1. Immunisation Update Seminar August/Sept 2019
Public Health Protection Unit
NHSGGC

2. Seminar Programme Welcome and introduction
General review and update of all immunisation programmes
Changes to the Flu vaccination programme in 2019/20
Update on national and local Vaccine Transformation Programme
Update on pharmacy issues including vaccine ordering and cold chain etc
Questions and answers

3. General Review and Update of all immunisation programmes

7. Rotavirus vaccine Uptake
The Centre for Global Vaccine Research, : University of Liverpool : Hungerford D et al., BMC Med Jan 29;16(1):10
The most deprived had a 54% increased risk of non vaccination
The most deprived had almost twice the risk of non-completion of both doses.

8. Meningococcal diseases by Age

9. Priority for the childhood vaccination programme
All HSCPs community clinics are fully established (40 clinics)
Some of them inherited long Q print particularly from practices with infrequent immunisation clinics
Now priority would be to target those babies late for primary doses and also to improve pre-school booster uptake
Stop the decline in uptake trend by dealing with vaccine hesitancy and anti-vaccination groups

10. School Immunisation Programmes
HPV programme for girls is a success story with > 90% reduction in cervical pre-cancerous lesions in vaccinated women with in-direct protection to other women
Significant impact on boys due to herd immunity
However risks to some boys/men remains including for head and neck and genital cancers
Boys programme to be introduced to all S1 boys in August 2019 with no catch up but eligible boys and girls will remain eligible until age 25 years
Aim is to eliminate cervical cancer in 30 years with combined screening and vaccination programmes

11. Flu programme 2019/20
Review epidemiology of last season including vaccine uptake and effectiveness data
Impact of last year’s flu season
Issues identified following evaluation of last year’s programme
Plan for 2019/20 season including vaccines to be used

12. Epidemiology of Influenza by age and types

14. Why vaccinate these risk groups?
Influenza-related population mortality rates and relative risk of death among those aged six months to under 65 years by clinical risk group in England, September 2010 – May 2011
Number of fatal flu cases (%)
Mortality rate per 100,000 population
Age-adjusted relative risk
In a risk group
213 (59.8)
4.0
11.3 ( )
Not in any risk group
143 (40.2)
0.4
Baseline
Chronic renal disease
19 (5.3)
4.8
18.5
Chronic heart disease
32 (9.0)
3.7
10.7 ( )
Chronic respiratory disease
59 (16.6)
2.4
7.4 ( )
Chronic liver disease
15.8
48.2 ( )
Diabetes
26 (7.3)
2.2
5.8 ( )
Immunosuppression
71 (19.9)
20.0
47.3 ( )
Chronic neurological disease (excluding stroke/transient ischaemic attack)
42 (11.8)
14.7
40.4 ( )
Total
378
0.8
Increasing flu vaccine uptake in clinical risk groups is important because of the increased risk of serious illness should people in these groups catch flu. The table above shows flu mortality by clinical risk group and demonstrates the increased risk of death.
The national flu immunisation programme 2018/19

16. Flu Epidemiology in England

17. Seasonal flu vaccine uptake in Scotland       
65 years and older 
74.5% 
72.8% 
73.7% 
Under 65yrs- At risk (excluding healthy pregnant women and carers) 
48.0% 
44.9% 
44.8% 
42.4% 
Pregnant women-no risk 
49.9% 
49.3% 
48.1% 
44.5% 
Aged 2-5yrs(not yet in school) 
57.1% 
59.0% 
56.9% 
55.8% 
Primary School 
71.5% 
73.0% 
72.9% 
Healthcare workers 
33.2% 
35.3% 
45.7% 
51.2% 
Data source Health Protection Scotland
HPS Data visualisation of vaccine uptake in all groups and geographical areas can be found here: 

19. Vaccine uptake trend for 65+ by SIMD

22. Vaccine Uptake Trend by SIMD for at risk groups

24. Flu vaccine effectiveness
Efficacy varies from one season to the next depending on circulating strains and how well they match
Generally, lower efficacy is seen in the elderly although immunisation has been shown to reduce severe disease including hospitalisation and mortality
It is hoped that the use of adjuvanted and the new egg and cell based quadrivalent vaccines will improve protection in the elderly and those most at risk of flu
A 2012 meta-analysis included studies when the influenza virus strains in the vaccine were drifted or mismatched with those in circulation and suggested an overall efficacy against confirmed disease of 59% (95% confidence interval 51-67) in adults aged 18 to 65 years.1 In the elderly, protection produced by the vaccine may be lower2, although immunisation has been shown to reduce the incidence of severe disease including bronchopneumonia, hospital admissions and mortality.3, 4
A PHE study5 found that the 2014/15 mid-season estimates of flu vaccine, which is used primarily in adults, provided low protection against flu infection due to one particular subtype, H3N2. This was because a drifted strain of flu A(H3N2) emerged in 2014/15 after the 14/15 A(H3N2) vaccine strain had been selected in February This resulted in a mismatch between the vaccine strain and the main A(H3N2) strain that circulated in the UK. The study was based on the results from 1,314 patients presenting in primary care across the UK and found that vaccine effectiveness in preventing laboratory confirmed influenza was estimated to be 3% overall (with an upper 95% confidence interval of 35%). This compares to approximately 50% vaccine effectiveness that has typically been seen in the UK over recent years, with generally a good match between the strains of flu in the vaccine and those that subsequently circulate in the population.
Flu vaccine effectiveness estimates are available at
References:
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),
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.

