timing of influenza vaccination in india
DESCRIPTION
Latest data regarding what is the best time to give Flu vaccine in IndiaTRANSCRIPT
Influenza vaccination in IndiaWhen, whom & how to vaccinate?
Dr Gaurav Gupta,Pediatrician,
Member AAP, IAP,Charak Clinics, Mohali
March 2013
Conflict of Interest
• Received grants from various vaccine manufacturers including – - Sanofi Pasteur– - GSK– - Abbott(Manufacturers of different Influenza vaccines)
Overview
• Influenza – what is it ?• Is it really that big a problem – World/ India/
Children ?• Influenza vaccine – rationale for use• What data exists regarding Influenza vaccine
safety & effectiveness, especially from India ?• When, whom & how to vaccinate ?
CASE
Alisha 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)
Let us learn from our past!!!
Impact of influenza on children
Annual attack rate in preschool age exceeds 40% and in school age more than 30% during outbreaks
Influenza contributes to:Up to 3 days of fever, 5 days school absenteeismUp to 35% increase in OPD visits and excess hospitalizationUp to 20-30% increase in AntibioticsComplications Absenteeism in parents, more with those nursing younger children
1. Neuzil KM et al. The effect of influenza on hospitalizations,outpatient visit and courses of antibiotics in children,NEJM 2000,342:225-312. Turner D et al, National Institute of Clinical Excellence.Systematic review and economic decision modelling for the prevention and treatment of influenza A & B 29th Apr 2002.
< 6 months
6-12 months
1-3 years 3-5 years 5-15 years0
20
40
60
80
100
120
104
50
19
94
Age
ex
ce
ss
in h
os
pit
aliz
ati
on
(p
er
10
00
0 p
er
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ar)
Indian Scenario:Reality
• Limited data in public domain on annual Influenza cases and deaths in Indian scenario*
• Influenza vaccine is in Indian market since 2004
• There is no published data on safety, tolerability and effectiveness of Influenza vaccine in Indian children**
9
*India to compile database for influenza. Available from: URL: http://www.livemint.com/2009/05/31215156/India-to-compile-database-on-s.html. Accessed on 22 May, 2010.**Joseph L Mathew. Influenza vaccination for children in India. Indian Pediatrics. 2009 ;46:304-307.
Indian scenarioRegion Period Influenza positive Additional
Delhi (NCDC) May 09 – Sep 10
7943 / 33751 (23.5%)
11.1% (+) for seasonal influenza
Delhi (AIIMS-Ballabhgarh)
Jan - Dec 09 315 / 1071 (29% for all)
51% of these- pandemic, 49%- seasonal strains
Jan - Dec 10 116 / 661 (17% for all)
51% of these- pandemic, 49%- seasonal strains
Kolkata Jul – Aug 10 129 / 440 (29.3%) 47 pts (11%) comorbidities, 4 patients died
Rajasthan Nov 09 – Apr 10 533 / 1782 (29.9%) -
Sangli (Maharashtra)
Oct 09 – Sep 10 142 / 466 (30.47%) Maximum deaths in monsoon
Surat (Gujarat)
Jun 09 – Mar 10 154 / 824 (18.68%) 37.66% comorbidities (MC DM and HT)ARDS, need for ventilator and comorbidities – poor prognosis
Choudhry A. Indian J Med Res. 2012 Apr;135(4):534-7.Broor S et al. PLoS One. 2012;7(1):e29129Biswas DK. Indian J Med Res. 2012 Apr;135(4):529-33.Joshi V. Indian J Med Res. 2012 Mar;135:437-8.Rajderkar SS. IJHSR Vol.2; Issue: 2; May 2012 Bhatt KN. J Assoc Physicians India. 2012 May;60:15-9.
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
Private pediatric outpatient (clinical) setting
Aims of the study - • Clinical Effectiveness of Seasonal Flu vaccine in
preventing ILI 1, 2
1. WSPID, Nov 2011, Melbourne, Poster Presentation.2. ISPOR Asia Conference, September 2010, Thailand, Poster Presentation.
