Immunisation & Treatment - Societal benefits of immunising children

00:00 ESWI Secretariat
Welcome to ESWI Airborne. This series on immunisation and treatment is made possible thanks to the kind support of AstraZeneca, GSK, Novavax and Roche.

00:27 Clare Taylor
Welcome everyone to ESWI Airborne. This is your host, Clare Taylor speaking, and in this episode we'll be talking all about immunising children—a very important and sometimes sensitive topic—and we'll be learning why this matters for our children and indeed for all of us. So I'm really delighted we have a sort of child immunisation super group here in the studio with us today, and I'm very pleased to welcome Paula Tahtinen, adjunct professor at the University of Turku in Finland and ESWI board member. Good to see you again, Paula.

01:04 Paula Tahtinen
Thank you, Clare, so I'm very happy to be here.

01:07 Clare Taylor
Also with us we have Hanna Nohynek, Chief Medical Officer, team Leader of Vaccine Programme Development at the National Institute for Health and Welfare in Finland and a Senior Technical Vaccine Advisor nationally and internationally. Welcome, Hanna.

01:25 Hanna Nohynek
Thanks.

01:26 Clare Taylor
And, last up, a very warm welcome to Andrew Pollard, who is such a distinguished immunologist that I hardly know where to start. Professor, Sir Andrew Pollard is also a paediatrician. He was chief investigator of the Oxford COVID-19 vaccine trials. He is a director of the Oxford Vaccine Group. He climbs mountains, he wrestles bears. He hosts his own podcast, the Oxford Colloquy. Check it out and welcome, Andy, to ESWI Airborne.

01:57 Sir Andrew Pollard
Thank you so very much for that very kind introduction.

02:00 Clare Taylor
And thanks to all of you for joining us today. Let's just jump right into this. Now, most parents are familiar with the routine immunisations in early childhood—you know, polio, MMR, chickenpox and so on—but perhaps we're less familiar with what the best practice is for protecting young children against respiratory viruses such as flu and COVID-19. And I mean just to throw this open: it seems that COVID-19 is usually a mild illness in children, so why should they be vaccinated?

Well, thanks very much for starting with the toughest of the questions with COVID-19. And of course, we have to always think about the context we're in at this moment when thinking about vaccination. And today not only is COVID-19 a mild illness in children, but actually most children have already had it and therefore, as a result of both the infections they’ve been through in childhood and some children being vaccinated, there is today an incredibly low risk of any child ending up with severe disease or hospitalisation, and so many countries no longer, for healthy children, have any programme to vaccinate children against COVID-19 because that risk is near to zero. However, there are some subgroups of children who we recognised earlier in the pandemic, before the virus had spread, were at particular risk from more severe disease, and many countries still retain advice to vaccinate in those groups—so particularly children with neurological problems, Down syndrome, where there may be a greater risk. Having said that, in my own paediatric practice today we really are not seeing children in hospital with COVID-19. And I think that really does reflect this changing place that we're in now, where this virus perhaps has changed itself so it's a slightly milder infection, but also most of the child population is immune. It is important to say that some countries still retain that earlier advice and in the US you can be vaccinated from six months of age. But here in the UK there's no longer a major effort to vaccinate children, simply for that reason that the benefit for the health system in doing that would be very small.

04:27 Clare Taylor
Hanna, what's your take on this?

04:29 Hanna Nohynek
I very much agree with what Andy just said and actually in Finland, where I come from, we recommend COVID vaccination for children 12 years and up who are severely immunocompromised, meaning that they are children with cancer and who get immunosuppressive treatment. So very much in line with what the UK does. However, there are countries that think differently, and actually the WHO Strategic Advisory Group of Experts has said that, depending on the epidemiologic situation of a country and in-country decision-making, countries may want to consider vaccinating children, but it is not really a recommendation for vaccinating healthy children.

05:14 Clare Taylor
So important to keep updated on the best advice, as the context, as Andy rightly highlighted, changes with it. So how about the flu shot? Paula? What do you recommend to the parents of the children that you see in your practice?

