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This summary has been abrdige for print. View this summary at guidelines.co.uk/454313.article.

 

Recommendations for the use of the vaccines

The objectives of the influenza immunisation programme are to protect those who are most at risk of serious illness or death should they develop influenza and to reduce transmission of the infection, thereby contributing to the protection of vulnerable patients who may have a suboptimal response to their own immunisation.

Expansion of the programme

  • In light of the risk of flu and COVID-19 co-circulating this winter, the national flu immunisation programme will be absolutely essential to protecting vulnerable people and supporting the resilience of the health and care system
  • As indicated in the letter of 14 May, providers should focus on achieving maximum uptake of the flu vaccine in existing eligible groups, as they are most at risk from flu or in the case of children transmission to other members of the community.The full list of those eligible in 2020/21 as part of the NHS funded flu vaccination programme can be viewed below. This includes individuals meeting existing flu eligibility criteria
  • This year as part of our wider planning for winter, and subject to contractual negotiations, this season flu vaccination will be additionally offered to:
    • household contacts of those on the NHS Shielded Patient List. Specifically individuals who expect to share living accommodation with a shielded person on most days over the winter and therefore for whom continuing close contact is unavoidable
    • children of school Year 7 age in secondary schools (those aged 11 on 31 August 2020)
    • health and social care workers employed through Direct Payment (personal bugets) and/or Personal Health Budgets, such as Personal Assistants, to deliver domiciliary care to patients and service users
  • PHE aims to further extend the vaccine programme in November and December to include the 50–64-year-old age group subject to vaccine supply. This extension is being phased to allow you to prioritise those in at risk groups first. Providers will be given notice in order to have services in place for any additional cohorts later in the season
  • This season an inactivated vaccine may be offered to those children whose parents refuse the live attenuated influenza vaccine (LAIV) due to the porcine gelatine content, in order to prevent localised outbreaks this year
  • It is essential to increase flu vaccination levels for those who are living in the most deprived areas and from BAME communities. Equitable uptake compared to the population as a whole needs to be ensured and help protect those who are more at risk if they are to get COVID-19 and flu. It will therefore require high quality, dedicated and culturally competent engagement with local communities, employers and faith groups.

Groups included in the national flu immunisation programme

  • In 2020/21, flu vaccinations will be offered under the NHS flu vaccination programme to the following groups:
    • all children aged two to eleven (but not twelve years or older) on 31 August 2020
    • people aged 65 years or over (including those becoming age 65 years by 31 March 2021)
    • those aged from six months to less than 65 years of age, in a clinical risk group such as those with:
      • chronic (long-term) respiratory disease, such as severe asthma, chronic obstructive pulmonary disease (COPD) or bronchitis
      • chronic heart disease, such as heart failure
      • chronic kidney disease at stage three, four or five
      • chronic liver disease o chronic neurological disease, such as Parkinson’s disease or motor neurone disease
      • learning disability
      • diabetes
      • splenic dysfunction or asplenia
      • a weakened immune system due to disease (such as HIV/AIDS) or treatment (such as cancer treatment)
      • morbidly obese (defined as BMI of 40 and above)
    • all pregnant women (including those women who become pregnant during the flu season)
    • household contacts of those on the NHS Shielded Patient List, or of immunocompromised individuals, specifically individuals who expect to share living accommodation with a shielded patient on most days over the winter and therefore for whom continuing close contact is unavoidable
    • people 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, for instance, prisons, young offender institutions, university halls of residence, or boarding schools (except where children are of primary school age or secondary school Year 7).
    • those who are in receipt of a carer’s allowance, or who are the main carer of an older or disabled person whose welfare may be at risk if the carer falls ill
    • health and social care staff, employed by a registered residential care/nursing home or registered domiciliary care provider, who are directly involved in the care of vulnerable patients/clients who are at increased risk from exposure to influenza 
    • health and care staff, employed by a voluntary managed hospice provider, who are directly involved in the care of vulnerable patients/clients who are at increased risk from exposure to influenza
    • health and social care workers employed through Direct Payments (personal budgets) and/or Personal Health Budgets, such as Personal Assistants, to deliver domiciliary care to patients and service users
  • Additionally, in 2020/21, flu vaccinations might be offered under the NHS flu vaccination programme to the following groups:
    • individuals between 50-64 years, following prioritisation of other eligible groups and subject to vaccine supply
  • Organisations should vaccinate all frontline health and social care workers, in order to meet their responsibility to protect their staff and patients and ensure the overall safe running of services
  • The list above is not exhaustive, and the healthcare professional should apply clinical judgement to take into account the risk of flu exacerbating any underlying disease that a patient may have, as well as the risk of serious illness from flu itself
  • Healthcare practitioners should refer to the influenza chapter in ‘Immunisation against infectious disease’ (the “Green Book”) for further detail about clinical risk groups advised to receive flu immunisation and for full details on advice concerning contraindications and precautions for the flu vaccines. This can be found at: www.gov.uk/government/collections/immunisation-against-infectious-disease-the green-book.

