Dr Robert Menzies
School of Public Health and Community Medicine, UNSW
Ms Telphia Joseph
School of Public Health and Community Medicine, UNSW
Associate Professor James Ward
South Australian Health and Medical Research Institute
Australian Centre for Research Excellence in Aboriginal Sexual Health and Blood Borne Viruses
Professor Raina MacIntyre
University of New South Wales

Despite improvements in vaccine uptake in Aboriginal and Torres Strait Islander people, adults experience greater rates of influenza hospitalisation than non-Indigenous adults of the same age. 

What is the gap and why is it important?

Influenza, and other vaccine preventable diseases, still cause a higher disease burden in Indigenous adults compared to non-Indigenous adults.1,2
The death rate due to pandemic influenza in 2009 was 5.8 times higher in Indigenous people compared to non-Indigenous people.3 In 2015 respiratory disease caused 5.4% of hospitalisations and 7.6% of deaths in Indigenous people, constituting 12% of the mortality gap between Indigenous and non-Indigenous people.4 

A national policy is in place to address this — free influenza vaccine for all Indigenous people 6 months and older — under the National Immunisation Program.5 However, while coverage in elderly Indigenous (≥65 years) is adequate at >70%, uptake of less than 30% 18-49 year-olds is inadequate.6, 7

What does the best available evidence tell us?

Influenza vaccine is recognised internationally as the most effective method of preventing influenza-related morbidity and mortality.8 It is effective in preventing influenza infection and influenza-related serious morbidity and mortality in healthy young adults, adults with chronic disease or immunosuppression, the elderly, and in preventing influenza-related respiratory and cardiac disease.9 Effectiveness varies from year to year depending on the match between circulating and vaccine strains, and between individuals depending on their age and the presence of medical conditions that affect the immune response. At time of publication, the current influenza vaccine has been estimated to be 45% effective overall against the 2019-2020 seasonal influenza A and B viruses.10

However, the successful implementation of vaccination policies requires a strong national system, including national leadership, strategies and plans to identify and target the under-vaccinated, as well as a skilled workforce, an accurate health information system and community support.11 Further, systematic reviews have identified strategies that are effective in increasing vaccination coverage in targeted or hard-to-reach groups. These include measures to increase provider recommendations to clients such as reminders, incentives and feedback to providers, supportive immunisation information systems, provisions to enable vaccination by non-medical personnel, and incentives, reminders and recalls for clients.12 While information specific to implementing vaccination programs targeted at Indigenous people is lacking, effective implementation of Indigenous Australian healthcare in general has been found to be supported by clearly defined management systems, employment of Indigenous health workers as leaders, community control, partnerships, tailoring for diverse places and settings and active facilitation methods.11

What is current practice or policy?

Current national policy is for broader recommendations and eligibility for free annual influenza vaccine for Indigenous people (ie. all aged 6 months and older) compared to non-Indigenous adults (6 months to less than 5 years; aged 6 months and over with medical at-risk conditions; pregnant women at any time and those aged 65 years or older), due to higher rates of serious outcomes in Indigenous adults.9 This policy appears to be appropriate, based on available evidence, however current practice remains inadequate to achieve satisfactory implementation.

Areas where current practice at the national level is not consistent with the best evidence outlined above are: inadequate national leadership, inability to identify and target the under-vaccinated and inadequate health information systems. For strategies targeting hard-to-reach groups, there are no incentives for vaccination and strategies such as recall and reminders are at the discretion of individual providers. There are also limitations on the use of strategies that are effective in Indigenous healthcare delivery in general, including the use of Indigenous health workers and community control. More specifically, vaccination coverage data are available only once every eight years from the National Aboriginal and Torres Strait Islander Health Survey, down to the state/territory level but not smaller areas.1

An expansion of the Australian Childhood Immunisation Register to include all ages13 has occurred but adult vaccinations are substantially under-reported14 and substantial obstacles exist to its ability to adequately identify Indigenous people in the future. There are no performance indicators related to Indigenous adult vaccination at the national, state/territory or local levels.15 The accreditation of Aboriginal Health Workers to vaccinate occurs in only a minority of jurisdictions.16 Indigenous community engagement and the involvement of Aboriginal Health Workers (AHW) are determined at the local level and the extent of these practices at a broader level is not known.17 Given the limited distribution of Aboriginal Community Controlled Health Services, substantial reliance is placed on General Practice to implement this policy, with no requirements for community engagement or employment of AHWs and low levels of identification of the Indigenous status of clients.18

What would the impact be if the proposed action was implemented?

The implementation of strategies to correct the deficiencies in current practice mentioned above are likely to result in a substantial increase in vaccination coverage and have flow-on impacts on other areas of health care delivery through strengthening systems. However, community consultation and engagement, as well as rigorous evaluation will be required to ensure the potential benefits are realised. 

