Influenza vaccinations 2018 19 Major changes and update

Influenza vaccinations 2018 -19 Major changes and update Lucinda Longwill (Practice nurse, Aberfeldy Practice and Clinical lead for network 7)

Aims of the session Revise the background of the annual flu campaign Risk groups The vaccines: QIV a. TIV LAIV PGDs

At-Risk Groups Chronic respiratory disease, including asthma Chronic heart disease Chronic renal disease Chronic liver disease Chronic neurological disease Diabetes Immunosuppression Pregnancy Morbid obesity BMI>= 40 People in long stay facilities Carers Elderly Healthy children from age 2 (on 31 st august 2018)

The flu vaccine acronyms LAIV: Live Attenuated Influenza Vaccine QIV: Quadrivalent Influenza Vaccine a. TIV: adjuvented Trivalent Influenza Vaccine

LAIV: Fluenz Tetra® All children aged 2 -17 years* inclusive in a risk group Healthy children aged 2 and 3 years* – in GP All children in School Yrs R, 1, 2, 3, 4 and 5 Special schools Pilots of children in whole schools * Age as on 31 st August 2018

LAIV contraindications Outside age range, i. e. <2 yrs or >=18 yrs Hypersensitivity to contents – includes egg Immunosuppression (controlled HIV infection is ok) Salicylate therapy Pregnancy Severe asthma: children who have taken oral steroids in the past 14 days or are currently taking a high dose of an inhaled steroid, budesonide/clenil >800 micrograms/day or equivalent (eg fluticasone >500 micrograms/day) Postpone if acute fever/systemic illness or wheeze

Porcine gelatine & LAIV Fluenz Tetra® contains a highly purified form of porcine gelatine Gelatine was found to be the best stabiliser for the LAIV Some faith groups do not accept the use of porcine gelatine in medicinal products There is no live attenuated vaccine available that does not contain porcine gelatine.

Porcine gelatine & LAIV PHE’s view is that there is no suitable alternative to Fluenz Tetra®. The purpose of the childhood programme is to interrupt transmission & therefore indirectly protect whole population. We therefore cannot offer the QIV injection if Fluenz is declined UNLESS child is in a risk group Seewww. gov. uk/government/news/vaccines-and-gelatine-pheresponse for Q&As and more information on vaccines and gelatine

Which vaccination for healthy and atrisk children under 18? Eligible cohort Vaccine available: Children in clinical risk groups* Vaccine available: Children not in clinical risk groups Six months to less than two years old Offer suitable quadrivalent inactivated flu vaccine. Not applicable Children aged two years to less than 18 years old Offer LAIV (Fluenz Tetra®) (unless medically contraindicated 1) Offer LAIV (Fluenz Tetra®)

a. TIV: Fluad® Only licensed with one manufacturer- Seqirus For age 65 and over only This adjuvented vaccine is more effective in this population Usual contraindications, including egg allergy Licensed for IM only.

a. TIV: Fluad® The NHSE PGD states: “Individuals on stable anticoagulation therapy, including individuals on warfarin who are up-to-date with their scheduled INR testing and whose latest INR was below the upper threshold of their therapeutic range, can receive intramuscular vaccination. A fine needle (equal to 23 gauge or finer calibre) should be used for the vaccination, followed by firm pressure applied to the site (without rubbing) for at least 2 minutes. If in any doubt, consult with the clinician responsible for prescribing or monitoring the individual’s anticoagulant therapy. ”

a. TIV: Fluad® Comes in pre-filled capped syringes, with needles supplied Contact Seqirus with any questions on service. uk@seqirus. com or 08457 451 500

QIV: multiple suppliers Check the SPC for the license ages for your specific brand QIV available on Imm. Form for those infants and children contraindicated for the Fluenz Tetra® Otherwise, it is for those aged 18 -64… …and for those 65 and over who are contraindicated for the a. TIV (including egg allergy, as long as the ovalbumin content of your chosen brand is very low*)

PGDs Available now for LAIV, IM Influenza, PPV at: https: //www. england. nhs. uk/london/ourwork/immunis-team/

Risk of errors Patients aged 65 years and over who have inadvertently received QIV instead of a. TIV: Although a. TIV is recommended for those aged 65 and over, QIV is licensed in this age group and should provide protection against flu. Therefore, no further vaccination is recommended this flu season for an individual who has inadvertently received QIV. The patient should be offered reassurance, the local Screening and Immunisation team should be informed and systems reviewed to prevent this happening again. Patients under 65 years of age in an at risk category that inadvertently receive a. TIV vaccine instead of QIV Although a. TIV is not licensed for people under 65, the vaccine should still provide protection to those under 65 years who receive it inadvertently. No further vaccination is required this flu season. The patient should be offered reassurance and advised of the risk of local reactions. The local Screening and Immunisation team should be informed and systems reviewed to prevent this happening again.

Giving other vaccines together QIV/a. TIV & Shingles: YES PPV & shingles: YES QIV/a. TIV & PPV & shingles: probably Shingles & MMR: NO. Must be a 4 week gap.

A Note on Egg allergy Except for those with severe anaphylaxis to egg which has previously required intensive care, children with an egg allergy can be safely vaccinated with LAIV in any setting (including primary care and schools) (JCVI 2015) Except for those with severe anaphylaxis to egg which has previously required intensive care, adults with egg allergy can be immunised in any setting using an inactivated influenza vaccine with an ovalbumin content less than 0. 12 micrograms/ml.

A note on egg allergy Inactivated flu vaccines are available with a very low ovalbumin content (see Green Book for the brands) LAIV (Fluenz Tetra®) ovalbumin content has been reduced to a very low level

Which flu vaccine for which patient? Recommendations 2018 -19 AGE TARGET GROUP FLU VAC OF CHOICE <6 mths Not given None licensed 6 mths-<2 yrs In high-risk group QIV (Imm. Form) 2 yrs-<18 yrs High-risk group & healthy children in target age cohorts LAIV Fluenz Tetra® (Imm. Form) 18 yrs-<65 yrs In high risk group QIV Pregnancy All women, all trimesters QIV 65 yrs and over All a. TIV Fluad®

*ALMOST…