Another year, another flu outbreak. As sure as winter follows autumn, influenza viruses will spread across Europe, increasing hospitalisations and – in some cases – leading to death.
While we do not know how severe this year’s annual epidemic will be, it is likely to take the heaviest toll on the elderly and people with chronic conditions such as lung disease, diabetes and heart complaints.
That is why these groups, along with pregnant women and healthcare workers, have been identified by the World Health Organisation as priority groups for flu vaccination.
But healthy children get flu too. And when they do, they are more likely to see their doctor or be hospitalised than people in older age groups, according to data from England where children over two years of age are now offered an inhaled live attenuated flu vaccine.
European diversity
Thankfully most children infected by a flu virus make a full recovery – albeit after a very unpleasant illness. And children who are at higher risk of complications due to underlying illnesses are offered the flu vaccine in most European countries.
The question is whether it is worth vaccinating all children against flu. The answer to this question depends on who you ask. In Europe, eight countries recommend vaccination of children or adolescents against flu but only three – Finland, Latvia and the UK – provide the vaccine free of charge.
In the UK, part of the rationale for childhood flu vaccination put forward by the Joint Committee on Vaccination and Immunisation (JCVI) which advises the government, included the indirect benefits of reducing the risk to vulnerable groups such as older people. A successful pilot project has since been expanded.
Should all children receive a flu shot?
YES
- Hospitalisation rates among children are high
- Parents miss work when their children are ill
- Children can pass the virus to people at high-risk of complications
- Flu vaccine effectiveness among older people is sub-optimal
- Inhaled vaccine available
- Serious side effects are rare
Prof Alistair McGuire, London School of Economics, United Kingdom, says there is great diversity in the approaches taken across Europe, adding that the flu vaccine recommended for all children in the US.
Speaking at a pre-conference session of the European Public Health Conference in Glasgow, Prof McGuire noted that influenza among young people had a broad range of impacts on the health system and the economy.
“Young people who catch the flu can suffer bronchitis, acute otis media, pneumonia, febrile convulsions, and other complications. This puts pressure on the health system by increasing demand for GP consultations, hospital admissions, medicines and even intensive care,” he said.
Indirect benefits
Each infection also has a knock-on effect in terms of lost working hours for parents and the risk of passing the virus to others. Prof McGuire said that while the US and Canada had strong immunisation policies that favoured vaccinating children against flu, the traditional approach to immunisation policy in Europe was to focus on those at most risk of dying from influenza.
However, he argued that vaccinating young school-aged children would directly protect many young people and reduce health costs. It would, Prof McGuire said, also have a strong “spill-over effect” on the wider community.
This is particularly valuable in protecting older groups where the effectiveness of existing vaccines is often considered less than ideal because the immune system wanes as we age.
Prof McGuire’s message was clear: “We’ve got the technology and we know vaccines are safe and effective. The evidence to support seasonal vaccination of children and adolescents against influenza is strong from a public health and efficiency perspective.”
So why have all European countries not yet followed the UK example?
A note of caution
Dr Ole Wichmann, Department for Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany, agreed that flu vaccines are safe and effective, but he was cautious about advocating the vaccination of children and adolescents.
Should all children receive a flu shot?
NO
- Healthy kids are at low risk of serious complications
- Sick children are already a target group
- Greatest benefits in very young kids for which there is no approved vaccine
- Two doses are required
- Could crowd the vaccine schedule
- Young people should not be used as tools
He noted that, despite an EU target to vaccinate 75% of older people against flu, most countries have fallen short and many are a long way off reaching this target. The WHO attaches the highest priority to pregnant women, followed by other risk groups including children aged 6 and older. Yet few countries have been as proactive as the UK in immunising healthy school kids.
Dr Wichmann’s hesitation in backing flu vaccination for children included the need to deliver two doses of the vaccine to younger children and mixed results on vaccine effectiveness in some studies. The fact that flu vaccine is required annually is also a drawback compared to measles vaccination which provides protection for decades.
He agreed that severe adverse events were extremely rare and that influenza causes considerable ill-health even beyond those at highest risk of complications. “Children have the highest annual attack rates and contribute significantly to influenza outbreaks.”
However, Dr Wichmann said the children at the highest risk of hospitalisation were those aged below two years. He is yet to be convinced that vaccine effectiveness was good enough in this group and, in any case, the inhaled vaccine used in the UK is not approved for use in children younger than 24 months.
