Kick-off meeting of new Working Group on:

Clinic of Social and Family Medicine Department of Social Medicine, School of Medicine, University of Crete, Greece

EFPC 2016 Conference, September 4-6, Riga, Latvia

Current state and general background info Interpreting current state, mapping needs to address challenges

Health providers

The patient

Context

Tools and behavioral change

‘New challenge’ of migration, refugees, etc.

Focus of Working Group and Action Plan

Diphtheria epidemic recorded in Eastern Europe with 160.000 cases

referred and 4000 deaths reported1

Morbidity from diphtheria and pertussis seems to be stable in adult life2

Booster doses for tetanus provides protection against tetanus, diphtheria and

pertussis1

WHO recommends a booster vaccination for tetanus-diphtheria (Td) every 10

years, with a vaccinated target ≥90%2

1. National Foundation for Infectious Diseases, Bethesda, MD. Immunization: Supporting a Healthier Life Throughout the Lifespan - National Adult Immunization Awareness Week 2008

Campaign Kit. http://www.nfid.org/pdf/publications/naiaw08.pdf Accessed November 12, 2009.

2. Michel JP, Chidiac C, Loebenstein BG, et al. Advocating Vaccination of Adults Aged 60 Years and Older in Western Europe: Statement by the Joint Vaccine Working Group of the European

Union Geriatric Medicine Society and the International Association of Gerontology and Geriatrics–European Region. REJUVENATION RESEARCH. 2009;12(2):127-136.

Usually it affects adults over 50 years old1

The implication of tetanus is under 0.2/ 100,000

in EU of 15 members2

Mortality 10% - 20%4

In the USA, more deaths in people >60 years old from Diabetes

People with tetanus may need special care in the hospital3

Vaccination coverage in people >65 years old in France is 60.5% which is under the target of WHO at 90%1

Vaccination coverage reduces as we grow older5

In Greece the protection percentage in men >60 and women>30 is low6

1. Michel JP, Chidiac C, Loebenstein BG, et al. Advocating Vaccination of Adults Aged 60 Years and Older in Western Europe: Statement by the Joint Vaccine Working Group of the European Union Geriatric Medicine Society and the International

Association of Gerontology and Geriatrics–European Region. REJUVENATION RESEARCH. 2009;12(2):127-136.

2. European Centre for Disease Prevention and Control. Annual Epidemiological Report on Communicable Diseases in Europe Report on the Status of Communicable Diseases in the EU and EEA/EFTA Countries Executive Summary

http://www.ecdc.europa.eu/en/publications/publications/0706_sur_annual_epidemiological_report_2007_executive_summary.pdf Accessed on November 12, 2009.

3. National Foundation for Infectious Diseases, Bethesda, MD. Immunization: Supporting a Healthier Life Throughout the Lifespan - National Adult Immunization Awareness Week 2008 Campaign Kit. http://www.nfid.org/pdf/publications/naiaw08.pdf

Accessed November 12, 2009.

4. Plotkin S, Orenstein W, Offit P. Vaccines. 5th Edition. Saunders Elsevier.

5. Tetanus. VPD Surveillance Manual, 4th Edition, 2008: Chapter 16:1-7.

6. Simeonidis et al, Eur J Epidemiol 2003

Pertussis (Whooping cough) is very infectious3

The transmission is very high2

Parents and grandparents constitute the source of infection to their children2

According to data from Australia the pertussis imports are increased in babies until 6 months and people over 85 years old2

A million cases are recorded annually in the USA between teenagers and adults3

Pertussis may cause death in adults2

1. National Foundation for Infectious Diseases, Bethesda, MD. Immunization: Supporting a Healthier Life Throughout the Lifespan - National Adult Immunization Awareness Week 2008 Campaign Kit. http://www.nfid.org/pdf/publications/naiaw08.pdf

Accessed November 12, 2009.

2. Michel JP, Chidiac C, Loebenstein BG, et al. Advocating Vaccination of Adults Aged 60 Years and Older in Western Europe: Statement by the Joint Vaccine Working Group of the European Union Geriatric Medicine Society and the International

Association of Gerontology and Geriatrics–European Region. REJUVENATION RESEARCH. 2009;12(2):127-136.

3. Zimmerman RK, Middleton DB, Burns IT, et al. Routine vaccines across the life span, 2007. The Journal of Family Practice. 2007;56(2):S18-36.

1. Miller E., Marshall R., Vudien J. Epidemiology, outcome and control of varicellazoster infection. Rev Med Microbiol 1993;4:222-30. 2. Oxman MN, Levin NJ, Johnson GR, et al. A Vaccine to Prevent Herpes Zoster and Postherpetic Neuralgia in Older Adults. N Engl J Med .2005;352:2271-84. 3. Scott FT, Leedham-Green ME, Barrett-Muir WY et al. A study of shingles and the development of postherpetic neuralgia in East London. J Med Virol 2003;70 Suppl 1:S24-S30. 4. Oxman MN. Clinical manifestations of herpes zoster. In: Arvin AM, Gershon AA, eds. Varicella zoster virus: virology and clinical management. Cambridge, England: Cambridge University Press, 2000:246-75. 5. DeMelker H, Berbers G, Hahne S, et al. The epidemiology of varicella and herpes zoster in the Netherlands: Implications of varicella zoster virus vaccination. JVAC 6029. 2006: 1-7.