25. Flu vaccine effectiveness in 2018/19
For all ages adjusted Vaccine Efficacy (aVE) was 44.3%
aVE for year old children receiving LAIV was 48.6%
aVE for year olds was 44.2%
Overall aVE for all those aged 65 years and over for all vaccine types over was 49.9%
Overall aVE for all those that received aTIV was 62%

26. Adjuvanted influenza vaccine (aTIV)
during 2018/19, an adjuvanted trivalent influenza vaccine (aTIV) was used for those aged 75 years and over
this year (2019/20), aTIV will be used for all those aged 65 years and over
adjuvants are added to vaccines to enhance the immune response and should improve protection against flu in elderly people
aTIV (Fluad®) was licenced in the UK in 2017 but has been in use for 20 years with over 93 million doses distributed in 20 countries
Fluad® has been proven to be safe and effective. There were no issues in 2018/19
The national flu immunisation programme 2018/19

27. Quadrivalent influenza cell culture vaccine (QIVc)
QIVc (Flucelvax® TETRA) was first licenced in the US in 2016 and in the UK in December 2018 for those age 9 years and over
It is a quadrivalent vaccine containing two subtypes of Influenza A (H3N2 and H1N1pdm00) and both B virus lineages.
QIVc has a similar safety profile to other flu vaccines. More than 36 million doses administered with no serious safety concerns
The manufacturing process uses animal cells to grow the influenza virus rather than traditional egg based methods
This manufacturing process eliminates the risk of egg-adaptation and may result in the vaccine containing virus that is a closer match to the circulating flu viruses (though cell-adaptation can still occur). Also may speed up vaccine production

28. Seasonal Flu Vaccination Programme 2019/20 Healthcare workers
Vaccination of healthcare workers protects them and reduces risk of spreading flu to their patients, service users, colleagues and family members
HCWs can transmit infection to patients and other close contacts even before respiratory symptoms begins
The Chief Officers strongly encourage that all NHS staff are vaccinated against seasonal flu, particularly front-line staff and those working in areas where patients might be a greater risk.
Health care workers will be offered one dose of quadrivalent inactivated egg-based vaccine(QIVe) 
Uptake in 2018/19: around 50%
Target for 2019/20: 60% uptake
Please note a separate resource offering further information to healthcare workers is available on the NES website
Patients at greater risk include paediatric, oncology, maternity, care of the elderly, haematology, ICU’s.
The target is to vaccinate 75% of front line staff and all efforts should be made to make the vaccine available at times and places that are convenient for staff.  Senior clinicians and NHS managers should ensure staff fully understand the role flu vaccination plays in preventing transmission of the flu virus.
As in previous years, free seasonal influenza immunisation should be offered by NHS organisations to all employees directly involved in delivering care.
Vaccination against flu should be considered an integral component of standard infection control procedures.

29. Flu Vaccination Programme for children, 2019/20
There is no change to the recommendation of Quadrivalent  live attenuated  intranasal vaccine Fluenz Tetra ® (LAIV )– for children (2-5 year olds not yet in school, all primary school aged children and those in clinical risk groups in secondary school) 
If Fluenz contraindicated, use injectable QIV
Please note that  separate resources are available on the NHS Education for Scotland website relating to the childhood programme

