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All you need to know about flu clinics

Kirsty Armstrong
SRN FPcert BSc(Hons) NPDip PGCert Ed PGDip
Senior Lecturer/Practitioner in Primary Care
St George's Hospital
London

Influenza is an acute infection caused by a virus. Three category strains - A, B and C - are used in the formulation of the vaccine each year. These strains are those most prevalent in the worldwide spread of influenza. The virus does exhibit antigenic drift most seasons and antigenic shift periodically.1 This means a new formulation of the vaccine is needed every year.

Infection occurs through the spread of droplet particles, aerosols (smaller, airborne particles) and direct contact, such as shaking hands or touching door handles. The incubation period is one to three days and illness can last from two to 10 days.

Typically, the flu season occurs in the months from December to March. During this time, the Health Protection Agency (HPA) and the Royal College of General Practitioners measure consultations for "flu-like illness" to determine the levels of flu in the community.2 If consultations exceed 50 in 100,000, there may be a Chief Medical Officer recommendation to issue antiviral treatments to at-risk groups.

Most flu vaccines are available from late September to help cover at-risk groups as early as possible. The earlier you get the flu jab, the more cost-effective and preventive it is, as you are protected for the whole season. Flu vaccines were first given in the late 1960s and, today, the NHS provides about 14 million doses of the vaccine for at-risk groups.3

Questions raised by patients

"Last year when I had the vaccine I still got the flu - why is this?"
Full vaccine protection takes between 10 and 14 days to develop, will last for one year and gives 70-80% protection.1 However, if your patient has just been to visit Auntie Joan, who has the flu, and now wishes to get the vaccine to protect themselves, it may be ineffective as they have already been in contact with the virus and could be developing the flu as they receive the vaccine.

If you encounter the flu virus having had the flu vaccine your attack will be less virulent and so may appear to be rather like a cold. The coryza virus (or common cold) is different from the flu virus, but symptoms in lesser attacks of flu may mimic a bad cold.

"I am not in an at-risk group but I get the flu every year. Can I still have the vaccine?"
Some practices will have a reciprocal arrangement with a sister or other practice to give the flu vaccine privately, as your own NHS practice cannot provide your NHS patients with private services. Ask around and set up such an agreement with another practice to keep your "worried well" happy.

"Is there a flu pandemic coming?"
We are well overdue a flu pandemic as this is the longest period in history without one having occurred.4 At-risk groups should be fastidiously identified and vaccinated. There are substantial plans in place within the NHS and HPA to counteract the effects of such a pandemic and these can be viewed on the HPA website (see Resources).4

"I am allergic to hen eggs - does this mean I can't have the vaccine?"
Nearly all of the flu vaccines contain traces of egg protein but you should establish if the patient is truly anaphylactically allergic to eggs or just has an intolerance, as this is not a contraindication. However, there is an egg-free flu vaccine called Optiflu (produced by Novartis), which you could use as an alternative. Always consider the three absolute contraindications to vaccination: fever; anaphylaxis to any ingredient in the vaccine; or previous anaphylaxis to a vaccine such as this. Relative contraindications, such as immunosuppression, are discussed at length in the Green Book produced by the Department of Health.1

"Are there any side-effects of the vaccine?"
You should discuss the side-effects of the vaccination with your patient and advise them on what to do if they develop some of the more common ones, such as a sore, red arm or low-grade pyrexia (fever).