Table 1: Clinical risk groups who should receive influenza immunisation

Clinical risk categoryExamples (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.

 

Chronic obstructive pulmonary disease (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 the precautions section of the full guideline 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, and 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 (e.g. polio syndrome sufferers). Clinicians should offer immunisation, based on individual assessment, to clinically vulnerable individuals including those with cerebral palsy, learning disabilities, 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.

Immunosuppression (see contraindications and precautions section of the full guideline 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 (e.g. IRAK-4, NEMO, complement disorder).

 

Individuals treated with or likely to be treated with systemic steroids for more than a month at a dose equivalent to prednisolone at 20 mg or more per day (any age), or for children under 20 kg, a dose of 1 mg 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

Pregnant women at any stage of pregnancy (first, second, or third trimesters).

 

See the precautions section of the full guideline on live attenuated influenza vaccine

Morbid obesity 

(class III obesity)[A]

Adults with a body mass index ≥40 kg/m2

[A] Many of this patient group will already be eligible due to complications of obesity that place them in another risk category

Other groups

  • The list above is not exhaustive, and the medical practitioner should apply clinical judgment to take into account the risk of influenza exacerbating any underlying disease that a patient may have, as well as the risk of serious illness from influenza itself
  • Vaccination should also be offered to household contacts of immunocompromised individuals, i.e. individuals who expect to share living accommodation on most days over the winter and therefore for whom continuing close contact is unavoidable. This may include carers (see below)
  • In addition to the above, immunisation should be provided to healthcare and social care workers in direct contact with patients/clients to protect them and to reduce the transmission of influenza within health and social care premises, to contribute to the protection of individuals who may have a suboptimal response to their own immunisations, and to avoid disruption to services that provide their care. This would include:
    • health and social care staff directly involved in the care of their patients or clients
    • 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. Vaccination should be given on an individual basis at the GP’s discretion in the context of other clinical risk groups in their practice
    • others involved directly in delivering health and social care such that they and vulnerable patients/clients are at increased risk of exposure to influenza (further information is provided in guidance from UK health departments)

