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The national flu immunisation programme 2017/18 - training for professionals

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This training slide set about the National Flu vaccination programme 2017-2018 is intended for healthcare practitioners and includes detailed information on:
• the background of the programme
• vaccine handling, administration and constituents
• eligibility and resource

For additional guidance on delivering the programme please visit https://www.gov.uk/government/collections/annual-flu-programme

Published in: Healthcare
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The national flu immunisation programme 2017/18 - training for professionals

  1. 1. The national flu immunisation programme 2017/18 Training for healthcare practitioners
  2. 2. Key messages • flu immunisation is one of the most effective interventions we can provide to reduce harm from flu and pressures on health and social care services during the winter • it is important to increase flu vaccine uptake in clinical risk groups because of increased risk of death and serious illness if people in these groups catch flu • for a number of years, only around half of patients aged six months to under 65 years in clinical risk groups have been vaccinated • influenza during pregnancy may be associated with perinatal mortality, prematurity, smaller neonatal size, lower birth weight and increased risk of complications for mother • vaccination of health and social care workers protects them and reduces risk of spreading flu to their patients, service users, colleagues and family members • by preventing flu infection through vaccination, secondary bacterial infections such as pneumonia are prevented. This reduces the need for antibiotics and helps prevent antibiotic resistance 2 The national flu immunisation programme 2017/18
  3. 3. Aims of resource The purpose of this training resource is to: • develop the knowledge base of healthcare practitioners regarding the 2017/18 seasonal flu vaccination programme • support healthcare practitioners involved in discussing flu vaccination with those eligible by providing evidence based information • promote high uptake of flu vaccination in those eligible by increasing the knowledge of those involved in delivering the vaccination programme • provide information on the administration of flu vaccines 3 The national flu immunisation programme 2017/18
  4. 4. Learning outcomes On completion of this resource, healthcare practitioners will be able to: • describe the cause of flu • understand how flu is transmitted and the possible effects of flu • understand the evidence base for the administration of flu vaccination to those aged 65 years and over and those in clinical risk groups • explain which vaccines will be used and the precautions and contraindications to the administration of flu vaccines • explain the sequence of steps in flu vaccine administration • explain the possible side effects from flu vaccines • understand the importance of their role in promoting and providing evidence based information about flu vaccination to patients • identify sources of additional information 4 The national flu immunisation programme 2017/18
  5. 5. Flu overview • flu is an acute viral infection of the respiratory tract (nose, mouth, throat, bronchial tubes and lungs) • it is a highly infectious illness which spreads rapidly in closed communities • even people with mild or no symptoms can infect others • most cases in the UK occur during an 8 to 10 week period during the winter 5 The national flu immunisation programme 2014/15 The national flu immunisation programme 2017/18
  6. 6. Influenza viruses A viruses • cause outbreaks most years and are the usual cause of epidemics • live and multiply in wildfowl from where they can be transmitted to humans • also carried by other mammals B viruses • tend to cause less severe disease and smaller outbreaks • predominantly found in humans • burden of disease mostly in children 6 The national flu immunisation programme 2017/18
  7. 7. FluAvirus 7 The role of haemagglutinin is to bind to the cells of the infected person The role of neuraminidase is to release the virus from the cell surface Two surface antigens: • Haemagglutinin (H) (blue) • Neuraminidase (N) (red) Genetic material (RNA) in the centre There are 18 different types of H and 11 different types of N The national flu immunisation programme 2017/18
  8. 8. Genetic changes in the flu virus – what this means Changes in the surface antigens (H and N) result in the flu virus constantly changing • antigenic drift: minor changes (natural mutations) in the genes of flu viruses that occur gradually over time • antigenic shift: when two or more different strains combine. This abrupt major change results in a new subtype. Immunity from previous flu infections/vaccinations may not protect against the new subtype, potentially leading to a widespread epidemic or pandemic Because of the changing nature of flu viruses, WHO monitors their epidemiology throughout the world. Each year WHO makes recommendations about the strains of influenza A and B which are predicted to be circulating in the forthcoming winter. These strains are then included in the flu vaccine developed each year 8 The national flu immunisation programme 2017/18
  9. 9. Flu vaccine effectiveness • efficacy calculated at between 50-60% for adults aged 18 to 65 years • lower efficacy in elderly although immunisation shown to reduce incidence of severe disease including bronchopneumonia, hospital admissions and mortality • in 2014/15 the flu vaccine only provided limited protection against infection as the main A(H3N2) strain that circulated differed from the A(H3N2) strain selected for the vaccine • however, throughout the last decade, there has generally been a good match between the strains of flu in the vaccine and those that subsequently circulated 9 The national flu immunisation programme 2017/18
  10. 10. Features of flu • easily transmitted by large droplets, small-particle aerosols and by hand to mouth/eye contamination from a contaminated surface or respiratory secretions of infected person • people with mild or no symptoms can still infect others • incubation period 1-5 days (average 2-3 days) though may be longer especially in people with immune deficiency Common symptoms include: • sudden onset of fever, chills, headache, muscle and joint pain and extreme fatigue • dry cough, sore throat and stuffy nose • in young children gastrointestinal symptoms such as vomiting and diarrhoea may be seen 10 The national flu immunisation programme 2017/18
