In 2009, the European Council of Ministers recommended that all EU Member States reach influenza vaccination coverage of 75% in all risk groups by the 2014/2015 winter season. In Ireland, the National Immunisation Advisory Committee recommends influenza vaccine to adults and children who are at risk of influenza-related complications.¹ Influenza vaccine is free in Ireland for all persons who are at risk of influenza-related complications and for all those aged 65 years and over. Influenza and its related illnesses remain a major cause of preventable morbidity and mortality in older people worldwide. Among older people, vaccination is thought to reduce influenza-related hospitalisation by 50-60% and influenza-related mortality by 70-80%.^2,3

Influenza vaccination (both vaccine and administration) is free for all medical cardholders and GP visit cardholders. An administration charge may apply to people who don’t hold medical cards or GP visit cards. Influenza vaccine uptake among medical cardholders (aged 65 years and older) has been monitored by HPSC since 2003.⁴ This surveillance project was expanded to include GP visit cardholders during the 2006/2007 influenza season and pharmacy data during the 2012/2013 season.^a,5

Between September and December 2013, the median number of people aged 65 years and older who had either a medical card or a GP visit card was 452,931 (79.7% of the population in that age group). Only 53% of the population aged 65 to 69 years had a medical card or a GP visit card during this period.^b

Methodology

Data were obtained from the Primary Care Reimbursement Service (PCRS), HSE-Finance Shared Services on the number of registered medical cardholders and GP visit cardholders aged 65 years and older, as well as the number of patients vaccinated with the influenza vaccine (by age group and HSE-Area), at GP clinics and pharmacies. Data refer to GP and pharmacy returns received by the PCRS between September and August of each influenza season. The data provided in this report relate to the 2011/2012, 2012/2013 & 2013/2014 influenza seasons.

Influenza uptake rates in those aged ≥ 65 years were calculated based on the proportion of registered patients with medical cards and GP visit cards who were vaccinated during the period September to August of each influenza season. Definitions of the number vaccinated and the number of patients with medical cards/GP visit cards used in the calculation of influenza vaccine uptake are outlined below:

1. The number of patients aged ≥ 65 years vaccinated with influenza vaccine refers to the number of GP and pharmacy paid claims for influenza vaccine reimbursement reported from the PCRS for the period September to August of each influenza season. ‘Paid claims’ refer to claims for payment from GPs/pharmacies for influenza vaccination of patients with medical cards/GP visit cards.
2. The median number of registered medical and GP visit cardholders aged ≥ 65 years were calculated for the period September – December of each influenza season, which is the period of time when the majority of influenza vaccinations were administered.

To assess variations reported by age group and region, uptake was analysed by various age groups (aged 65 years and older) and also by HSE-Area.

Results

The average influenza vaccine uptake nationally in medical and GP visit card holders aged 65 years and older attending GP clinics and pharmacies for vaccination was 59.4%, during the 2013/2014 influenza season. This uptake rate is an increase compared to that reported for the 2012/2013 season (56.9%) and the 2011/2012 season (56.9%), however remains lower than the highest uptake recorded during the 2008/2009 season (70.1%) (table 1).

Pharmacy claims accounted for 1.6% (n=8940) of all paid influenza vaccine claims in those aged 65 years or older for the period September 2013 to August 2014, with GP claims accounting for 98.4% (n=260262). Therefore, the inclusion of pharmacy claims increased influenza vaccine uptake during the 2013/2014 influenza season by 1.9%, from 57.5% to 59.4%. During the 2012/2013 season, the number of pharmacy claims accounted for 0.9% of all paid influenza vaccine claims in this age group. Pharmacy data were not available prior to the 2012/2013 season.

Variation in vaccination coverage was observed between age groups, with the highest uptake in those aged 75 years and older (64.3% in 2013/2014, 64.1% in 2012/2013 and 61.4% in 2011/2012) and the lowest uptake in those aged 65-69 years (49.1% in 2013/2014, 44.1% in 2012/2013 and 47.3% in 2011/2012) (table 2).

Variation in vaccination coverage was also observed between HSE areas, ranging from 55.6% in HSE-MW to 62.4% in HSE-SE in those aged 65 years and older during the 2013/2014 season. Overall uptake has improved in the majority of HSE-Areas during the 2013/2014 season compared to the previous two seasons (figure 1).

Provisional unpublished data for the 2014/2015 influenza season has also shown a further increase in uptake, at 60.2%. A full report on influenza vaccine uptake for those aged 65 years and older for the 2014/2015 season will be published in Epi-insight (publication pending).

 
Table 1: Percentage seasonal influenza vaccine uptake in Medical Card and GP Visit Card Holders^c aged 65 years and older attending GP clinics and pharmacies, by season (September – August), 2004/2005 – 2013/2014.