30. Seasonal Flu Vaccination Programme 2019/20 Adults; Vaccines to be used
Individuals aged 65 years and over
adjuvanted Trivalent Inactivated Vaccine (aTIV) (Fluad ®) in NHSGGC or
cell based Quadrivalent Inactivated Vaccine (QIVc) (Flucelvax Tetra®)
Individuals aged years with at-risk conditions
egg based Quadrivalent Inactivated Vaccine (QIVe) in NHSGGC
Healthcare workers
egg based Quadrivalent Inactivated Vaccine (QIVe)
Those with severe egg allergy
Cell based Quadrivalent Inactivated Vaccine (QIVc)
JCVI advice on the vaccine recommendations for each age group and the fact that they are considered equivalent in terms of effectiveness can be found at this link 
JCVI noted potential explanations for the declining vaccine effectiveness against influenza A(H3N2) that has been observed in recent years. These include: 
 Immunosenescence in older people (age related reduction in immune response)
 genetic drift of the circulating viral strain compared to the vaccine strain (which happened e.g. in 2014/15)
 egg adaptation (in recent seasons mutations during manufacturing that arise with the A(H3N2) strain when flu vaccine strains are propagated in eggs) which means that the vaccines do not work as well
There are a number of changes in the flu vaccines that the JCVI has advised for use in different patient groups. The changes are in response to a wider range of vaccines being available which offer better protection.
For those aged 65 and over, there are three vaccines that JCVI advised are equally suitable for use. The adjuvanted trivalent influenza vaccine (aTIV) continues to be recommended for this age group as it is likely to be a more effective vaccine than the standard dose non-adjuvanted trivalent and egg-based quadrivalent influenza vaccines. Equally suitable, is the newly licensed cell-based quadrivalent influenza vaccine (QIVc). While previous flu vaccines have been cultured on eggs there may be an advantage to using cell derived flu vaccines. This is because it overcomes egg adaptation, when mutations potentially arise during the manufacturing process when flu vaccine virus strains are propagated in eggs. This means that the egg grown vaccines may not work as well in protecting against flu as the cell grown one, particularly in relation to the A(H3N2) strain. Whilst also suitable for this age group, the newly licensed high dose trivalent influenza vaccine (TIV-HD) has not been purchased as part of the centralised procurement of influenza vaccine for the Scottish vaccination programme in
For those aged 18 to 64 years, there are two vaccines which JCVI advises are equally effective and suitable for use. The standard egg-grown quadrivalent influenza vaccine (QIVe) and the newly licensed cell-based quadrivalent influenza vaccine (QIVc). Both offer protection against four strains of flu (two influenza A strains and two influenza B strains).
As part of the national arrangements for ordering and distribution of vaccine, practices in each NHS board will routinely receive one type of vaccine suitable for use in those aged 65 years and over and one type of vaccine for those aged years with at risk conditions.

31. Egg allergy and Flu Vaccine
children with an egg allergy can be safely vaccinated with LAIV in any setting (including primary care and schools)
children who have required admission to intensive care for a previous severe anaphylaxis to egg should be given LAIV in the hospital setting
children with severe egg allergy that contraindicate LAIV (eg severe immunosuppression) should be offered an* inactivated flu vaccine with a very low ovalbumin content (less than 0.12μg/ml) or an egg free vaccine,
Flucelvax® TETRA (over age 9 years)
egg-allergic children with asthma can receive LAIV if their asthma is well-controlled (see next slide on severe asthma)
JCVI has advised (JCVI, 2015) that children with an egg allergy – including those with previous anaphylaxis to egg – can be safely vaccinated with LAIV in any setting (including primary care and schools). The only exception is for children who have required admission to intensive care for a previous severe anaphylaxis to egg, for whom no data are available; such children are best given LAIV in the hospital setting. LAIV remains the preferred vaccine for this group and the intranasal route is less likely to cause systemic reactions.
Children with egg allergy but who also have another condition which contraindicates LAIV should be offered an inactivated influenza vaccine with a very low ovalbumin content (less than 0.12 micrograms/ml). Children in a clinical risk group and aged under nine years who have not been previously vaccinated against influenza will require a second dose (of either LAIV or inactivated vaccine as appropriate).
The national childhood flu immunisation programme 2019/20

32. Acute and severe asthma
New guidance for 2019 from JCVI based on recent data
children with asthma on inhaled corticosteroids may safely be given LAIV irrespective of the dose prescribed
LAIV is not recommended for children and adolescents currently experiencing an acute exacerbation of symptoms including
- those who have had increased wheezing and/or
- needed additional bronchodilator treatment in the previous 72 hours
children who require regular oral steroids for maintenance of asthma control, or have previously required intensive care for asthma exacerbation should only be given LAIV on the advice of their specialist
Such children should be offered a suitable inactivated influenza vaccine to avoid a delay in protection
JCVI have advised (2019) that, on the basis of recent data, children with asthma on inhaled corticosteroids may safely be given LAIV, irrespective of the dose prescribed. LAIV is not recommended for children and adolescents currently experiencing an acute exacerbation of symptoms including those who have had increased wheezing and/or needed additional bronchodilator treatment in the previous 72 hours. Such children should be offered a suitable inactivated influenza vaccine to avoid a delay in protection.
There are limited safety data in children who require regular oral steroids for maintenance of asthma control, or have previously required intensive care for asthma exacerbation – such children should only be given LAIV on the advice of their specialist. As these children may be at higher risk from influenza infection, those who cannot receive LAIV should receive a suitable inactivated influenza vaccine. Children with significant asthma and aged under nine years who have not been previously vaccinated against influenza will require a second dose (of either LAIV or inactivated vaccine as appropriate).
The national childhood flu immunisation programme 2019/20

