Influenza Training Webinar 2016-17

What is flu? Flu is a highly infectious viral illness and can cause serious disease People with mild or no symptoms can still infect others Incubation period 1-3 days (average 2-3 days) though may be longer, especially in hosts with immune deficiency Notes: In healthy individuals it is usually self-limiting with recovery within 5-7 days. Influenza update 2016/17

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 Influenza update 2016/17

Flu spreads rapidly, especially in closed communities. e. g 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 Influenza update 2016/17

2016/17 vaccine composition Trivalent vaccines will contain the following three viruses: A/California/7/2009 (H1N1)pdm09-like virus A/Hong Kong/4801/2014 (H3N2)-like virus 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 Notes: Because of the changing nature of influenza viruses, the World Health Organisation monitors the epidemiology of influenza viruses throughout the world. Each year it makes recommendations about the strains to be included in the vaccines for the forthcoming winter for the northern and southern hemispheres. The A/H3N2 strain has changed for 2016/17. Also the B strain in the trivalent vaccine to has changed since last year but quadrivalent vaccines will contain the same two B strains as last year:   There is only one injectable quadrivalent vaccine licensed in the UK: FluarixTM Tetra.   It is licensed for adults and children from 3 years of age, it is presented in a prefilled syringe without a fixed needle. The live and inactivated flu vaccines contain the same strains (with additional B strain in quadrivalent vaccines) and comply with the WHO recommendations. Influenza update 2016/17

Flu epidemiology Influenza-like illness consultation rate per 100,000 practice population in Welsh sentinel practices Notes: The 2015-16 influenza season in Wales saw medium intensity activity. The season started 4-5 weeks later than 2014/15, in mid January. Influenza A(H1N1)pdm09 was the predominant circulating virus for the majority of last season and the strain appeared well matched to the vaccine strain. Wales, along with elsewhere in the UK, also saw significant circulation of influenza B virus. Source Vaccine Preventable Disease Programme Public Health Wales Influenza update 2016/17

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 Notes: This slide highlights the burden of influenza in 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 The average age of patients diagnosed or confirmed with flu this season was lower than in 2014-15children (<15y) and adults aged 45y to 64y accounted for half of all cases. Influenza A(H3) circulated last year and the peak of cases was in older adults. The highest proportion of confirmed cases in 2015-16 were in children and younger to middle-aged adults. Although the 2015-16 season saw slightly higher numbers of patients diagnosed with and confirmed with flu than 2014-15, the level of excess seasonal mortality was lower – probably because the elderly were less affected by the flu viruses which circulated in 2015-16 and this is the age-group which usually contributes most to excess mortality. Influenza update 2016/17

Seasonal influenza vaccine effectiveness (VE) Efficacy calculated at between 50-60% for adults aged 18-65yrs, 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 Notes: Seasonal influenza vaccine effectiveness is calculated at between 50-60% for adults aged 18-65yrs, Lower efficacy is seen in the elderly although immunisation is shown to reduce incidence of severe disease including bronchopneumonia, hospital admissions and mortality These estimates show levels of protection similar to the 2010 to 2011 season, when (H1N1)pdm09-like virus was first used in the seasonal vaccine. The UK provisional estimate of end of season overall adjusted vaccine effectiveness was 52.4%, similar to the mid-season estimate published earlier this year, and broadly in line with in a typical flu season. Influenza update 2016/17

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 The WHC was published on the 3rd August The main change to the programme this year are: Children’s programme The children’s programme in primary schools will be extended by an additional school year to include children in year 3. Therefore, children in school reception class, year 1 (ages5-6 years), year 2 (ages 6-7 years) year 3 (ages 7-8 years) are to be offered the vaccine through the school nursing service. Adult Programme Morbidly obese adults with a Body Mass Index (BMI) of 40 or more who have no other risk factors will be eligible as a specific group for vaccination in line with guidance in the Green Book. A top up allocation will be provided to health boards for this additional cohort. Influenza update 2016/17

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) Notes: Pebody RG, McLean E, Zhao H, Clearly P, Bracebridge S, Foster K, Charlett A, Hardelid P, Waight P, Ellis J, Bermingham A, Zambon M, Evans B, Salmon R, McMenamin J, Smyth B, Catchpole M,Watson JM,: Pandemic Influenza A (H1N1) 2009 and mortality in the UK: risk factors for death, April 2009 to March 2010; 15 (20) pii=19571. Available on line: http://www.eurosurveillance.org/viewArticle.aspx?ArticleId=19571 ©Leah Milinship Influenza update 2016/17

