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Flu 2016/17 Template Training Set Vaccine Preventable Disease Programme Public Health Wales Vaccine Preventable Disease Programme: Promoting immunisation in Wales Notes to trainers This template slide set has been produced to assist with the delivery of local update sessions, to explain current flu epidemiology, and evidence, to share key information, and promote positive messages about flu vaccination The content is not exhaustive, local trainers should check prior to use and amend as appropriate. This template is designed to allow slides to be added/removed to suit local delivery It is important to critically appraise sources of information prior to using them in the training session Material contained in this document may be reproduced without prior permission provided it is done so accurately and is not used in a misleading context Acknowledgement to Public Health Wales NHS Trust Vaccine Preventable

Disease Programme to be stated Vaccine Preventable Disease Programme template slide set Learning objectives At the end of this training session, learners will be able to: Describe influenza infection and the associated complications Describe the different types of influenza virus Explain the importance of annual influenza vaccination for eligible groups Outline the influenza programme for 2016/17

Explain why different brands of vaccine are recommended for certain individuals Outline the contraindications and precautions for live attenuated intranasal vaccine and injectable influenza vaccine Outline the administration technique for live attenuated intranasal vaccine and injectable influenza vaccine, and possible adverse reactions Outline strategies for improving uptake of influenza vaccination Describe further sources of information on influenza and influenza vaccination Vaccine Preventable Disease Programme template slide set What is flu? Flu is a highly infectious viral illness and can cause serious disease Easily transmitted by large droplets, small-particle aerosols and by hand to mouth/eye contamination from an infected surface or respiratory secretions of infected person People with mild or no symptoms can still infect

others Incubation period is 1-3 days (average 2-3 days), though may be longer especially in hosts with immune deficiency Vaccine Preventable Disease Programme template slide set Influenza (flu) viruses There are 3 types of influenza (flu) viruses: A - Causes epidemics and pandemics; animal reservoir wildfowl, also carried by other mammals B - May cause epidemics, predominantly found in humans C - Minor respiratory illness only Vaccine Preventable Disease Programme template slide set Genetic changes in the flu virus what this means Changes in the surface antigens (H & N) result in the flu virus constantly changing

Antigenic drift: refers to minor changes (natural mutations) in the genes of flu viruses that occur gradually over time Antigenic shift: when two different strains combine. This abrupt major change results in a new subtype. Immunity from previous flu infections/ vaccinations may not protect against the new subtype, potentially leading to a widespread epidemic or pandemic Because of the changing nature of flu viruses, WHO monitors their epidemiology throughout the world. Each year WHO makes recommendations about the strains of influenza A and B which are predicted to be circulating in the forthcoming winter. These strains are then included in the influenza vaccine developed each year Vaccine Preventable Disease Programme template slide set Influenza vaccine composition for 2016/17 Trivalent vaccines will contain the following three viruses: an A/California/7/2009 (H1N1)pdm09-like virus; an A/Hong Kong/4801/2014 (H3N2)-like virus;

a B/Brisbane/60/2008-like virus. It is recommended that quadrivalent vaccines containing two influenza B viruses contain the above three viruses and a B/Phuket/3073/2013-like virus. None of the influenza vaccines for the 2016/17 season contain thiomersal as an added preservative More detailed information on the characteristics of the available vaccines, including age indications can be found in the June issue 248 of vaccine update Vaccine Preventable Disease Programme template slide set Common symptoms include Vaccine Preventable Disease Programme template slide set Complications of flu Common: Bronchitis

Otitis media (children) Sinusitis Secondary bacterial pneumonia Less common: Meningitis, encephalitis Primary influenza pneumonia Most serious illness is seen in neonates, pregnant women, older people and those in clinical risk groups Vaccine Preventable Disease Programme template slide set How flu spreads Flu spreads rapidly, especially in closed communities. e.g. Care homes/hospitals the virus can live on hard surfaces for 24 hours Transmission is by droplets, aerosol, or through direct contact with respiratory secretions of someone infected with flu A person with flu infection may be contagious before they feel ill

Some individuals may be asymptomatic even with the infection The illness can be infectious from one day before to several days after symptoms start Vaccine Preventable Disease Programme template slide set Burden of influenza season 2015/16 >9,887 patients diagnosed by GPs to have flu-like illness 807 patients in hospital confirmed to have influenza 125 patients in intensive care units (ICU) in Wales were confirmed with influenza This season, confirmed cases of influenza were seen in all age-groups, children (<15y) and adults aged 45y to 64y accounted for half of all cases 20 outbreaks reported to PHW (in hospitals, residential homes nurseries and an army barracks) Much lower level of seasonal excess mortality than last year