We estimate that increasing influenza vaccination coverage in Indigenous adults from 34% to 90% would prevent 1,200 hospitalisations and 250 deaths in Indigenous adults each year.19

References

  1. Dyda A, Karki S, Kong M, Gidding HF, Kaldor JM, McIntyre, P, Banks E, MacIntryre CR, Liu B. Influenza vaccination coverage in a population based cohort of Australian born Aboriginal and non-Indigenous older adults. Commun Dis Intell 2019; 43 (https://doi.org/10.33321/cdi.2019.43.30)
  2. Li-Kim-Moy J, Yin JK, Patel C, Beard FH, Chiu C, Maccartney KK, et al. Australian vaccine preventable disease epidemiological review series: influenza 2006 to 2015. Commun. Dis. Intell Q Rep. 2016; 40(4):E482-95.
  3. Naidu L, Chiu C, Habig A, et al. Vaccine preventable diseases and vaccination coverage in Aboriginal and Torres Strait Islander people, Australia 2006 –2010. Communicable Diseases Intelligence 2013;37 Suppl:S1-95.
  4. Australian Institute of Health and Welfare 2015. The health and welfare of Australia’s Aboriginal and Torres Strait Islander peoples 2015. Cat. no. IHW 147. Canberra: AIHW
  5. Australian Government Department of Health. Immunisation for Aboriginal and Torres Strait Islander people. https://beta.health.gov.au/health-topics/immunisation/immunisation-throughout-life/immunisation-for-aboriginal-and-torres-strait-islander-people. Accessed 9/4/2019. 
  6. Webster F et al. What isn't measured isn't done – eight years with no progress in Aboriginal and Torres Strait Islander adult influenza and pneumococcal vaccination, 2019. Australian and New Zealand Journal of Public Health, Indigenous Health 43 (6) 558-562
  7. AIHW 2011. 2009 Adult Vaccination Survey: summary results. Cat. no. PHE 135. Canberra: AIHW.
  8. Vaccines against influenza. WHO position paper November 2012 Weekly Epidemiological Record No. 47, 2012, 87, 461–476 Available at: http://www.who.int/wer/2012/wer8747.pdf?ua=1
  9. Australian Government Department of Health and Ageing. The Australian Immunisation Handbook 10th edition, updated 2017 Canberra, Australian Government; 2017.
  10. Dawood FS, Chung JR, Kim SS, et al. Interim Estimates of 2019–20 Seasonal Influenza Vaccine Effectiveness — United States, February 2020. MMWR Morb Mortal Wkly Rep 2020;69:177–182. DOI: http://dx.doi.org/10.15585/mmwr.mm6907a1external icon.
  11. World Health Organisation. Global Routine Immunization Strategies and Practices (GRISP): a companion document to the Global Vaccine Action Plan (GVAP). Available at: http://apps.who.int/iris/bitstream/10665/204500/1/9789241510103_eng.pdf?ua=1
  12. Jacob V, Chattopadhyay SK, Hopkins DP, Murphy Morgan J, Pitan AA, Clymer JM. Increasing Coverage of Appropriate Vaccinations. Am J Prev Med.50:797-808
  13. Australian Government Department of Human Services. Australian Immunisation Register. Available at: https://www.humanservices.gov.au/individuals/services/medicare/australian-immunisation-register
  14. Hull B. et al. Exploratory analysis of the first 2 years of adult vaccination data recorded on AIR, National Centre for Immunisation Research and Surveillance Australia, 2019
  15. Australian Government Productivity Commission. National Partnership on Essential Vaccines performance report. Available at: https://www.pc.gov.au/research/ongoing/essential-vaccines-assessment/2016-2017
  16. McCalman J, Bainbridge R, Percival N, Tsey K. The effectiveness of implementation in Indigenous Australian healthcare: an overview of literature reviews. [Review] International Journal for Equity in Health. 15:47, 2016 Mar 10.
  17. Immunisation Provider Competency Working Group, National Immunisation Committee. National Immunisation Education Framework for Health Professionals. Available at: https://beta.health.gov.au/resources/publications/national-immunisation-education-framework-for-health-professionals
  18. Thomson A, Morgan S, O'Mara P, Tapley A, Henderson K, van Driel M, Oldmeadow C, Ball J, Scott J, Spike N, McArthur L, Magin P. The recording of Aboriginal and Torres Strait Islander status in general practice clinical records: a cross-sectional study. Australian and New Zealand Journal of Public Health:40(S1);1753-6405.
  19. Newall AT, Wood JG, MacIntyre CR. Influenza-related hospitalisation and death in Australians aged 50 years and older. Vaccine 2008;26:2135-41.