  11. 11. Possible complications of flu Common: • bronchitis • otitis media (children), sinusitis • secondary bacterial pneumonia Less common: • meningitis, encephalitis, meningoencephalitis • primary influenza pneumonia Risk of most serious illness is higher in • children under six months • older people • those with underlying health conditions such as respiratory disease, cardiac disease, long-term neurological conditions or immunosuppression • pregnant women (flu during pregnancy may be associated with perinatal mortality, prematurity, smaller neonatal size and lower birth weight) 11 The national flu immunisation programme 2017/18
  12. 12. Flu epidemiology 12 Weekly all age GP influenza-like illness rates for 2016 to 2017 and past seasons, England (RCGP) • flu activity usually between September to March (weeks 37 and 15) • impact of flu varies from year to year • moderate levels of influenza activity seen in 2016/17 season • biggest impact in older adults, increased numbers of care homes outbreaks and excess mortality seen particularly in the 65+ year olds • high number admissions to hospital and ICU/HDU admissions – although lower than seen in the past two seasons The national flu immunisation programme 2017/18
  13. 13. UK flu vaccination programme • Late 1960s: annual flu immunisation recommended to directly protect those in clinical risk groups who are at a higher risk of influenza associated morbidity and mortality • 2000: flu vaccine policy extended to include all people aged 65 years or over • 2010: pregnancy added as a clinical risk category for routine flu immunisation • 2013: phased introduction of an annual childhood flu vaccination programme for all children aged 2-16y began with vaccine offered to all children aged 2 and 3 years and seven geographical pilots in primary school aged children • 2014: phased introduction of childhood flu vaccination programme continued with vaccine offered to all children aged 2, 3 and 4 years and geographical pilots in primary and secondary school aged children • 2015: offer to all 2, 3 and 4 year old children and children of school years 1 and 2 age • 2016: offer to all 2, 3 and 4 year old children and children of school years 1, 2 and 3 age • 2017: offer to all 2 and 3 year old children and children of reception and school years 1, 2, 3 and 4 age (all children who are aged two to eight years old on 31 August 2017 ) 13 The national childhood flu immunisation programme 2017/18
  14. 14. Flu vaccine eligibility: 2017/18 flu season • all those aged two and three (but not four years or older) on 31 August 2017 (ie date of birth on or after 1 September 2013 and on or before 31 August 2015) • all children in reception class and school years 1, 2, 3 and 4 • all primary school-aged children in former primary school pilot areas • people aged six months to under 65 years in clinical risk groups • all pregnant women (including those who become pregnant during flu season) • people aged 65 years and over (including those becoming 65 years by 31 March 2018) • people living in long-stay residential care homes or other long-stay care facilities • carers and household contacts of immunocompromised individuals Frontline health and social care workers with direct patient/service user contact should be provided with flu vaccination by their employer. This includes staff in all NHS trusts, general practices, care homes, and domiciliary care 14 The national flu immunisation programme 2017/18
  15. 15. Morbidly obese patients • JCVI has advised morbidly obese patients (BMI of 40 or above) could benefit from flu vaccination • those with morbid obesity (BMI>40) found to be at higher risk of hospitalisation and death following pandemic influenza infection • many in this patient group already eligible due to complications of obesity that place them in another risk category • in 2017/18, a key change to the flu programme is that vaccination of the morbidly obese (defined as BMI of 40 and above) will now attract a payment under the directed enhanced services (DES) 15 The national flu immunisation programme 2017/18
  16. 16. Clinical risk groups who should receive flu vaccine (1) Clinical risk category Examples (this list is not exhaustive and decisions should be based on clinical judgement) Chronic respiratory disease Asthma that requires continuous or repeated use of inhaled or systemic steroids or with previous exacerbations requiring hospital admission. Chronicobstructivepulmonarydisease(COPD) including chronic bronchitis and emphysema; bronchiectasis, cystic fibrosis, interstitial lung fibrosis, pneumoconiosis and bronchopulmonary dysplasia (BPD). Children who have previously been admitted to hospital for lower respiratory tract disease. see precautions section on live attenuated influenza vaccine Chronic heart disease Congenital heart disease, hypertension with cardiac complications, chronic heart failure, individuals requiring regular medication and/or follow-up for ischaemic heart disease. Chronic kidney disease Chronic kidney disease at stage 3, 4 or 5, chronic kidney failure, nephrotic syndrome, kidney transplantation. Chronic liver disease Cirrhosis, biliary atresia, chronic hepatitis Chronic neurological disease (included in the DES directions for Wales) Stroke, transient ischaemic attack (TIA). Conditions in which respiratory function may be compromised due to neurological disease (eg polio syndrome sufferers). Clinicians should offer immunisation, based on individual assessment, to clinically vulnerable individuals including those with cerebral palsy, learning difficulties, multiple sclerosis and related or similar conditions; or hereditary and degenerative disease of the nervous system or muscles; or severe neurological disability Diabetes Type 1 diabetes, type 2 diabetes requiring insulin or oral hypoglycaemic drugs, diet controlled diabetes. 16 The national flu immunisation programme 2017/18
  17. 17. Clinical risk groups who should receive flu vaccine (2) Clinical risk category Examples (this list is not exhaustive and decisions should be based on clinical judgement) Immunosuppression (see contraindications and precautions section on live attenuated influenza vaccine) Immunosuppression due to disease or treatment, including patients undergoing chemotherapy leading to immunosuppression, bone marrow transplant, HIV infection at all stages, multiple myeloma or genetic disorders affecting the immune system (eg IRAK-4, NEMO, complement disorders) Individuals treated with or likely to be treated with systemic steroids for more than a month at a dose equivalent to prednisolone at 20mg or more per day (any age), or for children under 20kg, a dose of 1mg or more per kg per day. It is difficult to define at what level of immunosuppression a patient could be considered to be at a greater risk of the serious consequences of influenza and should be offered influenza vaccination. This decision is best made on an individual basis and left to the patient’s clinician. Some immunocompromised patients may have a suboptimal immunological response to the vaccine. Asplenia or dysfunction of the spleen This also includes conditions such as homozygous sickle cell disease and coeliac syndrome that may lead to splenic dysfunction. Pregnant women Pregnantwomenat anystageofpregnancy(first,secondor third trimesters). (see precautions section on live attenuated influenza vaccine) 17 The national flu immunisation programme 2017/18