Well, flu that's caused by the influenza virus is actually a significant virus among children, and it causes a lot of hospitalisations for children, especially for younger children, and that's why I always recommend parents to give the flu vaccine to their children. The reason why they should get it every year is that the influenza viruses change all the time, which means that there are mutations in their genome that make them escape from the body's immune system. The virus is changed just enough to escape from the immune system, but not enough to become a completely new version of the virus, and that's why they should have it every year. Also, the antibody levels may decline over time. And when we talk about getting the flu vaccine with parents, I always talk about other diseases as well. It's important to note that the influenza vaccine also gives some protection against secondary diseases, such as ear infections and pneumonia.

06:50 Clare Taylor
This is important to know, and I think that a lot of parents are often rightly cautious, perhaps, regarding immunisation. And I mean, I'm curious to know a little bit more about the process of what happens before a government or a health authority makes a recommendation for a new vaccine. Hanna and Andy, I think you both have something to share with us.

07:14 Hanna Nohynek
Yes indeed. Well, that very much depends on the funding basis of the national programme that the country has. In the UK and Finland, it's the government, the taxpayers, that pay for the national programme, and therefore it's really important that the new vaccines that are introduced also bring sufficiently justified health return. At least in Finland, we first look into the disease burden, then we look into the safety of the vaccine on individual and population level, and lastly, we do increase the budget for vaccinations and then it's introduced. So it's a rather formal and sometimes long, tedious process.

08:10 Clare Taylor
Hanna, how long does it take?

08:11 Hanna Nohynek
Well sometimes it can take years, because I mean, we've done the specialised analysis and made the recommendation for the government, but if the parliament doesn't find the funding for it—which has been the case, for example, with the Zoster vaccine for elderly—we've been waiting for several years already. So that very much depends on how a government wants to spend its taxpayers' money, and not all countries, even in the EU, are similar.

08:39 Clare Taylor
Andy, do you see differences in the UK?

I think our experience is really very similar to those that Hanna just outlined. One of the jobs of the Joint Committee on Vaccines and Immunisation, which is the scientific committee that advises the government on vaccines, is to assess new vaccines to make sure that the evidence is there that they're safe, that they're effective, and that there's an appropriate burden of disease which could be prevented by their use. But then the final question is: are we making good use of public money? And we have a formal process for assessing that around cost-effectiveness that makes sure that, with the limited healthcare budgets that are available, we’re not spending that money on things which have much less impact in the health system when that same money could be spent more efficiently on some other product or process within the health system. So I think that really is very similar to Hanna's experience. It can take a while to implement, and that's not just delays through the process of government, but also there's quite a lot of work to do to put in new vaccines into a programme and educate all of the staff across the health system who are going to be delivering it, to make sure that we're ready and that we can communicate that to the public. I mean, one good example of that is flu, which you were just talking about, and here in the UK we give a live attenuated flu vaccine. So that's the nasal spray vaccine to all children at now up to the age of 15 years and that's a huge program to implement. We started it and it took several years to roll it out, increasing the cohorts of children who are included, because the amount of staff and and capacity you need in the system to deliver that, even when you've got the decision, is very difficult to put in place in England anyway in one year just because of the number of people who need to be vaccinated. And of course, as you were hearing from Paula, there's direct benefits for the children by having their flu prevented. But also it reduces transmission of the influenza virus, so we have less infections in adults and particularly older adults. So we get an added benefit which can be included in that cost-effectiveness analysis about the benefits of vaccination.

11:02 Clare Taylor
Thanks for that. That's a really important point and I'm going to come back to that later. Indeed, on the wider benefits, but I just want to know first from you, Hanna and Andy is there any difference between adults and children when you're recommending a new vaccine?

11:18 Hanna Nohynek
Not really. I mean our processes to do the expert work is very similar. The data elements are the same. Of course it may take more time to actually study the disease burden among adults and elderly, simply because there are so many more risk groups than among children, but the elements of that decision making are very much the same.

11:39 Clare Taylor
Okay it's the same kind of process.

I think the only thing I would add is that there are some operational differences and you have to take that into account. Delivering within a childhood program and the opportunities for delivery or in pregnancy, for vaccines in pregnancy, are different from those that you might see in the adult population.

