Childhood Influenza vaccination Programme 201617 Template Training Set

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Childhood Influenza vaccination Programme 2016/17 Template Training Set Vaccine Preventable Disease Programme Public Health

Childhood Influenza vaccination Programme 2016/17 Template Training Set Vaccine Preventable Disease Programme Public Health Wales Vaccine Preventable Disease Programme: Promoting immunisation in Wales

Key messages • In 2012 the Joint Committee on Vaccination and Immunisation (JCVI) recommended

Key messages • In 2012 the Joint Committee on Vaccination and Immunisation (JCVI) recommended that the seasonal influenza (flu) programme should be extended to all children aged between 2 years and less than 17 years • This extension to the flu vaccination programme should reduce the impact of seasonal flu on children and reduce transmission of flu within the community • The phased introduction of the childhood flu programme began in 2013 • From 1 st September 2016, all children aged 2 to 7 years old (and those in clinical risk groups aged 6 months or older) will be offered flu vaccination (age on 31 August 2016) • Once fully implemented, the children’s flu programme will ultimately avert many cases of severe flu and flu-related deaths • Nasal spray flu vaccine is recommended for children aged 2 years or older Vaccine Preventable Disease Programme – template slide set

Notes to trainers • This template slide set has been produced to assist with

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 relating to the childhood flu programme, 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

Learning objectives At the end of this training session, learners will be able to:

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 flu virus • Understand how flu is transmitted and the possible effects of flu for children • Outline the childhood influenza programme for 2016/17 • Explain which vaccine should be used and the contraindications and the precautions to this vaccine • Explain the possible side effects from the live attenuated flu vaccine (Fluenz® Tetra) • Explain the sequence of steps in Fluenz® Tetra administration • Identify sources of additional information Vaccine Preventable Disease Programme – template slide set

What is Flu?

What is Flu?

Influenza (flu) viruses There are 3 types of influenza (flu) viruses: A - Causes

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

How flu spreads • Flu spreads rapidly, especially in closed communities. e. g. schools/hospitals/care

How flu spreads • Flu spreads rapidly, especially in closed communities. e. g. schools/hospitals/care homes • 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 • A person with flu infection may be contagious before they feel ill - can be infectious from one day before to several days after symptoms start (Hawker et al 2012) Vaccine Preventable Disease Programme – template slide set

Features of flu • Incubation period is 1 -3 days though may be longer

Features of flu • Incubation period is 1 -3 days though may be longer especially in people with immune deficiency • People with mild or no symptoms (asymptomatic) can still infect others Common symptoms include: • Sudden onset of fever, chills, headache, muscle and joint pain and extreme fatigue • Dry cough, sore throat and stuffy nose • In young children gastrointestinal symptoms such as vomiting and diarrhoea may be seen Vaccine Preventable Disease Programme – template slide set

 Possible complications of flu • Common: – Bronchitis – Otitis media (children) –

Possible 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

Why vaccinate children against flu?

Why vaccinate children against flu?

Why vaccinate children against flu? • Extension of the seasonal flu vaccination programme to

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

Childhood Flu Vaccine Programme 2016 -17

Childhood Flu Vaccine Programme 2016 -17

Childhood programme 2016/17 The following age groups of children will be eligible for flu

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 1 September 2008 and 31 August 2014) A more detailed list can be viewed in the Welsh Health Circular (WHC (2016) 039) Vaccine Preventable Disease Programme – template slide set © Public Health Wales

Childhood programme 2016/17 Delivery location: Primary care • GPs should actively invite and offer

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 31 st August 2016 Dates of birth from: 1 st September 2012 to 31 st August 2014 inclusive Vaccine Preventable Disease Programme – template slide set

Childhood programme 2016/17 Delivery location: Primary schools • Children in reception class and school

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 Vaccine Preventable Disease Programme – template slide set

Children’s flu programme 2016/17 school programme exemptions: • Parents of children in the school

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 31 st August 2016) This includes: • A small amount of four year olds who have not started mainstream school • Home educated children • Some independent schools Vaccine Preventable Disease Programme – template slide set ©Leah Milinship

2016 -17 childhood flu vaccination programme Age on st 31 August 2016 Child’s date

2016 -17 childhood flu vaccination programme Age on st 31 August 2016 Child’s date of birth (on or between) School year Less than two years old Eligible for routine child flu vaccine Location flu vaccine offered Notes Not eligible unless in a ‘risk group’ for flu and aged six months or older on day of vaccination No 1 st September 2012 Two or three years old to Yes GP surgery 31 st August 2014 Reception class Four, five, six or seven years old Year 1 Yes Year 2 Year 3 In school Children in this age group who do not attend a school where flu vaccine is offered can obtain their flu vaccine at their GP surgery Primary school Eight to 16 years old Years 4 - 6 Secondary school years 7 - 11 No Not eligible this year unless in a ‘risk group’ for flu

