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Update on influenza vaccination in the UK

 - Primary care nurses have a critical role in ensuring eligible patients are offered flu vaccination

 - Despite the high risks of serious illness and death, only around half of patients in the clinical risk groups are vaccinated each year

 - Achieving a high vaccine uptake will bring great benefits to individuals, communities and health and social care services by substantially reducing flu-related illness, GP consultations, hospital admissions and deaths

Immunising patients against influenza - or flu - is one of the most effective interventions primary care nurses can undertake to reduce the risks of flu and the pressures on health and social care services each winter. For most healthy people, flu is a very unpleasant but usually self-limiting illness, but for young infants, older people, pregnant women and those with underlying disease or immunosuppression, catching flu brings an increased risk of serious illness and death.

Despite the high risks, for a number of years, only around half of patients in the clinical risk groups have been vaccinated. Primary care nurses have a critical role in ensuring eligible patients are offered flu vaccination. The purpose of this article therefore, is to provide an update on the current UK flu immunisation programme.

UK flu immunisation programme

Annual flu immunisation for those in clinical risk groups has been recommended in the UK since the 1960s in order to directly protect patients who are at a higher risk of flu-associated morbidity and mortality. In 2000, flu vaccine policy was extended to include all people aged 65 years and over and in 2010, pregnancy was added as a clinical risk group for routine flu immunisation following a growing body of evidence that contracting flu in pregnancy brings an increased risk of complications both for the pregnant woman1,2  and her child (premature birth, smaller birth size and weight.3-5) In 2013, the phased introduction of a childhood programme in which all children aged between two and 17 will be offered annual flu immunisation began, with flu immunisation being offered to all children aged two and three years and to primary school children either in a small number of different geographical pilot sites (England) or in a single year group or school (Northern Ireland, Scotland and Wales). This ambitious programme, which will eventually see around 9 million children being offered immunisation every year in a two-month period, will be extended in gradual phases over the next few years; with the vaccine being offered this year to all children aged two, three and four years in primary care and the extension of the geographical pilots to include both primary and secondary school aged children. 

While recognising it as an enormous undertaking, the Joint Committee on Vaccination and Immunisation (JCVI) advised that extending the annual flu programme to include children is likely to be highly cost-effective as it provides both direct protection to the child and indirect protection to others by lowering flu transmission.6 It has been estimated that if just 30% of children had the flu vaccine, there could be 2,000 fewer deaths and 11,000 fewer hospitalisations due to flu each year. The evaluation of the first phase of the childhood flu programme in 2013/14 is encouraging: despite low flu activity last year, in pilot areas compared to non-pilot areas there were fewer GP consultations and A&E attendances for 'influenza like' and respiratory illness and fewer people tested positive for flu in primary care.7

Exactly how the programme will roll out year-by-year, and for how long, will be guided by the experience of the previous years' programme. It is anticipated that the programme will be extended to all two to 17 year olds by 2017/18.8 However, this is subject to negotiation and funding and will be kept under review. The JCVI will continue to monitor the impact of the programme and the detail for each flu season will be confirmed on a yearly basis.

Symptoms and epidemiology

Flu is an acute viral infection of the respiratory tract. It is a highly infectious illness which spreads rapidly in closed communities and even people with mild or no symptoms can infect others (30-50% of infections are asymptomatic)9. Those with symptoms may experience a sudden onset of fever, chills, headache, myalgia & extreme fatigue with a dry cough, sore throat and congested nose. The illness may be complicated by bronchitis, secondary bacterial pneumonia, otitis media, meningitis and encephalitis.

Most cases in the UK occur during an eight to 10 week period during the winter. The impact of flu on the population is influenced by changes in the virus. These changes affect the proportion of the population that are susceptible to infection and the severity of the illness. Although flu viruses circulate each winter, the degree of activity varies substantially from year to year: 2013/14 saw low levels of circulating flu but there were an estimated 11,000 deaths attributable to flu in the 2012/13 season.10 

Flu season vaccine eligibility 2014/15 

The following people are eligible for flu immunisation in the 2014/15 flu season: 

 - Those aged 65 years and over on or before 31 March 2015.

 - Those aged six months to under 65 years in clinical risk groups.

 - Pregnant women at any stage of pregnancy.

 - All children aged two, three and four years on or before 1 Sept 2014.                

 - School-aged children in pilot areas.

 - Those in long-stay residential care homes.

 - Those in receipt of a carer's allowance, or who are the main carer of an elderly or disabled person.

 - Those living in long-stay residential care homes/care facilities.

