Dr Toni Hazell discusses the vital role of primary care in rolling out the flu and COVID-19 vaccination programmes this autumn

Read this article to learn more about:

Image of Dr Toni Hazell

Dr Toni Hazell

  • eligibility groups for flu vaccination, and which vaccines are recommended for different groups
  • addressing common concerns about the flu vaccines
  • COVID-19 boosters and third primary doses, and how these will fit in with the flu vaccination programme.

Key points

Implementation actions for STPs and ICSs

Read this article online at: GinP.co.uk/456368.article

My 17 years as a GP seem to be marked by the cycle of flu vaccination seasons—every year, as we plan our main ‘flu jab Saturday’, I’m surprised that it has come around again so soon, and I have to remind myself who should be offered which vaccine, and where in the fridge the different types are kept.

Last year, we dealt with an expanded flu cohort to include all over 50s, along with the additional challenges of social distancing. For the 2021–2022 flu season, there are also COVID-19 vaccinations to take into account—boosters and third doses of the primary course for immunosuppressed patients. This article will provide an overview of the flu vaccination campaign for 2021–2022, and discuss what is currently known about the COVID-19 booster campaign, an area in which information is constantly changing.

Each year, flu vaccinations are formulated anew, in an attempt to match the strains that are likely to be circulating in the upcoming flu season. We don’t find out until after the flu season has finished how well the vaccination matched the circulating strains, and this varies from year to year. There are concerns that the flu season this year may begin earlier than usual, and that there could be up to 50% more cases than usual.1 This is presumably due to reduced immunity as less people contracted flu during the periods of lockdown,1 making it all the more important that we get on top of flu vaccination as soon as possible, even if we have to work around delays in the delivery of vaccines.2

Who is eligible for flu vaccination?

Broadly speaking, a patient may be eligible for their flu vaccination for one or more of four reasons—their age, their occupation, their household contacts, or their medical history. Box 1 lists those who are eligible for an NHS flu vaccination in the 2021–2022 season.

Box 1: Groups eligible for flu vaccination in 2021–2022

Eligibility by age1

  • All children aged 2–15 on 31 August 2021 (that is, up to and including school year 11)
  • All adults aged ≥50 years (those aged 50–64 years are now eligible from the start of the flu vaccination season, which is a change from last year when they had to wait until December).3

Eligibility by occupation or household contacts1

  • Front-line health and social care staff employed by:
    • a registered residential care or nursing home
    • a registered domiciliary care provider
    • a voluntary managed hospice provider
    • Direct Payment (personal budgets) and/or Personal Health Budgets, such as Personal Assistants
  • Close contacts of immunocompromised individuals
  • Those in long-stay residential care homes
  • Carers.

Eligibility by medical history1,4

  • Pregnant women
  • Those aged 6 months to under 50 years in the following clinical risk groups:
    • chronic respiratory disease
    • chronic heart disease
    • chronic kidney disease
    • chronic liver disease
    • chronic neurological disease
    • diabetes
    • immunosuppression
    • asplenia or dysfunction of the spleen
    • obesity with a body mass index of ≥40 kg/m2.

Those of a similar vintage to me might look back with fondness to the days when every patient had the same flu vaccine. However, for the past few years, the type of vaccine offered differs depending on the patient. This is to do with a phenomenon known as immunosenescence, in which the number and effectiveness of B and T cells reduces with age, while levels of pro-inflammatory cytokines increase.5 For this reason, all those aged 65 years and over are offered an adjuvanted flu vaccine, as it is more effective for this age group than the standard vaccine, which does not contain an adjuvant.1,4

Table 1 shows the first choice of vaccine for each group of patients who are eligible for the flu vaccination.1

Table 1: Summary of flu vaccines for each eligibility group1
Eligibility groupType of vaccine

At-risk children aged from 6 months to less than 2 years

QIVe

Children aged 2–17 years

LAIV

Children aged 2–17 years who cannot have the live vaccine (if LAIV is contraindicated or otherwise unsuitable)

QIVc

Adults aged 18–64 years (including pregnant women and those at risk)

QIVc or QIVr

(or QIVe if QIVc or QIVr are not available)

Adults aged ≥65 years

aQIV

(or QIVc or QIVr if aQIV is not available)

There is another adjuvanted vaccine on the market (QIV-HD) but it is not available in the UK

QIVe=quadrivalent influenza vaccine, egg-grown; LAIV=live attenuated influenza vaccine; QIVc=quadrivalent influenza vaccine, cell grown; QIVr=recombinant quadrivalent influenza vaccine; aQIV=adjuvanted quadrivalent influenza vaccine; QIV-HD=high-dose quadrivalent influenza vaccine

Contains public sector information licensed under the Open Government Licence v3.0.