People with certain underlying chronic health conditions from 6 months of age Chronic respiratory disease Chronic heart disease Chronic kidney disease Diabetes Asplenia or splenic dysfunction Pregnancy Chronic liver disease Chronic neurological disease Immunosuppression Morbidly obese (class lll obesity) (BMI) of 40 or more 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 Notes: On average a person in one of these risk groups is more likely to die if they catch flu than a person who is not in any of these groups. In some groups the risk is far higher; people who are immunosuppressed or who have chronic liver disease or chronic neurological disease are at the highest risk of dying if they catch flu. Anyone over 6 months of age who is in any of these groups should be offered flu vaccination every year. The Joint Committee on Vaccination and Immunisation (JCVI) has also advised that morbidly obese people (defined as BMI 40+) could also benefit from a flu vaccination. Many in this patient group will already be eligible due to complications of obesity that place them in another risk category. Individuals with morbid obesity (BMI>40) were found to be at higher risk of severe outcome (both hospitalisation and death) following pandemic influenza infection compared to individuals with obesity and to normal weight individuals. 8,9,10    Individuals who are immunosuppressed are around 47 times more likely to die if they catch flu Source: Green Book chapter 19 - Influenza Influenza update 2016/17

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.     Notes: Uptake was 66.6% in those aged 65 years and over in Wales during 2015/16, a decrease of 1.4 from 68.0% last season. Uptake was 46.9% in patients aged six months to 64 years in one or more clinical risk groups, a decrease of 2.4 from 49.3% last season. Influenza update 2016/17

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. Notes: All of the uptake figures presented here, apart from the measure of uptake in pregnant women, were calculated using data provided by general practices through Audit+. The uptake figure for pregnant women was calculated using data from a survey of women giving birth during a five day period in January and April 2016, carried out by Public Health Wales and Health Board Midwives. Influenza update 2016/17

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 Notes: Pregnant women are 7 times more likely to die from flu than a non pregnant woman (Pebody et al, 2010) 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 Influenza update 2016/17

Childhood programme 2016/17 The following age groups of children will be eligible for flu vaccine in 2016-17: All children aged between two and seven years on 31 August 2016 (children born on or between 1st September 2008 and 31st August 2014) A more detailed list can be viewed in the Welsh Health Circular (WHC (2016) 039) Why vaccinate children against flu? As well as providing direct protection to the children who are immunised, experts believe that immunising children against flu will substantially reduce the amount of flu illness in the whole population. Flu vaccine is NOT licensed or recommended for use in children under 6 months of age. However these children can be protected against flu by ensuring that women are offered flu vaccination during pregnancy. Age 6 months of age and over: There are vaccines available for all ages over 6 months. The Green Book provides advice on age indications for different vaccines. Children aged 2 to 17 years: Fluenz® Tetra is the recommended flu vaccine for eligible children between the ages of 2 and 17 unless contraindicated. When Fluenz® Tetra is contraindicated FluarixTM Tetra (quadrivalent inactivated influenza vaccine) is the second choice for most children over 3 years. Otherwise an age appropriate inactivated influenza vaccine should be given. © Public Health Wales Influenza update 2016/17

Delivery location: Primary care Childhood programme 2016/17 Delivery location: Primary care GPs should actively invite and offer nasal spray flu vaccine to all registered patients aged two and three years old on 31st August 2016 Dates of birth from: 1st September 2012 to 31st August 2014 inclusive Influenza update 2016/17

Childhood programme 2016/17 Delivery location: Primary schools Children in reception class and school years 1, 2 and 3 will be offered flu vaccination in school via the school nursing service For practical reasons all children in these school years should be offered vaccination irrespective of their date of birth Where consent for the vaccination has been received but the child is unable to attend the arranged school vaccination session, a letter will be provided by the school nursing service advising that a flu vaccination appointment may be made with their GP. Where no consent has been received, the option to have the vaccine at the GP will not be available. Influenza update 2016/17

Children’s flu programme 2016/17 school programme exemptions: Parents of children in the school cohort who do not attend a school where flu vaccine is offered should contact their GP to obtain their vaccine (aged 4 to 7 years on 31st August 2016) This includes: A small amount of four year olds who have not started mainstream school Home educated children Some independent schools The majority of children aged four years on the 31st August 2016 will be attending school in reception classes. For the small number who do not, GPs should offer the intranasal flu vaccine on parental request, or opportunistically to children who attend for other purposes. GPs should also offer vaccination opportunistically to eligible children who do not attend a school covered by a health board flu immunisation programme. Health boards should make appropriate arrangements to offer the vaccine to eligible children who are not in mainstream schools. ©Leah Milinship Influenza update 2016/17

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 children’s flu vaccination until the programme is more established Notes: Uptake in the primary care cohort was 6% higher than 2014/15 . Influenza update 2016/17

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 doesn’t 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 Notes: Some people are offered the flu vaccine because if they became ill with flu they might not be able to care for someone who depends on them, or they might give the illness to someone who would find the illness difficult to fight off, or their absence from work might have a serious impact on an essential service.   Influenza update 2016/17