  18. 18. Flu immunisation should also be offered to: • those living in long-stay residential care homes or other long-stay care facilities where rapid spread is likely to follow introduction of infection and cause high morbidity and mortality (this does not include prisons, young offender institutions, university halls of residence etc) • those who are in receipt of a carer’s allowance, or those who are the main carer of an elderly or disabled person whose welfare may be at risk if the carer falls ill • household contacts of immunocompromised individuals, specifically those who expect to share living accommodation on most days over the winter and therefore for whom continuing close contact is unavoidable • health and social care staff in direct contact with patients/service users should be vaccinated as part of an employer’s occupational health obligation 18 The national flu immunisation programme 2017/18
  19. 19. Other groups who should receive flu vaccine • the list of clinical risk groups is not exhaustive • healthcare practitioners should apply clinical judgement to take into account the risk of flu exacerbating any underlying disease as well as the risk of serious illness from flu itself • flu vaccine should be offered to such patients even if the individual is not in the clinical risk groups specified in the risk groups list • child contacts of very severely immunocompromised individuals should be given inactivated vaccine 19 The national flu immunisation programme 2017/18
  20. 20. Why vaccinate these risk groups? Number of fatal flu cases (%) Mortality rate per 100,000 population Age-adjusted relative risk In a risk group 213 (59.8) 4.0 11.3 (9.1-14.0) Not in any risk group 143 (40.2) 0.4 Baseline Chronic renal disease 19 (5.3) 4.8 18.5 Chronic heart disease 32 (9.0) 3.7 10.7 (7.3-15.7) Chronic respiratory disease 59 (16.6) 2.4 7.4 (5.5-10.0) Chronic liver disease 32 (9.0) 15.8 48.2 (32.8-70.6) Diabetes 26 (7.3) 2.2 5.8 (3.8-8.9) Immunosuppression 71 (19.9) 20.0 47.3 (35.5-63.1) Chronic neurological disease (excluding stroke/transient ischaemic attack) 42 (11.8) 14.7 40.4 (28.7-56.8) Total 378 0.8 20 Influenza-related population mortality rates and relative risk of death among those aged six months to under 65 years by clinical risk group in England, September 2010 – May 2011 The national flu immunisation programme 2017/18
  21. 21. Vaccination of clinical risk groups • increasing flu vaccine uptake in clinical risk groups is important because of increased risk of death and serious illness if people in these groups catch flu • for a number of years only around half of patients aged six months to under 65 in clinical risk groups have been vaccinated • despite those with liver disease and chronic neurological disease having some of the highest mortality rates, they have low flu vaccine uptake rate compared with those in other clinical risk groups • vaccine uptake for all those in clinical risk groups needs to improve - particularly in those with chronic liver and neurological disease 21 The national flu immunisation programme 2017/18
  22. 22. Flu vaccine uptake by age and clinical risk group in 2016/17 (Patientsaged6monthstounder65years) 22 The national flu immunisation programme 2017/18
  23. 23. Flu vaccine uptake rates 2015/16 – 2016/17 23 The national flu immunisation programme 2017/18 2016/17 2015/16 Uptake ambition 2017/18 Patients aged 65 years or older 70.5% 71.0% 75% Patients aged six months to under 65 years in risk groups (excluding pregnant women without other risk factors) 48.6% 45.1% 55% (maintain higher rates where this has already been achieved) Pregnant women 44.9% 42.3% 55% (maintain higher rates where this has already been achieved) Health care workers 63.2% 50.6% 75% Children aged two years old (including those in risk groups) 38.9% 35.4% 40-65% (eligible children aged 2 to 8 years) Children aged three years old (including those in risk groups) 41.5% 37.7% Children aged four years old (including those in risk groups) 33.9% 30.0%
  24. 24. Pregnant women All pregnant women are recommended to receive the inactivated flu vaccine irrespective of their stage of pregnancy • pregnant women at increased risk from complications if they contract flu • having flu during pregnancy may be associated with premature birth and smaller birth size and weight • flu vaccination during pregnancy provides passive immunity against flu to infants in the first few months of life • studies on safety of flu vaccine in pregnancy show that inactivated flu vaccine can be safely and effectively administered during any trimester of pregnancy • no study to date has demonstrated an increased risk of either maternal complications or adverse fetal outcomes associated with inactivated flu vaccine • women should be offered the vaccine every time they are pregnant 24 The national flu immunisation programme 2017/18
  25. 25. Rationale for vaccinating children against flu Extension of the seasonal flu vaccination programme to all children aims to appreciably lower the public health impact of flu by: •providing direct protection thus preventing a large number of cases of flu infection in children •providing indirect protection by lowering flu transmission from children: • to other children • to adults • to those in the clinical risk groups of any age Reducing flu transmission in the community will avert many cases of severe flu and flu-related deaths in older adults and people with clinical risk factors Annual administration of flu vaccine to children is expected to substantially reduce flu-related illness, GP consultations, hospital admissions and deaths 25 The national flu immunisation programme 2017/18
