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1 THE SCOTTISH OFF I Department of Health Dear Colleague fr<lt~i-~~;:' I u~f-~:-:-"~:, i, -=--~~=~-~~ =>... \...-. INFLUENZA IMMUNISATION: EXTENSION OF CURRENT POLICY TO INCLUDE ALL THOSE AGED 75 YEARS AND OVER This letter is to inform you that the Government has accepted a recommendation from the Joint Committee on Vaccination and Immunisation (JCVI) to extenet the risk groups recommended to be offered annual influenza imriiunisation to include all those aged 75 years and older. Recent analyses show that this is not only medically. justified but also represents good value for money in comparison with other health care interventions. The change takes effect this year. Further information on the reasons for the change are given in the attached Annex A. Most, but not all, influenza vaccine is administered in primary care (some is most appropriately given during hospital admissions, before discharge from hospital or in out-patient clinics). Uptake data suggest that a significant proportion of those over 75 years of age are already being immunised. A summary of the revised influenza immunisation policy is attached at Annex B. Please ensure all staff who m-ay be Involved - III organising and administering influenza immunisation see this. Details of vaccines available are contained in this annex. Doctors and pharmacists should liaise to determine the quantities of vaccine required and orders placed in the usual way. Orders not already placed - and supplements to orders - should be made as soon as possible to allow manufacturers to adjust the amount made available if necessary. It is not usually possible to manufacture extra quantities of influenza vaccine at short notice during the influenza season ~-'._._--,... T.,_ i-i ~rl ht)~,_ 'd,,~,~\.,\;~ i : i..,.- '\. '\ -< " '!'.;Y t hi i ~ ~~~- ~~-tt~~~' ",~ ~~~Je- _; I ~11)~ D;i,; /' Ifiiu.l./ =-~=--=----:-TI~.7-=-;:::-::-_~ -;-~":' '~_!...,--.',.,~ From the Chief Medical Officer, Chief Nursing Officer and Chief Pharmaceutical Officer Sir David Carter MD FRCS(E) Miss Anne Jarvie RGN RM BA Mr Bill Scott Bsc Msc MRPharmS St. Andrew's House Edinburgh EH1 3DG Telephone Fax August 1998 SODoHlCMO(98) 15 For action All Doctors Community Pharmacists Trust Chief Pharmacists For information Health Board General Managers CAMOIDPHs Chief Executives, NHS Trusts Medical Directors, NHS Trusts Health Board Directors of Nursing Executive Nurse Directors ofnhs. -Trusts Chief Administrative Pharmaceutical Officers Director, SCIEH CPHMs (CD&EH) Directors of Primary Care Further enquiries Dr Barbara Davis Department of Health Room 326 St Andrew's House Edinburgh EHl 3DG Tel: Fax: Supplies of leaflet from: Mrs R Vardy Department of Health PHPU 111 Room 401 Edinburgh EHI 3DG Tel

2 A MEL is being issued to the NHS. The leaflet 'What should I do about flu' is being updated. This can be obtained from the PHPU address on the front of the letter. Yours sincerely I SIR DAVID CARTER Chief Medical Officer MISS ANNE JARVIE Chief Nursing Officer MR BILL SCOTT Chief Pharmaceutical Officer

3 ANNEX AlSODoHlCMO(98)15 INFLUENZA IMMUNISATION: BACKGROUND TO CHANGE IN POLICY For some time there have been suggestions in the medical press that the UK should move to an 'age-related' influenza immunisation policy, recommending immunisation for all persons above a certain age, as do many other countries. The costs and benefits of such a policy for the UK have been unclear, however, and the most important question - whether immunising the 'fit' elderly offers any incremental benefit over and above that from the current policy of immunising the highest risk groups where there is most gain - has not been addressed. Influenza, and the effectiveness of influenza immunisation, are notoriously difficult to study: i. the incidence and severity of influenza can vary considerably from year to year, so that studies in one year cannot be extrapolated to other years - ideally studies should span a number of years; ii. the extent of the match between vaccine and circulating virus strains varies, so that the effectiveness of the vaccine may vary from year to year; 111. since influenza is largely a clinical diagnosis, and other respiratory viruses may cause similar illness, estimates of the extent of illness due to influenza are imprecise, even during the 'influenza' season; iv. serological studies over-estimate the extent of influenza illness as sub-clinical infections occur; v. the important end-points for measuring vaccine effectiveness, such as pneumonia, hospital admissions or death, are also multifactorial and therefore imprecise; estimates have to be made of the extent to which hospital admissions and excess winter mortality are attributable to influenza. Many of the studies of the effectiveness of influenza immunisation both in medical and cost/benefit terms have been performed in the USA, where the cost of vaccine and the cost and pattern of medical care differ, or in institutionalised patients who are already among those recommended for influenza vaccine in the UK. Few studies have differentiated between 'high risk' and 'lower risk' elderly and most have considered 'the elderly' in only one age-band - those aged over 65 years. More UK data have become available in recent years which confirm that the elderly without high risk conditions do have an increased morbidity due to influenza, although of a lesser order than do those with underlying medical conditions. These data have now been used in cost-effectiveness analysis. They show that immunisation of the over 75s is not only medically justified but also represents good value for money in comparison with other health care interventions. The benefits for those aged years are less clear and will be the subject of further investigation and analysis.

