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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.


  • In 2020/21 groups eligible for the NHS funded flu vaccination programme are the same as last year, although this may change if the programme is expanded, and include:
    • all children aged 2 to 10 (but not 11 years or older) on 31 August 2020
    • those aged 6 months to under 65 years in clinical risk groups (see table below)
    • pregnant women
    • those aged 65 years and over
    • those in long-stay residential care homes
    • carers
    • close contacts of immunocompromised individuals
    • health and social care staff employed by a registered residential care/nursing home, registered domiciliary care provider or a voluntary managed hospice provider
  • We expect universal vaccination of health and care workers and further guidance will be published in due course

Prioritising flu vaccine uptake

  • Flu vaccination is one of the most effective interventions we have to reduce pressure on the health and social care system this winter. We are currently seeing the impact of COVID-19 on the NHS and social care, and this coming winter we may be faced with co-circulation of COVID-19 and flu. We understand that planning this year is more challenging with the uncertainties of staff absences, and how long policies around social distancing and school closures will remain in place. However, it is more important than ever to make every effort to deliver flu vaccination
  • Those most at risk from flu are also most vulnerable to COVID-19. We must do all we can to help protect them this winter. We anticipate that concerns about COVID-19 may increase demand for flu vaccination in all groups this year, and some in at risk groups may have concerns about maintaining social distancing when being given the vaccine
  • All those eligible should be given flu vaccination as soon as possible so that individuals are protected when flu begins to circulate. Providers should aim to schedule their immunisation services to match vaccine supply, usually from September, and complete vaccination by the end of November, where possible
  • Clinical risk groups who should receive the influenza immunisation are set out in Table 1. Influenza vaccine should be offered to people in the clinical risk categories set out in Table 1.

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


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)


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

SupplierProduct detailsVaccine typeAge indicationsOvalbumin contentContact details

AstraZeneca UK Ltd


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


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


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


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


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.


  • 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:




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 2020/21. May 2020. 

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

Published date: March 2013.

Last updated: June 2020.