Which flu vaccine should be used? Vaccine Preventable Disease Programme – template slide set

Which flu vaccine should be used? Vaccine Preventable Disease Programme – template slide set

Influenza vaccine composition for 2016/17 • Trivalent vaccines will contain the following three viruses:

Influenza vaccine composition for 2016/17 • Trivalent vaccines will contain the following three viruses: – an A/California/7/2009 (H 1 N 1)pdm 09 -like virus; – an A/Hong Kong/4801/2014 (H 3 N 2)-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 issue 248 PHE Vaccine Update Vaccine Preventable Disease Programme – template slide set

Types of flu vaccines Two main types of vaccine available: • Inactivated – by

Types of flu vaccines Two main types of vaccine available: • Inactivated – by injection • Live (attenuated) - by nasal application • None of the flu vaccines can cause clinical influenza in those individuals 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 • Quadrivalent vaccines may be better matched and provide better protection against circulating B strain(s) than trivalent flu vaccines. The live intranasal vaccine and the inactivated vaccine recommended for children aged 3 years and above who cannot receive live vaccine, are both quadrivalent vaccines so are the preferred choice in children Vaccine Preventable Disease Programme – template slide set

Live Attenuated Influenza Vaccine (LAIV) • Fluenz® Tetra is the recommended flu vaccine for

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 included • 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: Astra. Zeneca UK Ltd Vaccine Preventable Disease Programme – template slide set

Recommended doses of Fluenz® Tetra • Most children will only require a single dose

Recommended doses of Fluenz® Tetra • Most children will only require a single dose of Fluenz ® Tetra each year. However children in risk groups aged 2 to < 9 years, who have not received a flu vaccine before should be offered two doses of Fluenz® Tetra with a minimum 4 week interval between doses • Infants in a clinical risk group aged 6 months to under 2 years should receive an age appropriate inactivated flu vaccine. If they are receiving the flu vaccine for the first time they should receive a second dose not less than four weeks later Vaccine Preventable Disease Programme – template slide set

Eligible cohort Vaccine available: Children in risk groups* Vaccine available : Children not in

Eligible cohort Vaccine available: Children in risk groups* Vaccine available : Children not in risk groups Six months to less than two years old Offer suitable inactivated flu vaccine Not applicable Children aged 2 and 3 years old Offer LAIV (Fluenz® Tetra) If LAIV is medically contraindicated, then offer a suitable inactivated flu vaccine Children in reception class (age 4 -5 years), year 1 (age 5 -6 years) year 2 (age 6 -7 years) year 3 (7 -8 years) Offer LAIV (Fluenz® Tetra ) If LAIV is medically contraindicated, then offer a suitable inactivated flu vaccine Offer LAIV (Fluenz® Tetra) If LAIV is medically contraindicated, then offer a suitable inactivated flu vaccine Children older than school year 3 (age 7 -8 years) but less than 18 years Offer LAIV (Fluenz® Tetra) Not applicable If LAIV is medically contraindicated, then offer a suitable inactivated flu vaccine

Fluenz® Tetra • Generic name: influenza vaccine (live attenuated, nasal) • Brand name: Fluenz®

Fluenz® Tetra • Generic name: influenza vaccine (live attenuated, nasal) • Brand name: Fluenz® Tetra • Marketed by Astra. Zeneca • Licensed from 24 months to less than 18 years of age • Nasal spray (suspension) in a prefilled nasal applicator • Supplied as pack containing 10 doses Image courtesy of Astra. Zeneca • Ready to use (no reconstitution or dilution required) • The suspension is colourless to pale yellow, clear to opalescent. Small white particles may be present • Each applicator contains 0. 2 ml (administered as 0. 1 ml per nostril) Vaccine Preventable Disease Programme – template slide set

Storage of Fluenz® Tetra • Fluenz® Tetra must be stored in accordance with manufacturer’s

Storage of Fluenz® Tetra • Fluenz® Tetra must be stored in accordance with manufacturer’s instructions: – Store between +2°C and +8°C – 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 0 C. 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

Administration of Fluenz® Tetra • Fluenz® Tetra is delivered as a fine mist •

Administration of Fluenz® Tetra • Fluenz® Tetra is delivered as a fine mist • Fluenz® Tetra can be administered at the same time as other vaccines including live vaccines • Patient should breathe normally - no need to actively inhale or sniff • No need to repeat either half of dose if the child sneezes, blows their nose or their nose drips following administration • Fluenz® Tetra is different from other influenza vaccine, it is a nasal vaccine and must not be injected Vaccine Preventable Disease Programme – template slide set © Public Health Wales

