convenient as parents do not need to book a GP appointment. Ball believes the vaccine can also prevent illness in children, even if the symptoms are minor. “Having a child off ill for a few days in winter is quite inconvenient because they [parents] have to arrange childcare,” he says.
In 2018, a Cochrane review summarising the results of various studies conducted in western Europe, the US, Russia, and Bangladesh between 1984 and 2013 found that vaccination of healthy children helped decrease the number of influenza cases. The authors estimated that at least five children would need to be vaccinated to prevent one case of flu and at least 12 would need to be vaccinated to avoid one case of flu-associated illness. Children aged four and older generally have a healthy immune system and are more resilient to infection than their grandparents for which influenza can be life-threatening.
The over-65s themselves are generally good at taking up the vaccine, says Ball – around 72 per cent in the last two years – but for other risk groups, such as pregnant women, people with health conditions such as asthma or those that are morbidly obese, uptake is particularly low.
Jonathan Kennedy, a global public health and vaccine hesitancy expert at Queen Mary University of London, says there are generally two reasons why vaccination coverage is not as high as public health agencies would want: supply and demand.
Flu vaccines are usually delivered from September to November and PHE has already been stockpiling but Brexit could spoil its grand plan for the season. One supplier – the French drug giant Sanofi – is running behind schedule and may not be able to deliver all the supplies before the October 31st deadline. The company said that one million doses for people with long-term conditions will not be delivered until November, but it that was prepared to fly in the doses in the event of problems at the Dover port.
Over the last few years, a number of surveys pointed out that many parents are reluctant to vaccinate their children because of concerns about the effectiveness and side effects. A survey from the Royal Society of Public Health found that one in five parents chose not to give their child the flu vaccine. “The concerns about vaccine effectiveness are not totally unjustified. The effectiveness of the flu vaccine varies from year to year,” says Kennedy. He stresses, however, that the effectiveness varies across age groups, being much more effective in younger people and not very effective in the elderly. “This underlines the fact that it is important for children and health workers to get the flu jab,” he says.
Deciding on which groups of people to target is not the only challenge when it comes to preventing flu epidemics. When it comes to flu, vaccination is no guarantee of protection because of its unpredictable nature. In February each year, the World Health Organisation (WHO) assesses the strains of flu virus that are most likely to be circulating over the following season and makes a recommendation for the composition of the northern hemisphere vaccine to give pharmaceutical companies enough time to produce and distribute it. The mixture usually protects against three or four types of flu virus, which are named after the place they were first identified, and this year, reads like an exotic cocktail from Brisbane, Kansas, Colorado and Phuket.
PHE’s annual flu report showed that last year’s jab was 44.3 per cent effective against the types of flu that were circulating in the 2018/19 season – up from 15 per cent the year before – although it was considerably higher (62 per cent) for the elderly. That was likely because the majority of over-65s were offered a new “adjuvanted” trivalent vaccine (aTIV) for the first time, which includes additional compounds such as aluminium salts and squalene that is extracted from fish oil. These adjuvants are meant to improve the immune response to the vaccine and help produce more antibodies to fight the flu virus strains. The adjuvanted vaccine was first licensed in 1997 and has been in use in over 20 countries, but couldn’t be introduced to the UK until the manufacturing company, Seqirus, obtained a local license in 2017.
To ensure a high take up of vaccines, the PHE and the NHS are actively reaching out to eligible groups through TV and radio ads and social media. Doug Brown, chief executive of The British Society for Immunology stresses however that targeted activities such as personalised letters to those eligible for the free flu vaccine will be key. “We also need to make sure we make it as easy as possible for people to get vaccinated,” he says. “The exact solutions will differ depending on the needs of individual communities, but this could mean GPs holding clinics outside core hours or encouraging people to access services within the community, such as at pharmacies.”
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