Boosting flu vaccination uptake to meet this year's tough targets

With significant increases in the Department of Health's targets for seasonal flu vaccination — especially in 'at risk' groups and pregnant women — practice nurses are going to need all the help they can get to maximise uptake: Jenny Greenfield offers a reminder of what is required, and some practical advice on how to go about it

Influenza is a highly contagious acute viral infection of the respiratory tract. The disease is usually self-limiting in otherwise healthy individuals, with recovery within 2-7 days. More severe illness and complications can occur in at risk groups. Prevention is therefore important.

From October through to February each year, UK practices deliver a programme of vaccination against seasonal influenza to people aged 65 years and older, and to those in certain risk groups, including pregnant women. Although last winter was a quiet flu season for England, we must not become complacent as flu can be a dangerous and highly unpredictable illness.

This year, the bar has been raised — despite fact that targets set for 2012-13 were not achieved.

The seasonal flu plan for winter 2013-14 (DH June 2013) sets out a coordinated and evidence based approach to planning for, and responding to, the demands of flu across England. The rest of the UK adopts a similar approach. Taking into account the experiences and lessons learned during previous flu seasons, it provides health professionals with all the information required to run an effective local flu programme. July to September is the planning period, where primary care should be confirming orders of vaccine and arranging dates for clinics. September to February is the implementation period.

THE TARGETS

This season the DH has proposed that targets of 75% are reached in the uptake of seasonal flu vaccination for people aged 65 years and older, as recommended by the World Health Organization, and also to reach or exceed targets of 75% in those under 65 years with clinical conditions, and pregnant women.

The uptake rates nationally for 2012-13 were:

• Over 65 years — 73.4%
• Under 65 years in an 'at risk group' — 51.3%
• Pregnant women — 40.3%
• Practice staff — 45.6%

So we have a long way to go in reaching the DH targets!

We should also be protecting ourselves as health care workers by having the vaccine. Last year only 45.6 per cent of NHS health care workers had the seasonal flu jab, the lowest uptake among any staff group, according to DH figures. Not only does vaccination protect healthcare professionals (HCPs) themselves, it reduces the risk of transmission by HCPs to vulnerable patients, some of whom may have impaired immunity and may not respond well to vaccination. In addition, vaccination of healthcare staff has been shown to significantly reduce sickness absences, which can add to the strain of a busy flu season for other members of the practice team. So please, consider the importance of immunisation for yourself.

Research has been undertaken to try and establish why people are less likely to be vaccinated. It has been found that people from ethnic minority or immigrant populations, who are in good health, think vaccination is unnecessary or do not understand why it is needed. There is also the fear of adverse reactions to vaccines, lack of time or finding it difficult to access vaccination. People with chronic disease often do not understand why they need a vaccine and think that they are more likely to experience complications onside-effects, because of their underlying condition. Some people think the risk of vaccination is greater than risk of disease, and many people attribute mild flu-like symptoms to the vaccination itself.

THIS YEAR'S VACCINE

A safe and effective inactivated vaccine is produced ahead of each flu season based on strain recommendation provided by the WHO. There are three main types of influenza virus: A (this is usually the more severe virus), B and C (these are relatively uncommon). The WHO monitors the epidemiology of flu viruses throughout the world. Influenza viruses mutate with new strains being identified each year, determined by the nuclear material within the viral particle. The composition for 2013/14 is:

• An A/California/7/2009 (H1N1) pdm09-like virus
• An A (H3N2) virus antigenically like the cell-propagated prototype virus A/Victoria/361/2011
• A B/Massachusetts/2/2012-like virus
• In addition, the vaccine will contain an Influenza B/Brisbane/3/2007 (Yamagata) — the first time a quadrivalent vaccine will be available.

Vaccination is about 60—70% effective, and protection lasts for one year.

ELIGIBLE GROUPS

Eligible groups should be offered the flu vaccine and for the first time, children without a chronic condition will also be offered vaccination. The DH is introducing this programme over a number of years to include all children aged two to sixteen inclusive.