  26. 26. Health and social care workers • frontline health and social care workers have a duty of care to protect their patients and service users from infection • vaccination of health and social care workers protects them and reduces risk of spreading flu to their patients, service users, colleagues and family members • evidence vaccination significantly lowers rates of flu-like illness, hospitalisation and mortality in the elderly in long- term healthcare settings • reduces transmission of flu to vulnerable patients, some of whom may have impaired immunity and may not respond well to immunisation • vaccination of frontline workers also helps reduce sickness absences and contributes to keeping the NHS and care services running through winter pressures 26 The national flu immunisation programme 2017/18
  27. 27. Health and social care workers (cont) • NHS and social care bodies have a responsibility to ensure, as far as is reasonably practicable, that health and social care workers are free of, and are protected from exposure to infections that can be caught at work (Health and Social Care Act 2008, Code of Practice on the prevention and control of infections) • responsibility for funding and administering seasonal flu vaccine to staff lies with employers • trusts/employers must ensure that health and social care staff directly involved in delivering care are encouraged to be immunised and that processes are in place to facilitate this • overall level of flu vaccine uptake in health care workers is still below the 75% aspiration • see NHS Employers flu fighter campaign www.nhsemployers.org/flu 27 The national flu immunisation programme 2017/18
  28. 28. Key messages to health and social care workers • duty of care as professionals to patients or residents to do everything in your power to protect them against infection, including being immunised against flu • getting vaccinated against flu can help protect you, your patients and family • everyone is susceptible to flu, even if you are in good health and eat well • you can be infected with the virus and have no symptoms but can still pass flu virus to others including patients or residents • good infection control measures reduce spread of flu and other acute respiratory infections in healthcare settings but are not sufficient alone to prevent them • impact of flu on frail and vulnerable patients can be fatal and outbreaks can cause severe disruption in communities, care homes and hospitals • flu vaccine has a good safety record and will help protect you. It cannot give you flu. Having the vaccination can encourage your colleagues to do likewise • throughout the last ten years there has generally been a good to moderate match between the strains of flu virus in the vaccine and those that subsequently circulated • staff act as positive role models for patients aged 65 and over, those with long-term health conditions and pregnant women to take up the offer too 28 The national flu immunisation programme 2017/18
  29. 29. When to vaccinate • those eligible should be given flu vaccination as soon as vaccine is available so that people are protected when flu begins to circulate in the community • ideally most vaccination should be completed before the end of December before flu circulation usually peaks • flu can circulate considerably later than this however so clinical judgement should be applied to assess needs of individual patients and whether it is appropriate to continue to offer vaccination from January to March • this decision should take into account level of flu-like illness in community and fact that the immune response following flu vaccination takes about two weeks to develop fully • protection afforded by the vaccine thought to last at least one influenza season • however, as antibody levels likely to reduce in subsequent seasons and there may be changes to circulating strains from one season to next, annual revaccination is important 29 The national flu immunisation programme 2017/18
  30. 30. 30 Which flu vaccine should be used? The national flu immunisation programme 2017/18
  31. 31. Types of flu vaccines Two main types of vaccine available: • inactivated – by injection • live attenuated – by nasal application None of the flu vaccines can cause clinical influenza in those that can be vaccinated  Trivalent: flu vaccines contain two subtypes of Influenza A and one type B virus  Quadrivalent vaccines contain two subtypes of Influenza A and both B virus types* As quadrivalent vaccines contain both lineages of B viruses and therefore may provide better protection against the circulating B strain(s) than trivalent flu vaccines, the live intranasal vaccine offered to children aged 2 years and over is a quadrivalent vaccine, as is the inactivated vaccine recommended for children aged 3 years and above who cannot receive live attenuated vaccine *Quadrivalent inactivated flu vaccine only authorised for children aged 3 years and older. 31 The national flu immunisation programme 2017/18
  32. 32. Live attenuated influenza vaccine (LAIV) • a live attenuated intranasal spray is the recommended vaccine for the childhood flu programme • the live attenuated influenza vaccine (LAIV) has been shown to be more effective in children compared with inactivated influenza vaccines • it may offer some protection against strains not contained in the vaccine as well as to those that are and has the potential to offer better protection against virus strains that have undergone antigenic drift • since this vaccine is comprised of weakened whole live virus, it replicates natural infection which induces better immune memory (thereby offering better long-term protection to children than from the inactivated vaccines) • in addition to being attenuated (weakened), the live viruses in LAIV have been adapted to cold so that they cannot replicate efficiently at body temperature • LAIV has a good safety profile in children aged two years and older 32 The national flu immunisation programme 2017/18
  33. 33. Inactivated flu vaccines • a number of different manufacturers produce flu vaccines. Those available for 2017/18 season are listed in ‘The national flu immunisation programme 2017/18’ letter available on PHE website • most of the inactivated vaccines are administered by intramuscular injection, although one vaccine (Intanza®) is administered by the intradermal route • all currently available flu vaccines are prepared from viruses grown in embryonated hens’ eggs – details of ovalbumin content available in the product SPC • some flu vaccines are restricted for use in particular age groups. The SPC for individual products should always be referred to when ordering vaccines for particular patients 33 The national flu immunisation programme 2017/18
  34. 34. Storage of flu vaccine Efficacy, safety and quality may be adversely affected if vaccines are not stored at the temperatures specified in the licence Flu vaccines must be stored in accordance with manufacturer’s instructions: • store between +2⁰C and +8⁰C • do not freeze • store in original packaging • protect from light Check expiry dates regularly: • the LAIV has an expiry date 18 weeks after manufacture – this is much shorter than inactivated flu vaccines • it is important that the expiry date on the nasal spray applicator is checked before use 34 The national flu immunisation programme 2017/18