33. Likely Flu epidemiology in 2019/20
Flu remains very unpredictable
Some indication from flu from the Southern hemisphere
Best to plan for the worst case scenario
Vaccination remains the best way to protect against Flu as well as good personal hygiene and infection control

34. ILI reported rate from GP surveillance practices in Australia in 2019

35. Number of reported Lab confirmed cases of Influenza in Australia (2019)

37. Shingles epidemiology
Shingles is a painful illness with pain persisting for months or years
Incidence and severity of illness increases with age from age 70 years onwards
Complications of shingles including PHN increases as people get older
A live vaccine (zostavax) introduced in Sept 2013 for adults age 70 years with a phased catch up programme for 71 – 79 year olds

38. Shingles vaccine evaluation in England
Uptake rate below 50% for both routine programme age 70 and catch up cohorts
First 3 years of the programme
- 35% reduction in shingles cases and 50% reduction in PHN for the 3 routine cohorts
- 33% reduction in shingles and 38% reduction in PHN for catch up cohorts
- VE of 62% against shingles and 70-88% against PHN

39. Shingles epidemiology in Scotland : 1

42. Shingles vaccination programme
From 1st September 2019, all those ages 70 to 79 years are eligible if not vaccinated already
Approximately 3 to 5% of eligible cohort have genuine contraindication (see Green Book and PGD)
Most eligible adults can be immunised without complication but if in doubt, seek advice
On-line screening tool available

43. Measles outbreaks
Outbreaks in a number of European and other countries globally
On-going outbreaks in England and UK lost measles free status
Sporadic imported cases in Scotland but no sustained outbreak
Unvaccinated travellers remain at risk of infection

46. Pertussis
Vaccination against pertussis with current vaccine does not provide life long immunity
People who have had pertussis can become re-infected and spread disease to others
Epidemiology of pertussis changed in UK since 2012 with increase in cases
For adults, may be a mild infection but very young children it can be fatal
90% of deaths from pertussis in last 10 years in infants aged 3 months or less
In 2012, vaccination of pregnant women recommended

47. Pertussis and Pregnant women
Pregnant woman should be offered a single dose of dTaP/IPV vaccine (Boostrix IPV®) or Repevax
Vaccine should be offered from 16 weeks of pregnancy
Woman who have not received vaccine in pregnancy can be offered vaccine until their child receives their first pertussis vaccine

48. Pertussis and HealthCare Workers (HCWs)
Outbreaks in healthcare settings
HCWs an important source of infection to infants
JCVI advised in 2016; all HCWs with direct contact with vulnerable patients (pregnant women and infants) should be vaccinated if not received a pertussis containing vaccine in the last 5 yrs:
- Priority Group 1: staff working with women in the last month of pregnancy and neonatal and paediatric ICU staff
- Priority Group 2: paediatric staff and primary care staff in regular contact with unimmunised infants
- Priority Group 3: HCWs with intermittent contact with unimmunised infants including staff in primary care
Vaccine to be used either Repevax or Boostrix-IPV and occupational health to roll out a phased programme

49. Vaccine Transformation Programme (VTP)
To support the evolving roles of general practice
Implementation coordinated nationally by the SG with input from all NHS Boards
3 year phased programme from April 2018 to be fully implemented by April 2021
Programme moved from GP Practice delivery only if safe and sustainable to do so
The scope of VTP include all programmes including pre-school, school based, adults and travel health.

50. VTP summary for 2019/20 Routine childhood; moved to HSCP clinics
Ad-hoc unscheduled immunisation for those older than 6 yrs; to remain with General practice
2-5 year flu; with general practice other than pilot practices
Primary school Flu; mop up with practices
Adult Flu; remain with practices but opportunistic immunisation in Community Pharmacies
Shingles and pneumococcal; remain with practices
Flu and pertussis for pregnant women; will move to maternity services from October 2019
Travel health service including vaccination; remain with practices

51. VTP Implementation Overview in NHSGGC

52. VTP in NHSGGC
In NHSGGC, on-going planning for alternative delivery model but key challenges remains including IT, workforce and accommodation
The ambition is to offer more standardised approach to vaccination with ease and equity of access to reduce variations; weekdays, evenings and weekends
Opportunity for staff with spare capacity to work additional hours during October to Mid-December
Any questions phone Nurse Bank , option 2
Practices must continue their efforts to maximise uptake until services are fully transferred to an alternative model
Primary care staff will remain critical in supporting the immunisation programme in the future even if actual vaccine delivery elsewhere

55. Acknowledgment
Colleagues at PHPU
PHE
HPS
NES