Administration of Fluenz® Tetra Video clip showing administration • Click on the following link

Administration of Fluenz® Tetra Video clip showing administration • Click on the following link to access the video clip showing how to administer Fluenz® Tetra vaccine http: //nww. immunisation. wales. nhs. uk/administration-of-fluenztetra-intranasa • This video has been developed by Health Protection Scotland/NHS Education for Scotland Vaccine Preventable Disease Programme – template slide set

Patient Group Directions (PGDs) • Two separate PGDs are available: – One for the

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 Patient Group Direction (PGD) Template for Fluenz Tetra, Live attenuated influenza vaccine (LAIV) Vaccine Preventable Disease Programme – template slide set

Contraindications to LAIV • There are very few children who cannot receive any flu

Contraindications to LAIV • There are very few children who cannot receive any flu vaccine • Where there is doubt, expert advice should be sought promptly so that the period the child is left unvaccinated is minimised • 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 LAIV • Confirmed anaphylactic reaction to a previous dose of flu vaccine

Contraindications to LAIV • Confirmed anaphylactic reaction to a previous dose of flu vaccine • Confirmed anaphylactic reaction to any component of the vaccine including gentamicin and gelatine • 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 • High dose corticosteroids • Receiving salicylate therapy • Known to be pregnant Green Book influenza Chapter 19 Vaccine Preventable Disease Programme – template slide set

Severe asthma or active wheezing • LAIV (Fluenz® Tetra) is not recommended for children

Severe asthma or active wheezing • LAIV (Fluenz® Tetra) 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 mcgs/day or equivalent (e. g. Fluticasone > 500 mcgs/day) should only be given LAIV 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 LAIV 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 condition 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 • Children with an egg allergy can be safely vaccinated with LAIV

Egg allergy • Children with an egg allergy can be safely vaccinated with LAIV in any setting (including primary care and schools) • Children with a history of severe anaphylaxis to egg which has previously required admission to an intensive care unit, should be referred to a specialist for immunisation in hospital • Those with both egg allergy and clinical risk factors that contraindicate LAIV (e. g. immunosuppression) should be offered an inactivated flu vaccine with a very low ovalbumin content (less than 0. 12 μg/ml) • For children with egg allergy and asthma, follow recommendations for severe asthma (previous slide) Vaccine Preventable Disease Programme – template slide set

Fluenz® Tetra - Precautions • Acute severe febrile illness, defer until recovered • Heavy

Fluenz® Tetra - Precautions • Acute severe febrile illness, defer until recovered • Heavy nasal congestion may impede delivery of the vaccine to the nasal mucosa; defer until resolved or consider inactivated influenza vaccine Please note: Minor illnesses without fever or systemic upset are not valid reasons to postpone vaccination • Use with antiviral agents against flu – LAIV should not be administered at the same time as flu antiviral agents – LAIV should not be administered within 48 hours of cessation of treatment with flu antiviral agents – Administration of flu antiviral agents within two weeks of administration of LAIV may adversely affect the effectiveness of the vaccine Vaccine Preventable Disease Programme – template slide set

LAIV and pork gelatine • LAIV contains highly purified pork (porcine) gelatine, an essential

LAIV and pork gelatine • LAIV contains highly purified pork (porcine) gelatine, an essential ingredient in many medicines including some vaccines • Inactivated injectable flu vaccine may only be offered as an alternative to LAIV when children are in a clinical risk group or when children have clinical contraindications to LAIV • LAIV provides better protection for children than inactivated injectable flu vaccine particularly against flu B strains • It is up to an individual parent/guardian to decide if they would like their child vaccinated against flu on the basis of informed consent Vaccine Preventable Disease Programme – template slide set

Risk of transmission • There is the potential for transmission of live attenuated influenza

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 health care 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 LAIV 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

Exposure of healthcare professionals to live attenuated influenza vaccine viruses • There may be

Exposure of healthcare professionals to live attenuated influenza vaccine viruses • There may be some low level exposure to the vaccine viruses for those administering LAIV and/or from recently vaccinated patients • The vaccine viruses are cold-adapted and attenuated and therefore unlikely to cause symptomatic flu • As a precaution, very severely immunosuppressed individuals should not administer LAIV • Other healthcare workers who have less severe immunosuppression or are pregnant, should follow normal clinical practice to avoid inhaling the vaccine and ensure that they themselves are appropriately vaccinated Vaccine Preventable Disease Programme – template slide set

