“Rome 24 April 2020
Maintain and increase vaccination coverage in children and the elderly: avoid adding epidemics to the pandemic
Appeal of the Calendar for Life Board: maintain and increase coverage also by reorganising vaccination services and reassuring the population
The current COVID-19 emergency risks bringing serious consequences for other infectious diseases as well. In recent weeks it has become evident that vaccination coverage for children, adolescents and adults (healthy, with chronic diseases, or above a predetermined age) is declining in many Italian regions for a number of concomitant reasons: displacement of staff normally employed in vaccination services to functions related to the management of the pandemic emergency, fear on the part of citizens towards access to the health service to carry out vaccinations, sometimes unjustified interruptions of active calls and requests to provide vaccines in non-emergency situations.
The Board of the Calendar of Life regards these events with great concern. It has rightly been observed that the lack of a vaccine against a new virus such as SARS-CoV2 is the cause of the serious health and economic situation in which the whole world finds itself. And just as we would find ourselves in such emergencies much more frequently if we did not have all the other vaccines, the effect of which is to make us normally free from diseases with serious complications and sometimes fatal (diphtheria, polio, measles, etc.). The absence or low impact of these diseases is taken for granted, but it is linked to the persistence of high vaccination coverage. Vaccination coverage against diseases that have a particular impact on the elderly population and on people of any age suffering from chronic diseases (heart disease, chronic bronchitis, cancer, diabetes, etc.), such as influenza and pneumococcus, become of particular urgency and importance in a possible scenario of return of COVID-19 infections in the coming winter season. In such a situation – which to date cannot be excluded – adding the difficulties of differential diagnosis of flu-like syndromes (ILI), in addition to the damage caused by infectious agents that occur every winter to those of COVID-19, could make the situation highly critical. In other words, it is absolutely urgent to protect the fragile sections of the population with all the means at our disposal, vaccines first and foremost. Vaccine coverage against influenza in the over-65s and chronic patients, respectively around 55% and 25-30% in recent seasons, must necessarily increase dramatically this autumn, as must pneumococcal vaccination, whose national average in the elderly and chronically ill is unacceptably low, with an increase in the active and free supply of vaccination including the over-55s.
Many countries in Europe and around the world have understood the urgency of such interventions, and have already opted for increased quantities of vaccines for next autumn, with the intention of increasing coverage, and not finding themselves competing for a number of doses inevitably limited and probably insufficient to cover all global demands. It should not be forgotten that vaccines are increasingly subject to shortages, also because it is impossible to increase the quantities produced in a short time due to the very high quality standards and safety requirements to which they are subject.
It is worth remembering how the World Health Organization – European Region (WHOEuro) has strongly emphasized in a guideline issued last March 20:
‘Any interruption of immunisation services, even for short periods, leads to an accumulation of susceptibility and a higher probability of vaccine-preventable disease outbreaks. Such epidemics can result in deaths related to preventable diseases and an increased burden on health systems already worn out by the response to the COVID-19 pandemic’.
It is therefore clear that the following urgent actions are indispensable:
- Guarantee paediatric vaccination coverage to all newborns and paediatric recalls and adolescents, not interrupting active calls and scheduled sessions. In the current phase of foreseeable progressive return to the usual activities, it is necessary to guarantee sufficient personnel to carry out immunization activities in all Regions, considering the vaccination services as critical for maintaining the health of the population.
- Re-organise the way pediatric and adolescent vaccinations are offered. The details of the reorganization processes may vary from one Region or Autonomous Province to another depending on the different organizational models – also in order to give complete reassurance to citizens that vaccinations can be carried out safely. Some lines of action can be outlined: – involvement of the paediatrician in the practice of vaccination, in order to offer more extensive methods of application, as already happens in some regional realities, also in order to reduce the movement of families and encourage the execution of health budgets; – co-administration of more than 2 vaccines in the same session, remembering that in some countries up to 5 different vaccines are administered in the two femoral quadriceps without significantly increasing the frequency of side effects compared to the sum of the separate vaccinations (the injections must be carried out at least 2. 5 cm away from each other when administered in the same muscle); – acceptance by appointment, which is scheduled with the non-attendance of users in the waiting room in crowded situations, and the post-vaccination stay for observation of any adverse events in a suitable environment with physical distancing.
- Recovery programmes for vaccinations not carried out after the start of the COVID-19 emergency. It is recommended to quickly plan recovery actions for children and adolescents not vaccinated for COVID-19 emergency, for compulsory vaccinations for access to school (hexavalent; Measles-Parotite-Rosolia-Varicella or MPRV), but with the same urgency also for strongly recommended vaccines (conjugated pneumococcus, conjugated quadrivalent/C meningococcus, meningococcus B, HPV in adolescence). To this end, it should be remembered that all co-administrations are possible unless expressly excluded in the technical data sheet, that inactivated and live attenuated vaccines can be administered either simultaneously or at any time. The only warning to be observed is the administration either simultaneously or at a minimum distance of 4 weeks for two or more live attenuated vaccines. For vaccines (such as hexavalent and conjugated pneumococcus) to be administered in 3 doses as a basic cycle, remember the minimum distance of 8 weeks between first and second dose, and at least 4 months between second and third dose. A discontinued vaccination cycle is never re-started, and there are no problems in continuing the cycle, regardless of the time elapsed from one or more doses already administered.