Methodology
• Prospective Observational Cohort Study• Vaccinated cohort (n=170) vs. Unvaccinated
cohort (n=330)Study Design
• Healthy child, of either sex, above 6 months of
age up to 18 years of age
• No chronic illness except asthma
Inclusion criteria
• Standard Predefined Data Form used. • Parameters measured –
ILI, Absenteeism, ARI, Unscheduled Physician visits Data Collection
13
Methodology
• Private outpatient pediatric setting (Charak
Care Clinics, Mohali)Study site
• September, 2010 to May, 2011Study period
14
Continued…..
Clinical Effectiveness of Influenza vaccine-1
Sr.No
Parameters Odds Ratio CI VE % P-value
1 Influenza like illness
0.58 0.24-0.92 42 0.009
2 Visits to Physician 0.71 0.33-1.09 29 0.039
Fully vaccinated cohort (n=154) vs. Unvaccinated cohort (n=330)*
Conclusion: Influenza vaccine is effective in reducing the ILI and visits to physician for ARI in fully vaccinated Indian children as compared to unvaccinated children.
*Renuka R, Gupta G, Tiwari P. Clinical effectiveness of the 2010-2011 seasonal influenza vaccine among healthy Indian children. WSPID-2011, Melbourne.
Clinical Effectiveness of Influenza vaccine-2
Sr.No Age group (no.) Odds Ratio
CI P-value VE %
1 6 m – 3 y (78) 0.57 0.46-1.31 0.55
2 3 y – 9 y (64) 0.48 0.17-0.72 0.002 52 %
3 9 y – 18 y (28) 0.69 0.39-1.03 0.06
Age-wise efficacy for prevent of ILI*
Conclusion: Children aged 3-9 year had the best protection rates against ILI as compared to unvaccinated children.
*Renuka R, Gupta G, Tiwari P. Clinical effectiveness of the 2010-2011 seasonal influenza vaccine among healthy Indian children. WSPID-2011, Melbourne.
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
WHOM TO VACCINATE???
Vaccine Recommendations
• Ideally, all
individuals
should have the
opportunity to be
vaccinated
against
influenza.
• Priority should
be given to high
risk population
• 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 http://www.cdc.gov/mmwr/preview/mmwrhtml/rr59e0729a1.htm?s_cid=rr59e0729a1_e http://www.sehd.scot.nhs.uk/cmo/CMO(2010)14.pdf http://www.biomedcentral.com/content/pdf/1471-2334-10-168.pdf
*
Recommendation on influenza vaccine. Available at:http://www.iapindia.org/component/content/article/315. Accessed on: 16 April 2012
HOW TO VACCINATE???
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
When to vaccinate?
Influenza Activity And Peaks
Global surveillance network:
106 Member countries136 NIC6 WHO CCS4 ERLS11 H5 Ref Labs
WHO National Influenza Center(as of April 2011)
• Pune (NIV),• Kasauli (CRI)• & Mumbai (Haffkine Institute)
WHO recommendations
• For countries in equatorial regions, epidemiological considerations influences which recommendation (February or September) individual national and regional authorities consider more appropriate
• 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
2009July- August
2010July- August
India
India 2011
Influenza virus circulation peaks in June-August
J J A S
March- April August - October
IAP 2012 recommendations
• Data since 2004 suggests a clear peaking of circulation during the rainy season across the country- ‘June to August’ in north (Delhi), west (Pune) and east (Kolkata), and ‘October to December’ in south (Chennai)
• Influenza vaccines are given before the peak
season. Hence, the best time for offering vaccine for individuals residing in southern states would be just before the onset of rainy season, i.e. before October while for rest of the country, it should be before June
IAPCOI. Consensus Recommendations on Immunization and IAP Immunization Timetable 2012. Indian Pediatr. 2012 Jul 8;49(7):549-64.
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
NH vaccineRecommended composition of influenza virus vaccines for use in the 2012-2013 northern hemisphere influenza season
an A/California/7/2009 (H1N1)pdm09-like virus; an A/Victoria/361/2011 (H3N2)-like virus; a B/Wisconsin/1/2010-like virus.
WHO recommendation for SH 2013 : 21 September 2012
Strains are same as those in NH 2012-13
Exciting Future ahead ?
QUADRIVALENT LIVE INFLUENZA VACCINE
FDA NEWS RELEASEFor Immediate Release: Feb. 29, 2012FDA approves first quadrivalent vaccine to prevent seasonal influenza
The 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
The European vaccine study involved an antibody that neutralizes all the influenza-A subtypes.