The live attenuated flu vaccine

The live attenuated influenza vaccine (LAIV) is a live vaccination and therefore cannot be given to children who are immunocompromised as a result of disease or medication.1,4 Conditions which are a contraindication to use of LAIV are listed in Box 2.4–8

Box 2: Contraindications to and precautions for the use of the LAIV

Contraindications to the use of LAIV:4–8

  • leukaemia or lymphoma
  • untreated HIV
  • cellular immune deficiency
  • high-dose corticosteroids (>2 mg/kg/day for 1 week or >1 mg/kg/day for 1 month)
  • anyone taking systemic salicylates
  • adolescents who are pregnant or breastfeeding.

Precautions for the use of LAIV:4–8

  • children and adolescents with severe asthma or active wheezing, or asthma that has required ITU admission in the past
  • children and adolescents with unrepaired craniofacial abnormalities.

Conditions that are not a contraindication to the use of LAIV:4–8

  • HIV treated with antiretrovirals
  • those treated with corticosteroids that are only topical or inhaled
  • those treated with low-dose oral corticosteroids
  • those in which corticosteroids are used as replacement therapy—for example, for adrenal insufficiency.

LAIV=live attenuated influenza vaccine; HIV=human immunodeficiency virus; ITU=intensive care unit

Concerns about transmission of the vaccine virus

Parents have been known to enquire about whether a child who has the LAIV can ‘shed’ the live vaccine, and whether this would be dangerous if they have a household contact who is immunocompromised. It is possible that such queries may become more common this year, because there is more awareness about the group of household contacts of immunocompromised people, as they are now entitled to a flu vaccine based solely on their contact status.1

Public Health England (PHE) says that the risk is largely theoretical and that there have been no reported cases of illness or infection from household contacts of children vaccinated with LAIV.9 It advises: ‘Where close contact with very severely immunosuppressed contacts (for example, household members) is likely or unavoidable, however, consideration should be given to using an appropriate inactivated flu vaccine instead.’9 The PHE guidance does not define ‘very severely immunosuppressed’, but a patient group direction for LAIV gives an example of someone who is isolating after a bone marrow transplant.9,10 The majority of families can be reassured that it is safe for their child to have the LAIV.

Offer information tailored to cultural and social needs

In recent years, there has been some publicity about religious groups pointing out that porcine gelatine is used in the manufacturing process of the LAIV. The gelatine degrades and is not present in the vaccine itself, but some individuals in Muslim and Jewish faith groups have expressed unhappiness at the use of this vaccine in their children. If this concern is expressed to you, there are various resources available that give opinions from Muslim and Jewish scholars that using this vaccine does not break religious law.11–14 If a parent is still unwilling to allow their child to have the LAIV, but would accept an injectable vaccine, then one should be offered.1 For the first time this year, this is the case from the very start of the flu season, both for children in an at-risk group and those being offered the vaccine on the basis of their age alone.1

Flu vaccines and egg allergy

Another query that is frequently brought to GPs’ attention is the question of egg allergy; it is a common urban myth that anyone with an egg allergy should not have a flu vaccination. This is not entirely correct—it is only an issue for those adults or children who have an egg allergy that has previously required admission to intensive care. Influenza: the green book, chapter 19 advises that children in this situation should have their LAIV vaccination in hospital, and adults should be referred to a specialist for assessment with regard to receiving immunisation in hospital.4

Children with a lesser degree of egg allergy can be safely vaccinated with LAIV in any setting. Adults with an egg allergy, and children who also have another condition which contraindicates LAIV, should be vaccinated with an inactivated flu vaccine that has a very low ovalbumin content of less than 0.12µg/ml.4 The ovalbumin content can be checked on the PHE website; this year, many of the commonly used brands are either egg free, or fit into the low ovalbumin content category.15

Coordinating the COVID-19 vaccination programme alongside flu vaccinations

Finally, we need to consider how the flu vaccination programme will fit in with COVID-19 booster vaccinations. There are two groups that are eligible for a third COVID-19 vaccine this winter.

Third primary dose for individuals with severe immunosuppression

A group of patients who are severely immunocompromised aged 12 years and over are being offered a third primary dose of a COVID-19 vaccine, due to concerns that they may not have mounted a strong immune response to the first two doses.16,17 It is preferred that those in this group who are aged 18 years or over are given an mRNA vaccine (Pfizer–BioNTech or Moderna), even if they had the AstraZeneca–Oxford University vaccine for their first two doses; the Pfizer–BioNTech vaccine is preferred for those aged 12–17 years.16 The AstraZeneca–Oxford University vaccine should only be given as the third dose to patients for whom it was the primary course, and when it is necessary to facilitate delivery that would otherwise be difficult.16 This may be relevant for some individuals in nursing homes or those who are housebound.