- Provide in all Regions and Autonomous Provinces with extreme urgency the preparation of tenders for the supply of flu vaccines with suitable quantities to increase coverage. As already mentioned, many countries have already opted for increased quantities of flu vaccines for the next winter season. The quantities available at an international level are limited, and the principle of greater availability for those who opt for doses first applies. The regionalised tendering system for the supply of flu vaccines risks turning into a debacle in Italy if the regional health authorities do not prepare the forecasts for the quantities tendered out well in advance. The Ministerial Circular on Influenza Vaccination for the 2020/2021 Season is ready and currently being examined by the Regions. The Board of the Calendar for Life hopes that it will be published as a matter of urgency and that concrete actions will be taken to promote a high level of adherence to the offer this autumn, both in the elderly and in risk categories and healthy children between 6 months and 6 years of age, as the Board of the Calendar for Life has been proposing for some time. Once again, it is important to pay attention to the use of the most appropriate vaccines according to age, as has been recalled for the last two years in the Ministerial Circulars (quadrivalent vaccines for the population from 6 months to 75 years of age; vaccines for the population ≥75 years of age).
- Prepare plans to increase coverage for influenza, pneumococcal, tetanus-pertus and shingles. At the same time, there must also be strong action to increase vaccination coverage in the same categories for pneumococcal, tetanus diphtheria-pertussis (dTpa) and shingles. In particular, for the 2020/2021 influenza vaccination campaign, with the already mentioned proposal to lower the age of active and free offer to individuals over 55 years of age, an earlier and longer start than in previous years (beginning of October – end of January) should be envisaged, in order to manage the access of a larger number of individuals with an organisational model characterised by social distancing and biocontainment both in family medicine settings and in vaccination centres. The plan to increase the vaccine supply must therefore provide, in addition to the commitments already described by the regional side, a central intervention of the state through a commitment of ad hoc resources for the support with direct purchase by the Civil Protection (mechanism already practiced for the vaccination coverage referred to the H1N1 pandemic) to support the ordinary budgets of the Regions for part of the increase in vaccines required and related to the particular emergency condition related to the possible coexistence with SARS-CoV-2 infection, in the influenza season 2020/2021. It is more urgent than ever to increase protection for all diseases that could add to COVID-19, further worsening the health status of the most fragile categories of the population. Moreover, there is a great risk of post-infection viral bacterial overlap (such as pneumococcal pneumonia after influenza). And the largely underestimated number of cases of whooping cough in the elderly or chronically ill adults, whose clinical features similar to those of COVID-19 also pose difficulties in the differential diagnosis between the two pathologies (a problem that also exists for seasonal influenza). Last but not least, the social importance of vaccination against herpes zoster and post-herpetic neuralgia, the treatment of which is even more complex in the current situation, should be remembered. In this respect, innovative and concerted methods of offering should be developed with family medicine, bearing in mind that co-administration of flu, anti-pneumococcal, dTpa and anti-herpes zoster vaccines are possible and particularly useful at this time to reduce the number of accesses to health services and studies by general practitioners, consistent with a longer vaccination campaign period as mentioned above increased from the current two months to the proposed four months. It is still necessary and not procrastinable to set up an organisational method to guarantee, not only for the next season, an active and free offer to the fragile population, i.e. the elderly and people with serious neurological, chronic pathologies and disabilities of various kinds or with other health problems, in social-healthcare residential facilities and at home. Finally, in order to offer the highest level of protection to users and operators, adequate planning is required for the supply, in quantity and quality, of personal protective equipment and other products and devices necessary for the prevention and control of diseases transmitted by contact and droplets and by air.
The Board of the Calendar of Life appeals to the National and Local Health Authorities for a strong and coordinated commitment in favour of the widest offer and acceptance of vaccinations, whose vital importance for collective health is now even more evident to all, in order to avoid that delays in the initiatives now necessary should add damage from other epidemics to those suffered by our population due to the COVID-19 pandemic.
Calendar Board for Life:
Italian Society of Hygiene, Preventive Medicine and Public Health – SItI (Chairman: Italo F Angelillo)
Italian Society of Paediatrics – SIP (President: Alberto Villani)
Italian Federation of Paediatricians – FIMP (President: Paolo Biasci)
Italian Federation of General Practitioners – FIMMG (Secretary: Silvestro Scotti)
Scientific Coordination Board Calendar for Life (Coordinator: Paolo Bonanni)”.