Table 2 (A, B, & C): Percentage seasonal influenza vaccine uptake in Medical Card and GP Visit Card Holders^c by age group (in years) in those aged 65 years and older, attending GP clinics and pharmacies, by season

A.      2013/2014

 B.      2012/2013

C.      2011/2012

 A.      2013/2014

B.      2012/2013




C.      2011/2012

Figure 1:  Percentage seasonal influenza vaccine uptake in medical and GP visit card holders by age group (in years), by HSE-Area for patients attending GPs and pharmacies for influenza vaccination and season (A) 2013/2014, (B) 2012/2013 and (C) 2011/2012.

Discussion

In Ireland, the average seasonal influenza vaccination uptake rate ( 59.4%), increased among medical cardholders and GP visit cardholders aged 65 years of age and older for the 2013/2014 season compared to the previous two seasons. However, it still remains lower than the highest uptake recorded during the 2008/2009 season (70.1%).⁶ Provisional influenza vaccine uptake data for the 2014/2015 influenza season (60.2%) have shown a further increase (Epi-insight; publication pending).

A cross-sectional retrospective telephone survey conducted by HPSC in 2013 in Ireland showed that of 1,762 respondents, 370 (21%) reported they had been vaccinated against influenza from September 2012. The uptake was 60% among those aged 65 years and older; 28% among individuals aged 18 to 64 years with a health risk and 28% among healthcare workers.^d This telephone survey corroborates the use of the PCRS claims data as a valid surveillance tool for measuring influenza vaccine uptake in those aged 65 years and older.

A study of various European countries during the 2012/2013 influenza season reported uptake rates in older people ranging from 1.0% to 77.4% (median 44.7%) with only two countries reaching the 75% uptake target.⁷ The Council of the European Union issued a formal recommendation on seasonal influenza vaccine in December 2009.⁹ Their recommendations included a target of 75% seasonal influenza vaccine uptake in older age groups and people with chronic medical conditions prior to the 2014/2015 influenza season or earlier if possible. The European recommendation also included prioritising the provision of education, training and information exchange on seasonal influenza and vaccination against seasonal influenza to health care workers, risk groups and their families and the removal of obstacles to improving influenza vaccination uptake. The World Health Organization (WHO) set a target of 75% for influenza vaccine uptake in those aged 65 years and older, to be reached by 2010 (an increase from the 50% WHO target that was set for 2006). Despite the gradual increase in seasonal influenza vaccine uptake noted in this aged group in Ireland, we have not yet reached the recommended EU and WHO targets. In this context, it is important that we continue to strive in our endeavours to achieve the recommended targets.

Limitations of the PCRS claims dataset are primarily based on the eligibility criteria for medical/GP visit cards, for the period of time the report covers. From mid-2001 to the end of 2008, all individuals aged 70 years and older were eligible for a medical card. Between 2009 and 2015, automatic entitlement to a medical card for those aged 70 years and older no longer applied. All those aged 70 years and older who applied for a medical card were subject to a means test based on income. There were different guidelines for the means test dependent on age, with three age categories: under 66 years, 66-69 years and 70 years and older. GP visit cards have been available since mid-2006 and up to 2015 were also subject to a means test based on income and age. Planned changes to eligibility criteria of medical/GP visit cards for those aged 70 years and older during 2015, do not cover the period of time covered in this report. It is notable that influenza vaccine data for the 65-69 year age group do not include approximately 47% of the population in this age group.

In Ireland, although influenza vaccine is recommended and free for all those aged 65 years and older, it is evident that there is inconsistent and incomplete uptake amongst this group with uptake increasing with age. Reasons for inadequate vaccination uptake rates, particularly among those aged 65-74 years are unclear. National telephone surveys of risk groups and the uptake of influenza and pneumococcal vaccine in Ireland conducted in 2006¹⁰, 2010 and most recently in 2012/ 2013^e reviewed reasons for not getting vaccinated. In all surveys the most commonly reported reasons cited for not getting the seasonal influenza vaccine was a perception of low risk of getting influenza. The influence of family doctors in recommending vaccine is evident from all surveys, with the majority of respondents stating that they would get the vaccine if recommended by their doctor.¹⁰ Other studies have also reported the cost of vaccination, lack of awareness of self-risk associated with influenza disease, as well as distrust of vaccinations, disbelief in vaccine efficacy and inadequate strength of recommendations from health professionals as possible reasons for inadequate vaccination uptake. ^{8,11, 12, 13, 14}

HPSC is working closely with PCRS to improve influenza vaccine uptake data. For forthcoming seasons, more timely influenza vaccine uptake data are anticipated. Risk group data for all age groups are now being reported from PCRS to HPSC. However, the lack of easily accessible denominator data on chronic disease makes it difficult at present to measure influenza vaccine uptake in persons with chronic diseases. Ultimately, a national immunisation register is ever more relevant in order to estimate more timely and complete influenza vaccination uptake rates in all risk groups, individuals aged 65 years and older and health care workers.