Flu epidemiology Influenza-like illness consultation rate per 100,000 practice population in Welsh sentinel practices Source Vaccine Preventable Disease Programme Public Health Wales Vaccine Preventable Disease Programme template slide set Seasonal influenza vaccine effectiveness (VE) Efficacy calculated at between 50-60% for adults aged 1865yrs, Lower efficacy in elderly although immunisation shown to reduce incidence of severe disease including bronchopneumonia, hospital admissions and mortality End of season overall adjusted VE of the 2015-2016 influenza vaccine in preventing medical consultation in primary care with a laboratory confirmed Influenza like illness (ILI) across the UK was 52.4% Pebody et al. Effectiveness of seasonal influenza vaccine in preventing laboratory conformed influenza in primary care in the United Kingdom:

2015/16 mid-season results. Euro Surveill. 2016;21 (13):pii=30179 Vaccine Preventable Disease Programme template slide set The National Influenza Immunisation Programme 2016/17 Eligibility In 2016-17 the following groups are eligible for flu vaccination: those aged 65 years and over those aged six months to under 65 years in clinical risk groups pregnant women those in long-stay residential care homes carers and third sector carers members of voluntary organisations providing emergency first aid community first responders all two and three year olds (age on 31 August 2016) All children in reception class and year 1,2 and 3 in primary school In addition, all health and social care workers with direct patients/client

contact should be offered flu vaccine by their employer A more detailed list can be viewed in the Welsh Health Circular (2016) 039 Vaccine Preventable Disease Programme template slide set Individuals over the age of 65 years Individuals aged 65 years of age and over who catch flu are about twenty times more likely to die than individuals under 65 years of age who get flu. (Pebody et al, 2010) Leah Milinship Vaccine Preventable Disease Programme template slide set People with certain underlying chronic health conditions from 6 months of age Chronic respiratory disease

Chronic heart disease Chronic kidney disease Chronic liver disease Chronic neurological disease Diabetes Immunosuppression Asplenia or splenic dysfunction Pregnancy Morbidly obese (class lll obesity)

(BMI) of 40 or more Source: Green Book chapter 19 - Influenza Individuals who have chronic liver disease are around 48 times more likely to die if they catch flu than someone with no underlying health condition Individuals with neurological disease are around 40 times more likely to die if they catch flu Individuals who are immunosuppressed are around 47 times more likely to die if they catch flu

Vaccine Preventable Disease Programme template slide set Pregnant women All pregnant women are recommended to receive the inactivated flu vaccine irrespective of their stage of pregnancy and with each subsequent pregnancy Pregnant women at increased risk from complications if they contract flu Having flu during pregnancy may be associated with premature birth and smaller birth size and weight Flu vaccination during pregnancy provides passive immunity against flu to infants in the first few months of life

Studies on safety of flu vaccine in pregnancy show that inactivated flu vaccine can be safely and effectively administered during any trimester of pregnancy No study to date has demonstrated an increased risk of either maternal complications or adverse foetal outcomes associated with inactivated flu vaccine Vaccine Preventable Disease Programme template slide set Benefits of flu vaccine for mother and infant Risk of serious illness and death from flu is higher in pregnant women.(1) Influenza vaccine given to pregnant women is 91.5% effective in preventing hospitalisation of their infants from influenza in the first six months of life.(2) 1.Pebody Ret al (2010) Pandemic influenza A (H1N1) 2009 and mortality in the United Kingdom: risk factors for death, April 2009 to March 2010.

Eurosurveillance 15(20): 19571. 2.Benowitz I, et al. Influenza vaccine given to pregnant women reduces hospitalization due to influenza in their infants. Clin Infect Dis 2010; 51 (12):1355-61 Vaccine Preventable Disease Programme template slide set Uptake of influenza vaccinations in pregnant women participating in the 2013 -2016 surveys, by Health Board * Vaccine Preventable Disease Programme template slide set Why vaccinate children against flu? Extension of the seasonal flu vaccination programme to all children aims to appreciably lower the public health impact of flu by: Providing direct protection thus preventing a large number of

cases of flu in children Providing indirect protection by lowering flu transmission from children: to other children to adults to those in the clinical risk groups of any age Reducing flu transmission in the community will avert many cases of severe flu and flu-related deaths in older adults and people with clinical risk factors Annual administration of flu vaccine to children is expected to substantially reduce flu-related illness, GP consultations, hospital admissions and deaths Vaccine Preventable Disease Programme template slide set Uptake of flu vaccine in children 2015/16

Uptake of influenza immunisation in children aged two to three years was 44.4% Uptake of influenza immunisation in primary school cohort (reception class, year 1 and 2) was 63.4% No specific target will be set for childrens flu vaccination until the programme is more established Vaccine Preventable Disease Programme template slide set Who else needs the flu vaccine? People who could give the illness to someone who is vulnerable or who would leave a vulnerable person at risk if they were ill Health and social care workers with patient/client contact Residents of long-stay care facilities such as residential homes and nursing homes Anyone who is the main carer for a vulnerable person (this doesnt include parents of healthy children) Third sector/voluntary carers