  35. 35. Flu vaccines for patients in clinical risk groups Age Which vaccine? How many doses? Children aged six months to less than two years of age in clinical risk groups These children should be offered inactivated trivalent influenza vaccine Those who have not received flu vaccine before should receive a second dose of vaccine at least four weeks later Children aged two to less than 18 years of age in clinical risk groups These children should be offered the live intranasal vaccine unless it is medically contraindicated For those children for whom the live vaccine is medically contraindicated, a suitable inactivated flu vaccine should be offered The quadrivalent inactivated influenza vaccine (Fluarix™ Tetra) is authorised for children from the age of three years and is preferred because of the additional protection offered. The quadrivalent vaccine has both lineages of influenza B and may therefore provide better protection against the circulating B strain(s) than trivalent inactivated influenza vaccines Children aged two years should be given an inactivated trivalent vaccine Those aged two to less than nine years who have not received flu vaccine before should receive a second dose of vaccine at least four weeks later Over 18 years Any of the inactivated vaccines (except Intanza®15μg which is for those age 60 years and over) A single dose 35 The national flu immunisation programme 2017/18
  36. 36. Which vaccine and how many doses? Vaccine type Authorised age indication Dose Live attenuated intranasal vaccine Children aged two to under 18 years (if no contraindications) Singleapplicationineach nostril of 0.1ml Children NOT in clinical risk groups only require one dose of this vaccine. Childrenin clinicalrisk groups aged two to under nine years who have not received influenza vaccine before should receive a second dose of vaccine at least four weeks later. N.B Follow Green Book not SPC Inactivated intramuscular vaccine (number of different brands) Children aged six months and older and adults (N.B some of the vaccines are not authorised for young children) Single injection of 0.5ml Children aged six months to under nine years who have not received influenza vaccine before should receive a second dose of vaccine at least four weeks later. Inactivated intradermal vaccine - Intanza® 15µg Adults aged 60 years and older Single injection of 0.1ml 36 The national flu immunisation programme 2017/18
  37. 37. Trivalent vaccines will contain the following three viruses: • an A/Michigan/45/2015 (H1N1)pdm09-like virus • an A/Hong Kong/4801/2014 (H3N2)-like virus • a B/Brisbane/60/2008-like virus In addition to the above, the quadrivalent vaccine will also contain: B/Phuket/3073/2013-like virus None of the influenza vaccines for the 2017/18 season contain thiomersal as an added preservative More detailed information on the characteristics of the available vaccines, including age indications can be found in the Influenza chapter of the Green Book (Immunisation against infectious disease) and the product SPCs 37 Flu vaccine composition 2017/18 The national flu immunisation programme 2017/18
  38. 38. Flu vaccine presentation and dosage 38 • inactivated flu vaccines for intramuscular (IM) administration supplied as suspensions in pre-filled syringes containing a 0.5ml dose • if SPC for IM inactivated flu vaccine states young children can be given either a 0.25ml or a 0.5ml dose, give 0.5ml dose • Intanza®, the intradermal vaccine, is supplied in a micro-needle injection system (but not available in 2017/18 flu season) • the live intranasal flu vaccine is supplied as a nasal spray suspension in a special single use, pre-filled, nasal applicator. No reconstitution or dilution required. Each applicator contains 0.2ml (administered as 0.1 ml per nostril) The national flu immunisation programme 2017/18
  39. 39. Vaccine administration (inactivated vaccines) Intramuscular flu vaccines should be given into the upper arm (or anterolateral thigh in infants under one year of age) Individuals with a bleeding disorder should be given vaccine by deep subcutaneous injection to reduce the risk of bleeding Intradermal: Intanza® is supplied in a micro-needle injection system that should be held at right-angles to the skin. The device allows intradermal vaccination to be performed without the need for additional training • both inactivated and live flu vaccines can be given at the same time as, or at any interval before or after, other live and inactivated vaccines • different vaccines should be given at separate sites, preferably in a different limb. If given in the same limb, they should be given at least 2.5cm apart 39 The national flu immunisation programme 2017/18
  40. 40. Administration of LiveAttenuated Influenza vaccine (LAIV) • LAIV is different from other flu vaccines – it is a live attenuated nasal vaccine and must not be injected • do not attempt to attach a needle • LAIV can be administered at the same time as, or at any interval from other vaccines including live vaccines • patient should breathe normally – no need to actively inhale or sniff • the vaccine is rapidly absorbed so no need to repeat either half of dose if patient sneezes, blows their nose or their nose drips following administration 40 The national flu immunisation programme 2017/18
  41. 41. 41 Supply and administration of flu vaccines A range of mechanisms can be used for the supply and administration of vaccines, including: • patient specific prescription written manually or electronically by a registered medical practitioner or other authorised prescriber • Patient Specific Direction (PSD) • Patient Group Direction (PGD) PGD templates for the administration of the live and inactivated flu vaccines are available on the PHE website: https://www.gov.uk/government/collections/immunisation-patient-group-direction-pgd Those using national immunisation PGDs developed by PHE must ensure that each PGD is organisationally authorised and signed in section 2 by an appropriate authorising person, in accordance with Human Medicines Regulations 2012 (HMR2012) Without such authorisation, the PGD is not legal or valid The national flu immunisation programme 2017/18