Administration

  • The inactivated influenza vaccines should normally be given into the upper arm (or anterolateral thigh in infants) preferably by intramuscular injection. Influenza vaccines licensed for intramuscular or subcutaneous administration may alternatively be administered by the subcutaneous route
  • Individuals on stable anticoagulation therapy, including individuals on warfarin who are up-to-date with their scheduled International Normalised Ratio (INR) testing and whose latest INR was below the upper threshold of their therapeutic range, can receive intramuscular vaccination
    • a fine needle (23 or 25 gauge) should be used for the vaccination, followed by firm pressure applied to the site (without rubbing) for at least 2 minutes
    • if in any doubt, consult with the clinician responsible for prescribing or monitoring the individual’s anticoagulant therapy
  • Individuals with bleeding disorders may be vaccinated intramuscularly if, in the opinion of a doctor familiar with the individual’s bleeding risk, vaccines or similar small volume intramuscular injections can be administered with reasonable safety by this route
    • a fine needle (23 or 25 gauge) should be used for the vaccination, followed by firm pressure applied to the site (without rubbing) for at least 2 minutes
    • the individual/parent/carer should be informed about the risk of haematoma from the injection
  • The live attenuated influenza vaccine (LAIV) is administered by the intranasal route (Fluenz Tetra®) and is supplied in an applicator that allows a divided dose to be administered in each nostril (total dose of 0.2 ml, 0.1 ml in each nostril):
    • administration of either dose does not need to be repeated if the patient sneezes or blows their nose following administration
    • as heavy nasal congestion might impede delivery of the vaccine to the nasopharyngeal mucosa, deferral of administration until resolution of the nasal congestion should be considered, or if appropriate, an alternative intramuscularly administered influenza vaccine
  • Inactivated influenza vaccines can be given at the same time as other vaccines. LAIV can also be given at the same time as other live or inactivated vaccines
  • Intramuscular and intradermal vaccines should be given at separate sites, preferably in a different limb. If given in the same limb, they should be given at least 2.5 cm apart
  • After immunisation, protective immune responses may be achieved within 14 days
  • Although influenza activity is not usually significant in the UK before the middle of November, the influenza season can start early, therefore the ideal time for immunisation is between September and early November

For information on administration, and all influenza vaccines marketed in the UK for the 2020/21 season, see the full summary at guidelines.co.uk/454313.article

  • Flu viruses change continuously and the World Health Organization (WHO) monitors the epidemiology of flu viruses throughout the world making recommendations about the strains to be included in vaccines. For further information on the strains for 2020/21, see the WHO website
  • Providers should ensure that they have ordered adequate supplies of the recommended vaccines for their different patient groups, as set out in the letter from NHS England in December 2019
  • In summary these are:
    • for those aged 65 and over—the adjuvanted trivalent influenza vaccine (aTIV) (with the cell-based quadrivalent influenza vaccine (QIVc) offered if aTIV is unavailable)
    • for under-65s at risk, including pregnant women, offer QIVc or, as an alternative, the egg-grown quadrivalent influenza vaccine (QIVe)
  • The live attenuated influenza vaccine (LAIV) for children should be ordered through ImmForm from centrally purchased supplies and QIVe will be available to order for children in at risk groups aged less than 9 years old who are contraindicated to receive LAIV (see the The national flu immunisation programme 2020/21 letter for further information)

Table 2: Summary table of which influenza vaccines to offer

Eligible groupType of flu vaccine

At risk children aged from 6 months to less than 2 years

Offer QIVe.

 

LAIV and QIVc are not licenced for children under 2 years of age.

At risk children aged 2 to under 18 years

Offer LAIV

 

If LAIV is contraindicated or otherwise unsuitable offer:

  • QIVe to children less than 9 years of age.
  • QIVc should ideally be offered to children aged 9 years and over who access the vaccine through general practice. Where QIVc vaccine is unavailable, GPs should offer QIVe.
  • It is acceptable to offer only QIVe to the small number of children contraindicated to receive LAIV aged 9 years and over who are vaccinated in a school setting.

Aged 2 and 3 years on 31 August 2020

 

All primary school aged children and those in Year 7 (aged 4 to 11 on 31 August 2020)

Offer LAIV

 

If child is in a clinical risk group and is contraindicated to LAIV (or it is otherwise unsuitable) offer inactivated influenza vaccine (see above).

 

For children not in at risk groups, this year if a parent refuses LAIV in some areas an alternative QIVe or QIVc vaccine may be offered to them where possible.

At risk adults (aged 18 to 64), including pregnant women

Offer:

  • QIVc
  • QIVe (as an alternative to QIVc)

Those aged 65 years and over

Offer:

  • aTIV[A] should be offered as it is considered to be more effective than standard dose non-adjuvanted trivalent and egg-based quadrivalent influenza vaccines.
  • QIVc is suitable for use in this age group if aTIV is not available.

 

[A] It is recommended that those who become 65 before 31 March 2021 are offered aTIV ‘off-label’.

