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This resource provides the background to seasonal influenza immunisation, and includes the definition of influenza, and details of influenza vaccines. It covers up-to-date information on who to vaccinate, which vaccines are available and how to administer them, the contraindications and adverse effects of influenza vaccines, how to manage egg allergy, and what information and advice should be provided to people receiving a vaccine.
On completion of this module you will know:
PRACTICE NURSE FEATURED ARTICLE
This resource is provided at an intermediate level by Clarity Informatics. Read the article and answer the self-assessment questions, and reflect on what you have learned.
Complete the resource to obtain a certificate to include in your revalidation portfolio. You should record the time spent on this resource in your CPD log.
Seasonal influenza immunisation
What is influenza?
Influenza is an acute viral infection of the respiratory tract. Influenza types A and B are responsible for most cases of clinical illness in the UK.
In healthy people, seasonal influenza is usually a self-limiting condition, and recovery is typically within 2–7 days.
In older people and those in specific clinical risk groups, seasonal influenza may be more likely to result in serious complications such as pneumonia, meningitis, encephalitis, and death.
The World Health Organization (WHO) makes recommendations each year about the strains to be included in influenza vaccines for the forthcoming winter for the northern and southern hemispheres, based on worldwide monitoring. For more information see the WHO website. https://www.who.int/influenza/en/
All but one of the influenza vaccines available in the UK are inactivated and do not contain live viruses. Inactivated vaccines are usually administered intramuscularly. Inactivated influenza vaccines are either trivalent, containing two subtypes of influenza A and one B virus, or quadrivalent, with an additional B virus.
One vaccine (Fluenz Tetra) is a quadrivalent attenuated live vaccine administered by nasal spray.
An annual list of the influenza vaccines available in the UK is published ahead of each influenza season in the National flu immunisation programme plan for England, available at https://www.gov.uk/government/collections/annual-flu-programme.
Who should be offered the seasonal influenza immunisation?
Influenza vaccination should be given as soon as possible to provide protection before flu starts to circulate and should ideally be completed by the end of November, but can also take place up until the following 31 March.
Annual seasonal influenza immunisation is recommended for people who are more at risk of the complications of influenza, including:
Seasonal influenza immunisation is also recommended in certain healthy people to reduce the risk of transmission to vulnerable groups, including:
In addition, for 2020/21, seasonal flu vaccination will also be offered to:
What are the clinical risk groups that should be offered the seasonal influenza immunisation?
Clinical risk groups in people aged 6 months and older include (note this list is not exhaustive):
Use clinical judgement to assess whether influenza vaccine should be offered to newly pregnant women, particularly if after the usual immunisation time period, taking into account the level of influenza-like illness in the community, and the fact that the immune response following immunisation takes about 2 weeks to fully develop.
Which vaccines are available?
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None of the vaccines listed in the table contain thiomersal as an added preservative. Most of the viruses are grown in embryonated hens' eggs and are then chemically inactivated before being further treated and purified.
Quadrivalent vaccines contain two subtypes of influenza A virus and two subtypes of influenza B virus.
In the 2020/21 influenza season in the northern hemisphere, it is recommended that egg-based quadrivalent vaccines include:
In the 2020/21 influenza season in the northern hemisphere, it is recommended that cell- or recombinant-based quadrivalent vaccines include:
What vaccine should be used?
In the 2020/21 influenza season, it is recommended that:
Note: Fluenz Tetra contains a highly-processed form of porcine gelatine that may not be acceptable to some faith groups. Children and young people in a clinical risk group who choose not to have the nasal spray should be offered a QIVe. For 2020/21, children who are not in a clinical risk group may be offered an alternative vaccine (providers will receive notification of a suitable alternative).
For children in clinical risk groups aged from 6 months to less than 2 years, offer a suitable QIVe. Children who have not received influenza vaccine previously should be offered a second dose at least 4 weeks later.
Note: inactivated influenza vaccines can be considered interchangeable for children younger than 9 years of age who require a second dose of influenza vaccine (but see product inserts for advice about use in specific age groups).
What contraindications and cautions are associated with influenza vaccines?
Do not give influenza vaccine to people with a confirmed anaphylactic reaction to:
If there is any uncertainty about the appropriate management of a person with a suspected or confirmed history of anaphylaxis, seek specialist advice from the local immunisation co-ordinator, consultant in communicable disease control, or a consultant paediatrician, to minimise the time period that the person is left unvaccinated.
