A review of policies and coverage of seasonal influenza vaccination programs in the WHO Eastern Mediterranean Region

Abstract Background Although there has been an effective seasonal influenza vaccine available for more than 60 years, influenza continues to circulate and cause illness. The Eastern Mediterranean Region (EMR) is very diverse in health systems capacities, capabilities, and efficiencies, which affect the performance of services, especially vaccination, including seasonal influenza vaccination. Aims The aim of this study is to provide a comprehensive overview on country‐specific influenza vaccination policies, vaccine delivery, and coverage in EMR. Materials and Methods We have analyzed data from a regional seasonal influenza survey conducted in 2022, Joint Reporting Form (JRF), and verified their validity by the focal points. We also compared our results with those of the regional seasonal influenza survey conducted in 2016. Results Fourteen countries (64%) had reported having a national seasonal influenza vaccine policy. About (44%) countries recommended influenza vaccine for all SAGE recommended target groups. Up to 69% of countries reported that COVID‐19 had an impact on influenza vaccine supply in the country, with most of them (82%) reporting increases in procurement due to COVID‐19. Discussion The situation of seasonal influenza vaccination in EMR is varied, with some countries having well established programs while others having no policy or program; these variances may be due to resources inequity, political, and socioeconomic dissimilarities. Few countries have reported wide vaccination coverage over time with no clear trend of improvement. Conclusion We suggest supporting countries to develop a roadmap for influenza vaccine uptake and utilization, assessment of barriers, and burden of influenza, including measuring the economic burden to enhance vaccine acceptance.


| INTRODUCTION
Seasonal influenza is a contagious acute respiratory infection caused by influenza viruses, which circulate in all parts of the world. 1,2 Up to a billion people get seasonal influenza every year with the increasing fear of influenza pandemic; hence, there is an urgent need to monitor circulating respiratory viruses, including influenza. 3 This monitoring informs the vaccine composition recommendations that WHO issues twice a year. 4 Influenza causes high morbidity and mortality around the world, contributing to more than 4.6 million cases from 149 countries globally with 3 million cases of severe disease and half a million deaths annually. 5 Vaccination is considered the most effective control measure against influenza in spite of the presence of number of antiviral drugs approved by Food and Drug Administration (FDA) and heir availability in Eastern Mediterranean Region (EMR). 6 The protection acquired from these vaccines is limited to the vaccine antigen and fades by time. 7 Despite this, annual vaccination is highly recommended to all age groups, and the strain used in these vaccines is based on the updated data in the surveillance report of World Health Organization (WHO) laboratories. 8 Influenza vaccination is one of the key components of the strategic objectives of the global influenza strategy (2019-2030), 9 which advocates expansion of seasonal influenza prevention and control policies and programs to protect vulnerable. 10 The WHO strategic advisory group of experts on immunization (SAGE), which was established by the Director-General of the WHO in 1999 to provide guidance on the vaccines, has recommended seasonal influenza vaccination for high-risk groups as a high priority such as older adults (over 65 years), health workers, pregnant women, and individuals with underlying health conditions. 11 To reduce overall burden of influenza, including morbidity and mortality, CDC recommends annual flu vaccination as long as flu activity is ongoing once yearly as a first effective protective strategy against influenza infections. 12 Although the availability of safe, effective, and well-tolerated influenza vaccines with rare significant side effects have been in use for more than 60 years, the uptake of influenza vaccines in EMR remains sub-optimal. 13 There are several challenges, such as lack of local evidence, competing health priorities, limited collaboration among stakeholders, and vaccine hesitancy and misconceptions. 14 Consequently, in EMR, influenza vaccination implementation and use vary among countries. 15 Seasonal influenza epidemics can lead to severe economic drops through loss of workforce productivity, whether by increased morbidity, mortality, or overwhelming the capacity of health services. 16 That is why it is necessary to estimate BoD to revive influenza vaccination and convince decision-makers to strengthen their programs. 17 We would like to provide an overview of influenza vaccination in EMR to better understand gaps and work needed to strengthen influenza vaccination uptake and utilization in the region. We will describe country-specific influenza vaccination policies, distribution and delivery, coverage, COVID-19 vaccine deployment, influenza vaccination, and public awareness of influenza vaccination in EMR.