Members of certain voluntary organisations who may be involved in the provision of care at mass gatherings. This includes members of the British Red Cross and St John Ambulance Community first responders Vaccine Preventable Disease Programme template slide set Healthcare workers Patients can infect healthcare workers. Healthcare workers are at risk of occupationally acquired flu. Healthcare workers can infect patients. Several studies show patients in risk groups such as the elderly are at increased risk of catching and dying from flu if cared for by unvaccinated staff Vaccination of healthcare workers against flu is a World Health Organisation recommendation. It has been policy in the United Kingdom since 2000

Vaccine Preventable Disease Programme template slide set Key messages to health and social care workers Duty of care as professionals to patients or residents to do everything in your power to protect them against infection, including being immunised against flu Getting vaccinated against flu can help protect you, your patients and family Everyone is susceptible to flu, even if you are in good health and eat well You can be infected with the virus and have no symptoms but can still pass flu virus to others including patients or residents Impact of flu on frail and vulnerable patients can be fatal and outbreaks can cause severe disruption in communities, care homes and hospitals Flu vaccine has a good safety record and will help protect you. It cannot give you flu. Having the vaccination can encourage your colleagues to do likewise Throughout the last ten years there has generally been a good to moderate match between the strains of flu virus in the vaccine and those that subsequently circulated Staff act as positive role models for patients aged 65 and over, those with long-term health conditions and pregnant women to take up the offer too Vaccine Preventable Disease Programme template slide set

Healthcare workers Click here to view: Flu signs Vaccine Preventable Disease Programme template slide set Healthcare workers Are you a healthcare worker? Will you get your flu vaccine this year? Unsure, Watch Louises story Get your flu vaccine to protect yourself, your family and your patients Vaccine Preventable Disease Programme template slide set Uptake of influenza immunisation in Occupational Health departments in Health Boards and Trusts 2012/13 2015/16 Abertawe Aneurin Betsi Cardiffand

Bro Bevan UHB Cadwaladr Vale UHB Morgannwg UHB UHB 30.2% 31.0% 27.6% Cwm Taf Hywel Dda Powys Public Velindre Welsh UHB UHB Teaching Health NHS Trust Ambulance

HB Wales NHS Service NHS Trust Trust 35.5% 40.6% 42.9% 46.0% 69.1% 62.9% 52.2% 55.1% 2015-16 season 33.9%

41.2% 36.8% 42.4% 48.6% 55.7% 41.2% 34.8% 48.7% 2014-15 season 29.8% 35.9% 41.1% 44.9% 48.3%

2013-14 season 36.5% 41.0% 44.9% 44.8% 35.9% 41.0% 49.6% 43.6% 37.6% 39.4% 40.0% 40.8% 35.9% 41.1% 41.0%

52.1% 2012-13 season Wales Source: Public Health Wales Vaccine Preventable Disease Programme template slide set When to vaccinate As early as possible between September and early November before flu starts circulating in the community The immune response following flu vaccination takes about two weeks to develop fully so early vaccination is important Efforts to vaccinate should continue until the end of March and should include people who fall into an at risk group during the flu season (for example women who become

pregnant during the influenza season) Protection afforded by the vaccine is thought to last at least one influenza season However, as antibody levels are likely to reduce in subsequent seasons and there may be changes to circulating strains from one season to the next, annual revaccination is important Vaccine Preventable Disease Programme template slide set Uptake targets for seasonal flu vaccination in Wales 75% uptake for: Those age 65 years and over; Those aged six months to under 65 years in clinical risk groups; Pregnant women. 50% uptake for: Healthcare workers with direct patient care. No specific target will be set for childrens flu vaccination until the programme is more established

Vaccine Preventable Disease Programme template slide set Influenza vaccine uptake rates in Wales 2015/16 66.6% of patients aged 65 years and older have been vaccinated against influenza (Health Board range 63.9% to 68.9%) 46.9% of patients aged six months to 64 years in at-risk groups have been vaccinated against influenza (Health Board range 43.2% to 49.4%) Annual uptake of influenza immunisation in Health Board and NHS staff in Wales, reported by Health Board Occupational Health Departments continues on a positive trend and was 46.0% during 2015/16, an increase of 3.1 from 42.9% last season Vaccine Preventable Disease Programme template slide set Trends in seasonal influenza immunisation uptake in patients aged 65 years and over and in those aged six months to 64 years in clinical risk groups, Wales, 2008/09 2015/16.