Immunisation of clinical risk groups

The clinical risk groups include those with chronic respiratory, heart, kidney, liver and neurological disease and those with diabetes, immunosuppression, asplenia and splenic dysfunction. More detail about each risk group category is provided in the annually updated Green Book (GB) Influenza chapter11. It is very important that immunisers are familiar with who should be offered the flu vaccine and are proactive in offering it. Studies of flu mortality by clinical risk group show that people with immunosuppression are 47 times more likely to die from flu than immunocompetent people. People with chronic neurological conditions and liver disease are 40 and 48 times respectively more likely to die and it is both for this reason, and the fact that patients in these two risk groups have the lowest flu vaccine uptake rate among those in clinical risk groups that immunisation providers have been requested to prioritise the improvement of flu vaccine uptake in these two groups in 2014/15.10

Immunisation of health and social care workers

For several years, health and social care workers who are in direct contact with patients/clients have been urged to be vaccinated. This not only offers important personal protection against flu but will also reduce the transmission of flu within health and social care premises, contribute to the protection of individuals who may have a suboptimal response to their own flu immunisation, protect families, friends and colleagues; and keep the NHS and care services running through winter pressures. In 2013/14 there was a marked improvement in vaccine uptake of frontline health care workers with an uptake of 55% compared to 46% the previous year. However, the overall uptake is still below the 75% aspiration and this therefore remains a priority area for improvement. Responsibility for funding and administering the seasonal flu vaccine to health and social care staff directly involved in delivering care lies with employers, and employers should ensure that staff are encouraged to be immunised and that arrangements are in place to facilitate this. 

Flu immunisation

The ideal time for flu immunisation is between September and early November before flu starts circulating in the community. However, as flu can circulate considerably later than this, clinical judgment should be applied to assess the needs of individual patients for immunisation beyond this time period, taking into account the level of flu-like illness in the community.

Protection afforded by the vaccine is thought to last at least one flu season. However, as antibody levels are likely to wane and there may be changes to circulating strains from one season to the next, annual revaccination is important.

There are two main types of vaccine available: an inactivated vaccine given by injection and a live vaccine for children given intranasally. The inactivated flu vaccines provide 70-80% protection when the vaccine strains are well matched to circulating strains. They are less protective in the elderly but still significantly reduce bronchopnemumonia, hospitalisations and mortality. The live attenuated influenza vaccine (LAIV) has been shown to provide a higher level of protection for children than inactivated flu vaccines12 (around 83%13) and it may offer some protection against strains not contained in the vaccine as well as to those that are. 

Most flu vaccines are trivalent, containing the two subtypes of influenza A and one B virus, predicted by the World Health Organization as most likely to be the circulating strains for the forthcoming winter. Two quadrivalent vaccines (one live and one inactivated) which include both B strains are now also available. These should improve the potential for matching the vaccine to the circulating flu strain(s). The live quadrivalent vaccine (Fluenz Tetra®) will be offered to all eligible children in the 2014/15 flu season.

Since the live vaccine is comprised of weakened (attenuated) whole live virus, it replicates natural infection which induces better immune memory - thereby offering better long-term protection to children than the inactivated vaccines. In addition to being weakened, the live viruses have been adapted to cold. This means the virus will not replicate well at body temperature in the lungs but will reproduce at the cooler temperatures found in the nasal mucosa. This allows the child to produce antibodies in the lining of the airways which then protect against infection. By limiting viral reproduction to the nose, the live vaccine cannot cause clinical flu in immunocompetent children. Inactivated flu vaccines cannot cause flu either since the viruses in these vaccines have been killed. 

There are a number of different inactivated flu vaccines available for the 2014/15 season. Some are restricted for use in particular age groups so the product SPC should always be referred to. Most inactivated vaccines are administered by intramuscular injection, although one vaccine (Intanza®) should be administered intradermally. While a single dose is recommended for all patients aged over nine years, two doses of inactivated flu vaccine are recommended for younger children (six months to under nine years) who have not received flu vaccine before in order to achieve adequate antibody. Studies of LAIV in previously unvaccinated children have shown good efficacy after a single dose however,14 so only children in clinical risk groups aged two to under nine years who have not received flu vaccine before need receive a second dose of LAIV four weeks later. 

The inactivated vaccines are supplied in pre-filled 0.5ml syringes. Fluenz Tetra® is supplied as a nasal spray suspension in a special pre-filled applicator that allows a divided dose to be administered into both nostrils (0.1ml in each nostril). All flu vaccines should be stored between 2-8ºC and it is particularly important to check the expiry date of Fluenz Tetra® as it has a short shelf life of only 18 weeks. 

Contraindications and precautions

There are very few people who cannot receive any flu vaccine and where LAIV cannot be given, it is likely that inactivated vaccine could be given instead.

None of the flu vaccines should be given to those who have had a confirmed anaphylactic reaction to a previous dose of the vaccine or to any component of the vaccine.

LAIV should not be given to children or adolescents who are severely immunodeficient due to conditions or immunosuppressive therapy. These children, and children with HIV infection who are not on highly active antiretroviral therapy, should be given inactivated flu vaccine. Additionally, since there is a potential for transmission of the live virus to severely immunocompromised contacts for one to two weeks following immunisation, where close contact with very severely immunocompromised people is unavoidable, inactivated flu vaccines should be considered instead. 

LAIV is not recommended for children with severe asthma or with active wheezing at the time of vaccination and it is not licensed for children under two years.

