In preparation of 2021/22's flu vaccination programme

Primarily this article will describe arrangements for the flu vaccination programme in England. The programme is delivered in Scotland¹, Northern Ireland² and Wales³, however, there may be subtle differences in programme delivery in the devolved nations and nurses working there should ensure that they are following relevant guidance specific to the area in which they practice.

In the UK influenza vaccination has been offered to increasing eligible groups of the population since the 1960s.⁴ From 2000 until 2012 the programme was very stable with eligible groups including adults and children with at risk conditions and everyone over 65 years of age. In 2012 the childhood flu programme was introduced⁵and the first quadrivalent vaccines (containing four strains of the virus) were marketed in UK.⁶

The different strains of influenza virus which circulate the globe, with new strains emerging constantly, mean that each year the strains used in the vaccines must be changed⁷ and annual vaccination of eligible groups is offered.

In recent years the decades of work, by researchers and vaccine manufacturers, to produce more effective flu vaccines, have come to fruition. The vaccines available in UK are now diverse with jabs for children, younger adults and older adults.⁸

Nurse immunisers who have been involved in the flu vaccination programme for many years will have seen it increase in complexity and in terms of the eligible population. Gone are the days of one type or brand of vaccine in the fridge given to every eligible patient. Immunisers must familiarise themselves with the different vaccines, the advice about which eligible groups get which vaccine and be able to explain the rationale for the different vaccines to their patients and clients. More information about the different vaccines and the rationale for their use can be found in the influenza chapter of the green book¹ and in another article by this author.⁸

The overwhelming majority of influenza vaccines were trivalent influenza vaccines (TIV), containing three strains of the virus and the viruses used to make them were cultured in eggs; now abbreviated to TIVe. All the vaccines in our programme also now quadrivalent influenza vaccines (QIV) which contain four strain of the virus giving wider protection to recipients against both influenza A and B strains that are predicted to circulate in the coming season.⁴

Newer vaccines include live attenuated influenza vaccine (LAIV), recommended for children aged 2 – 18 years. For adults over 65 years of age influenza vaccines containing an adjuvant (aQIV), and high dose vaccines (with 4 times as much antigen in each dose (QIV-HD) are available. For various ages of patients’ vaccines made in cells as opposed to eggs (QIVc) and recombinant vaccines (QIVr) are also available.

Impact of the pandemic on the influenza vaccination programme

The emergence of the SARS-CoV-2 coronavirus pandemic in January 2021 has reminded the world of the impact of a deadly infectious disease on a population, especially in the absence of a vaccine. This article will not go into detail about the pandemic, SARS-CoV-2, nor the disease it causes, Covid-19, but will discuss the flu vaccination programme in the context of the pandemic.

The SARS-CoV-2 virus pandemic was declared towards the end of the influenza season of 2019/20. The influenza disease rates that year had been relatively low.⁹ In the early months of 2020 Public Health England reported that some, mainly elderly patients, had contracted both influenza and SARS-CoV-2 virus and that the outcomes for these patients were poor.¹⁰

As the pandemic unfolded the high mortality and morbidity quickly became evident with large numbers of people sick and dying. This created massive challenges for UK health and social care systems. The seasonal influenza epidemics also add to winter pressures in health and social care each winter.¹¹ As the pandemic progressed attention had to be given to the likelihood of an autumn wave of the disease combined with the usual seasonal influenza epidemic. This is also a possibility for the coming winter season.