Patients aged 65y and over 68.3% 48.5% 50.0% 49.7% 51.1% 2011-12 2012-13 2013-14 63.5%

67.7% 2010-11 Patients aged under 65y at risk 65.7% 67.7% 68.0% 66.6% 59.5% 49.1% 49.3%

46.9% 2015-16 2014-15 2009-10 2008-09 40.8% Summary of influenza uptake rates in patients aged 65 years and over and six months to 64 years at risk, by individual risk group, Wales, 2015/16. 2015-16 summary data 65y and older Younger than 65y at risk Diabetes Immunosuppression

Chronic kidney disease Chronic respiratory disease Chronic heart disease Neurological conditions Chronic liver disease Morbidly obese Pregnant women Carers Vaccine Preventable Disease Programme template slide set 66.6% 46.9% 62.3% 55.9% 51.2% 46.4% 46.7% 44.6% 40.6%

34.8% 75.6% 49.1% Which flu vaccine should be used? Vaccine Preventable Disease Programme template slide set Types of flu vaccines Two main types of vaccine available: Inactivated by injection Live - by nasal application None of the flu vaccines can cause clinical influenza in those that can be vaccinated Trivalent: flu vaccines contain two subtypes of Influenza A and one type B virus Quadrivalent vaccines contain two subtypes of Influenza A and two B virus types* As quadrivalent vaccines may be better matched and therefore may provide better protection against the circulating B

strain(s) than trivalent flu vaccines, the live intranasal vaccine offered to children aged 2yrs and over is a quadrivalent vaccine *Quadrivalent inactivated flu vaccine only authorised for children aged 3 years and older Vaccine Preventable Disease Programme template slide set Live Attenuated Influenza Vaccine (LAIV) Fluenz Tetra is the recommended flu vaccine for children between the ages of 2 and 17 unless it is contraindicated Live attenuated influenza vaccine (LAIV) provides good protection against flu for children* JCVI statement on the nasal spray vaccine It may offer some protection against strains not contained in the vaccine as well as to those that are It is cold adapted, so it replicates in the cooler nasal mucosa but not at body temperature in the lungs. It cannot cause a systemic flu illness Fluenz Tetra contains 4 (two A and two B) influenza virus strains as directed by WHO

Image source: AstraZeneca UK Ltd Vaccine Preventable Disease Programme template slide set Inactivated flu vaccines A number of different manufacturers produce flu vaccines. Those available for 2016/17 season are listed in the June issue 248 2016 Vaccine Update Most of the inactivated vaccines are administered by intramuscular injection, although one vaccine (Intanza) is

administered by the intradermal route Most flu vaccines are prepared from viruses grown in embryonated hens eggs details of ovalbumin content available in Vaccine Update June 2016 and product SPC Some flu vaccines are restricted for use in particular age groups. The SPC for individual products should always be referred to when ordering vaccines for particular patients Vaccine Preventable Disease Programme template slide set Vaccine Update Issue 248 June 2016 Suitable Flu vaccines for patients in clinical risk groups Age Which vaccine?

How many doses? Children aged six months to less than two years of age in clinical risk groups These children should be offered inactivated trivalent influenza vaccine Those who have not received flu vaccine before should receive a second dose of vaccine at least four weeks later. Children aged two to less than

18 years of age in clinical risk groups These children should be offered the live intranasal vaccine Fluenz Tetra unless it is contraindicated. For those children for whom Fluenz Tetra is contraindicated, a suitable inactivated flu vaccine should be offered. Those aged two to less than nine years who have not received flu vaccine before should receive a second dose of vaccine at least four weeks later The quadrivalent inactivated influenza vaccine (Fluarix Tetra) is authorised for children from the age of three years and is preferred because

of the additional protection offered. The quadrivalent vaccine has both lineages of influenza B and may therefore provide better protection against the circulating B strain(s) than trivalent inactivated influenza vaccines. Children aged two years should be given an inactivated trivalent vaccine. Over 18 years Any of the inactivated vaccines Vaccine Preventable Disease Programme template slide set A single dose Which vaccine and how many doses? Vaccine type Authorised age indication

Dose Live attenuated intranasal vaccine - Fluenz Tetra Children aged two to under 18 years (if no contraindications) Single application in each nostril of 0.1ml Children NOT in clinical risk groups only require one dose of this vaccine. Children in clinical risk groups aged two to under nine years who have not received influenza vaccine before should receive a second dose of vaccine at least four weeks later. N.B Follow Green Book not SPC

Inactivated intramuscular vaccine (number of different brands) Inactivated intradermal vaccine - Intanza 15g Children aged six months and older and adults (including adults aged 60 years and older) Single injection of 0.5ml Children aged six months to under nine years who have not received influenza vaccine before should receive a second (N.B some of the vaccines are dose of vaccine at least four weeks not authorised for young

later. children) Adults aged 60 years and Single injection of 0.1ml older Vaccine Preventable Disease Programme template slide set Storage of flu vaccine Flu vaccines must be stored in accordance with manufacturers instructions: Store between +2C and +8C Store in original packaging Protect from light Fluenz Tetra may be taken out of the fridge, without being replaced, for a maximum of 12 hours at a temperature not above 25 0C. If the vaccine has not been used after this 12 hour period, it should be disposed of