| METHODS
An analysis of (1) a retrospective data from the WHO-UNICEF-Joint Reporting Form (JRF) for the period of 2017-2021 was conducted (these data are collected through a standard questionnaire sent to all countries 18 ); (2) data from the 2021-2022 influenza season regional survey of EMR; and (3) data and information generated regularly by the countries.
Because reporting was inconsistent in the JRF, therefore, to compliment the findings, a regional survey was conducted to collect more robust and comprehensive data. These data were collected using the regional survey on seasonal influenza vaccination policies and programs (2021-2022). A similar survey was conducted previously (2016)(2017), and this regional survey (2021-2022) was developed using a standardized self-administered questionnaire, used in 2016-2017, composed of 41 questions for collecting data on vaccine policy, programs, distribution points, coverage, and target groups. Survey link was sent to the influenza vaccination focal persons and/or EPI managers at the Ministries of Health via emails, and the responses were compiled in early September 2022. Consistency and level of data completeness varied for different variables in both the JRF and regional survey, and because of this incompleteness issues, we were unable to undertake analyses of all variables from each country.
Variables covered by both the JRF and EMR survey were vaccination policies, target groups, licensure, national immunization program plans and policies, AEFI, roadmap to increase influenza vaccination use, awareness, procurement, COVID-19 vaccine deployment, delivery point, delivery method, cost, type of vaccine, formulation, vaccine availability, doses distributed, vaccination coverage, population coverage, BoD assessment, economic assessment, barrier assessments, and influenza hospitalizations and deaths.
Data collected through the survey was cleaned and validated by WHO at both country and regional levels. Any discrepancies or missing data were excluded, and analysis was done by Influenza team of EMRO.

| Vaccine delivery
Influenza vaccine is primarily delivered through Primary Health Care centers and hospitals (12/16; 75%) and outpatient clinics (7/16; 43.8%). The main delivery strategy is through fixed sites (14/16; 88%); however, vaccines were also delivered by eight mobile units and on two locations they used drive through system. Thirteen (81%) countries reported providing influenza vaccine free to either certain groups or universally. Bahrain reported providing influenza vaccine free of charge only for Bahraini, and vaccine costs were covered for those who were insured. Iran reported covering of costs for prisoners and nursing care centers, in addition to their other target groups.

| Vaccination coverage and data
Ten (10/16; 63%) countries reported routinely collecting vaccination coverage data for their targeted groups. Six of the same countries reported that influenza vaccination coverage is collected as part of routine immunization. Only six (38%) countries reported that they have data, which have both numerator and denominator of the covered population.
Of the 16 countries that reported having influenza vaccination policies or recommendation to all SAGE target groups, less than 50% reported having target coverage and (<44%; 7/16) reported actual coverage in the three preceding influenza seasons (Table 1)   countries reported that COVID-19 had an impact on influenza vaccine supply management. Majority (9/11) of countries reported increases in procurement and supply of influenza vaccine, while two countries reported decreases in procurement due to COVID-19.
In terms of repurposing/using existing influenza vaccination program components for COVID-19 vaccine deployment, eight (50%) countries in the region reported repurposing/using existing program components for COVID-19 vaccine deployment ( Figure 4).

| Difference between 2016 to 2022 in the EMR
In 2022, the regional influenza vaccination survey was conducted based on the questions and variables of 2016 EMR Regional Survey.
This survey was complimentary to the JRF that is conducted each year. In the 2016 survey, 20 countries responded; only exception were Bahrain and Djibouti. In our analysis, we only considered the variables that were common in both surveys ( Overall, the number of countries has remained stable for each target group, with the greatest discrepancy between the two time periods being the inclusion of long-term care facilities, with a 50% drop between the two time periods. Promisingly, there have been slight increases in inclusions of HCWs, children, and universal coverage ( Figure 5).

