NVAC Influenza Vaccine Recommendations and Strategies Subgroup

1. NVAC Influenza Vaccine Recommendations and Strategies Subgroup Members: Jerome Klein (Chair), Jeff Davis, Jon Abramson, Carolyn Bridges, Nancy Cox, Ben Schwartz, Jane Seward, David Shay, Lone Simonsen,

2. Subgroup Objectives • Examine data on influenza disease burden and vaccination program impacts • Determine whether current surveillance provides adequate data to monitor burden & impact • Suggest strategies to improve surveillance • Consider potential alternate influenza vaccination strategies and identify critical issues that NVAC can address as they are being evaluated

3. Estimating Influenza Disease Burden • Challenges • Annual variation in disease • No pathognomonic syndrome and infrequent etiological diagnosis • May present without respiratory symptoms and may contribute to exacerbations of non-respiratory illnesses (e.g., CHF) • Modeled disease burden estimates • ~36,000 respiratory and circulatory deaths per year

4. Trends in Pneumonia & Influenza (P&I) Mortality and Influenza Vaccine Coverage Unadjusted data, age 65+ % vaccine coverage Excess P&I Mortality per 100,000 pop Influenza season during 1968-1999, US Simonsen, unpublished data

5. Excess All-Cause Mortality, 1969-1999, “Young Elderly”

6. Excess P&I and All-Cause Mortality, 1969-1999, “Older Elderly”

7. Caveats and Conclusions • Caveats • Ecological data are inconsistent with case-control and cohort studies showing significant impacts of influenza vaccine on hospitalization and death • Conclusions • A substantial number of influenza associated deaths occur despite the vaccination program • Influenza vaccine effectiveness is lower in the elderly compared with younger persons • Vaccination coverage in the elderly has not increased in recent years

8. U.S. Influenza Surveillance: Objectives and Systems

9. U.S. Influenza Surveillance: Gaps • No data on rates of influenza disease or death • No routine monitoring of vaccine effectiveness

10. Recent and Proposed Enhancements to Influenza Surveillance • New Vaccine Surveillance Network • Population-based surveillance for influenza hospitalization in children <5 y.o. in 3 metro areas • Prospective, sensitive diagnostic testing on all children admitted with febrile or respiratory illness • Emerging Infection Program Sites • Identify positive influenza diagnostic tests in children from 10-population based surveillance sites • National reporting for influenza deaths in children (proposed to CSTE) • CDC RFA for annual influenza VE studies

11. Subgroup Recommendations: Disease Burden, Program Monitoring & Impact • Expand active, prospective surveillance with etiological diagnosis in sentinel populations of children and adults • Collaborate with health care organizations to obtain rapid turn-around data on ILI and documented influenza for VE studies • Meet to evaluate different methods of estimating program impacts; propose studies, as needed, to resolve differences • Provide support for expanded surveillance activities

12. New Influenza Vaccination Strategies • Subgroup supports ACIP evaluation of expanded (universal?) influenza vaccination • Potential NVAC roles • Assessment of vaccine supply issues • Assessment of vaccine delivery strategies (e.g., in schools) and delivery technologies (e.g., intranasal, patch) • Assessment of vaccine financing options • Assessment of universal vaccination programs in other areas (e.g., Ontario, Canada)