Why is promoting seasonal influenza guidance and vaccines especially difficult

I've dusted off my notes on the need to build better capacity to promote demand for the seasonal influenza vaccine, and how this could be used in response to pandemic influenza and even other respiratory pathogens of zoonotic origin.

How can we strengthen health systems and programming to be more effective in responding to outbreaks of seasonal influenza, preparing for pandemics, or to build expertise to surge in response to other outbreaks like the bird flu?

Not all organizations and health systems connect influenza programs to responding to respiratory pathogens of zoonotic origin, but I still think this capacity and practice in routine seasonal influenza health programme could go a long way.

Any vaccines that are offered to adults help condition the adult population to receive vaccines in the future emergencies or against new future pathogens.

It helps when we think from point of view of different populations, not vertical programmes.

It's especially difficult to ensure high seasonal influenza vaccine uptake

Seasonal influenza has unique attributes that makes it difficult to ensure high adherence to guidance including robust vaccine uptake. These include factors such as:

• Historic flu vaccine coverage in countries with robust adult flu immunization programmes is quite low compared to childhood routine vaccinations
• Low prioritization in LMIC immunization programmes which have historically focused on children’s vaccines
• Different countries prioritize different population groups for seasonal influenza vaccine, eg pregnant women, older people, health workers, etc.
• In many countries with long standing immunization programmes for flu, collaborating with the world of work and community based organizations has helped bring flu shots to people’s workplaces and doorsteps, long before COVID-19 experience.
• Low risk perception contributes to low flu vaccine uptake among general populations and health workers
• Policies encouraging flu vaccination usually are not as far reaching as those during the COVID-19 pandemic, eg vaccine mandates, making it harder to achieve high vaccine uptake or achieve herd immunity
• Changing seasonal formulation of the flu vaccine can result in varying levels of effectiveness against dominant flu strains, and therefore affecting risk perception and perception of the benefits of the flu vaccination
• Year to year, the dominant flu strain may have different levels of severity or present different symptoms in different populations, which can result in having to provide updated guidance, eg severe outcomes observed in healthy young adults this year compared to last year, which affected children and the elderly
• Respiratory pathogens and flu can cross the human-animal interface, requiring coordination with one health programmes
• Persistent mis- and disinformation about flu vaccine affects vaccine confidence, especially among vulnerable populations, eg pregnant women, minority communities, etc
• Risk comparisons and messaging around COVID-19 vaccine has collided with flu season and flu vaccine campaigns, which have complicated public health responses to twindemics

All of these challenges need active management during and off influenza season, because no matter what time of year it is, the flu season is occurring somewhere in the world, affecting community conversations and health programme responses globally.

Vaccine demand must be promoted at community level, within health systems, and at a policy level, so that people have confidence and trust in vaccines that vaccines work, are safe and are part of a trustworthy medical system.

Many of the factors listed above can impact vaccine confidence and uptake and must be considered when developing effective confidence and demand strategies. High quality health service delivery, supported by adequate supply, and appropriate policies, must meet high community demand for a flu vaccine to reach high vaccine coverage and promote herd immunity and thereby reducing morbidity and mortality.

Health workers and populations will remember their experience of COVID-19 pandemic through their lifetimes

The experience of the COVID-19 pandemic has had multiple impacts on populations and health systems. Challenges have included erosion of trust in science, vaccines, and health service delivery in communities.

Overworked and burned out health workforces have had to contend with supply chain issues, staffing shortages, rapidly changing policies, vaccine hesitancy in their own ranks, and breakdown of the primary heath care delivery, as health systems struggled to support COVID-19 mitigation and vaccination efforts.

As the COVID-19 pandemic drew on, new unanticipated challenges emerged, including pandemic fatigue, major impacts on economic, social and educational outcomes, further polarization of societies, rapid dissemination and amplification of health mis- and disinformation.

This has permanently changed how populations will perceive and interact with the health system and emergency response in future emergencies and pandemics. The next pandemic response will be messier.

Seasonal flu programs are the places in the health system where the capacity for a future respiratory pathogen pandemic can be built

The speed and effectiveness of emergency response to an unknown respiratory pathogen or a novel influenza outbreak will be determined by a health program’s familiarity with best practices and tools for promoting vaccine demand for seasonal flu.

Recent pandemics have taught us that the beginning stages of an emergency are not the time to build from scratch entirely new ways of promoting adherence to public health guidance and promoting vaccine demand.

Therefore, a strong seasonal influenza programme that uses tools and strategies to address the above challenges effectively will be much better prepared to quickly adapt them to future influenza pandemics and epidemics.

What should we be teaching and practicing in seasonal influenza vaccine demand promotion?

• Learning from the past: what previous flu outbreaks and pandemics have taught us
• State of the global seasonal flu picture
• Essentials of a flu vaccination programme (includes seasonal flu surveillance, vaccine supply, vaccine development, outbreak response, policies, health worker training, microplanning)
• Health equity, vulnerable populations and seasonal flu recommendations
• Introduction of public health and social measures to seasonal flu response
• Building vaccine confidence in health workers
• Supporting health workers to effectively address flu outbreaks
• Building demand for seasonal flu vaccine
• Infodemic management for seasonal flu
• Science communication for seasonal flu
• Building partnerships with the world of work
• Cocreation of guidance and tools with vulnerable populations

This should be supported with mini toolboxes on technical topics, such as:

• Measuring socio-behavioral determinants for seasonal flu vaccination
• Essentials of crisis and emergency risk communication for flu
• Infodemic management resources and tools, eg standard Boolean search strings on flu topics, common flu-related misinformation and strategies to address them, social listening taxonomy, infodemic insights development
• Guidance and tool cocreation strategies and approaches
• Health and science communication essentials
• Flu surveillance primers and explainers

This whole approach could also easily be adapted to respiratory pathogens of zoonotic origin - adding things like crossectoral animal-environment-human health coordination and actions; building confidence in farmworkers; etc).

Either way, people's perceptions of