12:01 Clare Taylor
So when you say operationally, andy, do you mean in the timing of it, or you made the point that the flu vaccine is being delivered through nasal spray rather than by injection?

I think it's more which bit of the healthcare system is involved in delivery. I mean, for example, some flu vaccinations are given through pharmacies in the UK and in many other countries, whereas a lot of, in fact the majority of, childhood vaccinations currently are given through the primary care system of the general practitioners and practice nurses.

12:33 Hanna Nohynek
So we actually talk about platforms. We talk about the childhood vaccination platform, we talk about the healthcare worker platform, we talk about the pregnancy platform and adult or elderly platform, and the services may differ and the capabilities of giving vaccines isn't always the same in all these different platforms and places.

12:53 Clare Taylor
Okay, and the platform is like the sort of operational delivery mode, like how it happens. Okay, that's really useful, thank you. So let's take another example. You know we've got new RSV vaccines are available and, Paula, I particularly remember when we talked before in the Meet the yes, we Members podcast series you explained really the greater burden of disease from RSV in particularly young children, children under two years of age, and saying that two to three percent are hospitalised. So what's the state of play with these new vaccines and are they recommended for children?

Well, yes, they are, and I, as a clinician, have been very happy to see that during the past year, we actually have seen several advances in relation to protection against RSV. So in Europe, the European Medicines Agency actually approved the use of this long-lasting monoclonal antibody against RSV last fall and they also approved the use of the first RSV vaccine in July 2023. The monoclonal antibody it's called Nirsevimab it's a very difficult word to pronounce for a non-native speaker, but it mimics the antibody that the body makes, but it's actually made in the laboratory and it helps to prevent to get the severe disease, and this is called passive immunoprophylaxis, and now it may be used for all infants during their first RSV season. So this is a great new product that we could use to prevent those severe diseases.

Another interesting topic is the maternal vaccines that we already heard a little bit about. So we can actually vaccinate mothers when they are pregnant and, if they get the RSV vaccine, that can protect the newborn by not getting the RSV disease, and this is another type of passive immunisation for the infant. And these are two new options that we have, and I'm really looking forward to see what kind of changes we see in the hospitalisation rate among infants.

15:21 Clare Taylor
And is this kind of year zero now? And, andy, are you seeing this in the UK as well? What are the recommendations there?

Well, I think my first comment is I'm not sure that Nirsevimab is an English word either. I don't know what language it comes from, but I don't think we should worry about the difficulty in pronouncing it. So I think from the UK perspective we are really excited about the availability of these new products, both the vaccine in pregnancy as well as the monoclonal for the newborn because of this huge burden of RSV disease that we see in the frontline and in the UK it's between about 22,000 and 30,000 hospital admissions every year, with some of those babies ending up in intensive care. And if we can reduce those by the amount that is promised from the trials let's assume there's high coverage of the products then it will dramatically change paediatric services in our hospitals in that very pressurised time in the winter, and so we see both of these, whichever one is eventually purchased by the UK government, to have a very high chance of having an impact against this very problematic disease. It is important to remember that, although it's a big burden on hospital services I mean high-income countries like ours from a global perspective this is one of the most important killers of infants in low and middle-income countries. So although it's very exciting for us, it's much more important in the life-saving opportunity that there is with these products in the future, and I do hope we're going to see them, before too long, rolled out in other countries too.

17:01 Clare Taylor
My goodness, that's really a stark reminder and thank you so much for giving us that additional context. I must say that putting the numbers and the you know different country context on it makes quite a difference from two to three percent, you know, as the first headline number. And I suppose, while we're on that, I mean when we're talking about immunising children, we're primarily concerned with protecting children, but there's also the consequences for those around the children, right, parents and families and caregivers and educators. And you know I think earlier, Andy, it was you that you mentioned transmission that there's like cuts transmission. I mean, what do we know about the wider benefits so far?