  42. 42. There are very few individuals who cannot receive any flu vaccine Where there is doubt, expert advice should be sought promptly so that the period the individual is left unvaccinated is minimised For children aged 2 years up to their 18th birthday, where live flu vaccine cannot be given, it is likely that inactivated vaccine could be given instead None of the influenza vaccines should be given to those who have had: • confirmed anaphylactic reaction to a previous dose of the vaccine • confirmed anaphylactic reaction to any component of the vaccine 42 The national flu immunisation programme 2017/18 Contraindications
  43. 43. The live attenuated flu vaccine should not be given to children who are: • clinically severely immunodeficient due to conditions or immunosuppressive therapy:  acute and chronic leukaemias  lymphoma  HIV infection not on highly active antiretroviral therapy  cellular immune deficiencies  high dose corticosteroids • receiving salicylate therapy • known to be pregnant • have severe asthma or active wheezing • children currently taking a high dose inhaled steroid should only be given live flu vaccine on the advice of their specialist The national flu immunisation programme 2014/15 Contraindications to flu vaccines (cont) 43 The national flu immunisation programme 2017/18
  44. 44. Acutely unwell: • defer until recovered Heavy nasal congestion: • defer live intranasal vaccine until resolved or, if the child is in a risk group, consider inactivated flu vaccine to provide protection without delay Use with antiviral agents against flu: • live flu vaccine (LAIV) should not be administered at the same time or within 48 hours of cessation of treatment with flu antiviral agents • administration of flu antiviral agents within two weeks of administration of LAIV may adversely affect the effectiveness of the vaccine 44 The national flu immunisation programme 2017/18 Precautions to flu vaccines
  45. 45. Severe asthma or active wheezing • live flu vaccine is not recommended for children and adolescents with severe asthma or active wheezing eg those who are currently taking or have been prescribed oral steroids for respiratory disease in the last 14 days • children currently taking a high dose inhaled steroid - Budesonide >800mcg/day or equivalent (eg Fluticasone > 500mcg/day) should only be given live flu vaccine on the advice of their specialist As these children are in a defined flu risk group, those who cannot receive LAIV should receive an inactivated flu vaccine • vaccination with LAIV should be deferred in children with a history of active wheezing in the past 72 hours or those who have increased use of bronchodilators in the previous 72 hours. If condition not improved after a further 72 hours then inactivated flu vaccine should be offered to avoid delaying protection in this high-risk group 45 The national flu immunisation programme 2017/18
  46. 46. Egg allergy – adults • most flu vaccines are prepared from flu viruses grown in embryonated hens’ eggs – the final vaccine products contains varying amounts of egg (as ovalbumin) • adults with egg allergy can be immunised in any setting using an inactivated flu vaccine with an ovalbumin content less than 0.12 µg/ml (equivalent to <0.06µg for 0.5ml dose) • adults with severe anaphylaxis to egg that has previously required intensive care should be referred to specialists for immunisation in hospital • there is no ovalbumin-free vaccine available for the 2017/18 flu season • see July 2017 edition ‘Vaccine Update’ or individual vaccine SPCs for ovalbumin content 46 The national flu immunisation programme 2017/18
  47. 47. Egg allergy – children • children with an egg allergy can be safely vaccinated with the LAIV in any setting (including primary care and schools) • those with both egg allergy and clinical risk factors that contraindicate LAIV (eg immunosuppression) should be offered an* inactivated flu vaccine with a very low ovalbumin content (less than 0.12μg/ml) • children with a history of severe anaphylaxis to egg that has previously required intensive care, should be referred to specialists for immunisation in hospital • LAIV is not otherwise contraindicated in children with egg allergy. Egg- allergic children with asthma can receive LAIV if their asthma is well- controlled (see previous slide on severe asthma) *Children in a clinical risk group and aged under nine years who have not been previously vaccinated against influenza will require a second dose whether given LAIV or inactivated vaccine 47 The national flu immunisation programme 2017/18
  48. 48. Flu vaccines with low ovalbumin content The following vaccines, available for the 2017/18 flu season, have a very low ovalbumin content (<0.12μg/ml – equivalent to <0.06μg for a 0.5ml dose) and may be used safely in individuals with egg allergy LAIV (Fluenz Tetra®), which has ovalbumin content of ≤0.12 (≤0.024/0.2ml dose)has also been shown to be safe for use in most egg allergic children 48 The national flu immunisation programme 2017/18 Supplier Name of product Vaccine type Age indication Ovalbumin content per dose ( μg/dose) AstraZeneca UK Ltd Fluenz Tetra Live attenuated, nasal (quadrivalent) From 24 months to less than 18 years of age ≤0.12 (≤0.024/0.2ml dose) GSK Fluarix Tetra Split virion inactivated virus From three years ≤0.1 (≤0.05/0.5ml dose) MASTA Inactivated Influenza Vaccine (Split Virion) BP Split virion inactivated virus From six months ≤0.1 (≤0.05/0.5ml dose) MASTA Quadrivalent Influenza Vaccine (Split Virion, inactivated) Split virion inactivated virus From three years ≤0.1 (≤0.05/0.5ml dose) Sanofi Pasteur Vaccines Inactivated influenza vaccine (split virion) BP Split virion inactivated virus From six months ≤0.1 (≤0.05/0.5ml dose) Sanofi Pasteur Vaccines Quadrivalent Influenza Vaccine (Split Virion, inactivated) Split virion inactivated virus From 3 years ≤0.1 (≤0.05/0.5ml dose) See Vaccine Update July 2017 for list of all flu vaccines and their ovalbumin content
  49. 49. • theoretical potential for transmission of live attenuated virus to immunocompromised contacts • risk is for one to two weeks following vaccination • extensive use of the live attenuated influenza vaccine in US – no reported instances of illness or infections from the vaccine virus among immunocompromised patients inadvertently exposed to vaccinated children • however, where close contact with very severely immunocompromised patients (eg bone marrow transplant patients requiring isolation) is likely or unavoidable (eg household members) consider an appropriate inactivated flu vaccine instead 49 The national flu immunisation programme 2017/18 Risk of transmission of live vaccine virus