Other practical issues should also be considered. While fewer flu cases would reduce pressure on health services, delivering vaccines to every child would pose a new set of logistical issues for family doctors.
The task for policymakers, he said, was to figure out how best to reduce the burden of flu but it was also essential to consider the impact on the existing childhood vaccine schedule. “We don’t want the schedule to be too busy – we don’t want people to drop other vaccines that their child needs because we have added flu to the list,” Dr Wichmann said.
He also questioned the long-term effect of repeated annual vaccination from an early age given that a study had shown the best effects from flu vaccine are seen among those who had not been vaccinated previously. These question marks are enough to give pause for thought, according to Dr Wichmann.
Ethical issues
Even if the risk of any unintended consequences was extremely small, the conference heard that experts are facing a number of dilemmas. The ethics of vaccinating children to protect older people are fraught. While healthcare workers are a priority group for the flu jab because they can help to protect their patients, it is more complex when dealing with people – children – who cannot make their own decisions.
Governments and their advisors in some countries may be reluctant to promote childhood flu immunisation until the scientific and economic case is watertight. At the same time, on the other side of the ethical equation, decision-makers are weighing the morality of doing nothing.
“When is the right time to make a decision? You never want to take a decision which you later regret. But at the same time, you never have all the data you want,” said Dr Wichmann.
Germany, like many others, is watching the UK with interest. As real-world data accumulates in the UK, the scientific and economic case may harden. The outstanding questions then would be ethical:
(a) Should children be part of strategy to cut flu deaths which largely occur in older age groups?
(b) Is it reasonable to do nothing when the technology is available to save lives?
This report is based on a pre-conference session at the European Public Health Conference in Glasgow on November 20th 2014. The event was organised by EUPHA Sections on Child and Adolescent Public Health, Infectious Disease Control and Ethics in Public Health. It was supported by an unrestricted grant from AstraZeneca.
The ethics of immunising healthy children against flu
Should healthy young people be vaccinated in order to protect their grandparents?
Experts are broadly agreed that flu vaccination can reduce the burden of flu for society in general. This could be particularly useful to older people who are at the highest risk of dying from flu but for whom current influenza vaccines offer least protection due to their waning immune system.
There is also strong consensus that serious adverse events associated with flu vaccines are very rare. But the risk of any intervention is never absolutely zero.
So should younger people be immunisations in part to protect themselves but also to protect others – just as health professionals are offered flu vaccines to protect their vulnerable patients? Or is it simply unethical to use kids to protect others?
Dr Peter Schröder-Bäck, a philosopher at the Maastricht University Department of International Health, attempted to tackle these questions during a pre-conference session at the EUPHA European Public Health Conference in Glasgow.
The answer, it turns out, depends on how you approach the problem. To begin with, Schröder-Bäck said that just because something (in this case, vaccination) is useful or cost-effective does not justify its use: Just because we can doesn’t mean we should.
For doctors, the first port of call on ethical matters is often the Hippocratic Oath, whereby they promise not to harm their patient. Sound straightforward. But this, says Schröder-Bäck, is not an ideal approach because it implies that a doctor should look after the interests of their patient without regard for wider society or for other patients. It is, he said, just too simple to help solve complex problems.
Another way of looking at medical dilemmas is based on utilitarianism. This requires us to do the greatest possible good for the greatest possible number in order to ‘maximise aggregate happiness’. It is useful in that it takes on board all the costs and benefits of action (and inaction) but can be used to support almost anything because ‘The end justifies the means’.
At the opposite end of the philosophical spectrum is libertarianism. Viewing the flu vaccination question through this lens would make it impossible to immunise one group of people (in part) to protect another. For libertarians, it’s all about the individual. The idea that children should be ‘instruments’ of public health protection won’t wash with them. Nor, of course, does the idea of striving for herd immunity against measles in order to protect those too young or too sick to have a vaccine. This perspective is seen as somewhat uncaring.
A ‘social justice’ approach gives greater weight to protecting those who cannot protect themselves, says Schröder-Bäck. If protecting vulnerable groups is challenging, it may be legitimate to do so by recruiting healthy people to the cause.
None of these four theories is sufficient to solve the problem but a blend of approaches can offer some guidance, according to Schröder-Bäck. “There are many good reasons for offering an immunisation programme to children,” he said, provided all patients have genuine choice, efforts are made to retain public trust and engage health professionals, and the evidence supporting the decision is kept under close review.