Vaccine efficacy (%) - 95%CI

Placebo

n=19,276

Zostavax®

n=19,270

p<0.001

CI: 44.2-57.6%

n=642

No

. o

f cases

n=315

-51.3%

Placebo

n=19,276

Zostavax®

n=19,270

n=80

n=27

-66.5%

No of cases:

38,546

No of doses:

One subcutaneous injection of

0.5ml of zoster vaccine

Duration of study:

Nov 1998 – Apr 2004

Duration of follow-up:

Median 3.12 years

Efficacy of Zostavax® in reducing the incidence of herpes zoster

Zostavax® significantly reduced the number of PHN cases

No

. o

f cases

p<0.001

CI: 47.5-79.2%

Placebo

n=19,276

Zostavax®

n=19,270

p<0.001

CI: 51.1-69.1%

5.68

BO

I S

co

re

2.21

-61.1%

Efficacy of Zostavax® in reducing the burden of illness of herpes zoster

Shingles prevention study

Zostavax® decreased the incidence of HZ & PHN and reduced burden of illness (BOI)

Vaccination reduces the burden of illness

of HZ and the number of PHN

cases

1. Aspinall R, Giudice GD, Effros RB, et al. Challenges for vaccination in the elderly. Immunity & Ageing. 2007;4:9.

2. Kumar R, Burns EA. Age-related decline in immunity: implications for vaccine responsiveness. Expert Rev Vaccines 2008;7:467-479.

3. Cytokines in cancer pathogenesis and cancer therapy. Nature reviews cancer. 2004. http://www.nature.com/nrc/journal/v4/n1/fig_tab/nrc1252_F1.html

Immune response to infection

Innate immunity Non pathogen-specific

Adaptive immunity Pathogen-specific

Aging affects as much

as pathetic and

energetic immunization 1

With aging, the immune

system operates

weakly1

The number and/ or the

functions of the

immune cells are

affected 2

T cell

B cell

CD4+

T cell

CD8+

T cell

Macrophage

Natural Killer

Cell

Neutrophil

T cell

Natural Killer

Cell

Antibodies

Cellular components of the immune responses3

Example: Vaccination hesitancy A lot of work to be done still on improving uptake and overall coverage!

Various initiatives – right now:

Vaccine uptake in under 19s NICE quality standard Draft for consultation September 2016 An estimated 3 million children and young people aged 18 months to 18 years may have missed either their first or second MMR vaccination. The potential exposure of so many children and young people to the measles virus means that there is a risk of a large outbreak. Measles can lead to serious complications and can be fatal.

Education in students and health care workers in vaccination issues

Participation of healthcare workers in sorting vaccination

during the visit in the practice Vaccination in special population groups (teenagers, pregnant

women, soldiers, workers and physicians) and Vaccination of vulnerable groups: uninsured and immigrants, refugees – relevant projects (e.g., EUR-HUMAN lessons) as contrasted and compared to:

Vaccination and participation of local government and NGOs

Canadian study of large sample (patients and providers, surveys and focus groups) focusing on four vaccine-preventable diseases and vaccines (diphtheria-tetanus-pertussis, zoster, pneumococcus and influenza). Positive attitudes towards vaccines paralleled concern about the burden of illness

and confidence in the vaccines, with providers being more aware of disease burden and confident in vaccine effectiveness than the public.

Barriers and facilitators to improved vaccine coverage in adults, such as trust-mistrust of health authorities, pharmaceutical companies and national recommendations, autonomy versus the public good and logistical issues (such as insufficient time and lack of vaccination status tracking), were identified by both the public and providers.

MacDougall et al. (2015) The challenge of vaccinating adult: attitudes and beliefs of the Canadian public and healthcare providers. BMJOpen, 5:e009062.doi:10.1136/bmjopen-2015-009062

HCWs constitute a priority group for immunization (e.g., H1N1)

Nevertheless, low vaccination rates have been documented (e.g., influenza pandemic) and are associated with the onset of nosocomial cases and outbreaks

HCWs, health-care institutions, and public health bodies have the moral obligation to protect vulnerable patients and therefore weigh the benefits of mandatory vaccination. A particular challenge at a time of austerity.

Maltezou and Tsakiris. (2011) Vaccination of health-care workers against influenza: our obligation to protect patients. Influenza Other Respir Viruses. 2011 Nov;5(6):382-8. doi: 10.1111/j.1750-2659.2011.00240.x. Epub 2011 Mar 21. Maltezou and Lionis (2015) The financial crisis and the expected effects on vaccinations in Europe: a literature review. Infect Dis (Lond). 2015 Jul;47(7):437-46. doi: 10.3109/23744235.2015.1018315. Epub 2015 Mar 5.

