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Analysis And Comment Public health

Influenza vaccination: policy versus evidence

BMJ 2006; 333 doi: https://doi.org/10.1136/bmj.38995.531701.80 (Published 26 October 2006) Cite this as: BMJ 2006;333:912

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Influenza vaccine uptake among British Muslims attending Hajj-2005 and 2006.

Correspondence to: Dr Shuja Shafi, Consultant Microbiologist,
Department of Microbiology and HPA Collaborating Laboratory, Northwick
Park Hospital, Watford Road, Harrow, Middlesex, HA1 3UJ Email:
shuja.shafi@nwlh.nhs.uk

Word count: 660

EDITOR--In recent years the overall rate of influenza vaccine coverage
among people of 65 years of age and over in the UK has been exceeding the national
target of 70%.1 However uptake by the minority ethnic population in the
same age group in the UK and USA has been much lower.2 Muslims are the
largest religious minority in the UK and every year 1% of British Muslims
travel to Saudi Arabia on Hajj pilgrimage. High rates of influenza have
been reported amongst pilgrims at the Hajj3 4 and the Saudi Arabian
Ministry of Health recommends that all travellers should receive influenza
vaccination before travelling on Hajj. In this context our aim was to
determine the uptake of influenza vaccination among British Hajj pilgrims,
particularly those in risk groups due to age or disease. We studied
pilgrims, who attended the British Hajj Delegation Clinic in Mecca and
mobile clinics set up by the investigators in Mina in the years 2005 and
2006.
Patients' demographic details, occupation, vaccination status and the
date and place of vaccination were recorded. Subsequently vaccination
histories were verified by contacting primary care staff in the UK, and
clarified by phoning the patients where inconsistent reports were
obtained. Pilgrims with "Green Book" specified underlying medical
conditions and those aged 65 years or more were categorised as "at risk"
individuals. The others were grouped as "not at risk".
One hundred and ninety six pilgrims were recruited in 2005 and 146 in 2006
creating a data set of 342. Age ranged from 2 to 83; 313 (92%) were men;
ethnically 41% were Pakistani, 28% Bangladeshi, 14% Indian, 7% other
Asian, 3% African, 2% White British, and for the rest (5%) ethnicity was
unknown. One hundred and four (30%) participants were from London.
Ninety two pilgrims (27%) were categorised at risk of influenza, one fifth
(n=19) of them solely because of age ¡Ý65 years and the rest because of
chronic diseases with or without age.

One hundred and eight pilgrims (32%) were vaccinated. Apart from two
pilgrims, all received the vaccine from their GPs. Vaccine coverage among
"at risk" and "not at risk" pilgrims were 55% (51/92) and 23% (57/250)
respectively (P<_0.001. coverage="coverage" among="among" over-65s="over-65s" and="and" under-65s="under-65s" regardless="regardless" of="of" underlying="underlying" chronic="chronic" disease="disease" was="was" _63="_63" _19="_19" _30="_30" _52="_52" _32="_32" _62="_62" respectively.="respectively." p="p"/>Immunisation uptake by all pilgrims in 2005 and 2006 was 27% (53/196) and
38% (55/146) respectively (P=0.036) and the coverage among "at risk"
people in these years were 51% (29/57) and 63% (22/35) respectively
(P=0.26).
Uptake by all pilgrims who lived in London in these two years was 20%
(21/104) compared to 37% (87/238) in other centres (P=0.003). These rates
compare with uptake by "at risk" residents of London of 38% (10/26)
compared with 62% (41/66) elsewhere (P=0.04) (Table). Among "at risk"
people: those in professional and technical occupations had full (100%)
vaccine coverage while students had low (25%) uptake.
Of the 342 pilgrims recruited, 47(14%) proved to have influenza infection
by PCR, 13 (28%) of these cases were vaccinated against influenza.

This study reveals that the rate of vaccination among "at risk" Muslims
is worryingly low (55%) as compared to nationwide uptake rate among the
target population;1 it is even lower among the residents of London. Uptake
could be improved by advertising, phone calls, patient and staff
education, standing orders, targeting people with high risk behaviours at
their meeting venues and offering home visit by the nurses.5 Clinics set
up, in partnership with community leaders travel agents and Imams, for
pilgrims planning to go on Hajj might further improve uptake. Hajj is
presently occurring during winter months; this poses an extra threat, over
the extreme crowding of millions of people, that a novel seasonal (or even
pandemic) virus will emerge.