LAIV Adverse reactions • Fluenz® Tetra (LAIV) is a black triangle ( ) drug

LAIV Adverse reactions • Fluenz® Tetra (LAIV) is a black triangle ( ) drug • Commonly reported adverse reactions (affects more than 1 in 10 Fluenz® Tetra recipients): § § Nasal congestion/rhinorrhoea Reduced appetite Pyrexia Tiredness, muscle aches and headache Vaccine Preventable Disease Programme – template slide set

Reporting suspected adverse reactions • As with all vaccines during the earlier stages of

Reporting suspected adverse reactions • As with all vaccines during the earlier stages of their introduction, Fluenz® Tetra carries a black triangle symbol (▼) • This is to encourage reporting of all suspected adverse reactions to the Medicines and Healthcare products Regulatory Agency (MHRA) using the Yellow Card scheme • Yellow card scheme: http: //mhra. gov. uk/yellowcard; • Voluntary reporting system for suspected adverse reaction to medicine/vaccines • Success depends on early, complete and accurate reporting • Report even if uncertain about whether vaccine caused condition Vaccine Preventable Disease Programme – template slide set

Inactivated Influenza Vaccine (IIV) for children contraindicated to receive LAIV • Children for whom

Inactivated Influenza Vaccine (IIV) for children contraindicated to receive LAIV • Children for whom LAIV is contraindicated should be offered a suitable alternative inactivated flu vaccine • Some inactivated flu vaccines have been associated with high rates of febrile convulsions in children • Some inactivated flu vaccines contain too much ovalbumin for egg allergic children • Check SPC for vaccine suitability before administration Fluarix® Tetra (Quadrivalent IIV) is the preferred vaccine for children aged ≥ 3 years who cannot receive Fluenz® Tetra Children 6 m to <3 yrs should be given trivalent inactivated influenza vaccine (Split Virion) BP® Vaccine Preventable Disease Programme – template slide set

If LAIV is contraindicated: • If LAIV is contraindicated Fluarix® Tetra is the preferred

If LAIV is contraindicated: • If LAIV is contraindicated Fluarix® Tetra is the preferred vaccine for children over 3 years as it provides protection against two flu A and two flu B strains (quadrivalent) • Children aged six months to under nine years who have not received inactivated intramuscular vaccine before should receive a second dose of vaccine at least four weeks later • Administration of intramuscular flu vaccine to children is not a role for HCSWs Vaccine Preventable Disease Programme – template slide set Image source: Glaxo. Smith. Kline

Uptake of flu vaccine in children 2015/16 • Uptake of flu vaccine in children

Uptake of flu vaccine in children 2015/16 • Uptake of flu vaccine in children aged two to three years was 44. 4% • Uptake of flu vaccine in the 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 Vaccine Preventable Disease Programme – template slide set

Resources and sources of information Vaccine Preventable Disease Programme – template slide set

Resources and sources of information Vaccine Preventable Disease Programme – template slide set

Resources Welsh Government Posters and leaflets hplibrary@wales. nhs. uk Phone number: 0845 606 4050

Resources Welsh Government Posters and leaflets hplibrary@wales. nhs. uk Phone number: 0845 606 4050 Vaccine Preventable Disease Programme – template slide set

Vaccine Preventable Disease Programme – template slide set

Vaccine Preventable Disease Programme – template slide set

2016 -17 Childhood Influenza Vaccination Programme in Wales - A short video for parents

2016 -17 Childhood Influenza Vaccination Programme in Wales - A short video for parents and guardians Vaccine Preventable Disease Programme – template slide set

Useful links • Welsh Health Circular: The national influenza immunisation programme 2016/17 WHC(2016)039 •

Useful links • Welsh Health Circular: The national influenza immunisation programme 2016/17 WHC(2016)039 • NHS Direct Wales –primary source of public facing flu information in Wales: http: //www. nhsdirect. wales. nhs. uk/encyclopaedia/f/article/flu, seasonal/ • Flu “Frequently Asked Questions” http: //nww. immunisation. wales. nhs. uk/questions • Template PGD http: //nww. immunisation. wales. nhs. uk/pgds-psds • Public Health Wales: Influenza page http: //www. wales. nhs. uk/sitesplus/888/page/43745 • 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 Vaccine Preventable Disease Programme – template slide set

Acknowledgements • This resource was prepared by the Vaccine Preventable Disease Programme, Public Health

Acknowledgements • This resource was prepared by the Vaccine Preventable Disease Programme, Public Health Wales as a national training template to support the Childhood 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