12

13

• Mandatory vaccination for certain diseases in certain groups (influenza, measles, mumps, rubella, hepatitis B, pertussis, varicella).

• Mandatory vaccination has been adopted by very few countries and for very limited indications.

• There are significant immunity gaps among HCWs against VPDs in Europe Measles example • Eliminating measles by 2010 has not been accomplished • Stronger recommendations and higher vaccination coverage against measles in

healthcare workers could contribute to eliminate measles in the general population. Recent work indicates that self-reported rates vary greatly (5.8% - 47.3 5%)

• Mandatory vaccinations were supported by 65.1% of 1,807 respondents, with wide

differences by disease.

• Multiple logistic regression analysis revealed higher rates of acceptance of mandatory vaccination in physicians compared with other HCW categories.

Healthcare providers

Primary care providers

Other specialties providing care outside standard PHC settings

The patient – the citizen – the community

Contextual factors, organizational settings,

policy decisions and action plans

Clients/ patients

The clinical setting

• Medical contract

• Motives or other factors

facilitating behavior change

The environment

• Health authorities

• Other stakeholders

• Lay opinion

• Economic conditions

Pharmacists

Physicians

Nurses

Theory of planned behaviour Health beliefs model Motivational interviewing

Copyright © 2006 Icek Ajken

Intention Behaviour

Actual behavioral

control

Behavioral Beliefs

Attitude toward the behaviour

Normative Beliefs

Subjective Norm

Control Beliefs

Perceived behavioral

control

Objective: reduce irrational prescribing of OTC medicines in general practice Intervention: 1-day training programme; poster presentation; visits of trained

professionals to the workplace; reminders and emails (4-week follow-up) Result: Reduced median intention scores in the intervention groups. High

overall acceptance and perceived practicality of the programme by GPs.

A patient visiting you health centre is asking you

to prescribe him medicines he has already

purchased from the pharmacy, without a

prescription. What do you do?

Prescribe it

Do not prescribe it

Prescribe it (and give advice on the risks

associated with the medicine

Prescribe it (for the last time; and give advice

on the risks associated with the medicine)

Lionis C, et al. BMC Fam Pract. 2014 Feb 17;15:34.

100

80

60

40

20

0

Pe

rce

nt

Intervention group

Before intervention After intervention

Desired behaviour change

Document experiences and establish a baseline for an overview of issues in practice

Additional issues given challenges from population with undocumented health records and/or false reporting (e.g., refugees, “irregular immigrants” and migrant workers going through multiple countries, etc.)

Need to implement shared decision-making

Need to interact with bodies, associations, fellow colleagues in other countries, other professions, etc. on the basis of established rationale – aiming for a unified approach

Establish the baseline and present and discuss related activities of

Immunize Europe, WHO, Vaccines Europe, etc. Currently, there are multiple forums of exchange with relatively

poor dissemination, visibility or interaction with primary care professionals

Room for improvement between public health and primary care interaction to better inform policy makers

Establish timeline of activities and team and start building ties with similar groups across professional board

Ensure all professions in primary care team work are represented and on board (opportunistic immunisation/vaccination)

Aim for initial mapping of efforts – public health perspective and primary care perspective for Porto 2017

Aim for outline of unified approach and/or Position Paper Crete 2018

Child (e.g., in hotspot or short-term centre) has significant vaccine

side effect (e.g., anaphylaxis or rare yet well documented idiosyncratic side effect); parents are reluctant to vaccinate other children, themselves, elderly family members

Narratives and practical advice on interaction and impact

assessment of such events in (for example) tight knit communities

Pandemic flu mitigation, example of “unlikely” tools and means:

Serious video games (SVGs) - an innovative tool that may serve public health, control spreading of infectious diseases and increase vaccination uptake

SVG are particularly appropriate for infections transmitted diseases as behaviors are key determinants for control and preventive measures

SVG may be a promising tool for promoting vaccination and an opportunity to describe and associate other preventive measures according to a disease

Ohannessian et al. (2016) A systematic review of serious video games used for vaccination. Vaccine, Vol 34, Issue 38, p.4478-4483

1. Simply reassure the patient about vaccination vaccination

2. Utilise motivational interviewing or other behaviour change approach

3. Ask advice/support to other healthcare practitioners

4. Both answers 2 and 3

Baseline – Questionnaire and probing

Share findings

Reach out and hold session to map activities

Overview of online courses, educational and training material

Awareness material, infographic and other resources

Overview of events and workshops related to vaccines and immunisation, as well as community activities

Best practice tracker and map of parallel activities from other bodies, organisations, etc.

A meeting place where experiences and ideas can be exchanged

Identify commonalities and essential

differences in priorities and contexts Develop a common approach and

provide key messages and information to…

…inform decision-makers and policy

decisions across Europe and globally

Contact details – Survey will stay open, emails to be sent to all participants to generate final mailing list elena.petelos@med.uoc.gr lionis@galinos.med.uoc.gr