Uncertainties about the effectiveness of immunisation against seasonal
influenza have been raised6 and as UK government policy does not advocate
influenza vaccination for all Hajjis a unique opportunity offered by the
Hajj could be to perform well-designed studies to obtain evidence of flu
immunisation effectiveness.

Acknowledgement
This work was supported from a DH grant
We thank British Hajj Delegation team, European Hajj Mission and the GPs
for help with the data collection and staff at HPA laboratory, London
& Respiratory Virus Unit, Health Protection Agency, Centre for
Infections, London, for performing the PCR tests.
Ethical Approval
Multicentre Research Ethics Committee, UK (MREC 02/2/12).
Competing interests
Roche supplied free courses of Tamiflu for treatment of pilgrims with
influenza infection on near-patient testing.
SS served as Chair, Health and Medical Committee of the Muslim Council of
Britain (until August 2006)

1 Muller D, Nguyen-Van-Tam JS, Szucs TD. Influenza vaccination
coverage rates in the UK: A comparison of two monitoring methods during
the 2002-2003 and 2003-2004 seasons. Public Health 2006; 120:1074-80.

2 Marin MG, Johanson WGJr, Salaz-Lopez D. Influenza vaccination among
minority populations in the United States. Prev Med 2002; 34:235-41.

3 El Bashir H, Haworth E, Zambon M, Shafi S, Zuckerman J, Booy R.
Influenza among UK pilgrims to Hajj, 2003. Emerg Infect Dis 2004;10:882-3.

4. Balkhy HH, Memish ZA, Bafaqeer S, Almuneef MA. Influenza a common viral
infection among Hajj pilgrims: time for routine surveillance and
vaccination. J Travel Med 2004; 11:82-6.

5 Ompad DC, Galea S, Vlahov D. Distribution of influenza vaccine to high-
risk groups. Epidemiol Rev 2006; 28:54-70.

6. Jefferson T. Influenza vaccination: policy versus evidence. BMJ 2006;
333:912-5.

Table: Distribution of pilgrims according to addresses and 
ethnicities with their vaccination rates.

Number of participants	Vaccinated	   

Not at Risk	At Risk	Not at risk
n(%)	At Risk
n(%)	   
Addresses	   
London	78	26	11(14)	10(38)	   
Birmingham	19	11	6(32)	8(73)	   
Dewsbury	14	2	4(29)	2(100)	   
Batley	11	4	0(0)	3(75)	   
Bradford	12	2	5(42)	1(50)	   
Leicester	9	2	1(11)	0(0)	   
Blackburn	8	3	1(13)	1(33)	   
Luton	6	4	3(50)	2(50)	   
Others	93	38	26(28)	24(63)	   
Ethnicity	   
Pakistani	102	39	31(30)	21(54)	   
Bangladeshi	64	32	9(14)	16(50)	   
Indian	39	8	8(21)	6(75)	   
Other Asian	19	5	3(16)	3(60)	   
African	10	1	0(0)	0(0)	   
White British	6	2	1(17)	1(50)	   
Others	1	0	0(0)	0(0)	   
Unknown	9	5	5(56)	4(80)

Competing interests:
Roche supplied free courses of Tamiflu for treatment of pilgrims with influenza infection on near-patient testing.
SS served as Chair, Health and Medical Committee of the Muslim Council of Britain (until August 2006)

Competing interests: Table: Distribution of pilgrims according to addresses and ethnicities with their vaccination rates.Number of participants Vaccinated Not at Risk At Risk Not at riskn(%) At Riskn(%) Addresses London 78 26 11(14) 10(38) Birmingham 19 11 6(32) 8(73) Dewsbury 14 2 4(29) 2(100) Batley 11 4 0(0) 3(75) Bradford 12 2 5(42) 1(50) Leicester 9 2 1(11) 0(0) Blackburn 8 3 1(13) 1(33) Luton 6 4 3(50) 2(50) Others 93 38 26(28) 24(63) Ethnicity Pakistani 102 39 31(30) 21(54) Bangladeshi 64 32 9(14) 16(50) Indian 39 8 8(21) 6(75) Other Asian 19 5 3(16) 3(60) African 10 1 0(0) 0(0) White British 6 2 1(17) 1(50) Others 1 0 0(0) 0(0) Unknown 9 5 5(56) 4(80)

29 November 2006
Shuja Shafi
Consultant Microbiologist
Harunor Rashid, Kamal Ali, Haitham El Bashir, Elizabeth Haworth, Ziad A Memish, Robert Booy
Clinical and HPA Collaborating Laboratory, Northwick Park Hospital, Harrow, Middlesex HA6 4UJ