It does vary with different products and I think the issue with RSV vaccines and the monoclonal is that we've got good evidence of the direct benefit that these products will in protecting the other members of the population who are not given these products. There are reasons to think that for RSV that the wider benefits may be less in terms of the indirect protection of toddlers or the elderly, because we're not sure how important very small infants are in the whole transmission cycle. There's some evidence, particularly most recently from Kenya, showing that it's toddlers who bring RSV into the household and infect the babies. So if the reservoir of infection is more in other age groups than it is in the very young severely affected infants, it might be that these products have less of an impact more widely. I think we're going to discover that as time goes on. But there are additional benefits which we're really hopeful about of RSV interventions. If we prevent severe disease, could we also prevent some of the childhood wheezing and asthma that's seen later. There is a very clear association between RSV infection and those diseases. But what we're not sure about at this moment is whether these products on the population level are actually going to prevent those long term outcomes, and that's something which I think we'll all be looking at very carefully once these programs start.

19:31 Clare Taylor
Hanna, what's your take on this?

19:34 Hanna Nohynek
Exactly as Paula and Andy said, that it's too early now to introduce. We're waiting for the analysis again on the cost effectiveness and then the decision making of politicians to have those vaccines in. I think both parents and doctors and healthcare workers are eager to see these coming in. However, it does take time and, just like with pneumococcal vaccines, where in the beginning we were not quite sure on how much that would prevent infection in the elderly, it's the same question here how much protection we can have to the nearby family and caregivers. But it's the long-term effects that we oftentimes cannot factor in into these cost-effectiveness calculuses, simply because long-term data is not there. But it's something that we need to be on the lookout. Equally for influenza. We know that influenza vaccination prevents not just influenza but the long-term consequences like brain insults and myocardial infarctions. The same may be with RSV for children, as Andy said, maybe preventing asthma and wheezing in later on life. But these are questions that we need to be very carefully looking into, very carefully looking into and luckily we do have health registers which then allow us to do long-term cohort studies and linking individual data of individual children to their long-term effects and health outcomes for later on. So there's a lot more that we will find out about these vaccines.

21:09 Clare Taylor
And when you say long-term, I mean what kind of timelines are we talking about? Is this 5, 10, 15 years out?

21:17 Hanna Nohynek
Well, with the wheezing, I think we are looking into like a five years time span, but with the other impacts of course those will come sooner. Whether there is indirect protection from those close by, whether we see that at all or some,

I suspect actually with the wheezing which we see particularly in the second and third year of life, what we know fondly in pediatrics as the happy wheezers, if that really is prevented, I think we'll know very soon after these programmes are implemented.

21:48 Clare Taylor
That's exciting, that's really exciting. And does this issue of kind of wider society and you know the kind of these bigger benefits, do you think this factors into parents' decision making? I mean, Paula and Andy, when you talk with parents about immunisation, what's most important for them?

Paula Tahtinen
22:09
Well, I think when we talk with parents about immunising their children, they very often think about themselves and their children. So quite often they want to know about possible harms or side effects of the vaccine, and this is something we always discuss. Luckily, the side effects are usually mild, such as pain and redness at the site of the injection, and when we think about vaccinating children, the benefits should always outweigh the harms, as we discussed earlier. But I think that the vaccination against COVID-19 actually made parents think more about this social responsibility. As we heard, COVID-19 very rarely is a severe disease for children, but there were many families who actually chose to vaccinate their children in order to protect grandparents, for example, so that the children could be near their grandparents and other people who are at risk of more severe infection.

Clare Taylor
23:24
Andy, did you encounter this in your discussions? The idea of the social contract or social responsibility? Did that factor into a family's decision making around this topic?