  50. 50. Exposure of healthcare workers to live attenuated influenza vaccine viruses • theoretically there may be some low level exposure to the vaccine viruses for those administering LAIV and/or from recently vaccinated patients • in the US, where there has been extensive use of LAIV, no reported instances of illness or infections from the vaccine virus among healthcare workers inadvertently exposed • risk of acquiring vaccine viruses from the environment is unknown but probably low • the vaccine viruses are cold-adapted and attenuated and therefore unlikely to cause symptomatic influenza • as a precaution, very severely immunosuppressed individuals should not administer LAIV • other healthcare workers who have less severe immunosuppression or are pregnant, should follow normal clinical practice to avoid inhaling the vaccine and ensure that they themselves are appropriately vaccinated 50 The national flu immunisation programme 2017/18
  51. 51. Inadvertent administration of LAIV • if an immunocompromised individual receives LAIV, the degree of immunosuppression should be assessed • if patient is severely immunocompromised, antiviral prophylaxis should be considered • otherwise they should be advised to seek medical advice if they develop flu-like symptoms in the four days following administration of the vaccine • if antivirals are used for prophylaxis or treatment, patient should also be offered inactivated flu vaccine in order to maximise their protection in the forthcoming flu season (this can be given straight away) 51 The national flu immunisation programme 2017/18
  52. 52. Commonly reported adverse reactions Following inactivated flu vaccine: • pain, swelling or redness at the injection site, low grade fever, malaise, shivering, fatigue, headache, myalgia and arthralgia • a small painless nodule may also form at the injection site • these symptoms usually disappear within one to two days without treatment Following live attenuated flu vaccine: • nasal congestion/rhinorrhoea, reduced appetite, weakness and headache Rarely, after live or inactivated vaccine, immediate reactions such as urticaria, angio- oedema, bronchospasm and anaphylaxis can occur 52 The national flu immunisation programme 2017/18
  53. 53. 53 The national flu immunisation programme 2017/18 Reporting suspected adverse reactions All serious suspected reactions following flu vaccination should be reported to the Medicines and Healthcare products Regulatory Agency using the Yellow Card scheme at http://yellowcard.mhra.gov.uk/ All of the quadrivalent flu vaccines carry a black triangle symbol (▼) (as do all vaccines during the earlier stages of their introduction) This is to encourage reporting of all suspected adverse reactions
  54. 54. Vaccine ordering • all flu vaccines for children (both live and inactivated) are purchased centrally by PHE for: • all children aged 2 and 3 years and children in reception class and school years 1 to 4 • all children in clinical risk groups aged 6 months to less than 18 years • PHE will supply LAIV for those children who can receive it and inactivated flu vaccine for those children for whom LAIV is contraindicated. • flu vaccines for children can be ordered through the ImmForm website as for other centrally purchased vaccines (www.immform.dh.gov.uk) • providers are responsible for ordering sufficient flu vaccine for all other eligible patients aged 18 years and older directly from manufacturers • ordering from more than one supplier is recommended in case of supplier delays or difficulties in the manufacture or delivery of the vaccine 54 The national flu immunisation programme 2017/18
  55. 55. Inactivated influenza vaccine for children contraindicated to receive LAIV • children for whom LAIV is contraindicated should be offered a suitable alternative inactivated flu vaccine • some inactivated flu vaccines have been associated with high rates of febrile convulsions in children • some inactivated flu vaccines contain too much ovalbumin for egg allergic children • check SPC for vaccine suitability before administration Guidance on which vaccines to use for those children who cannot receive LAIV can be found in the Green Book Influenza chapter • Fluarix Tetra® is the preferred vaccine for children aged ≥ 3years who cannot receive Fluenz Tetra® • children 6m to <3years should be given inactivated influenza vaccine (Split Virion) BP® 55 The national flu immunisation programme 2017/18
  56. 56. Beware of product confusion! Fluenz Tetra® is the live attenuated influenza vaccine given as a nasal spray to children aged 2 years to less than 18 years Fluarix® Tetra is an inactivated vaccine licensed from three years of age that can be given to children who cannot receive the live intranasal flu vaccine, the 65year olds and overs, the under 65 year oldss at risk, pregnant women and healthcare workers Care must be taken not to confuse the two ‘Tetra’ brands. One way of remembering which vaccine is which is: • Fluenz is the nazal flu vaccine • Fluarix is the arm injected vaccine 56 The national flu immunisation programme 2017/18
  57. 57. Recording of flu vaccine given As a wide variety of influenza vaccines are on the UK market each year, it is especially important that the following information be recorded: • vaccine name, product name, batch number and expiry date • dose administered • date immunisation given • route/site used • name and signature of vaccinator This information should be recorded in: • patient's GP record (or other patient record, depending on location) • personal Child Health Record (the ‘Red Book’) if a child • practice computer system • Child Health Information System if a child 57 The national flu immunisation programme 2017/18
  58. 58. Data collection • flu vaccine uptake data is collected via the web-based ImmForm system (www.immform.dh.gov.uk) where it is managed and published by PHE • over 90% GP practices are able to make automated data returns where the number of their patients vaccinated is directly extracted from their IT system and put into ImmForm • for data to be accurate and complete, it is critical that vaccines given outside the surgery, eg in antenatal clinics or pharmacies, are reported to the patient’s GP • uptake data for Reception class, school years 1 to 4 and pilot areas will be manually submitted by providers onto ImmForm • uptake data for HCWs is manually submitted by trusts and area teams via ImmForm • data is collected and published monthly on all the groups for whom flu vaccine is indicated at national level and local NHS England team level to enable performance to be reviewed and time to take action if needed 58 The national flu immunisation programme 2017/18
