Can the biggest ever flu vaccine programme stop a second wave?

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As the first lockdown restrictions began to ease across the UK in late May, the attention of Patrick Vallance, the UK government’s chief scientific adviser, was already turning towards the looming spectre of a second wave.
Concerned by the prospect of seasonal influenza circulating alongside Covid-19 from September onwards, potentially overwhelming fragile NHS emergency services in the process, Vallance needed a set of strategies which could help mitigate this threat.

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Over the following six weeks, he commissioned the Academy of Medical Sciences – an independent medical science research body – to evaluate the risk and devise potential solutions. This would ultimately result in the most comprehensive flu vaccination program in UK history, as well as an extra £3 billion of funding for A&E and emergency care.
“The key thing we identified was that there’s already a big backlog of work in the NHS as a result of Covid-19,” says Anne Johnson, vice president international at the Academy of Medical Sciences. “So we have to make the NHS resilient to the pressures coming this winter, and one of the key elements of that was getting on top of the flu epidemic.”
From September onwards, more than 30 million people will be eligible to receive a free flu jab, including all over 50s. Previously NHS flu vaccines have only been available to over 65s, or those with long-term health conditions. In the eyes of many flu experts, increasing the scope of the vaccination program to this extent could be crucial in ensuring hospitals and intensive care units have enough beds to cope with the predicted rise in Covid-19 cases this autumn.
“Last year influenza resulted in around 900 hospital admissions per 100,000 people in the 50-64 year old age range,” says Andrew Goddard, president of the Royal College of Physicians. “A significant number of people in that range end up in intensive care. By vaccinating this group, we hope to reduce hospital and intensive care admissions from flu by about a third.”

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A particularly severe flu winter could also overwhelm test and tracing capacity, making it far harder to monitor Covid-19 cases and keep a lid on further outbreaks. Many early symptoms of influenza and other respiratory infections – such as cough, fever and loss of smell – are very similar to Covid-19, and it is predicted that the number of people reporting such symptoms will rise from 100,000 a day right now, to 360,000 a day in winter.
The government is looking to tackle this by rolling out point-of-care tests, such as the DNANudge test which promises to diagnose Covid-19 as well as flu and respiratory viruses within 90 minutes. However, trying to limit flu transmission in the first place is a key part of the strategy. Because of this, all primary school children – who are known to play a substantial role in transmitting flu – will be eligible for free flu vaccines.
“This is a policy which was already being planned for a few years’ time, but has been brought forward to this winter because we know children are key drivers of flu epidemics,” says Azra Ghani, an Imperial College epidemiologist, who was involved in the Academy of Medical Sciences study.
But one of the problems for scientists trying to model the likely impact of the coming flu season alongside Covid-19 is the sheer unpredictability of the annual epidemic. While the 2018-19 and 2019-20 seasons were relatively mild, the winter of 2017-18 had a comparatively devastating impact.

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The latter flu season – which is being used as the worst case scenario in projections for the coming winter – saw rates of influenza-confirmed hospital admissions more than triple compared to the three preceding winters. That year excess winter mortality amounted to 49,410 deaths, with more than a third of them being directly attributed to a particularly virulent strain of flu, exacerbated by a run of exceptionally cold temperatures due to the so-called ‘Beast from the East’.
To understand what is likely to be in store for the UK, experts examine the impact of the influenza strains circulating in the southern hemisphere during their winter months which run from March to September. However this has proven more difficult than usual to assess in 2020, as when the southern influenza season began, most nations were already in the early stages of lockdowns due to Covid-19.
“It’s hard to tell whether it will be a bad flu season or not,” says Ghani. “From what we’re seeing in Australia and New Zealand, they don’t seem to have had much flu at all this winter, but that could be due to the lockdown measures. We will be in a very different behavioural setting once winter arrives in the UK.”
Some concerning findings have emerged from China about the potential impact of patients being co-infected with both seasonal influenza and Covid-19. Initially, research from the US, Italy, Japan, Spain, and Germany suggested that the risk of being infected with both viruses was negligible, but it now appears this is because those studies took place after the influenza season had passed its peak.
Data from Wuhan collected in January and February – where the influenza season was still ongoing – found that as many as 57 per cent of patients in one study were co-infected with influenza. Having co-infections appeared to make patients both more contagious and more likely to become severely unwell. Those co-infected with both Covid-19 and type B influenza were especially likely to develop serious illness.
“We now understand that the prevalence of co-infection changes with seasonality,” says Resat Ozaras, an infectious diseases physician at Istanbul’s Medilife Hospital, who has published papers calling for more countries across Europe to increase their vaccination coverage this winter. “If influenza and Covid-19 circulate together, co-infection rate is as high as around 50 per cent. If we experience another wave of Covid-19 this winter, high rates of co-infection appear inevitable.”
The risk of co-infections contributing to the death toll from Covid-19 is another reason why the UK government has ramped up vaccination coverage. But on a more positive note, there is also some reason to hope that influenza vaccines could make the elderly more resilient to the coronavirus as well as the flu, by stimulating the immune system to be more responsive to any viral infection. While evidence is certainly far from conclusive, a recent study in Italy did find that older people who had the flu vaccine last year appeared to be less likely to die from Covid-19.
As a result, one of the biggest challenges to the government’s plans this winter could simply be ensuring that all those eligible to receive a free flu vaccination, actually get one. The Academy of Medical Sciences revealed that poor vaccine uptake has long been an issue in those under 65 with underlying health conditions, as well as healthcare workers.
The latter population, which includes care home workers, social care and agency staff, are particularly at risk of being exposed to influenza and subsequently transmitting it to vulnerable patients. Last year influenza vaccination uptake ranged from 41 per cent to 74 per cent across the spectrum of healthcare workers.
“I think raising awareness of the importance of it is key,” says Ghani. “People don’t think about flu in the same way as you might do about Covid-19, and when it’s a vaccine that’s routine and normalised, then it’s quite easy to put it off. But after the impact of Covid-19, I think people will generally be viewing vaccination differently, so hopefully those rates will rise in the healthcare worker population.”
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