Fever, cough most common symptoms in almost all studies20-40 yrs mcly affected group
For the whole year 2012
SH: an A/Perth/16/2009 (H3N2)-like virus; a B/Brisbane/60/2008-like virus. It is recommended that trivalent vaccines for use in the 2013 influenza season (southern hemisphere winter) contain the following: – an A/California/7/2009 (H1N1)pdm09-like virus (a); – an A/Victoria/361/2011 (H3N2)-like virus (b); – a B/Wisconsin/1/2010-like virus (c).
Timing of Influenza vaccination in india
Influenza vaccination in India When, whom & how to vaccinate? Dr Gaurav Gupta, Pediatrician, Member AAP, IAP, Charak Clinics, Mohali March 2013
Conflict of Interest• Received grants from various vaccine manufacturers including – - Sanofi Pasteur – - GSK – - Abbott (Manufacturers of different Influenza vaccines)
Overview• Influenza – what is it ?• Is it really that big a problem – World/ India/ Children ?• Influenza vaccine – rationale for use• What data exists regarding Influenza vaccine safety & effectiveness, especially from India ?• When, whom & how to vaccinate ?
CASEAlisha is a 7-year-old girl brought to your Clinic by her mother, who tells you her daughter “suddenly came down with a bad cold.” She reports that “Alisha was fine when she went to bed” but in the morning suddenly became ill with vomiting, a dry cough, sore throat, and high fever. WHAT DO YOU THINK IS THIS??
Often misunderstood and underestimated, Influenza is not just “a bad cold”!
CLINICAL FEATURES & CASE DEFINITIONInfluenza can also present as croup, bronchiolitis, pneumonia, febrile diseasemimicking bacterial sepsisCan predispose to bacterial infections (otitis media, pneumonia, bronchiolitis) Laboratory Confirmation required for epidemiological purposes only JAMA 2000; 284 (13): 1740
Impact of influenza on children Annual attack rate in preschool age exceeds 40% and in school age more than 30% during outbreaks 120 Influenza contributes to: excess in hospitalization (per 104 100 Up to 3 days of fever, 5 days 10000 per year) school absenteeism 80 Up to 35% increase in OPD visits 60 50 and excess hospitalization 40 Up to 20-30% increase in Antibiotics 19 20 Complications 9 4 0 Absenteeism in parents, more with <6 6-12 1-3 years 3-5 years 5-15 years months months those nursing younger children Age1. Neuzil KM et al. The effect of influenza on hospitalizations,outpatient visit and courses of antibiotics in children,NEJM 2000,342:225-312. Turner D et al, National Institute of Clinical Excellence.Systematic review and economic decision modelling for the prevention and treatment of influenza A & B 29th Apr 2002.
Indian Scenario:Reality • Limited data in public domain on annual Influenza cases and deaths in Indian scenario* • Influenza vaccine is in Indian market since 2004 • There is no published data on safety, tolerability and effectiveness of Influenza vaccine in Indian children***India to compile database for influenza. Available from: URL:http://www.livemint.com/2009/05/31215156/India-to-compile-database-on-s.html. Accessed on 22 May, 2010. 9**Joseph L Mathew. Influenza vaccination for children in India. Indian Pediatrics. 2009 ;46:304-307.
Indian scenarioRegion Period Influenza positive AdditionalDelhi (NCDC) May 09 – Sep 7943 / 33751 11.1% (+) for seasonal influenza 10 (23.5%)Delhi (AIIMS- Jan - Dec 09 315 / 1071 (29% 51% of these- pandemic, 49%- seasonalBallabhgarh) for all) strains Jan - Dec 10 116 / 661 (17% for 51% of these- pandemic, 49%- seasonal all) strainsKolkata Jul – Aug 10 129 / 440 (29.3%) 47 pts (11%) comorbidities, 4 patients diedRajasthan Nov 09 – Apr 10 533 / 1782 (29.9%) -Sangli Oct 09 – Sep 10 142 / 466 (30.47%) Maximum deaths in monsoon(Maharashtra)Surat Jun 09 – Mar 10 154 / 824 (18.68%) 37.66% comorbidities (MC DM and HT)(Gujarat) ARDS, need for ventilator and comorbidities – poor prognosisChoudhry A. Indian J Med Res. 2012 Apr;135(4):534-7.Broor S et al. PLoS One. 2012;7(1):e29129Biswas DK. Indian J Med Res. 2012 Apr;135(4):529-33.Joshi V. Indian J Med Res. 2012 Mar;135:437-8.Rajderkar SS. IJHSR Vol.2; Issue: 2; May 2012Bhatt KN. J Assoc Physicians India. 2012 May;60:15-9.
Incidence of ILI from our center250200150100 50 0 jan - mar apr-jun july-sept oct 2008- jan to apr to july to Oct 2009 Jan to Apr to july to Oct 2010 Jan to Apr to 2008 2008 2008 dec 2008 march june 2009 sept 2009 to dec march june 2010 sept 2010 to dec march June 2009 2009 2010 2010 2011 2011
Private pediatric outpatient (clinical) settingAims of the study -• Clinical Effectiveness of Seasonal Flu vaccine in preventing ILI 1, 2 1. WSPID, Nov 2011, Melbourne, Poster Presentation. 2. ISPOR Asia Conference, September 2010, Thailand, Poster Presentation.
