Exploring indirect protection associated with influenza immunization – A systematic review of the literature. Issue 49 (20th November 2019)

• Record Type: Journal Article
• Authors: Friedman, Lindsay; Renaud, Ariane; Hines, Delaney; Winter, Anne; Bolotin, Shelly; Johnstone, Jennie; Kwong, Jeffrey C.; McGeer, Allison J.; Crowcroft, Natasha S.; Warshawsky, Bryna F.
• Is Part Of: Vaccine. Volume 37:Issue 49(2019)
• Page Start: 7213
• Page End: 7232
• Publication Date: 2019-11-20
• Subjects: VE vaccine effectiveness -- ARI acute respiratory illness -- MAARI medically attended acute respiratory illness -- ILI influenza-like illness -- P&I pneumonia and influenza -- Δ delta -- PCR polymerase chain reaction -- ED emergency department -- RCT randomized controlled trial -- US United States -- UK United Kingdom -- R reproductive number -- Ic herd immunity threshold -- IQR interquartile range; Indirect protection -- Vaccine effectiveness -- Influenza vaccine -- Seasonal influenza; Vaccines -- Periodicals; 615.372
• DOI: 10.1016/j.vaccine.2019.09.086
• Languages: English
• ISSNs: 0264-410X

Abstract

Abstract: Background: Influenza causes significant annual morbidity and mortality, particularly in older adults, for whom influenza vaccine effectiveness (VE) is also lower. Immunizing one group (e.g., children) against influenza may indirectly protect another group (e.g., older adults) against influenza and its complications. Methods: We updated previous systematic reviews on indirect protection against influenza by searching MEDLINE and EMBASE for relevant human studies published until January 4, 2017. We abstracted and critically appraised English language publications that reported or provided information to calculate indirect VE against influenza, as a percentage, in non-institutional settings. We developed a term called 'estimated actual protection' to explore the relationship between indirect protection and the product of direct VE and relative vaccine coverage. We calculated estimated actual protection for a subset of studies that reported coverage and indirect VE for: laboratory-confirmed influenza; outpatient care for respiratory illness; influenza-associated emergency visits; or influenza-associated hospitalizations. We ran linear mixed models to compare estimated actual protection against indirect VE for the four outcomes, and graphed the data. Results: Of 2320 unique records identified, we abstracted and appraised 26 articles describing 24 studies. The majority of included studies reported at least one outcome suggesting that immunizing one group reduced influenza-related outcomes in another group. Critical appraisal of the abstracted studies identified recurring methodological weaknesses, such as lack of laboratory-confirmed influenza. Our exploratory analyses of 18 studies indicated a positive but not statistically significant relationship between estimated actual protection and indirect protection for each of the four outcomes. Conclusions: Our systematic review and exploratory analyses suggest influenza immunization provides some level of indirect protection. However, our critical appraisal highlights the need for a standardized and consistently applied approach to measuring indirect protection against influenza to fill existing knowledge gaps. Additionally, the concept of estimated actual protection requires validation.