Flu vaccinations: an active step towards health equity 

By Dr Maia Melbourne-Wilcox and Dr Sue Crengle

9 April 2020

Influenza causes preventable morbidity and mortality.  Annually, it accounts for 1-2% of all deaths in Aotearoa [1]. Māori experience inequitable outcomes with the flu,  in that they have both a higher burden of the disease and suffer higher rates of associated complications[2]. This results in requiring additional medical reviews and hospitalisations. Māori have also been shown to be at much greater risk of dying prematurely from the flu. Māori are 3.6 times more likely than non-Māori to die due to the flu in a normal flu season [1]. This inequity could potentially be even greater in the setting of a pandemic, such as we are experiencing currently.

Annual flu vaccines are our best method of preventing the flu and have been shown to reduce rates of hospitalisation and those suffering flu-related complications [2].  It has been widely accepted that the 2020 influenza season will likely add additional pressure to our health system. The best way to prevent this additional burden on our system is by ensuring those most at-risk of flu, particularly those that experience more severe illness, all receive flu vaccines as a matter of urgent priority.  The Ministry of Health has provided guidance that overall our immunisation rates for Māori are notably lower compared to other groups [2]. 

Standard practice in primary care, often uses a combination of recall systems to trigger patient reminders and opportunistic vaccinations during in-person consultations. This approach however, ignores the existing barriers to care that some of our patients experience and contributes to our inequitable vaccination rates. Evidence has shown that the strongest single factor influencing patient uptake of the influenza vaccine is a personalised, specific recommendation from a doctor or nurse [3].

This year, with COVID-19, greatly reduced in-person appointments, and the public being in lock down from Wednesday 25 March, standard generic reminders will not likely be effective enough to reach those most at-risk.  Instead, specific and targeted measures will need to be taken in order to vaccinate our most vulnerable populations [1]. This will have the benefit of trying to protect the health of the most vulnerable and their families - and to help prevent additional preventable pressures being placed on our health system at a later time, when it may be most needed. 

Groups which require specific targeting in order to receive more equitable access to vaccinations are:

  • Funded high risk groups for 2020 (can be claimed from 18 March 2020):
    • Māori over 65 years with or without co-morbid conditions. 
    • Māori with particular comorbid conditions. 
    • Māori who are pregnant.
    • Māori under the age of 4 years who have a history of significant respiratory illness whether it required hospitalisation or not (e.g. bronchiolitis, asthma, pneumonia, bronchiectasis etc.).
  • Non-Funded high risk groups: 
    • Māori children (vaccination for 6mth to 3 years will be available from 1 April 2020).
    • Māori who are quintile 4 and 5 and those living in poor quality housing and overcrowded conditions.
    • Homeless or anyone whose ability to  adequately care for themselves may be impaired e.g. deterioration in mental health.
    • Note: While these groups are not currently funded, GPs should still identify and  offer flu vaccinations to these groups when allowed, as these groups still experience inequitable outcomes and complications with influenza.

Remember that:

  • This year’s funded flu vaccine is not contraindicated in those with egg allergies/anaphylaxis as the ovalbumin content is less than that required to trigger an anaphylactic reaction [2].
  • IMAC have made recommendations which means that patients who meet specific criteria may be able to leave before the usual 20 min observation period is up. This information can be found here.

Handy hints for primary care:

  • Talk about the importance of flu vaccination and offer opportunistic vaccine during every phone, virtual and in-person consultation with Māori patients. 
  • Keep some vaccinations aside for the opportunistic screening of Māori patients who might not be able to come back at another time because of transport or other barriers.  
  • Get your high-risk patients in now so that when flu vax is open to the general public you won’t be overwhelmed.  
  • Priority groups will need to be identified and specifically targeted. Focus should be on those who experience the most barriers to care AND those who are at highest risk of mortality and would require medical attention in the future if they were to contract influenza. 
  • Send out automated texts to these patient groups. One possible message could be ‘Kia ora, It’s really important to get your free flu vaccine this year. It’s here now. Please phone us to make a time to come in. It‘s okay to leave your house to come to the doctors.’ 
  • Remember that there will be people in the community without phone credit to ring you.  
  • Dedicate a clinical staff member to call Māori who don’t respond to the text to discuss their need for the flu vaccine and how it can have benefits for both them and the whānau who are in their ‘bubble’. Personal contact allows an opportunity to relay the importance and allay any fears, misinformation or hesitation [3]. Perhaps this could be someone that isn’t able to work in face-to-face care at the moment because of the pandemic. Plan to do this within one week of the text. 
  • Re-text the non-responders ‘Kia ora, your free flu vaccine is still here for you at our clinic. Or you can get one at your local pharmacy’.  Plan to do this within two weeks of the first text.