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   Notes: Vaccination isn’t just about keeping yourself safe, it’s about protecting your colleagues, your family and your patients. You can carry and pass the virus on to others without having any symptoms yourself, so even if you consider yourself healthy, you might be risking the lives of others .   Flu - Staff Occupational Health web page http://nww.immunisation.wales.nhs.uk/flu-staff-occupational-health  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 Influenza update 2016/17

DRAFT ONLY - Please see the disclaimer text on slide 1 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 Notes: Most current inactivated flu vaccines are trivalent, containing two subtypes of influenza A and one B virus. However, quadrivalent vaccines, containing two subtypes of influenza A and both B virus types have more recently been developed. The live intranasal vaccine is a quadrivalent vaccine (hence the ‘Tetra’ part of the name Fluenz® Tetra). An inactivated quadrivalent vaccine was made available for the first time in 2013 and is the preferred vaccine for children aged 3 years and over who are contraindicated to receive the live Fluenz® Tetra vaccine (quadrivalent inactivated flu vaccine is only authorised for children aged 3 years and older). NB The Fluenz® vaccine used in the 2013/14 flu season was a trivalent live vaccine. Fluenz® Tetra was first used in the 2014/15 flu season and will be used subsequently. Influenza update 2016/17

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 Notes: There is good evidence from established surveillance systems of the impact of the childhood influenza programme in the UK.  Data from the first two seasons indicates a reduced number of children presenting with flu like illness also hospital admissions were lower. There is also evidence of herd immunity, with reduced numbers of individuals presenting with flu like symptoms in other  non vaccinated age groups. (Public Health England, 2016) * The Joint Committe of Immunisation and Vaccination(JCVI) statement on the use of nasal spray vaccine for the childhood influenza programme -26th August 2016: In August 2016, the JCVI was asked to review updated data from the 2015/16 season in the UK and other countries, in light of emerging evidence of low effectiveness of Live attenuated influenza vaccine (LAIV, the nasal spray vaccine)), lower than inactivated flu vaccine, reported in the United States (US). After reviewing the evidence from across the UK, Finland, Canada and the US following the 2015/16 influenza season, much of which demonstrates good overall effectiveness, the JCVI continues to recommend using LAIV for preventing flu in children and strongly supports the continuation of the UK childhood influenza programme. The full statement can be viewed here: JCVI statement on the nasal spray vaccine Children are more susceptible to infection with influenza B than adults, therefore having two A plus two B influenza strains improves the protection children will receive from this vaccine. Image source: AstraZeneca UK Ltd Influenza update 2016/17

DRAFT ONLY - Please see the disclaimer text on slide 1 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 (except ovalbumin) 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 Notes: Confirmed anaphylaxis is rare. Other allergic conditions such as rashes may occur more commonly and are not contraindications to further immunisation. A careful history of the event will often distinguish between true anaphylaxis and other events that are either not due to the vaccine or are not life threatening. In the latter circumstance, it may be possible to continue the immunisation course. Specialist advice must be sought on the vaccines and the circumstances in which they could be given. The risk to the individual of not being immunised must be taken into account.   The live attenuated influenza vaccine (Fluenz® Tetra) should not be given to children or adolescents who are clinically severely immunodeficient due to conditions or immunosuppressive therapy such as: acute and chronic leukaemias; lymphoma; HIV infection not on highly active antiretroviral therapy (HAART); cellular immune deficiencies; and high dose corticosteroids. It is not contraindicated for use in children or adolescents with stable HIV infection receiving antiretroviral therapy; or who are receiving topical/inhaled corticosteroids or low-dose systemic corticosteroids or those receiving corticosteroids as replacement therapy, e.g. for adrenal insufficiency. The live attenuated vaccine Fluenz® Tetra is contraindicated in children and adolescents receiving salicylate therapy (other than for topical treatment of localised conditions) this is because of the association of Reye's syndrome with salicylates and wild-type influenza infection as described in the SPC for Fluenz® Tetra. Safety data for the live attenuated flu vaccine (Fluenz® Tetra) when given in pregnancy is limited. Whilst there is no evidence of risk with live attenuated flu vaccine, inactivated flu vaccines are preferred for those who are pregnant. There is no need, however, to specifically test eligible girls for pregnancy or to advise avoidance of pregnancy in those who have been recently vaccinated. Influenza update 2016/17

