This month is the 16th anniversary of when I joined my GP practice and it sometimes feels as if those years have been marked out in flu vaccination seasons.
Each summer the email comes round asking for volunteers for our late September, Saturday morning flu session and each time I wonder how another year can have passed. This year is going to be the mother of all flu seasons with an estimated 30 million patients targeted. 1
Eligibility criteria has been extended to household contacts of those in the shielding group and everyone aged 50 or over and it seems likely that there will be more uptake in those who have previously been eligible but declined vaccination, as people are so much more aware of respiratory viruses this year than in the past.
The current eligibility criteria are listed on the NHS website but not everyone is being offered a vaccination at the time of writing. Those aged 50-64 with no underlying health problems – a group who would not normally have been offered vaccination on the NHS – will have to wait until we know whether there is enough vaccine left after the over 65s and those with underlying health conditions have been vaccinated.1 The need for social distancing has led to creative solutions with patients being vaccinated in car parks, marquees, church halls and other unusual venues.
The vaccination offered varies depending on the age – see the table below. 2 The reason for the different vaccines is partly to do with immunosenescence, the phenomenon whereby the immune system becomes less active with age, with less B and T cells and poorer functioning of mature lymphocytes. For this reason, those aged 65 or over are offered the adjuvanted vaccination as it is more effective in this age group.
|65 or over||aTIV – if aTIV not available then they can have QIVc |
|18 – 64||QIVc first choice – if not available then they can have QIVe|
|2 – |
|LAIV unless immunocompromised in which case they should have QIVc if aged 9 or over and QIVe if aged 2 – 8|
Vaccination names in full:
aTIV= adjuvanted trivalent influenza vaccine
LAIV = live attenuated influenza vaccine (nasal spray)
QIVc = quadrivalent influenza vaccine (cell-grown)
QIVe = quadrivalent influenza vaccine (egg-grown)
As a practice nurse giving the flu vaccination you will be very accessible to patients who have questions and concerns and you should hopefully be able to do some myth-busting to increase uptake of the vaccination.
Some frequently asked questions:
‘I’m allergic to eggs – can I have this vaccination?’
This is only relevant for QIVe which is grown in egg – a patient who has been in ITU due to an egg allergy should not have QIVe and if they must have it then it should be given in hospital. All others with a less severe allergy can have QIVe, but as it is only a second line vaccine this year numbers should be small.3
‘My child is on inhaled steroids for asthma – does that mean she can’t have the live flu vaccine?’
LAIV should not be given to those who are immunocompromised. Their immune system may be suppressed due to disease such as poorly controlled HIV, leukaemia, lymphoma or a primary immunodeficiency or due to medications being given. These include oral prednisolone at 2mg/kg/day for a week or 1mg/kg/day for a month, or other equivalent oral steroids, plus other immunosuppressant drugs or chemotherapy. It does not include inhaled steroids. Adolescent patients who are breastfeeding or pregnant should not have the LAIV and neither should any children taking salicylates.
‘I am Muslim/Jewish and I have heard that this drug contains pork gelatine. Can I have a different one?’
LAIV is the only flu vaccine which contains porcine gelatine and so this objection may come from a parent about their child’s vaccination. Religious leaders in both faiths have advised that medicines containing porcine gelatine should not automatically be refused – making the patient aware of this may make them happy to accept the vaccine. If not then your action depends on the reason for vaccination. If they are in an at-risk group, they can have an injectable vaccination (as per the flow chart above) but if they are only having the vaccination due to age then there is no alternative available on the NHS.4,5 The child will benefit from herd immunity among their peers or the parent can access the vaccine privately.
‘We have an elderly/vulnerable relative at home – I have heard that a child who has the nasal flu vaccine can shed flu and might give it to my relative. Should my child have the injection instead?’
This is a theoretical risk but Public Health England are reassuring, saying that ‘in the US, where there has been extensive use of LAIV for many years, serious illness amongst immunocompromised contacts who are inadvertently exposed to vaccine virus has never been observed.’6 Having an immunocompromised relative at home is generally not a contraindication to LAIV – PHE say that only household contacts of those who are ‘very seriously immunocompromised’ should have the injectable vaccination. They do not define this group but it is likely that the relative’s consultant will let them know. Similarly, most immunocompromised children can go to school on the day that their peers get the nasal flu vaccination, with the only exception being those who are extremely immunocompromised, for example because of a recent bone marrow transplant. Such children may well be off school anyway as the risk of catching other infections is significant.
‘Can I go home straight after my flu jab, or do I have to wait to make sure that I don’t have a side-effect?’
Asking patients to wait for five minutes after a vaccination to ensure no adverse effects is one of those things that is often done but without much evidence. Both the Royal College of Nursing7 and the Green Book8 (the definitive UK reference for vaccinations) agree that no prolonged period of observation is necessary.
‘I never have the flu jab – it always gives me flu‘
This is a common misconception and an important one for us to counter. None of the injectable flu vaccines are live and so they cannot give the patient flu. However, we give the flu vaccine in the cough and cold season and so there will always be some patients who get a respiratory infection (or flu – the vaccine is not 100% effective) in the few days after the vaccine and therefore wrongly think that the vaccine has caused the infection. Vaccinations are not free of side-effects, which can include low grade fever, fatigue, muscle aches, headache and pain or redness at the injection site – these can resemble flu, but settle within a day or two, much more quickly than flu itself. More serious conditions such as fits, vasculitis and encephalomyelitis have been reported after flu vaccination (very rarely) but it is not clear if there is a causal link.4
There will always be some patients who will not be persuaded to have a vaccination. The anti-vaccination movement has been identified by the World Health Organisation as one of the top 10 threats to health9 and there are some who will always believe that we are part of the conspiracy of vaccinations. But for many who are vaccine hesitant, rather than vaccine refusers, having the information above at your fingertips might help them to feel comfortable having the vaccination. Flu vaccination is one of the most cost-effective things that we do in medicine; every extra high-risk patient who is vaccinated is a potential hospital admission or fatality avoided. This will be a flu season like no other both in terms of numbers and in the way we arrange our clinics. Good luck!