Check expiry dates regularly: The expiry date on the nasal spray applicator should always be checked before use. Fluenz Tetra has an expiry date 18 weeks after manufacture this is much shorter than inactivated flu vaccines. All Fluenz Tetra will have expired in early 2017 aim to vaccinate children before the Christmas holidays * Vaccine Preventable Disease Programme template slide set Vaccine administration Intramuscular flu vaccines should be given into the upper arm (or anterolateral thigh in infants). Administration of intramuscular flu vaccine to children is not a role for HCSWs

Individuals with a bleeding disorder should be given vaccine by deep subcutaneous injection to reduce the risk of bleeding Intradermal: Intanza is supplied in a micro-needle injection system that should be held at right-angles to the skin. The device allows intradermal vaccination to be performed without the need for additional training Both inactivated and live flu vaccines can be given at the same time as, or at any interval before or after, other live and inactivated vaccines Different vaccines should be given at separate sites, preferably in a different

limb. If given in the same limb, they should be given at least 2.5cm apart Vaccine Preventable Disease Programme template slide set Administration of Fluenz Tetra Fluenz Tetra is a live nasal vaccine and must not be injected Fluenz Tetra can be administered at the same time as, or at any interval from other vaccines including live vaccines Patient should breathe normally - no need to actively inhale or sniff The vaccine is rapidly absorbed so no need to repeat either half of dose if patient sneezes, blows their nose or their nose drips following administration Image courtesy of AstraZeneca Vaccine Preventable Disease Programme template slide set Patient Group Directions (PGDs) Two separate PGDs are available: One for the childhood Live Attenuated

Intranasal Vaccine (LAIV) - Fluenz Tetra One for the Inactivated Vaccines - Flu injection Template PGDs available at: http://nww.immunisation.wales.nhs.uk/pgds-psds Vaccine Preventable Disease Programme template slide set Contraindications There are very few individuals who cannot receive any flu vaccine Where there is doubt, expert advice should be sought promptly so that the period the individual is left unvaccinated is minimised For children aged 2-17 years, where live flu vaccine cannot be given, it is likely that inactivated vaccine could be given instead Vaccine Preventable Disease Programme template slide set

Contraindications to flu vaccines None of the influenza vaccines should be given to those who have had: Confirmed anaphylactic reaction to a previous dose of the vaccine Confirmed anaphylactic reaction to any component of the vaccine The live attenuated flu vaccine should not be given to children who are: Clinically severely immunodeficient due to conditions or immunosuppressive therapy: Acute and chronic leukaemias Lymphoma HIV infection not on highly active antiretroviral therapy Cellular immune deficiencies High dose corticosteroids

Receiving salicylate therapy Known to be pregnant Vaccine Preventable Disease Programme template slide set Precautions to flu vaccines Acutely unwell: defer until recovered Heavy nasal congestion: defer live intranasal vaccine until resolved or consider inactivated flu vaccine Use with antiviral agents against flu: The live intranasal vaccine (Fluenz Tetra) should not be administered at the same time or within 48 hours of cessation of treatment with flu antiviral agents Administration of flu antiviral agents within two weeks of administration of Fluenz Tetra may adversely affect the effectiveness of the vaccine Vaccine Preventable Disease Programme template slide set

Severe asthma or active wheezing Live flu vaccine is not recommended for children who are currently taking or have been prescribed oral steroids in the last 14 days Children currently taking a high dose inhaled steroid Budesonide >800 mcg/day or equivalent (e.g. Fluticasone > 500 mcgs/day) should only be given live flu vaccine on the advice of their specialist As these children are a defined flu risk group, those who cannot receive LAIV should receive an inactivated flu vaccine Vaccination with Fluenz Tetra should be deferred in children with a history of active wheezing in the past 72 hours or those who have increased use of bronchodilators in the previous 72 hours. If not improved after a further 72 hours then inactivated flu vaccine should be offered to avoid delaying protection in this high risk group Vaccine Preventable Disease Programme template slide set

Egg allergy - adults Most flu vaccines are prepared from flu viruses grown in embryonated hens eggs-the final vaccine products contains varying amounts of egg (as ovalbumin) Adults with egg allergy can be immunised in any setting using an inactivated flu vaccine with an ovalbumin content less than 0.12 g/ml (equivalent to <0.06 g for 0.5 ml dose) Adults with either severe anaphylaxis to egg which has previously required intensive care, or with both egg allergy and severe uncontrolled asthma should be referred to specialists for immunisation in hospital Vaccine Preventable Disease Programme template slide set Egg allergy - children

Children with an egg allergy can be safely vaccinated with Fluenz Tetra in any setting (including primary care and schools) Those with both egg allergy and clinical risk factors* that contraindicate Fluenz Tetra (e.g. immunosuppression) should be offered an inactivated flu vaccine with a very low ovalbumin content (less than 0.12 g/ml)g/ml) Children with a history of severe anaphylaxis to egg which has previously required intensive care, should be referred to specialists for immunisation in hospital For children with egg allergy and asthma, follow recommendations for severe asthma (previous slide) *Children in a clinical risk group and aged under nine years who have not been previously vaccinated against influenza will require a second dose whether given LAIV or inactivated vaccine Green Book influenza Chapter 19 Vaccine Preventable Disease Programme template slide set