Since most flu vaccines are prepared from viruses grown in embryonated hens eggs, they contains residual traces of ovalbumin, a major egg allergen, and caution should therefore be taken in egg allergic individuals. Fluenz Tetra® should not be given to children with any degree of egg allergy. However, inactivated flu vaccines with a very low ovalbumin content are available and studies show they may be used safely in individuals with egg allergy.15 Most patients with egg allergy can be immunised in primary care using a vaccine with a low ovalbumin content. Patients with either confirmed anaphylaxis to egg or with egg allergy and severe uncontrolled asthma should be referred to specialists for immunisation in hospital however. The ovalbumin content of each flu vaccine and clear guidance on egg allergy is given in the GB influenza chapter.11

A full list of contraindications and precautions is also provided in the GB flu chapter11 and these should be read carefully before administering any flu vaccine.

Role of primary care nurses

Several factors have been identified as being associated with a higher flu vaccine uptake in general practice. These include having a named individual within the practice who is responsible for the flu immunisation programme; holding a regularly updated register that can identify all eligible patients; having robust call and recall arrangements; starting vaccination as soon as practicable after receipt of the vaccine to ensure maximum  number of patients are protected before flu starts to circulate; collaborating with midwives to provide flu vaccination to pregnant women; offering flu vaccination opportunistically and working with other providers to offer flu vaccination to residents in care/nursing homes and house-bound patients. These factors have been published in a GP Practice Checklist10 and practices are encouraged to review their systems against this checklist.

Although the annual flu programme further increases the workload for primary care nurses at an already busy time of year, achieving a high vaccine uptake will bring great benefits to individuals, communities and health and social care services. It will substantially reduce flu-related illness, general practice consultations, hospital admissions and deaths. The increased risks of mortality and serious complications in clinical risk groups are clear and highlight why it is so important to identify and immunise people in these groups.  Adding the immunisation of all two, three and four year old children will bring further benefit for the children themselves, those in risk groups and the whole community. 

Primary care nurses are critical to the success of the programme. If they are knowledgeable and confident about flu immunisation and put processes in place to facilitate access to the vaccine, maximal uptake can be achieved.

Further Guidance

 - The updated influenza chapter of the online Green Book

 - Separate letters from the Departments of Health for England, Northern Ireland, Scotland and Wales have been published which provide details about the implementation of the flu programme in each country.

 - The GP practice checklist is Appendix D of the DH/PHE/NHS England letter detailing the 2014/15 flu programme

 - Country-specific training slides with accompanying notes, Q&As and leaflets and posters about the flu programme are available to immunisers on each country's immunisation webpages

 - The NHS Employers Flu Fighters webpage contains information and materials to assist healthcare worker flu vaccination campaigns


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2. Pebody R, et al. Pandemic influenza A (H1N1) 2009 and mortality in the United Kingdom: risk factors for death, April 2009 to March 2010. Eurosurveillance 2010;15(20):19571.

3. Pierce M, Kurinczuk JJ, Spark P et al. Perinatal outcomes after maternal 2009/H1N1 infection: national cohort study. BMJ 2011;342:d3214. 

4. McNeil SA, Dodds LA, Fell DB et al. Effect of respiratory hospitalization during pregnancy on infant outcomes. Am J Obstet Gynecol 2011;204:(6 Suppl 1)S54-7. 

5. Omer SB, Goodman D, Steinhoff MC et al. Maternal influenza immunization and reduced likelihood of prematurity and small for gestational age births: a retrospective cohort study. PLoS Med. 2011;8:(5):e1000441.

6. Joint Committee on Vaccination and Immunisation (2012) JCVI statement on the annual influenza vaccination programme—extension of the programme to children.

7. Pebody RG, Green HK, Andrews N et al. Uptake and impact of a new live attenuated influenza vaccine programme in England: early results of a pilot in primary school-age children, 2013/14 influenza season. Euro Surveill. 2014;19(22):pii=20823.

8. Department of Health, Public Health England, NHS England. Childhood flu immunisation programme: update and provisional roll-out schedule. 15 July 2014. 

9. Wilde JA, McMillan JA, Serwint J et al. Effectiveness of influenza vaccine in healthcare professionals: a randomised trial. JAMA 1999;281:908-13.

10. Department of Health, Public Health England, NHS England. The national flu immunisation programme 2014/15. 28 April 2014.

11. Immunisation against infectious disease ('the Green Book') Chapter 19 'Influenza'. Updated July 2014.

12. Belshe RB, Edwards KM, Vesikari T et al. (2007) Live attenuated versus inactivated influenza vaccine in infants and young children. New England Journal of Medicine 356(7):685-96. 

13. Osterholm MT, Kelley NS, Sommer A, Belongia EA. Efficacy and effectiveness of influenza vaccines: a systematic review and meta-analysis. The Lancet Infectious Diseases 2012;12(1.1):36-44.

14. Bracco Neto H, Farhat CK, Tregnaghi MW, et al. Efficacy and safety of 1 and 2 doses of live attenuated influenza vaccine in vaccine-naive children. Pediatr Infect Dis J 2009;28:365-71.

15. Des Roches A, Paradis L, Gagnon R, et al. Egg-allergic patients can be safely vaccinated against influenza. J Allergy Clin Immunol 2012;130(5):1213-6.