  59. 59. Achieving high uptake (GP Practice checklist) In order to obtain high vaccine uptake, it is recommended that GP practices: 1. Identify a named lead individual within the practice who is responsible for the flu vaccination programme and liaises regularly with all staff involved in the programme 2. Hold a register that can identify all pregnant women and patients in the under 65 years at risk groups, those aged 65 years and over, and those aged two to three years 3. Update the patient register throughout the flu season, paying particular attention to the inclusion of women who become pregnant and patients who enter at-risk groups during the flu season 4. Submit accurate data on the number of its patients eligible to receive flu vaccine and the flu vaccinations given to its patients on ImmForm (www.immform.dh.gov.uk), ideally using the automated function. Submit data on uptake among healthcare workers in primary care using the ImmForm data collection tool 59 The national flu immunisation programme 2017/18
  60. 60. Achieving high uptake (GPPractice checklist cont’d) 5. Order sufficient flu vaccine taking into account past and planned improved performance, expected demographic increase, and to ensure that everyone at risk is offered the flu vaccine. It is recommended that vaccine is ordered from more than one supplier and in respect of children, from PHE central supplies through the ImmForm website 6. Invite patients recommended to receive the flu vaccine to a flu vaccination clinic or to make an appointment (eg by letter, email, phone call, text). This is a requirement of the enhanced service specification 7. Follow-up patients, especially those in at risk groups, who do not respond or fail to attend scheduled clinics or appointments 8. Start flu vaccination as soon as practicable after receipt of the vaccine. This will help ensure the maximum number of patients are vaccinated as early as possible and protected before flu starts to circulate. Aim to complete immunisation of all eligible patients before flu starts to circulate and ideally by end of December 60 The national flu immunisation programme 2017/18
  61. 61. Achieving high uptake (GPPractice checklist cont’d ) 9. Collaborate with maternity services to offer and provide flu vaccination to pregnant women and to identify, offer and provide to newly pregnant women as the flu season progresses 10. Offer flu vaccination in clinics and opportunistically 11. Where the patient has indicated they wish to receive the vaccination but is physically unable to attend the practice (eg is housebound) the practice must make all reasonable effort to ensure the patient is vaccinated. The GP practice and/or CCG will collaborate with other providers such as community pharmacies and community or health and social care trusts to identify and offer flu vaccination to residents in care homes, nursing homes and house-bound patients, and to ensure that mechanisms are in place to update the patient record when flu vaccinations are given by other providers The GP practice checklist highlights good practice • it is based upon the findings from a study examining the factors associated with higher vaccine uptake in general practice • GP practices are encouraged to review their systems in the light of the checklist Most recommendations will apply to other settings where flu vaccine is given 61 The national flu immunisation programme 2017/18
  62. 62. 62 Presentation title - edit in Header and Footer
  63. 63. Key messages • flu immunisation is one of the most effective interventions we can provide to reduce harm from flu and pressures on health and social care services during the winter • it is important to increase flu vaccine uptake in clinical risk groups because of increased risk of death and serious illness if people in these groups catch flu • for a number of years, only around half of patients aged six months to under 65 years in clinical risk groups have been vaccinated • influenza during pregnancy may be associated with perinatal mortality, prematurity, smaller neonatal size, lower birth weight and increased risk of complications for mother • vaccination of health and social care workers protects them and reduces risk of spreading flu to their patients, service users, colleagues and family members • by preventing flu infection through vaccination, secondary bacterial infections such as pneumonia are prevented. This reduces the need for antibiotics and helps prevent antibiotic resistance 63 The national flu immunisation programme 2017/18
  64. 64. 64 The national flu immunisation programme 2017/18 Resources • Flu Plan and Letter detailing 2017/18 flu programme Department of Health, Public Health England, NHS England. Published 20 March 2017 Available at: https://www.gov.uk/government/publications/national-flu-immunisation-programme-plan • Green Book Influenza chapter Available at: https://www.gov.uk/government/collections/immunisation-against-infectious-disease-the-green-book • Leaflets, posters, information materials and other resources to support the annual flu programme Available at: https://www.gov.uk/government/collections/annual-flu-programme • PGD templates for flu vaccines https://www.gov.uk/government/collections/immunisation-patient- group-direction-pgd • A video for health professionals on how to administer the LAIV vaccine produced by NHS Education for Scotland is available at http://www.nes.scot.nhs.uk/education-and-training/by- theme-initiative/public-health/health-protection/seasonal-flu/childhood-seasonal-flu- vaccination-programme-resources-for-registered-practitioners.aspx • Summary of Product Characteristics (SPC) for flu vaccines are available at http://www.medicines.org.uk/emc/ • Find out more about antibiotic resistance, other ways to reduce its rise and how you can help through www.antibioticguardian.com
  65. 65. 65 The national flu immunisation programme 2017/18 About Public Health England Public Health England exists to protect and improve the nation's health and wellbeing, and reduce health inequalities. It does this through world-class science, knowledge and intelligence, advocacy, partnerships and the delivery of specialist public health services. PHE is an operationally autonomous executive agency of the Department of Health. Public Health England Wellington House 133-155 Waterloo Road London SE1 8UG Tel: 020 7654 8000 www.gov.uk/phe Twitter: @PHE_uk Facebook: www.facebook.com/PublicHealthEngland For enquiries relating to this document, please contact: immunisation.lead@phe.gov.uk © Crown copyright 2017 You may re-use this information (excluding logos) free of charge in any format or medium, under the terms of the Open Government Licence v3.0. To view this licence, visit OGL or email psi@nationalarchives.gsi.gov.uk. Where we have identified any third party copyright information you will need to obtain permission from the copyright holders concerned. Published August 2017 PHE publications gateway number: 2017247

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