Decisions on eligibility for a third dose, and the timing of it, should be made by the patient’s specialist,16 so any queries received in primary care should be directed towards secondary care. General principles include the fact that the third dose should ideally be given at least 8 weeks after the second dose, and delayed, if possible, for a period of 2 weeks after a period of immunosuppression, such as after chemotherapy, in addition to the time required for clearance of the therapeutic agent.16  If this is not possible, consideration should be given to vaccination during a treatment holiday or when immunosuppression is lowest, such as between doses of treatment.16  

Delivering booster vaccinations

The second group eligible for another dose of COVID-19 vaccine is those who were in priority groups 1–9 for the primary course; they should all be offered a booster vaccination at least 6 months after receiving their second dose of a COVID-19 vaccine. This includes:18

  • those living in residential care homes
  • all adults aged 50 years or over
  • front-line health or social care workers
  • all those aged 16–49 years with underlying health conditions that put them at higher risk of severe COVID-19 (this broadly corresponds to those who have always been offered a flu vaccination), and adult carers
  • adult household contacts of immunosuppressed individuals.

The preference is for this group to receive the Pfizer–BioNTech vaccine, regardless of which brand was given for the primary course. Data suggest that it should be well tolerated and provide a strong booster response.18 If this is not possible, then a half dose of the Moderna vaccine can be offered, with the AstraZeneca–Oxford University vaccine being given only to those who cannot have an mRNA vaccine due to allergies or other contraindications.18

Helpfully, the COVID-19 and flu vaccines can be given on the same day.18 Whether this actually happens will depend on how things work in each individual area; in some areas, COVID-19 vaccination is happening at GP surgeries, but in many places the logistics mean that COVID-19 vaccinations are mainly at larger centres which may not be able to co-administer the flu vaccine.

As well as third doses and boosters, vaccine centres continue to give first and second doses to adults who may have initially been vaccine hesitant and are now changing their minds, as well as a first dose to all 16- and 17-year-olds. Recently, it has also been announced that all 12–15-year-olds will be offered one dose of the COVID-19 vaccine, although these will primarily be given in school.19

This is unlikely to be the end of the story as the Joint Committee on Vaccination and Immunisation is still reviewing emerging data—we probably have more to learn about immunity to COVID-19 for different population groups, so watch this space as time goes on.

Summary

The flu vaccine is being offered to all adults who are 50 years or over, as well as the usual groups who are offered it due to their occupation or comorbidities. Most children of school age will receive the nasal flu vaccine in school but a small number will need the injection if they have a contraindication to live vaccines. Egg allergy is not a contraindication for the flu vaccination and it is very rare for a patient to need vaccination in hospital due to an egg allergy. The primary COVID-19 vaccination programme is continuing, along with boosters for eligibility groups 1–9, and a third primary dose for those who are significantly immunosuppressed.

Dr Toni Hazell

Portfolio GP, Tottenham, London

Key points

  • Groups eligible for flu vaccination in 2021–2022 include: 
    • all adults aged ≥50 years
    • all children aged 2–15 years on 31 August 2021
    • pregnant women, and individuals in clinical risk groups
    • front-line health and social care staff
    • contacts of immunocompromised individuals, those in residential care homes, and carers 
  • Those aged 65 years and over are offered an adjuvanted flu vaccine, as it is more effective for this age group than the standard vaccine
  • Most children will receive the LAIV, but injectable vaccine can be offered if live vaccines are contraindicated, or if parents object to LAIV because of its porcine gelatine content
  • The LAIV is contraindicated in children who are immunocompromised as a result of disease or medication
  • Egg allergy is not a contraindication for the flu vaccination, and only those who have required admission to intensive care due to egg allergy will need vaccination in hospital or specialist assessment
  • A third primary dose of COVID-19 vaccination is being offered to individuals aged ≥12 years with severe immunosuppression
  • Booster vaccinations for COVID-19 are being offered to those who were in priority groups 1–9 for the primary course, and should be given at least 6 months after the second dose
  • The COVID-19 and flu vaccines can be co-administered on the same day, depending on operational constraints.

LAIV=live attenuated influenza vaccine

Implementation actions for STPs and ICSs

written by Dr David Jenner, GP, Cullompton, Devon

The following implementation actions are designed to support STPs and ICSs with the challenges involved with implementing new guidance at a system level. Our aim is to help you consider how to deliver improvements to healthcare within the available resources.

  • Publish and disseminate clear guidance on the indications and contraindications of each flu vaccine in a simple, ‘one glance’ form
  • Consider establishing a COVID-19 and flu vaccination phone or e-helpline to respond to the inevitable queries about this complex programme
  • Provide patient information leaflets to those of Muslim or Jewish faith to address potential vaccine hesitancy, and share these proactively with local community leaders
  • Explore the potential for co-administration of COVID-19 and flu vaccines in local vaccination centres
  • Ensure that local secondary care specialists have systems in place to:
    • identify those with reduced immunity who require a third primary COVID-19 vaccination
    • deliver vaccination to those who require their COVID-19 or flu vaccine to be administered in hospital.

