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Independents' Day

Does flu vaccination need a helping hand?

As doubts on vaccine grow, focus falls on hand washing and COPD schemes

By Clare Ryan

As doubts on vaccine grow, focus falls on hand washing and COPD schemes

Dr Mark Smith, a GP in Barnsley, is holding the last of his flu clinics this week. And perhaps for the first time since the entire flu vaccination programme was introduced, things are running smoothly.

The vaccines have arrived, hours of nurse time have been set aside and the uptake rate looks good.

Dr Smith is an enthusiast for the flu vaccination campaign, insisting: ‘Since we improved our coverage the number of cases we see from respiratory infections has reduced.'

But not everyone is so sure, and recently a spate of studies have cast doubt on whether the hours of GP time spent on the vaccine programme are worthwhile.

A Health Protection Agency study last week found vaccination had no impact on hospital admissions for respiratory illness, while an earlier review in Lancet Infectious Diseases claimed the supporting evidence was ‘greatly exaggerated'.

Critics argue the millions of pounds pumped into the flu vaccination programme could be better invested elsewhere, for example in reducing RSV infections and COPD exacerbations. But how?

Simple hygiene

A new Cochrane review may offer some answers. The review includes all the clinical evidence of the effectiveness of interventions to interrupt or reduce the spread of respiratory viruses, excluding vaccines and antiviral drugs.

It finds strong evidence from a small number of the highest quality studies ‘that respiratory virus spread can be prevented by hygienic measures', especially around younger children.

Dr Tom Jefferson, co-ordinator of the Cochrane Vaccines Field and lead author of the study, believes the potential of simple public health measures is massive, but research in the area has been overshadowed by vaccination.

He argues: ‘Why doesn't the Government push hand washing? The trials we do have clearly show that washing your hands at least four times a day has a dramatic effect. Is it because there is nothing to sell?'

Nevertheless, vaccination is an obvious avenue to turn down, particularly for RSV infections. But the introduction of a viable vaccine is still some time away.

Even the most advanced vaccine – by MedImmune – is only in phase 1 trials.

Dr Douglas Fleming, member of the Joint Committee on Vaccination and Immunisation flu sub-group, says: ‘We haven't an effective vaccine against RSV and that's the problem. The experimental vaccines haven't stood the test of time.'

COPD focus

Another option is to focus on COPD patients, some of the most likely to be admitted to hospital with acute respiratory infections.

Dr Duncan Keeley, committee member of the General Practice Airways Group and a GP in Buckinghamshire, thinks general practice could make an impact in this area. He says: ‘The optimal primary care management of COPD is the thing that gives most scope for preventing hospital admissions.'

In one well-known initiative, GPs respond to Met office bulletins to warn patients if weather is coming that places them at high risk of exacerbations. A trial in Cornwall cut COPD admissions by half.

Other schemes provide patients with care packs, education and access to exercise and rehabilitation (see case study left).

While such schemes do seem to have benefits, many experts remain supportive of flu vaccination and do not believe hospital admission studies give the whole picture.

Dr Fleming is resolutely committed to the vaccine programme and rules out any kind of rethink. He says: ‘There was a serious problem a few years ago with flu but the vaccination has gone a long way to reducing It. Do I think there should be a change of policy? No I do not.'

Professor John Oxford, professor of virology at Queen Mary University of London, insists studies questioning the value of vaccination have been flawed, and adds: ‘We're beginning to target the RSV virus, but enemy number one is definitely influenza.'

But while the enemy may be clear, the debate over how to tackle it will rumble on.

Driving down admissions from COPD

Dr John Chinegwundoh, consultant respiratory physician at Kingston Hospital in Surrey, has worked closely with local GPs on a pioneering series of initiatives to drive down admissions among patients with COPD.
One initiative has encouraged practices to review patients' medication before the winter and issue care packs, to be used at the first signs of an exacerbation. After the first year of the initiative the number of admissions plummeted from 328 to 199.
Introducing pulmonary rehabilitation and exercise sessions has also had a significant impact, with an analysis of cohort admissions before and after rehabilitation showing admissions had fallen.

Critics argue money for flu vaccination would be better spent elsewhere Critics argue money for flu vaccination would be better spent elsewhere

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