• All patients over the age of 65 years
• All patients with chronic disease, aged 6 months or older
• Chronic respiratory disease, defined as

1. Asthma that requires continuous or repeated use of inhaled systemic steroids or with previous exacerbations requiring hospital admission

2. Chronic obstructive pulmonary disease (COPD) including chronic bronchitis, and emphysema; bronchiectasis and bronchopulmonary dysplasia (BPD)

3. Children who have previously been admitted to hospital with lower respiratory tract infections

• Chronic heart disease defined as:

1. Congenital heart disease

2. Hypertension with cardiac complications

3. Chronic heart failure

4. Individuals requiring regular medication and /or follow-up for ischaemic heart disease

• Chronic kidney disease defined as

1. Chronic kidney disease at stage 3,4 or 5

2. Chronic kidney failure

3. Nephrotic syndrome

4. Kidney transplantation.

• Chronic liver disease, defined as

1. Cirrhosis

2. Biliary atresia

3. Chronic hepatitis

• Chronic neurological disease, defined as

1. Stroke

2. Transient ischaemic attack (TIA).

3. Conditions in which respiratory function maybe compromised, due to neurological disease.

4. Other neurological conditions (cerebral palsy, multiple sclerosis or similar conditions) — should be considered on an individual basis according to clinical need

• Diabetes
• Immunosuppression, defined as

1. Immunosuppression due to disease or treatment

2. Consideration should also be given to the vaccination of household contacts of immunocompromised individuals

• Pregnant women (at any stage of pregnancy)

Vaccination is also recommended for people in long-stay residential or homes, excluding prisons, young offender institutions or university halls of residence; carers (people in receipt of a carer's allowance, or those who are the main carer, or the carer of an elderly or disabled person whose welfare may be at risk if the carer falls ill); health and social care staff, and finally, children aged 2—3 years.

This list is not exhaustive and the practitioner should apply clinical judgement to take into account the risk of flu exacerbating any underlying disease that a patient may have, as well as the risk of serious illness from flu itself. Flu vaccine should be offered in such cases even if the individual is not in the clinical risk groups specified above.

Consent

Vaccination should only be administered to patients who have given their consent. For infants and children, parental or legal guardian consent is required. Young people aged 16 and 17 years are entitled to consent to their own treatment. Younger children who understand fully what the proposed procedure entails (referred to as 'Fraser or Gillick competent') can also give consent, although ideally parents will be involved.

IMPROVING UPTAKE

Improving uptake of flu vaccination is not just an issue confined to general practice. It is essential that it is managed in a collaborative manner, involving not only GPs and practice nurses, but also other practice staff, district nurses, midwives, health visitors, obstetricians, school nurses, pharmacists and social workers. Multidisciplinary/professional training and education to emphasise the importance of protection against influenza are crucial.

Working with NHS England area teams will ensure that robust plans are in place locally to identify all eligible patients, that sufficient vaccine has been ordered by practices to meet their needs, and that high vaccination uptake levels are reached in clinical risk groups. Clinical Commissioning Groups (CCGs) have a duty of quality improvement, with immunisation being only one area, so collaborative working is also essential. Many pharmacies now offer flu vaccination, but often patients who have been immunised elsewhere do not inform their GP practice. They should be encouraged to do so, so that computer records can be updated.

An updated patient leaflet will be available from the immunisation page of the Gov.uk website before the start of the flu immunisation programme. Hard copies of the leaflet can be ordered by GP surgeries through Prolog.

The DH is encouraging practices to look at their own uptake for previous years, and recommends that each GP practice has a named individual who is responsible for the flu vaccination programme, and has a register that can identify all pregnant women, patients under the age of 65 years at risk groups and aged 65 years and over. The flu lead in each practice could send out a monthly uptake report to all clinicians, and to encourage practice teams to reach targets, a practice incentive could be offered.