Methodology • Prospective Observational Cohort Study Study Design • Vaccinated cohort (n=170) vs. Unvaccinated cohort (n=330) • Healthy child, of either sex, above 6 months ofInclusion criteria age up to 18 years of age • No chronic illness except asthma • Standard Predefined Data Form used.Data Collection • Parameters measured – ILI, Absenteeism, ARI, Unscheduled Physician visits 13
Continued….. Methodology • Private outpatient pediatric setting (Charak Study site Care Clinics, Mohali)Study period • September, 2010 to May, 2011 14
Clinical Effectiveness of Influenza vaccine-1 Fully vaccinated cohort (n=154) vs. Unvaccinated cohort (n=330)* Sr.No Parameters Odds Ratio CI VE % P-value 1 Influenza like 0.58 0.24-0.92 42 0.009 illness 2 Visits to Physician 0.71 0.33-1.09 29 0.039 Conclusion: Influenza vaccine is effective in reducing the ILI and visits to physician for ARI in fully vaccinated Indian children as compared to unvaccinated children.*Renuka R, Gupta G, Tiwari P. Clinical effectiveness of the 2010-2011 seasonal influenza vaccine amonghealthy Indian children. WSPID-2011, Melbourne.
Clinical Effectiveness of Influenza vaccine-2 Age-wise efficacy for prevent of ILI* Sr.N Age group (no.) Odds CI P-value VE % o Ratio 1 6 m – 3 y (78) 0.57 0.46-1.31 0.55 2 3 y – 9 y (64) 0.48 0.17-0.72 0.002 52 % 3 9 y – 18 y (28) 0.69 0.39-1.03 0.06 Conclusion: Children aged 3-9 year had the best protection rates against ILI as compared to unvaccinated children.*Renuka R, Gupta G, Tiwari P. Clinical effectiveness of the 2010-2011 seasonal influenza vaccine amonghealthy Indian children. WSPID-2011, Melbourne.
Conclusion• Flu vaccine is effective in reducing ILI & unscheduled visits to doctor. No effect of partial vaccination
SAGE Data- Protection against influenza• Vaccine effectiveness studies have found VE of 60-85% in children < 5 yrs age when vaccine strains match well with circulating strains• Limited data indicate additional protection of unvaccinated household and community contacts by immunization of children Sage working group: Background Paper on Influenza Vaccines and Immunization. April 2012
Vaccine Recommendations *• Ideally, all • Routine influenza • All those • Universal • Only in all individuals vaccination is aged over 6 Vaccination high risk should have the recommended months in a of all children children >6 opportunity to be for all persons clinical at- from the age months vaccinated aged ≥6 months risk group of 6 months. against • Special influenza. attention for• Priority should children upto be given to high 60 months risk population *CEVAG: Central European Advisory Group http://www.who.int/docstore/wer/pdf/2002/wer7728.pdf http://www.cdc.gov/mmwr/preview/mmwrhtml/rr59e0729a1.htm?s_cid=rr59e0729a1_e http://www.sehd.scot.nhs.uk/cmo/CMO(2010)14.pdf http://www.biomedcentral.com/content/pdf/1471-2334-10-168.pdf
Recommendation on influenza vaccine. Available at:http://www.iapindia.org/component/content/article/315. Accessedon: 16 April 2012
Vaccination Schedules Age group Dosage (im/sc) No. of doses6-35 months 0.25 ml 1 or 2*3-8 years 0.5 ml 1 or 2*> 9 years 0.5 ml 1* 2 doses at least 1 month apart for children receiving vaccine for the first time
Global surveillance network:106 Member countries136 NIC6 WHO CCS4 ERLS11 H5 Ref Labs
WHO National Influenza Center (as of April 2011)• Pune (NIV),• Kasauli (CRI)• & Mumbai (Haffkine Institute)
WHO recommendations• For countries in equatorial regions, epidemiological considerations influences which recommendation (February or September) individual national and regional authorities consider more appropriate• In most of the countries using influenza vaccine, the vaccination starts before the onset of peak influenza season, with the latest available strain of vaccine WHO Influenza Vaccine Recommendations
IAP 2012 recommendations • Data since 2004 suggests a clear peaking of circulation during the rainy season across the country- ‘June to August’ in north (Delhi), west (Pune) and east (Kolkata), and ‘October to December’ in south (Chennai) • Influenza vaccines are given before the peak season. Hence, the best time for offering vaccine for individuals residing in southern states would be just before the onset of rainy season, i.e. before October while for rest of the country, it should be before JuneIAPCOI. Consensus Recommendations on Immunization and IAP Immunization Timetable 2012. Indian Pediatr. 2012 Jul8;49(7):549-64.
Process of Influenza Recommendations and Vaccine Availability INTERNATIONAL SURVEILLANCE NETWORK VACCINE MANUFACTURER F M A M J J A S O N D J F M WHO PRODUCTION(Northern hemisphere) WHO PRODUCTION(Southern hemisphere)
NH vaccineRecommended composition of influenza virus vaccines for usein the 2012-2013 northern hemisphere influenza seasonan A/California/7/2009 (H1N1)pdm09-like virus;an A/Victoria/361/2011 (H3N2)-like virus;a B/Wisconsin/1/2010-like virus.WHO recommendation for SH 2013 : 21 September 2012 Strains are same as those in NH 2012-13
QUADRIVALENT LIVE INFLUENZA VACCINEFDA NEWS RELEASEFor Immediate Release: Feb. 29, 2012FDA approves first quadrivalent vaccine to prevent seasonalinfluenzaThe first quadrivalent live attenuated vaccine toprevent seasonal influenza has been approved byFDA. FluMist Quadrivalent (MedImmune), will beavailable for the 2013-2014 flu season. This too willbe administered as a nasal spray. The vaccine isindicated for individuals ages 2 years through 49years. FluMist Quadrivalent will contain 2 strains ofinfluenza A and 2 strains of influenza B. Including asecond influenza B strain improves the odds ofprotection against whichever B strain is circulating.http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm294057.htm
The European vaccine study involved an antibodythat neutralizes all the influenza-A subtypes.