Sir Andrew Pollard
23:35
I mean, I think this whole area is very interesting in talking with parents about vaccination. Of course the vast majority of parents are very accepting of vaccines and when we look at vaccination rates, particularly in Western Europe, they're really very pleasingly high. But there is always a proportion of individuals whose children are not vaccinated and it's really important to understand the reasons for that and what we find. Whether you're in South London or you're in some of the poorest communities in Africa, the reasons for being unvaccinated are largely around access to vaccines. It's not the hesitancy and the anti-vaccine lobby which get amplified in the media. It's because we don't have good systems in place to access those communities. And if you think, for example, as we do in London, some communities with very large family sizes — if you've got seven or ten children and the new baby needs to go to a vaccine clinic two bus rides away on a Tuesday, it's very unlikely that you're going to get that new baby vaccinated. And I mean I have three children and when they were small I would not have been able to take three of them on a bus ride on my own to get the new baby vaccinated. It's really tough. And so I think when we look at the many examples around, they're different for different communities. For why people are not vaccinated, it's very rarely these nuanced issues that we talk about. It's usually just access to the vaccines. We need to solve that everywhere in the world.

Clare Taylor
25:10
That's very immediate, that's practical. That's the platform, the delivery mode. How does this actually happen? Right, and Hanna, do you see this sort of conversation or the narrative around childhood immunisation? Have you seen that change at all in recent years?

Hanna Nohynek
25:26
Well, of course the social media brings bubbles and there is fierce discussion in some bubbles, but when you look into the overall vaccine coverage rates it doesn't really reflect there that much at all. The only vaccine where we haven't reached such good coverage is actually influenza, and there I think that the discussion is still very much like what it used to be ten years ago. Parents asking — is influenza truly so important that I need to vaccinate my child? And I think the understanding of what influenza does is something that we are trying out different ways of making parents understand. What it will be with the RSV — it remains to be seen. With COVID, I think the fact that so many have met the virus and are immune has kind of quieted down the conversation there. Of course there are always people who are concerned about vaccine safety, and when there is a new vaccine there are some parents who would rather wait and see what happens to the safety profile, but those are really a minority.

Clare Taylor
26:37
Andy, is there anything that you would like to see change in attitudes towards childhood immunisation?

Sir Andrew Pollard
26:44
Well, I think it would be ideal if we could reach a level of both the scientific understanding of vaccines and the acceptance of them in the wider public that we have for things like wearing seatbelts — where if I get into my car and the person in the passenger seat is not wearing a seatbelt, I feel very uncomfortable about setting off down the road. But it remains, I think, a problem where there's still a conversation around the benefits of childhood immunisation. There really shouldn't be a conversation. We should all just know the incredible benefits that we have as a society and for our children in protecting them against these serious diseases. So I hope we can one day reach a point where it is much more like that. I have to say that when I talk to people in the Scandinavian countries, I think society is much closer to that view of the world than we have in some other countries in Western Europe.

Clare Taylor
27:44
Yes, and I think on today's episode we have a particularly Finnish-dominated conversation about this, but it certainly is practice that we can hope will spread elsewhere. So that's it, I think we'll leave it there. That's a really kind of positive outlook that we can have — that the science and the societal viewpoints coincide — and we hope that with today's episode we have contributed some small part towards that goal. So, Hanna, Paula, Andy, thank you so much for being here and for having this conversation here today.

Sir Andrew Pollard
28:22
Great pleasure to join you, thank you.

Paula Tahtinen
28:23
Thank you.

Hanna Nohynek
28:24
Thank you so very much, and let's all be sure that all those who need their vaccines get vaccinated.

Clare Taylor
28:37
And thanks to all of you listeners for tuning in today to ESWI Airborne and getting really super expert and most up-to-date insights on immunising and protecting our children and one another. A tiny reminder that this episode is one of a three-part series on immunisation and treatment. Do check out the other episodes on travel medicine and lessons from the COVID-19 pandemic for flu prevention and treatment. Meanwhile, until next time, dear listeners — stay safe.

ESWI Secretariat
29:12
ESWI Airborne is brought to you by ESWI, the European Scientific Working group on Influenza and other acute respiratory viruses. These episodes would not be possible without the team's efforts and we would like to extend special thanks to our ESWI secretariat, our technical and IT teams, our arts team and our host, Clare Taylor. The podcasts are recorded virtually and we thank our guests for their participation in this inspiring series. Talks are adapted to a global audience and are intended to be educational. For any specific medical questions, please contact your local general practitioner. Many thanks to our sponsoring partners — and thank you for listening.

Immunisation & Treatment - Societal benefits of immunising children

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