Risk of transmission There is the potential for transmission of live attenuated influenza vaccine virus from the vaccinated person to other people. This does not pose a risk to most people (including healthcare workers). However transmission of live attenuated influenza vaccine virus to very severely immunocompromised contacts (e.g. bone marrow transplant patients requiring isolation) following immunisation with Fluenz Tetra may pose a risk to them Risk is for one to two weeks following vaccination Where close contact is likely or unavoidable (e.g. household members) consider using an inactivated flu vaccine For less severely immunocompromised close contacts, the benefits of immunisation outweigh any risks Vaccine Preventable Disease Programme template slide set Commonly reported adverse reactions Following inactivated flu vaccine:

Pain, swelling or redness at the injection site, low grade fever, malaise, shivering, fatigue, headache, myalgia and arthralgia A small painless nodule (induration) may also form at the injection site These symptoms usually disappear within one to two days without treatment Following live attenuated flu vaccine: Nasal congestion/rhinorrhoea, reduced appetite, weakness and headache Rarely, after live or inactivated vaccine, immediate reactions such as urticaria, angio-oedema, bronchospasm and anaphylaxis can occur Vaccine Preventable Disease Programme template slide set

Reporting suspected adverse reactions All serious suspected reactions following flu vaccination should be reported to the Medicines and Healthcare products Regulatory Agency using the Yellow Card scheme at http://yellowcard.mhra.gov.uk/ Fluenz Tetra and Fluarix Tetra carry a black triangle symbol () (as do all vaccines during the earlier stages of their introduction) This is to encourage reporting of all suspected adverse reactions Vaccine Preventable Disease Programme template slide set Data collection Public Health Wales will monitor and report on uptake of influenza immunisations for general practice and health boards Data will be collected automatically throughout the season via the Audit+ software

It is important that vaccinations are recorded in a timely manner in the GP practice clinical information system using appropriate read codes in order for it to be included in the data collection Guidance on appropriate read codes for data recording proposes will be provided by PHW on the Vaccine Preventable Disease Programme intranet site at: http://howis.wales.nhs.uk/immunisation Vaccine Preventable Disease Programme template slide set Strategies for improving uptake Several strategies have been identified which have been shown to increase flu vaccination rates in primary care settings. These include: Having an identified person in the practice who plans the vaccine campaign Using a computer search to identify the people who are eligible for vaccination (ideally using a programme specifically designed for this purpose)

Personally contacting patients to invite them for the flu vaccine Vaccine Preventable Disease Programme template slide set Strategies for improving uptake Ordering sufficient vaccine to meet at least 75% uptake Continuing to offer vaccinations until targets have been reached or the end of the flu season, rather than stopping earlier either on an arbitrary date or once an initial supply of vaccines has been used up Producing a written report on the practices campaign at the end of the campaign, including an assessment of the practices performance in the campaign Having midwives involved in the vaccination campaign (Dexter et al, 2012) Vaccine Preventable Disease Programme template slide set Resources Welsh Government Posters and leaflets NHS Wales immunisation leaflets and posters

[email protected] Phone number: 0845 606 4050 Vaccine Preventable Disease Programme template slide set Resources -websites NHS Direct Wales primary source of public facing flu information in Wales: http://www.nhsdirect.wales.nhs.uk/Encyclopaedia/f/article/flujab,seasonal/# Leaflets Flu Frequently Asked Questions http://nww.immunisation.wales.nhs.uk/check-the-faqs Template PGD

http://nww.immunisation.wales.nhs.uk/pgds-psds Public Health Wales: Influenza page http://www.wales.nhs.uk/sitesplus/888/page/43745 Influenza vaccination programme intranet page 2016-17 http://nww.immunisation.wales.nhs.uk/flu-2016-17-season Public Health Wales: Childhood influenza vaccination programme 2016-17 www.publichealthwales.org/childrensfluvaccine Childhood influenza vaccination programme intranet page 2016-17 http://nww.immunisation.wales.nhs.uk/childhood-influenza-vaccination-prog ramm-3 Vaccine Preventable Disease Programme template slide set Resources -websites WHO influenza information http://www.euro.who.int/en/what-we-do/health-topics/diseases-and-co nditions/influenza Beat Flu www.beatflu.org public facing information, fully endorsed by Public Health Wales

