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Influenza vaccination and antimicrobial resistance: strategic recommendations.

Heuvel. L. van, Caini, S., Dückers, M., Paget, J. Influenza vaccination and antimicrobial resistance: strategic recommendations. Utrecht: Nivel, 2021.
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Background
Antimicrobial resistance (AMR) is an increasing threat to global health. Vaccination has received heightened attention as an approach to combat antibiotic use and possibly AMR. Vaccination can prevent bacterial and viral infections that may otherwise be treated, sometimes inappropriately, with antimicrobial medicines. WHO has stated that increased uptake of influenza vaccines should be prioritized for its impact on antibiotic use and AMR. This reports aims to assess the association between influenza vaccination and AMR, and develop strategic recommendations regarding the implementation of influenza vaccination within a global strategy to combat AMR.

Methods
We have performed a mixed-methods study, including a literature review (systematic literature review, review of public health reports, and review of national action plans on AMR) and interviews with experts in the field of influenza and/or AMR. The literature review formed the basis for the interview questions. The results of the literature review and expert interviews were used to develop strategic recommendations, targeting policy, research and practice.

Results
The systematic review identified 18 RCTs and 16 observational studies on influenza vaccination and antibiotic use. These studies showed that influenza vaccination in children, adults and the elderly decreased the number of antibiotic courses (risk ratio 0.75 (95% CI: 0.62–0.90)) and the number of people receiving antibiotics (risk ratio 0.63 (95% CI: 0.51–0.79)). A total of 18 public health reports discussed the issue of vaccination and AMR, of which 8 specifically identified the association between influenza vaccination and AMR. Furthermore, the review of AMR national action plans revealed that 7/31 reports specified influenza vaccination as an approach to reduce AMR, while 20/31 plans included general information on vaccination.

Interviews with 12 experts (policy and public health experts, primary and hospital care physicians, and one expert from the pharmaceutical industry) presented diverse views and experiences regarding influenza vaccination and AMR. The main findings indicate that: (1) AMR is not seen as the primary argument for vaccination by primary care physicians or policy makers, (2) influenza vaccination should be mentioned in all AMR national action plans but these plans are frequently not implemented in practice, (3) there is a general need to focus efforts on increasing influenza vaccination coverage, and (4) COVID-19 can influence the attention to (influenza) vaccination but the effect is still unclear at the moment.

Conclusion
Scientific evidence shows that influenza vaccination reduces antibiotic use. This may go on to reduce AMR and this intervention has received greater awareness in recent years, yet it is often not implemented at a policy level. To increase attention, it is advisable to: (1) gather high-quality data to, among others, produce a cost-benefit analysis to raise awareness regarding vaccination and AMR among policy makers, (2) increase influenza vaccination coverage rates among healthcare professionals, risk groups and the general public, (3) raise global awareness and understanding of influenza vaccination to reduce antibiotic use and include this topic in all AMR national action plans, and (4) build on the experiences of the COVID-19 pandemic to strengthen the importance of vaccination against viral respiratory pathogens.