As the year unfolded information on the 2020/21 influenza season emerged.^{12, 13} This resulted in an extension to the programme with almost half of the UK population, 30 million people, being eligible for an flu vaccine at public expense.¹⁴ As happens every year those eligible were encouraged to take up the offer of influenza vaccine. The public and especially those particularly vulnerable to the worst effects of influenza heeded this advice and uptake for the 2020/21 season has been the highest in the history of the programme.¹⁵

Levels of influenza in 2020/21 season

Globally there has been the usual year-round surveillance of rates of influenza and viral strains.¹⁶ During the course of pandemic, across both the southern and northern hemispheres, the rates of influenza have been unseasonably low.¹⁶

The reasons why there have been such few cases of influenza reported in UK and globally are multi-factorial. Due to the scale of the pandemic response, it may be that some countries do not have capacity to test patients for influenza or that their surveillance systems are currently suspended or not reporting.¹⁶ Non-pharmaceutical measures to reduce transmission of SARS-CoV-2 virus, such as increased hand hygiene, wearing of facemasks and social distancing to name a few have also impacted on the transmission of SARS-Cov-2 and may have impacted the transmission of other respiratory spread viruses, including influenza. However, despite these measures SARS-CoV-2 continues to spread and this begs the question why influenza has not circulated as well. Another likely contributing factor on reduced rates of influenza has been attributed to something termed ‘viral interference’.¹⁷ This is when infection by one virus can be inhibited by the previous or current infection with another (related or unrelated) virus in the same host. It is thought to be due to stimulation of antiviral defences in the airway mucosa stimulated by another virus.¹⁷ These antiviral defences are likely due to stimulation of innate immune responses, particularly T cell responses, and are not necessarily virus specific. These may afford immunity against viruses other than those that prompted their production.

Another mechanism may be by direct blocking of viral entry to receptors on human cells by one virus.¹⁷ Viruses must enter cells in order to multiply, so one virus may block the receptors that viruses attach to in order to enter our cells.

The low influenza disease season could create some challenges for nurse immunisers this coming season. The public may be aware that there was very little influenza last season and may question why they need an flu vaccine this year. Influenza could return this winter or could be less prominent; there is no way of predicting what the case will be. Surveillance of influenza in the UK reveals the difficulty in predicting the extent and impact of influenza each year. Morbidity and mortality vary year to year with some years influenza attributed to high excess mortality rates especially in the elderly as was seen in 2016/17 and 2017/18 seasons.^{11, 18}

It is likely, as noted in 2020, that individuals who contract both influenza and SARS-CoV-2 viruses will have poorer outcomes than those with only one virus.¹⁰ Pressure on our social and health care systems is likely to remain high due to SARS-CoV-2 virus and the usual winter pressures this year. It is clear that the NHS cannot run the risk of having to deal with an influenza epidemic parallel to the current pressure it finds itself. It remains essential that health care, both primary led services but also secondary care actively promote the flu vaccine programme. Nursing and medical colleagues should be working in partnership with regard to offering and signposting patients toward the influenza vaccination, which includes attendance at CPD events to update both their knowledge and understanding about the influenza virus but also about new and existing vaccines should to support their patients to accept the offer of flu jab this year, as for every year.

Influenza vaccine guidance for 2021/22 season

Each year the Joint Committee for Vaccination and Immunisation (JCVI) consider the influenza vaccination programme. As in recent years JCVI has published advice on which vaccines should be offered to which eligible groups for the coming 2021/22 season.¹⁹

NHS England and NHS Improvement (NHS E&I) are responsible for commissioning the influenza programme, issuing contracts to providers, paying item of service payments and for remunerating the primary care providers for the cost of adult influenza vaccines given; vaccine which they procure directly from manufacturers.

Some of the newer vaccines available in the UK market, including those advised by JCVI, are more expensive than others. As a consequence, for the last three seasons NHS E&I have issued guidance to providers detailing which vaccines JCVI advise for eligible groups and stating which vaccine costs will be remunerated, and which will not.

NHS E&I guidance for the 2021/22 influenza season has been published.¹⁵ There are two different vaccines advised for use in both adults at risk and adults over 65 years of age. The guidance does not state which of the two vaccine types providers should order for their respective eligible populations.

