Socioeconomic risk groups, vaccination and pandemic influenza (PANRISK)

Pandemics are one of the most pressing global threats to human life and economic security. It is not a matter of if, but when a new influenza pandemic will arise. This project proposes to study the “forgotten” socioeconomic risk factors for unequal influenza outcomes and consequences. It will bear important implications for health.

The core idea of our proposal is that influenza has always been more than just a medical problem: its epidemiology and impact – both before and after vaccines became available – have been profoundly shaped by social and economic structures, thus affecting who falls ill, who dies, and who survives. 

The overarching aim of PANRISK is to study historical and modern data to enhance the understanding of social risk factors for influenza and improve pandemic preparedness. PANRISK has two interrelated overall objectives: 1) To map the poorly understood social risk groups in order to understand how social disparities leads to social disparities in influenza outcomes, vaccination uptake and repercussions of vaccination for health and mortality disparities. 2) To aid policy makers in developing targeted interventions by social indications in addition to medical indications, to reach the WHO goal of 75% vaccine coverage, to reduce social inequalities, to save lives, reduce social suffering and medical costs during outbreaks.

• Research area 1: What is the socioeconomic status (SES) of the chronically ill?
• Research area 2: To what extent is there an association between SES and pandemic outcomes? 
• Research area 3: How does SES affect vaccination uptake? 
• Research area 4: What are the health consequences for various SES groups of increased vaccination? 

Background: Influenza remains one of the world’s greatest public health challenges

Every year, there are an estimated 1 billion cases of influenza, of which 3-5 million are severe cases, leading to 290,000-650,000 deaths globally and in Norway to 2500 hospitalizations and 900 deaths. Such morbidity and mortality figures lead to huge economic burden due to direct health care spending and indirect costs, such as loss of productivity due to workplace absenteeism due to own sickness or care for others. In 2018-20, it has been 100 years since the pandemic of 1918-20 took the lives of at least 50 million people globally (2.5%), 2.6 million died in Europe (1.1%) and 15,000 in Norway (0.7%). A severe pandemic akin to the 1918 influenza could cost as much as 5% of the global GDP, nearly USD 4 trillion. Subsequent, less severe pandemics occurred in 1957-58, 1968-69, and 2009-10, resulting in 1-4 million, 1-4 million and 100,000-400,000 deaths respectively. 

The global threat from viruses combining high infectivity with high fatality is very serious today for several reasons: emergence of highly malignant avian viruses (H7N9), with 40% case-fatality in a 2017 Chinese outbreak, accidentally released viruses due to faulty safety procedures, bioterrorism, urbanization and increases in global population, interdependencies between countries and increased international travel. Moreover, climate change, increasing inequalities, the obesity epidemic, conflicts and antimicrobial resistance also increase our vulnerability to pandemic threats. Due to the enormous social, economic, and political impact, influenza pandemics are also a security threat.

For these reasons, it is not surprising that a new influenza pandemic is on the WHO top-ten list of threats to the global health in 2019. According to the WHO Director-General Dr Tedros Adhanom Ghebreyesus, their Global influenza strategy report 2019-2030 shows that the planet is ill-prepared for an inevitable new influenza pandemic, that can happen any time. Influenza vaccination is currently the best intervention for preventing and reducing the impact of influenza, and it provides cost savings to countries. However, resources are sparse, vaccination coverages for targeted at-risk groups for seasonal influenza (e.g. chronically ill and elderly), even in high-income countries, are low. The vaccination coverage among the chronically ill in Norway was only 28% in the 2016/17 influenza season; this rate is lower than in many other Western-European countries and far lower than the WHO goal of 75%. Since the chronically ill have much to gain from vaccination, their under-vaccination is an important challenge.

Although current research and recently funded EU projects focus primarily on medically defined risk groups, social inequalities are never explicitly taken into account in pandemic preparedness plans. This is highly surprising as severe outcomes during pandemics affects poor people the hardest. 

The implications of these questions, for which we already have preliminary evidence, underscore the need for a major readjustment in public health efforts to prepare for and to prevent influenza epidemics. Our preliminary findings suggest the need to target chronically ill and the lower socioeconomic status groups for improved vaccine uptake. This would prevent unjust influenza epidemics and pandemics, save lives and reduce social, medical and economic costs drastically. The PANRISK consortium has already gathered a strong interdisciplinary and international team of influenza researchers and key national policymakers in the field of influenza vaccination. 

Project manager

S-E Mamelund is research professor, president of the Norwegian Demographic society and the head of OsloMet Research Group of Historical Influenza Pandemics. Mamelund has been a leading expert on the demography of pandemic influenza for 24 years, has 70 publications of which 40 are peer-reviewed articles on influenza, pandemic, health, survival, and public policy, and has strong experience in translating research into preparedness policies and in building scenarios for health politicians during the 2009 pandemic. Mamelund co-authored Norway’s first influenza pandemic preparedness plan in 1999 and has served as expert at the ECDC (2018) and WHO (2019) meetings on community mitigating strategies for epidemic and pandemic influenza. 

Project group

The participants are at OsloMet Research group of Historical influenza pandemics (Mamelund, Shelley-Egan, Dimka), The Norwegian Institute of Public Health (Strand, Håberg, Skirbekk, Hauge, Klüwer) and the Universities of Umeå (Brännström) and Princeton (Todd). The group will employ one post-doc (demographer), one research assistant and master students, who all will be hosted at OsloMet. We have strong competence in influenza (Mamelund, Håberg, Hauge, Klüwer, Dimka), health/demography (all), epidemiology (Håberg, Strand, Todd, Skirbekk), statistics and mathematical modelling (Todd, Strand, Brännström, Dimka), survey and register studies (Håberg, Strand, Mamelund), Responsible Research and Innovation, anthropological and historical perspectives in epidemics (Shelley-Egan, Dimka, Mamelund), public health and influenza policy making (Hauge, Klüwer). Different disciplines use, ostensibly, the same statistical techniques, but they use them in different ways. By bringing the different disciplines together with key national policy makers (Hauge, Klüwer), the research environment, which this project creates, will lead to new interpretations and the formulation of new methodological and substantive questions and answers in the academic and policy field of influenza.