STP=sustainability and transformation partnership; ICS=integrated care system

References

  1. Public Health England, Department of Health and Social Care. The national influenza immunisation programme 2021 to 2022. London; PHE, DHSC, 2021. Available at: www.gov.uk/government/publications/national-flu-immunisation-programme-plan/national-flu-immunisation-programme-2021-to-2022-letter  
  2. BBC News website. Flu jab delay: doctors call for MPs to take action. www.bbc.co.uk/news/health-58446539 (accessed 6 October 2021).
  3. GOV.UK website. Free flu vaccinations rolled out to over 50s from December. www.gov.uk/government/news/free-flu-vaccinations-rolled-out-to-over-50s-from-december (accessed 6 October 2021).
  4. Public Health England. Influenza: the green book, chapter 19. PHE, 2020. Available at: assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/931139/Green_book_chapter_19_influenza_V7_OCT_2020.pdf
  5. McElhaney J, Verschoor C, Andrew M et al. The immune response to influenza in older humans: beyond immune senescence. Immun Ageing 2020; 17 (10).
  6. AstraZeneca UK Limited. Fluenz Tetra nasal spray suspension Influenza vaccine (live attenuated, nasal). www.medicines.org.uk/emc/ (accessed 6 October 2021).
  7. Public Health England. Contraindications and special considerations: the green book, chapter 6. PHE, 2017. Available at: assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/655225/Greenbook_chapter_6.pdf
  8. Royal College of General Practitioners website. Influenza: management and vaccination 2021/2022. elearning.rcgp.org.uk/course/view.php?id=498 (accessed 6 October 2021).
  9. Public Health England. The National childhood flu immunisation programme 2018/2019. Information for healthcare practitioners. London; PHE, 2018. Available at: www.england.nhs.uk/wp-content/uploads/sites/6/2018/10/childhood-flu-programme-information-for-healthcare-practitioners-2018-19.pdf  
  10. Public Health England. Live attenuated influenza vaccine nasal spray suspension (LAIV). Patient group direction (PGD). PHE, 2021. Available at: www.england.nhs.uk/north-east-yorkshire/wp-content/uploads/sites/49/2021/08/Fluenz-Tetra.pdf   
  11. Public Health England. Vaccines and porcine gelatine. London; PHE, 2020. Available at: assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/933552/Vaccines_porcine_gelatine_2020_A4.pdf
  12. Oxford Vaccine Group. Vaccine Knowledge Project website. Gelatine in vaccines. vk.ovg.ox.ac.uk/vk/gelatine (accessed 6 October 2021).
  13. The Jewish Chronicle website. Fluenz flu vaccine containing pork product is kosher. www.thejc.com/news/uk/fluenz-flu-vaccine-containing-pork-product-is-kosher-1.49557 (accessed 6 October 2021).
  14. Karimia Institute. Fatwa on flu vaccine containing porcine gelatine. Karimia Institute; Nottingham. Available at: biltonmedicalcentre.co.uk/website/B83660/files/Fatwa%20on%20flu%20vaccine.pdf  
  15. Public Health England website. Influenza vaccines: 2021 to 2022 flu season. www.gov.uk/government/publications/influenza-vaccine-ovalbumin-content/influenza-vaccines-2020-to-2021-flu-season (accessed 6 October 2021).
  16. NHS. Updated JCVI guidance for vaccinating immunosuppressed individuals with a third primary dose. London; NHS, 2021. Available at: www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2021/09/C1399-Updated-JCVI-guidance-for-vaccinating-immunosuppressed-individuals-with-third-primary-dose.pdf
  17. GOV.UK website. Joint Committee on Vaccination and Immunisation (JCVI) advice on third primary dose vaccination. www.gov.uk/government/publications/third-primary-covid-19-vaccine-dose-for-people-who-are-immunosuppressed-jcvi-advice/joint-committee-on-vaccination-and-immunisation-jcvi-advice-on-third-primary-dose-vaccination (accessed 6 October 2021).
  18. Public Health England website. JCVI issues updated advice on COVID-19 booster vaccination. www.gov.uk/government/news/jcvi-issues-updated-advice-on-covid-19-booster-vaccination (accessed 6 October 2021).
  19. GOV.UK website. Young people aged 12 to 15 to be offered a COVID-19 vaccine. www.gov.uk/government/news/young-people-aged-12-to-15-to-be-offered-a-covid-19-vaccine (accessed 6 October 2021).

Credit:

Lead image: Pormezz/stock.adobe.com