My Health Text My Health Text - supporting free text messaging services for general practice Vaccine Preventable Disease Programme template slide set Resources -videos Flu and you - a short video about the benefits of flu immunisation for those aged 65 and over Flu signs - We asked healthcare workers in Wales why they had their flu vaccine. This short video shares some of their answers Louises story - is a short video from a nurse who didnt get the flu jab Why would you not? - A short video encouraging health care workers to get the flu vaccination Message to say thank you for doing the right thing _- A short video highlighting that More NHS Wales staff decided to protect themselves and their patients

against flu last year than ever before Vaccine Preventable Disease Programme template slide set Resources e-learning Three flu related e-learning resources are available: FluOne (health) - Information for all NHS Staff FluOne (social) - Information for social care staff (in cluding care home workers) FluTwo - Information for immunisers Vaccine Preventable Disease Programme template slide set Vaccine Preventable Disease Programme template slide set References 1. Osterholm, MT, Kelley, NS, Sommer, A, and Belongia, EA (2012) Efficacy and effectiveness of influenza vaccines: a systematic review and meta-analysis. Lancet Infect Dis. 12(1.1), 36-44.

2. Fleming DM, Watson JM, Nicholas S et al. (1995) Study of the effectiveness of influenza vaccination in the elderly in the epidemic of 1989/90 using a general practice database. Epidemiol Infect 115: 5819 3. Wright PF, Thompson J, Vaughn WK et al. (1977) Trials of influenza A/New Jersey/76 virus vaccine in normal children: an overview of age-related antigenicity and reactogenicity. J Infect Dis 136 (suppl): S73141. 4. Mangtani P, Cumberland P, Hodgson CR et al. (2004) A cohort study of the effectiveness of influenza vaccine in older people, performed using the United Kingdom general practice research database. J Infect Dis 190(1): 110. 5. Pebody, R et al. (2015) Low effectiveness of seasonal influenza vaccine in preventing laboratory-confirmed influenza in primary care in the United Kingdom: 2014/15 mid-season results. Eurosurveillance. 20. Issue 5. www.eurosurveillance.org/ViewArticle.aspx?ArticleId=21025 6. Immunisation against infectious disease (the Green Book) Chapter 19 Influenza. Updated 21 May 2015. Available at: https://www.gov.uk/government/organisations/public-health-england/series/immunisation-against-infectious-disease-the-green-book 7. Public Health England. Surveillance of influenza and other respiratory viruses in the United Kingdom: winter 2014 to 2015. Published May 2015. Available at: https://www.gov.uk/government/statistics/annual-flu-reports 8. Morgan OW, Bramley A, Fowlkes A, et al. Morbid obesity as a risk factor for hospitalization and death due to 2009 pandemic influenza A(H1N1) disease PLoS One. 2010 Mar 15;5(3) 9. Fezeu L, Julia C, Henegar A, Bitu J et al. Obesity is associated with higher risk of intensive care unit admission and death in influenza A (H1N1) patients: a systematic review and metaanalysis. Obes Rev. 2011 Aug;12(8):653-9 10. Van Kerkhove MD, WHO Working Group for Risk Factors for Severe H1N1pdm Infection. Risk factors for severe outcomes following 2009 influenza A (H1N1) infection: a global pooled analysis. PLoS Med. 2011 Jul;8(7):e1001053 11. Public Health England. Influenza immunisation programme for England GP patient groups. Data collection survey. Season 2014 to 2015. Available at: https://www.gov.uk/government/statistics/seasonal-flu-vaccine-uptake-in-gp-patients-in-england-winter-season-2014-to-2015 12. Neuzil KM, Reed GW, Mitchel EF et al. (1998) Impact of influenza on acute cardiopulmonary hospitalizations in pregnant women. Am J Epidemiol. 148:1094-102

13. Pebody R et al. (2010) Pandemic influenza A (H1N1) 2009 and mortality in the United Kingdom: risk factors for death, April 2009 to March 2010. Eurosurveillance 15(20): 1957 14. Pierce M, Kurinczuk JJ, Spark P et al. (2011) Perinatal outcomes after maternal 2009/H1N1 infection: national cohort study. BMJ. 342:d3214. 15. McNeil SA, Dodds LA, Fell DB et al. (2011) Effect of respiratory hospitalization during pregnancy on infant outcomes. Am J Obstet Gynecol. 204: (6 Suppl 1) S54-7. 16. Omer SB, Goodman D, Steinhoff MC et al. (2011) Maternal influenza immunization and reduced likelihood of prematurity and small for gestational age births: a retrospective cohort study. PLoS Med. 8: (5) e1000441. 17. Benowitz I, Esposito DB, Gracey KD et al. (2010) Influenza vaccine given to pregnant women reduces hospitalization due to influenza in their infants. Clin Infect Dis. 51: 1355-61. 18. Eick AA, Uyeki TM, Klimov A et al. (2010) Maternal influenza vaccination and effect on influenza virus infection in young infants. Arch Pediatr Adolesc Med. 165: 104-11. Vaccine Preventable Disease Programme template slide set References (continued) 19. Zaman K, Roy E, Arifeen SE et al. (2008) Effectiveness of maternal influenza immunisation in mothers and infants. N Engl J Med. 359: 1555-64. 20. Poehling KA, Szilagyi PG, Staat MA et al.(2011) Impact of maternal immunization on influenza hospitalizations in infants. Am J Obstet Gynecol. 204:(6 Suppl 1) S141-8. 21. Dabrera G, Zhao H, Andrews N et al. (2014) Effectiveness of seasonal influenza vaccination during pregnancy in preventing influenza infection in infants, England, 2013/14. Eurosurveillance. Nov 13;19. www.eurosurveillance.org/ViewArticle.aspx?ArticleId=20959 22. Tamma PD, Ault KA, del Rio C et al. (2009) Safety of influenza vaccination during pregnancy. Am. J. Obstet. Gynecol. 201(6): 547-52. 23. Department of Health, Public Health England, NHS England. Flu Plan Winter 2015/16. Published March 2015. Available at: https://www.gov.uk/government/publications/flu-plan-2015to-2016 24. Joint Committee on Vaccination and Immunisation. JCVI statement on the annual influenza vaccination programme extension of the programme to children. 25 July 2012. Available at: https://www.gov.uk/government/publications/jcvi-statement-on-the-routine-annual-influenza-vaccination-programme 25. Potter J, Stott DJ, Roberts MA et al. (1997) The influenza vaccination of health care workers in long-term-care hospitals reduces the mortality of elderly patients. Journal of Infectious