Table 3: All influenza vaccines marketed in the UK for the 2020/21 season

SupplierProduct detailsVaccine typeAge indicationsOvalbumin contentContact details

AstraZeneca UK Ltd

Fluenz®Tetra

Quadrivalent LAIV (live attenuated influenza vaccine) supplied as nasal spray suspension

From 24 months to less than 18 years of age

<0.024 mcg per 0.2 ml dose)

0845 139 0000

GSK

Fluarix Tetra

QIVe (standard egg-grown quadrivalent influenza vaccine), split virion, inactivated

From 6 months

≤0.05 mcg per 0.5 ml dose

0800 221 441

MASTA

Quadrivalent influenza vaccine

QIVe (standard egg-grown quadrivalent influenza vaccine), split virion, inactivated

From 6 months

≤0.05 mcg per 0.5 ml dose

0113 238 7552

Sanofi Pasteur Vaccines

Quadrivalent influenza vaccine

QIVe (standard egg-grown quadrivalent influenza vaccine), split virion, inactivated

From 6 months

≤0.05 mcg per 0.5 ml dose

0800 854 430

Mylan

Quadrivalent Influvac® sub‑unit Tetra

QIVe (standard egg‑grown quadrivalent influenza vaccine), supplied as surface antigen, inactivated

From 3 years

≤0.1 mcg per 0.5 ml dose

0800 358 7468

Seqirus UK Ltd

Flucelvax®Tetra

QIVc (cell-grown quadrivalent influenza vaccine), surface antigen, inactivated

From 9 years

Egg-free

08457 451 500

Seqirus UK Ltd

Adjuvanted trivalent influenza vaccine

aTIV (egg-grown trivalent influenza vaccine), surface antigen, inactivated, adjuvanted with MF59C.1

From 65 years

≤0.2 mcg per 0.5 ml dose

08457 451 500

Sanofi Pasteur Vaccines

[A]Trivalent influenza vaccine, high‑dose

TIV-HD (high-dose egg‑grown trivalent influenza vaccine), split virion, inactivated

From 65 years

1.0 mcg per 0.5 ml dose

0800 854 430

[A] This vaccine will not be commissioned by NHSE/I and will not be reimbursed by NHSE/I in 2020/21.

Contraindications

  • The summaries of product characteristics for individual products should always be referred to when deciding which vaccine to give. There are very few individuals who cannot receive any influenza vaccine. When there is doubt, appropriate advice should be sought promptly from the screening and immunisation team in the NHS England area team, a consultant in communicable disease control or a consultant paediatrician, so that the period the individual is left unvaccinated is minimised
  • None of the influenza vaccines should be given to those who have had:
    • a confirmed anaphylactic reaction to a previous dose of the vaccine, or
    • a confirmed anaphylactic reaction to any component of the vaccine (other than ovalbumin—see the precautions section of the full guideline)

Adverse reactions

  • Pain, swelling or redness at the injection site, low grade fever, malaise, shivering, fatigue, headache, myalgia and arthralgia are among the commonly reported symptoms after intramuscular or intradermal vaccination
  • A small painless nodule (induration) may also form at the injection site. These symptoms usually disappear within one to two days without treatment. Nasal congestion/rhinorrhoea, reduced appetite, weakness, and headache are common adverse reactions following administration of LAIV
  • Immediate reactions such as urticaria, angio-oedema, bronchospasm, and anaphylaxis can occur

Full guidelines:

www.gov.uk/government/publications/influenza-the-green-book-chapter-19

www.gov.uk/government/publications/influenza-vaccine-ovalbumin-content

assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/907149/Letter_annualflu_2020_to_2021_update.pdf

Public Health England. Influenza: the green book, chapter 19. April 2019.

Public Health England.Influenza vaccine: ovalbumin content. June 2020.

Department of Health and Social Care, Public Health England and NHS England. The national flu immunisation programme 2020 to 2021 - update. August 2020. 

Contains public sector information licensed under the Open Government Licence v3.0.

Published date: March 2013.

Last updated: August 2020.