Intended for healthcare professionals


Is this the end of the line for flu vaccine as we know it?

BMJ 2001; 322 doi: (Published 17 March 2001) Cite this as: BMJ 2001;322:677

Influenza Vaccination is Worth the Effort

Dear Editor,

Higson and He’s analysis of influenza vaccination is one-sided and
inaccurate.1 Vaccination decreases hospitalisation for pneumonia (32-45%),
hospital deaths from respiratory conditions (43-50%) and all cause
mortality (27-30%).2 Vaccination of 30-75% of over 65 year olds may still
have favourable cost-benefits.3 These and other studies appear to support
the cost-effectiveness of influenza vaccination. In the future, intra-
nasal live attenuated or other vaccines may be more efficacious.

The goal of vaccination is to reduce the impact of predictable
seasonal rises in influenza. The WHO accurately predicts the antigenic
needs of this vaccine. A sudden antigenic shift and accompanying influenza
pandemic will require a multi-strategy approach, including the use of
antivirals. If effective vaccine can be produced, it will have a
significant role to play.

Uptake of vaccination in the high-risk patients of Angus was 45% in
1998/1999. Subsequently, increased multi-disciplinary efforts, influenza
publicity and item of service payments have improved uptake to >60% in
2000/2001. It is impossible to quantify what role “bribery” of GPs has
played, but the evidence suggests that single-strategy interventions are
likely to have a small impact on vaccination uptake, particularly when it
is already relatively high.4 It is hardly surprising, therefore, that item
of service payments have increased vaccination in East Sussex by, at most,
5%. The key to increasing and maintaining a high vaccination rate is the
use of a multi-strategy approach. Clearly this will be more cost-
effective in epidemic years, but an absence of influenza in the southern
hemisphere should not lead to reduced efforts; this would result in poor
uptake when vaccination is needed. Additionally, an opportunity to promote
other interventions, such as pneumococcal vaccination, would be lost.

A move from vaccination to neuroaminidase inhibitors for prevention
and treatment would require significant investment and “effort and
enthusiasm”. In contrast, the infrastructure for vaccination already
exists. Additionally, the only currently licensed agent (zanamavir)
appears to have an inadequate delivery system.5 In contrast to
vaccination, there is little data about the impact of these new agents on
hospitalisation and mortality. The widespread use of zanamivir in the
elderly is likely to result in significant financial wastage. Other anti-
influenza agents, such as amantidine, have notable adverse effects and are
effective only against influenza A. A strategy that needs further study
and is likely to be more cost-beneficial is the use of safe, effective and
adequately delivered anti-influenza agents in the unprotected, on a
background of improving uptake of vaccination in the majority.

Gavin Barlow
Specialist Registrar

Infection & Immunodeficiency Unit, Kings Cross Hospital, Tayside

University Hospitals NHS Trust. DD3 8EA

Janet Barlow
GP Non-Principal

Angus, Scotland

(No competing interests)

1. Higson N, He M. Is this the end of the line for flu vaccine as we
know it? BMJ 2001;322:677

2. Gross PA, Hermogenes AW, Sacks HS, Lau J, Levandowski RA. The efficacy
of influenza vaccine in elderly persons. A meta-analysis and review of the
literature. Ann Intern Med 1995;123:518-27

3. Reinders A, Postma MJ, Govaert TM, Sprenger MJ. Cost-effectiveness of
influenza vaccine in The Netherlands. Nederlands Tijdschrift voor
Geneeskunde 1997;141:93-97

4. Sarnoff R, Rundall T. Meta-analysis of effectiveness of interventions
to increase influenza immunisation rates among high-risk population
groups. Medical Care Research and Review 1999;55:432-56

5. Diggory P, Fernandez C, Humphreys A, Jones V, Murphy M. Comparison of
elderly people’s technique in using two dry powder inhalers to deliver
zanamavir: randomised controlled trial. BMJ 2001;322:577-9

Competing interests: No competing interests

28 March 2001
Gavin Barlow
Specialist Registrar in Infectious Diseases/Medicine
Infection & Immunodeficiency Unit, Kings Cross Hospital, Tayside University Hospitals NHS Trust.