Precautions to flu vaccines DRAFT ONLY - Please see the disclaimer text on slide 1 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 Notes: Minor illnesses without fever of systemic upset are not valid reasons to postpone vaccination. If the individual is acutely unwell, immunisation may be postponed until they have recovered. This is to avoid confusing the differential diagnosis of acute illness by wrongly attributing any signs or symptoms to the adverse effects of the vaccine. There are no data on the effectiveness of Fluenz® Tetra when given to children with heavily blocked or runny nose (rhinitis) attributable to infection or allergy. As heavy nasal congestion might impede delivery of the vaccine to the nasopharyngeal mucosa, deferral of administration until resolution of the nasal congestion should be considered or an appropriate alternative intramuscularly administered influenza vaccine should be considered. There is a potential for influenza antiviral agents to lower the effectiveness of the live attenuated influenza vaccine (Fluenz® Tetra). Therefore, influenza antiviral agents and Fluenz® Tetra should not be administered concomitantly. Fluenz® Tetra should be delayed until 48 hours following the cessation of treatment with influenza antiviral agents. Administration of influenza antiviral agents within two weeks of administration of Fluenz® Tetra may adversely affect the effectiveness of the vaccine6. Influenza update 2016/17

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 Influenza update 2016/17

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 µg/ml (equivalent to <0.06 µg 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 Notes: There is no Ovalubumin-free vaccine available for season 2016/17. Therefore inactivated influenza vaccines that have a very low ovalbumin content (<0.12 μg/ml - equivalent to <0.06 μg for a 0.5 ml dose) are recommended and studies show they may be used safely in individuals with egg allergy36. Vaccines with ovalbumin content more than 0.12 µg/ml or where content is not stated should not be given to egg-allergic individuals.   Adults Adult patients can also be immunised in any setting using an inactivated influenza vaccine with an ovalbumin content less than 0.12 μg/ml (equivalent to 0.06 μg for 0.5 ml dose), excepting those with severe anaphylaxis to egg which has previously required intensive care or with both egg allergy and severe uncontrolled asthma. Patients in the latter two categories should be referred to specialists for immunisation in hospital. Influenza update 2016/17

Green Book influenza Chapter 19 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 μg/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 *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 Notes: Children JCVI has advised that, except for those with severe anaphylaxis to egg which has previously required intensive care, children with an egg allergy can be safely vaccinated with Fluenz® Tetra in any setting (including primary care and schools); those with clinical risk factors that contraindicate Fluenz® Tetra should be offered an inactivated influenza vaccine with a very low ovalbumin content (less than 0.12 μg/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 please see the previous slide on severe asthma. Children in a clinical risk group and aged under nine years who have not been previously vaccinated against flu will require a second dose whether given LAIV or inactivated vaccine. Influenza update 2016/17

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 Notes: To help assess level of immunosuppresion, if the immunocompromised relative goes shopping and mixes freely with people then it is ok to give the child Fluenz® Tetra. Influenza update 2016/17

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 Notes: Pain, swelling or redness at the injection site, low grade fever, malaise, shivering, fatigue, headache, myalgia and arthralgia are among the commonly reported symptoms after intramuscular or intradermal vaccination. A small painless nodule (induration) may also form at the injection site. These symptoms usually disappear within one to two days without treatment. Nasal congestion/rhinorrhoea, reduced appetite, weakness and headache are common adverse reaction following administration of the live attenuated intranasal vaccine (Fluenz® Tetra).   Immediate reactions such as urticaria, angio-oedema, bronchospasm and anaphylaxis can occur rarely. Influenza update 2016/17

Resources - Welsh Government Posters and leaflets NHS Wales immunisation leaflets and posters Notes: It is anticipated that the flu leaflets, posters and midwifery stickers will be distributed across Wales in the usual way. Please email hplibrary@wales.nhs.uk or phone on 0845 606 4050 if you require more. hplibrary@wales.nhs.uk Phone number: 0845 606 4050 Influenza update 2016/17

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-programm-3   Notes: All leaflets now available to download from NHS Direct Wales (print friendly version): http://www.nhsdirect.wales.nhs.uk/Encyclopaedia/v/article/vaccinations,adults/#Fluvaccine Influenza update 2016/17

Resources -websites WHO influenza information http://www.euro.who.int/en/what-we-do/health-topics/diseases-and-conditions/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 Influenza update 2016/17

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 (including care home workers) FluTwo - Information for immunisers Influenza update 2016/17

References Influenza update 2016/17 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. 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: 581–9 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): S731–41. 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): 1–10. 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 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 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 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) 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 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 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 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 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 Pierce M, Kurinczuk JJ, Spark P et al. (2011) Perinatal outcomes after maternal 2009/H1N1 infection: national cohort study. BMJ. 342:d3214. 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. 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. 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. 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. Influenza update 2016/17

Acknowledgements This resource was prepared by the Vaccine Preventable Disease Programme, Public Health Wales to support the influenza vaccination programme 2016/17 Some information has been adapted for use by kind permission from colleagues in Public Health England Notes: 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 to be stated. © 2016 Public Health Wales NHS Trust. Influenza update 2016/17

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