"Can I have the vaccine if I am pregnant/immunosuppressed/have coeliac disease?"
There are many at-risk groups who should have the vaccine, including the over-65s. Visit the Green Book website for a list of these.1 There are relative contraindications to vaccination, which include immunosuppression through disease or treatment. Check with the managing physician to get the all clear before vaccinating. Pregnancy is neither an absolute nor relative contraindication to flu vaccination, and from 2009 it will be recommended to all pregnant women to help protect neonates.1

Thiomersal-free vaccines are recommended for pregnant and child patients. Thiomersal is a mercury-based preservative that was used to stabilise and preserve vaccines. Due to theoretical concerns about the exposure of babies to doses of mercury which exceed World Health Organization (WHO) recommendations, it is no longer used in any of the UK vaccines. More information can be found in the usual immunisation resources, such as the Green Book.1

"I never get the flu, so even if I am in an at-risk group would you agree that I don't need the vaccine?"
The patient's decision is final, but you need to use all the resources at your disposal to give them the necessary information to make an informed decision. This makes the consent you get from the patient valid.5 Older people are more likely to get the flu - declining immunity is usually one of the reasons - and those in at-risk groups and with long-term conditions may also suffer from anaemia.

"What about this new flu vaccine which you only have to have once or twice and lasts a lifetime?"
This vaccine is based on the newly isolated "M" strain of the flu virus, which rarely mutates. It is not yet available for patients, but is nearing the end of initial clinical trials. One or two doses with later boosters may give longer-lasting immunity, but it has only been used successfully in mice so far.6 In addition, a nasal mist spray vaccine is available in the USA, but has not yet been licensed for use in this country.6

Questions raised by nurses

"My GP/practice manager says I do not need to have a patient group direction to give vaccines. Is this true?"
Unless you are an independent prescriber, you need a patient group direction (PGD) to administer prescription-only medicines (POMs).7 These are available from your primary care trust (PCT), local pharmacy lead, training and development coordinator or even the NHS National Prescribing Centre website. PGDs are useful to help you identify those patients who you should not be immunising and who you should refer them to.

"Is it advisable to ask our healthcare assistants to do the documentation, while we do the jabs?"
Care should be taken with this method. The immuniser should document what they have done, otherwise there could be mistakes, which are very hard to rectify later. If you use another person to document you should check for mistakes at the end of each session; but legally you are accountable for your actions - this includes who you have immunised and any actions you may delegate.8

Conclusion
There is no substitute for meticulous organisation at your flu clinics. Appointment times should be adequate, immunisers kept up-to-date with injection technique, anaphylaxis and the need for precise documentation. Fridges should not be overfilled and should, as always, be checked daily for the optimum temperature of 2-8oC. This should be recorded daily and acted upon if the fridge is not at this temperature. At-risk groups should be identified, contacted and chased up if they do not respond, turn up or refuse vaccination. The Green Book and your anaphylaxis pack should also be in evidence when you immunise as you need to be very familiar with both to ensure safe vaccination.

References
1. Department of Health. Immunisation against infectious disease: the Green Book. London: DH; 2006. p. 189-200.
2. Health Protection Agency. Seasonal influenza. Available from: http://www.hpa.org.uk/webw/HPAweb&Page&HPAwebAutoListName/Page/119194217...
3. Joint Committee on Vaccination and Immunisation. Draft minutes of the meeting held on Wednesday 19 October 2005. Available from: http://www.advisorybodies.doh.gov.uk/jcvi/mins191005.htm
4. Health Protection Agency. Pandemic influenza. Available from: http://www.hpa.org.uk/webw/HPAweb&Page&HPAwebAutoListName/Page/119194217...
5. Department of Health. Reference guide to consent for examination or treatment. London: DH; 2001.
6. MacRae F. The vaccine to prevent every strain of flu. Daily Mail 29 December 2006. Available from: http://www.dailymail.co.uk/health/article-425227/The-vaccine-prevent-str...
7. National Prescribing Centre. Patient group
directions. A practical guide and framework of
competencies for all professionals using patient group directions. London: NPC; 2004. Available from: http://www.npc.co.uk/publications/pgd/pgd.pdf
8. Nursing and Midwifery Council. The Code: Standards of conduct, performance and ethics for nurses and midwives. Accountability advice sheet. London: NMC; 2008. Available from: http://www.nmc-uk.org/aFrame
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