Diseases 175: 1-6. 26. Carman WF, Elder AG, Wallace LA et al. (2000) Effects of influenza vaccination of healthcare workers on mortality of elderly people in long term care: a randomised control trial. The Lancet 355: 93-7. 27. Hayward AC, Harling R, Wetten S et al. (2006) Effectiveness of an influenza vaccine programme for care home staff to prevent death, morbidity, and health service use among residents: cluster randomised controlled trial. British Medical Journal doi:10.1136/bmj.39010.581354.55 28. Lemaitre M, Meret T, Rothan-Tondeur M et al. (2009) Effect of influenza vaccination of nursing home staff on mortality of residents: a cluster randomised trial. Journal of American Geriatric Society 57:1580-6. 29. 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. http://www.ncbi.nlm.nih.gov/sites/entrez/17301299 30. Ashkenazi S, Vertruyen A, Aristegui J et al. (2006) Superior relative efficacy of live attenuated influenza vaccine compared with inactivated influenza vaccine in young children with recurrent respiratory tract infections. The Pediatric Infectious Disease Journal 25(10): 870-9. http://www.ncbi.nlm.nih.gov/sites/entrez/17006279 31. Fleming DM, Crovari P, Wahn U et al. (2006) Comparison of the efficacy and safety of live attenuated cold-adapted influenza vaccine, trivalent, with trivalent inactivated influenza virus vaccine in children and adolescents with asthma. The Pediatric Infectious Disease Journal 25(10): 860-9. http://www.ncbi.nlm.nih.gov/sites/entrez/17006278 32. Allison MA Daley MF, Crane LA et al. (2006) Influenza vaccine effectiveness in healthy 6 to 21 month-old children during the 2003--2004 season. The Journal of Pediatrics 149: 75562. 33. Neuzil KM, Jackson LA, Nelson J et al. (2006) Immunogenicity and reactogenicity of 1 versus 2 doses of trivalent inactivated influenza vaccine in vaccine-naive 5-8-year-old children. Journal of Infectious diseases 194(8): 1032-9. http://www.ncbi.nlm.nih.gov/sites/entrez/16991077 34. Bracco Neto H, Farhat CK, Tregnaghi MW, et al. (2009) Efficacy and safety of 1 and 2 doses of live attenuated influenza vaccine in vaccine-naive children. Pediatr Infect Dis J. 28: 36571. 35. Block S L, Toback SL, Yi T et al. (2009) Efficacy of a single dose of live attenuated influenza vaccine in previously unvaccinated children: a post hoc analysis of three studies of children aged 2 to 6 years. Clin Ther. 31: 2140-7. 36. Des Roches A, Paradis L, Gagnon R, et al. (2012). Egg-allergic patients can be safely vaccinated against influenza. J Allergy Clin Immunol. 130(5):1213-6.

37. Centers for Disease Control and Prevention. Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices United States, 20132014. MMWR September 20, 2013 / 62(RR07);1-43 http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6207a1.htm#LiveAttenuatedInfluenzaVaccines 38. Department of Health, Public Health England, NHS England. The national flu immunisation programme 2015 to 2016: supporting letter. 27 March 2015. Available at: https://www.gov.uk/ government/publications/flu-plan-2015-to-2016 Vaccine Preventable Disease Programme template slide set Acknowledgements This resource was prepared by the Vaccine Preventable Disease Programme, Public Health Wales as a national training template to support the influenza vaccination programme 2016/17 Some information has been adapted for use by kind permission from colleagues in Public Health England Vaccine Preventable Disease Programme template slide set

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