 Key points

• Influenza vaccine uptake for those aged 65 years and older during the 2013/2014 season increased slightly compared to the previous two seasons, however remained below the EU and WHO target of 75% uptake.
• In Ireland, influenza vaccination uptake rates among medical cardholders and GP visit cardholders aged 65 years and older show regional and age group variation.
• Low influenza vaccine uptake in the 65-69 year age group needs to be addressed.  It is important to note that current available influenza vaccine uptake data for this age group does not include approximately 47% of the population in this age group.
• Health professionals should encourage and facilitate access to vaccination for their at-risk patients, including all patients aged 65 years and older.
• Work on increasing awareness within the wider community about the value of influenza vaccination for those at risk of influenza complications should be supported as part of efforts to improve vaccine coverage.
• The need for a national immunisation register is necessary to estimate more timely and complete influenza vaccination uptake rates in all risk groups, individuals aged 65 years and older and health care workers.
• Projects need to be developed to promote influenza vaccination uptake among risk groups including those aged 65 years and older as recommended by the European Centre for Disease Prevention and Control (ECDC).¹⁵

Lisa Domegan, Joan O’Donnell, Suzanne Cotter, Jolita Mereckiene and Darina O’Flanagan, HPSC.

Acknowledgements

The authors would like to thank the Primary Care Reimbursement Service (HSE-Finance Shared Services) for data provided for this study.

References

1. National Immunisation Advisory Committee. Immunisation Guidelines for Ireland. Influenza. Chapter 11. Updated August 2015. Royal College of Physicians of Ireland.  Click here.

2. Centers for Disease Prevention and Control (Atlanta, USA).  Chapter 12. Influenza. The Pink Book, 13^th Edition. 2015. Available here.

3. Grijalva CG, Zhu Y, Williams DJ, Self WH, Ampofo K, Pavia AT, et al. Association Between Hospitalization With Community-Acquired Laboratory-Confirmed Influenza Pneumonia and Prior Receipt of Influenza Vaccination. JAMA 2015 Oct 13;314(14):1488-97.

4. Sheahan A, Cotter S. Influenza vaccination uptake. Epi-Insight 2004; 5(11): 1.

5. Lisa Domegan, Joan O’Donnell, Darina O’Flanagan, HPSC. Influenza vaccine uptake in older people. Epi-Insight 2008; 9(1).

6. Lisa Domegan, Joan O’Donnell, Suzanne Cotter, Jolita Mereckiene and Darina O'Flanagan, HPSC. Improved uptake of flu vaccine among older people.  Epi-Insight 2012; 13(4).

7. ECDC. Technical report. Seasonal influenza vaccination in Europe. Overview of vaccination rates in the EU member States for the 2012–13 influenza season.  Available here.

8. Mereckiene J, Cotter S, Nicoll A, Lopalco P, Noori T, Weber J, et al. Seasonal influenza immunisation in Europe. Overview of recommendations and vaccination coverage for three seasons: pre-pandemic (2008/09), pandemic (2009/10) and post-pandemic (2010/11). Euro Surveill 2014;19(16):20780.  Available here.

9. Nicoll A. A new decade, a new seasonal influenza: the Council of the European Union Recommendation on seasonal influenza vaccination. Euro Surveill. 2010;15(1):pii=19458. Available here. 

10. Mereckiene J, O’Donnell J, Collins C, Cotter S, Igoe D, O’Flanagan D. Risk groups and uptake of influenza and pneumococcal vaccine in Ireland. Euro Surveill. 2007;12(12) Click here.

11. Kaufman Z, Green MS. Compliance with influenza and pneumococcal vaccinations in Israel, 1999-2002. Public Health Rev 2003; 31(1): 71-9.

12. Lewis-Parmar H, McCann R. Achieving national influenza vaccine targets - an investigation of the factors affecting influenza vaccine uptake in older people and people with diabetes. Commun Dis Public Health 2002; 5(2): 119-26.

13. Cornford CS, Morgan M. Elderly people's beliefs about influenza vaccination. Br J Gen Pract 1999; 49(441): 281-4.

14. Canova L et al. Prevalence rate and reasons for refusals of influenza vaccine in elderly. Swiss Med Wkly 2003; 133(43-44): 598-602.

15. Nicoll A, Ciancio BC, Tsolova S, Blank PR, Yilmaz C. The scientific basis for offering seasonal influenza immunisation to risk groups in Europe. Euro Surveill. 2008;13(43)