| Vaccine delivery
For both time periods, the most common outlet for vaccine delivery was primary health centers (9 in 2016 and 12 in 2022), followed closely by hospitals ( Figure 6).
Cost of influenza vaccination was difficult to report, as in 2016, there was not systematic capture of specific target groups. However, there was a small increase in terms of countries offering free influenza  (Table 2).

| Difference between high resourced countries and fragile states
To investigate the potential difference of influenza programs between high resource states and fragile states, a sub-analysis of the data was

| Vaccine delivery
In terms of vaccine cost, high resource countries provided influenza vaccine for free to all, whereas only two (25%) countries in fragile did so.
Consistently, high resource countries have had a higher number of doses distributed to their population as compared to fragile states.
Availability of vaccine has been more stable in high resource countries, than fragile states, except for the year 2017 ( Figure 9).

| Influenza vaccination program
For high resource countries, the majority have included influenza vaccine into their respective NIPs (4/6; 67%), with Oman also planning to F I G U R E 7 Types of influenza vaccine in use in the WHO Eastern Mediterranean Regional countries in 2016 and 2022.
F I G U R E 9 Availability of influenza vaccines and doses distributed in the WHO Eastern Mediterranean Regional countries from 2015-2021.
F I G U R E 1 0 Vaccination coverage data collection challenges by the two country groups in the WHO Eastern Mediterranean Regional countries in 2016 and 2022.

| DISCUSSION
The influenza vaccination situation in the EMR is varied, with some countries reporting having well established policies, programs, and strong supply of vaccine, whereas others having no policy or program and no supply systems; these differences may be due to resources, social, political, and economic variations. 19 This makes a strong case for development of regional roadmap for strengthening of influenza vaccination policies and programs with a targeted approach to address the different contexts of influenza vaccine use and to strengthen the seasonal influenza vaccination programs in EMR. 20 Since 2016, there has been a little change in the number of countries that have a formal national policy for influenza vaccination in their respective countries (64%) but with a larger proportion than was globally reported (59%). 15 Even among those regional countries that do, there is not universal policy coverage for all SAGE recommended groups as universal health coverage is not consistent in the region due to inconsistency in political, governance, decision making, and implementation factors. 21 In terms of the vaccine type used, TIV is the vaccine most commonly used, and there has been an increase in the more recent years of QIV use in the region that has public health and economic importance. 22 Over the time period, there was a greater variety of outlets used to deliver the vaccine, which is good, as this will improve access, particularly the use of outreach, such as mobile units, home visits, and rehabilitation centers, as the target groups would benefit from these services. Around 81% of countries reported providing influenza vaccine free to some of their target groups as providing seasonal influenza vaccine with no cost will increase the acceptancy and the willingness to vaccine uptake. 23 The main supported groups were HCWs, the elderly and groups with chronic diseases, which are the most common causes for receiving influenza vaccine globally. 24 The majority of countries, reporting universally providing vaccine free of charge, are the high resourced countries and that is mainly due to income and affordability by those countries. 25 Few countries reported wide ranges vaccination coverage over time with no clear trend of improvement, which has the same differences and inconsistency among most of countries depending on a lot of factors but especially socioeconomic status. 26 The main issue with reporting of vaccination coverage data is primarily from lack of data on vaccine delivery via the private sector. This is problematic for countries to track their progress, improve utilization, and uptake of influenza vaccination. For obvious reasons, high resource countries reported more coverage data than fragile ones. 33 This is because these programs have been established for many years; they have a better understanding of gaps, better documentation, data quality, and share their information by using global and regional platforms. supervision; writing-review and editing.