For people with a suspected or confirmed anaphylactic reaction to one or more excipients, ensure that the vaccine formulation is free of the identified excipients (for example, neomycin or other aminoglycosides). For further information, see the Summary of Product Characteristics for the individual influenza vaccines on the electronic Medicines Compendium website at http://www.medicines.org.uk/.
Do not give the influenza vaccine to people who are acutely unwell (with a febrile illness or acute infection) — postpone immunisation until they have fully recovered.
Minor illnesses without fever or systemic upset are not valid reasons to postpone immunisation.
Fluenz Tetra nasal spray is contraindicated in children or young people who:
Fluenz Tetra nasal spray is not recommended in children or young people:
How should a person with egg allergy be managed?
Determine if the person has a true egg allergy — the following are not considered to be true egg allergy:
For children with a history of severe anaphylaxis to egg that has previously required intensive care management in hospital, arrange referral to a paediatric immunologist or allergy specialist for immunisation in hospital.
Fluenz Tetra nasal spray is contraindicated in anyone who has had a severe allergic reaction (for example to anaphylaxis) to egg or to egg proteins.
For all other children with a history of egg allergy:
Fluenz Tetra can be given to most children with egg allergy in any setting, including primary care.
Egg-allergic children with asthma can receive Fluenz Tetra provided their asthma is well-controlled.
If there are contraindications to Fluenz Tetra, give an inactivated influenza vaccine with a very low ovalbumin content (less than 0.06 micrograms per 0.5 mL dose). For more information on the ovalbumin content of different influenza vaccines, see the Public Health England (PHE) immunisation web pages at https://www.gov.uk/government/publications/national-flu-immunisation-programme-plan
For adults with a history of severe anaphylaxis, which has previously required intensive care management in hospital, arrange referral to an immunologist or allergy specialist for immunisation in hospital.
For adults with less severe egg allergy, give an inactivated influenza vaccine with a very low ovalbumin content (less than 0.06 micrograms per 0.5 ml dose).
People aged 65 years and over with an egg allergy should be given the QIVc Flucelvax Tetra, as the aTIV vaccine contains more than the recommended ovalbumin content for people with egg allergy.
How should influenza vaccine be administered?
Seasonal influenza vaccine should be given annually, ideally between September and early November.
Obtain written or verbal consent at the time of vaccination for people aged over 16 years. For younger people, it is usual to get consent from a person with parental responsibility.
For Fluenz Tetra intranasal spray, give a single application of 0.1 ml in each nostril. The dose does not need to be repeated if the child or young person blows their nose or sneezes after administration.
Administer the other influenza vaccines by intramuscular injection (people taking anticoagulants and people with bleeding disorders may also be vaccinated intramuscularly).
Note: Some of the summaries of product characteristics (SPCs) for intramuscular inactivated influenza vaccines indicate that young children can be given either a 0.25ml or a 0.5ml dose. JCVI has advised that where these alternative doses are indicated, the 0.5ml dose of intramuscular inactivated influenza vaccine should be given to infants and children aged 6 months or older.
Ensure that the brand of vaccine, batch number, and administration site are accurately recorded in the person's records.
Influenza vaccines can be given at the same time as other live or inactivated vaccines — administer the vaccines at separate sites, preferably in a different limb (if appropriate).
If the vaccines need to be given in the same limb, use vaccination sites at least 2.5 cm apart.
If there is inadvertent administration of Fluenz Tetra to a person with a contraindication:
Very severely immunocompromised healthcare professionals should not administer Fluenz Tetra intranasal spray, due to a theoretical risk of acquiring vaccine virus due to exposure to the live attenuated vaccine.
What are the adverse effects of influenza vaccines?
Common adverse effects after influenza immunisation (which usually disappear within 1–2 days without needing treatment), include:
Rare adverse effects may include:
Report all serious suspected adverse reactions to influenza vaccines using the Yellow Card scheme (https://yellowcard.mhra.gov.uk).
Report any suspected adverse reactions to vaccines that are black triangle drugs, as they subject to intensive surveillance by the Medicines and Healthcare products Regulatory Agency (MHRA).
What information and advice should be given to people about influenza vaccines?
Advise the person or family/carers that:
They need to be vaccinated annually (usually before mid-November).
Provide sources of information and advice on the influenza vaccine and national influenza immunisation programme, including patient information leaflets published by Public Health England (PHE), available at https://www.gov.uk/government/publications/flu-vaccination-leaflets-and-posters.
During this module you have learned:
Run a report on the uptake of flu vaccine at the practice for at-risk groups over the past 5 years.
Record the percentage where the vaccine was given, not given, declined and where a contraindication was recorded.
Report on any trends within the practice.