Flu vaccination guidance updated for older patients

Public Health England (PHE) has updated its national immunisation guidance following evidence that adjuvanted trivalent influenza vaccines (aTIVs) work better for older patients than other flu jabs (PHE, 2017a).

The Green Book (PHE, 2017a), which features the latest information on vaccines and vaccination procedures in the UK, has been amended after the Joint Committee on Vaccination and Immunisation (JCVI) recommended aTIV, FLUAD®, for the 2018–19 flu season in its October meeting.

The Committee agreed that use of aTIVs in those aged 65 years and over is ‘more effective’ than current nonadjuvanted vaccines and ‘highly costeffective’ (JCVI, 2017).

Dr George Kassianos, national immunisation clinical lead for the Royal College of General Practitioners, said:

‘I very much welcome this guidance by the JCVI. Year on year, it is becoming more and more evident that conventional non-adjuvanted influenza vaccines do not provide sufficient protection for our older patients, particularly in years dominated by the influenza A(H3N2) virus, which dominated the flu season last year and the year before. Use of this adjuvanted vaccine is expected to result in fewer infections, fewer GP consultations and hospital admissions, and a significantly reduced winter burden on the NHS.

‘On the basis of the recent JCVI Meeting minutes outlining the clinical and cost-effectiveness evidence in elderly patients, GP practices are now able to seriously consider the adjuvanted flu vaccine for their patients aged 65 years and over for the 2018–19 flu season.’

Sharon Graham, senior lecturer in nursing at Staffordshire University and a former practice nurse, said:

‘In primary care we need to ensure that we can offer the most effective prevention against influenza to our patients aged over 65 years. This JCVI guidance will, I hope, help vaccinating health professionals to make the best choice of flu vaccine for next year’s season.’

Reasons behind the decision

Last year, PHE (2017b) declared conventional non-adjuvanted influenza vaccines provided little or no protection for over 65s in the 2016–17 flu season in the UK. This was recognised by the JCVI, who acknowledged ‘low influenza effectiveness’ in those aged 65–74 years throughout seasons affected by the A(H3N2) flu strain, and ‘non-significant vaccine effectiveness’ for all types of influenza in the over 75s (JCVI, 2017).

By comparison, the JCVI said aTIVs have ‘better immunogenicity and effectiveness’ in the elderly. While vaccine effectiveness decreases with increasing age and immunosenescence, a study from British Columbia used multivariate analysis to show vaccine effectiveness of around 60% in the elderly for aTIVs (Van Buynder et al, 2013). Almost half of the patients enrolled were aged over 85 years. Conversely, non-adjuvanted trivalent influenza vaccine was deemed ineffective. This is not uncommon, ineffectiveness of non-adjuvanted trivalent influenza vaccines in this patient population has been previously reported (Treanor et al, 2012).

A systematic review and meta-analysis of trivalent inactivated vaccine adjuvanted with MF59 found it was effective in reducing several influenza-related outcomes among the elderly, especially hospitalisations due to influenza-related complications (Domnich et al, 2017). It was also reported to be superior to non-adjuvanted vaccines.

Evidence presented at the European Scientific Working group on Influenza (ESWI) meeting in Riga, Latvia last September, revealed 1700 flu-related deaths could be prevented in those aged over 65 years who switched to an aTIV (Nguyen et al, 2017). Additionally, estimations by the researchers show as many as 195 600 cases of flu could be avoided. According to the researchers, this could reduce the number of GP visits by 21,800.

Research consultant and lead author of the study, Dr Van Hung Nguyen, said:

‘The model demonstrated that the adjuvanted vaccine had an incremental cost-effectiveness ratio of £3540 per quality-adjusted life year if used preferentially in those aged 65 years of age and over in the UK.

‘This is well within, and actually considerably below, the National Institute of Health and Clinical [sic] Excellence’s guideline threshold of £20 000 per quality-adjusted life year for medicines.’

Dr Marco Barbieri, from the Centre for Health Economics at the University of York, said:

‘Health economic analyses consistently show that more effective flu vaccines are very good value in older patients.

‘They reduce the number of GP consultations, A&E visits and episodes of serious illness and, of course, they help older people to remain healthy and independent.’ Commenting on the research presented at the ESWI, he said: ‘These data suggest that use of an adjuvanted influenza vaccine is a cost-effective option for the NHS immunisation programme.’

Mathematical modelling by PHE indicates the adjuvanted vaccine would be highly cost-effective in both the 65–74 and 75 year and over age groups, even under conservative estimates (PHE, 2017a).

Marketing authorisation of FLUAD®

The aTIV FLUAD® gained marketing authorisation in the UK in August 2017. It has been licensed in some countries in Europe since 1997 and in the US since 2015. According to its manufacturer, Seqirus, aTIV has superior seroconversion rates (the time period during which a specific antibody develops and becomes detectable in the blood) in the elderly, and superior geometric mean titres (the central number in a geometric progression of the concentration of a solution as determined by titration) in clinical risk groups against all three influenza vaccine types, compared to non-adjuvanted inactivated influenza vaccines.

Dr Russell Basser MD, chief medical officer of Seqirus, said:

‘We understand the devastating human impact of influenza infection in adults aged 65 years and older, the substantial societal impact of influenza, as well as the cost to the NHS in preventable GP appointments and preventable hospitalisations.

‘We believe that our strong and robust data on FLUAD®’s clinical efficacy, real-world effectiveness, and well-established safety profile, built up over 20 years of use, demonstrates convincingly that this adjuvanted influenza vaccine has clear advantages for adults aged 65 years and over when compared to existing conventional non-adjuvanted vaccines. We consider that FLUAD® can make a major contribution in reducing the burden of influenza on the health services, locally, regionally, and nationally.’

The company has recently announced a major investment in its Liverpool influenza vaccine manufacturing plant. This will allow-end-to-end manufacture of vaccines at the UK site, meeting growing demand and strengthening reliability of supply of FLUAD® for UK and global markets.

References

Domnich A, Arata L, Amicizia D, et al. 2017. Effectiveness of MF59-adjuvanted seasonal influenza vaccine in the elderly: A systematic review and meta-analysis. Vaccine. 35(4):513- 520

Joint Committee on Vaccination and Immunisation. 2017. Draft minute of the meeting on 4th October 2017. London: JCVI

Nguyen VH, Kelly C, Mansi JA. 2017. UK health economic model demonstrates use of adjuvanted trivalent seasonal influenza vaccine in older adults to be highly cost-effective [abstract]. Presented at the Sixth ESWI Influenza Conference, Riga, Latvia, 2017 September 10–13. http://eswi.org/ influenzaconferences/wp-content/uploads/ sites/13/2017/09/Nguyen_Kelly_Mansi.pdf (accessed 2 February 2018)

Public Health England. 2017a. Influenza: The Green Book. London: The Stationery Office

Public Health England. 2017b. Influenza vaccine effectiveness (VE) in adults and children in primary care in the United Kingdom (UK): provisional end-of- season results 2016-17. London: The Stationery Office

Treanor JJ, Talbot HK, Ohmit SE, et al. 2012. Effectiveness of seasonal influenza vaccines in the United States during a season with circulation of all three vaccine strains. Clin Infect Dis. 55(7):951-9

Van Buynder PG, Konrad S, Van Buynder JL, et al. 2013. The comparative effectiveness of adjuvanted and unadjuvanted trivalent inactivated influenza vaccine (TIV) in the elderly. Vaccine. 31(51):6122-8

Taken from Nurse Prescribing, published January 2018.