Box 1¹⁵ below details the vaccines that will attract item of service payments and reimbursement of vaccines costs when given to persons aged over 65 years and patients aged 18 to up to 65 years of age with conditions that make them at risk of suffering the worst effects of influenza:

JCVI has advised that QIV-HD can be given to those aged 65 years and over¹⁹, however, due to its significantly higher list price this vaccine is not eligible for reimbursement by NHS E&I.¹⁵ The committee also advise that QIVr could be given to those aged 65 years and over and those aged 18 to 64¹⁹ however this vaccine is not eligible for reimbursement at this stage.¹⁵

NHS E&I state further guidance may be issued on the use of QIVr vaccine in the 2021/22 season.¹⁵ Additionally, there is not, as yet, guidance on extending the eligible cohorts (for example to healthy 50–64-year-olds and children in school year 7 in England) as happened in 2020/21.^{12, 13}

Ordering vaccines for the 2021/22 season

Each group eligible for influenza vaccine can be given one of two types of vaccine. Deciding which of these vaccines to order is not going to be an easy decision. The clinical considerations for the use of each type of vaccine has been assessed by JCVI and those responsible for ordering vaccine at local vaccination service level are advised to read the JCVI statement.¹⁹

JCVI has stated that patients aged over 65 years of age should have aQIV or QIV-HD.¹⁹ Given that QIV-HD will not be reimbursed that only leaves aQIV for this group in primary care. JCVI has said that QIVc or QIVr could be given to this group if either aQIV or QIV-HD are not available.¹⁹

Similarly, JCVI has supported a preference for non-egg cultured vaccines for at risk adults aged 18 to 64 years¹⁹. Since QIVr is not currently reimbursable this would leave only QIVc for this group. JCVI has said that QIVe could also be considered for this group;¹⁹ NHS E&I has said QIVe can be used if QIVc is not available.¹⁵

Vaccine ordering decisions

So, what would ‘not available’ look like? It may be the manufacturer of a particular vaccine closes its order books for their vaccine due to reaching vaccine production capacity. It may be that the vaccination service provider decided not order a particular vaccine and therefore the alternative will not be available at that service. It may be that an individual service runs out of a particular vaccine due to high demand during the season.

In order to make the decision on what to order providers may find it useful to discuss ordering options with the various vaccine manufacturers; details are in the green book chapter.⁴ Establish when their order books will close, at what point in time will cancellations or change of orders be accepted, what is the likelihood of obtaining more vaccine later in the season. Providers may wish to consider ordering both types of vaccines for each group, in order to have contingency should there be a vaccine production problem which can result in supplies issues before or during the season. Additionally, vaccine service providers may wish to discuss vaccine ordering plans and options with their designated clinical commissioning group (CCG) influenza lead and their regional Public Health Commissioning Team.¹⁵

What is clear is that, as long as one of the two vaccines for a particular group (as detailed in Box 1) are given to eligible patients, providers will be reimbursed for the vaccine cost and paid an item of service for that activity. Influenza vaccines given to children will not be reimbursed since these will be procured centrally and should be ordered from ImmForm.¹⁵

In 2020/21 season the late policy decision to extend the programme to include more eligible groups required the Department of Health and Social Care ordered extra influenza vaccine supplies at central level.²⁰ It is yet to be confirmed whether this will happen again. Providers in primary care should place orders for sufficient volumes vaccine to offer to all the usual, and so far identified, eligible groups of patients in their practice population.

Concluding remarks

For many years now the flu vaccination programme has undergone change with new groups added and new vaccines advised for specific groups. The SARS-CoV-2 virus pandemic has added further complications for the programme and it is evident that policy changes are still undergoing some consideration for 2021/22 season. More guidance is expected and changes to the programme are inevitable as the season progresses. Nurses involved in the flu vaccination programme, including those responsible for advocating and sign posting their patients for influenza vaccine, should ensure they have updated their knowledge through the medium of CPD to ensure they are familiar with both new guidance and ongoing developments for the influenza vaccination programme as the season approaches and progresses.

References

In preparation of 2021/22’s flu vaccination programme

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