4 ANNEX B/SODoH/CMO(98)lS SUMMARY OF THE REVISED INFLUENZA IMMUNISATION POLICY The aim of influenza immunisation is to reduce the morbidity and mortality from influenza by immunising those most likely to develop severe or complicated illness consequent to influenza infection. Immunisation is therefore recommended for: 1. those of any age with chronic respiratory disease, including asthma chronic heart disease chronic renal disease diabetes mellitus immunosuppression due to disease or treatment 11. all aged 75 years and over 111. all in long-stay residential accommodation where influenza, once introduced, may spread rapidly. Routine influenza immunisation is not recommended for healthy children or adults under 75 years, or for particular occupational groups. The final decision as to who should be offered influenza immunisation is for the patient's medical practitioner. Influenza vaccine Influenza vaccine is prepared each year using virus strains or genetic reassortants similar to those considered most likely to be circulating in the forthcoming winter. The highly purified viruses are grown in embryonated hens' eggs, chemically inactivated and then further treated and purified. Current vaccines are trivalent containing two type A and one type B sub-types and in recent years have given a good match with subsequently circulating viruses. Two types of vaccine are available: 'split virus' vaccines contain virus components prepared by treating whole viruses with organic solvents or detergents and then centrifuging; 'surface antigen' vaccines contain highly purified haemagglutinin and neuraminidase antigens prepared from disrupted virus particles. The vaccines are equivalent in efficacy and adverse reactions.

5 Vaccines available The following manufacturers have indicated they will be supplying the UK market during the commg season: Manufacturer Name of Product Vaccine Type Wyeth Begrivac Split virus, Pasteur Merieux MSD Inactivated influenza Split virus vaccine (Split virion) BP Connaught Fluzone Split virus Solvay Influvac Surface antigen Medeva Pharma Fluvirin Surface antigen SmithKline Beecham Fluarix Split virus Orders should be placed in the usual way. Orders not already placed - and supplements to orders - should be made as soon as possible to allow manufacturers to adjust the amount made if necessary. It is not usually possible to manufacture extra quantities of influenza vaccine at short notice during the influenza season. Dose and administration of vaccine Adults and children aged 13 years and over: a single injection of 0.5ml im or deep sc Children aged 4-12 years: 0.5ml im or deep sc, repeated 4-6 weeks later if receiving influenza vaccine for the first time Children aged 6 months-3 years 0.25ml im or deep sc, repeated 4-6 weeks later if receiving influenza vaccine for the first time. The deltoid muscle is the recommended site for adults and older children. For infants and young children the preferred site is the anterolateral aspect of the thigh. Antibody levels may take up t~ days to rise. Influenza activity is not usually significant before the middle of November, and therefore the ideal time for immunisation is October/early November. Adverse reactions Influenza vaccine is usually well tolerated apart from occasional soreness at the immunisation site. In rare instances it can, however, cause: a. fever, malaise, myalgia and/or arthralgia beginning 6 to 12 hours after immunisation and lasting up to 48 hours.

6 b. Immediate reactions such as urticaria, angio-oedema, bronchospasm and anaphylaxis, most likely due to hypersensitivity to residual egg protein. Guillain-Barre syndrome has been reported very rarely after immunisation with influenza vaccine, although a causal relationship has not been established. Influenza vaccine contains inactivated virus and cannot cause influenza. Contraindications The vaccines are prepared in hens' eggs and should not be given to individuals with known anaphylactic hypersensitivity to egg products. There is no evidence that influenza vaccine prepared from inactivated virus causes damage to the fetus. However, it should not be given during pregnancy unless there is a specific indication. Organisation of immunisation Most influenza vaccine is given in general practice. Immunisation is likely to be given in a combination of special immunisation sessions during routine appointments during home visits by the doctor or district nurse by arrangement with managers of long-stay residential accommodation. Many of the risk groups, particularly in the younger age groups, remain under-immunised. Studies show that the single most important factor affecting whether an individual is immunised or not is whether the doctor or nurse recommended it. An organised immunisation programme is therefore recommended, with the following steps: 1. Compile a list of those to be recommended immunisation using any combination of the following (or other relevant practice systems): chronic disease management registers regular prescriptions for key drugs age breakdown of records to select those 75 years or over during routine contacts during the year. It is helpful if patient records are also marked in some way. 2. Order vaccine. 3. Arrange and advertise immunisation sessions, providing information on who is recommended for influenza vaccine. Liaise with community nursing colleagues to ensure any immunisation sessions are planned well in advance.

7 4. For those who are able to come to the surgery send a written or telephone invitation to an immunisation session with instructions for making alternative arrangements if the first offer is inconvenient. 5. Make arrangements with practice staff for immunisation of those who are homebound and receiving visits. 6. Make arrangements with managers of long-stay accommodation for immunisation of residents. 7. Send for extra leaflets/posters if needed (available from Scottish Office Department of Health, Room 401, St Andrew's House, Edinburgh, EHI 3DG, Tel: ). Local teams should be encouraged to adopt protocols covering also issues such as consent and record keeping - accurate records should be kept in medical notes or the notes of a residential/nursing home. References and further reading 1. UK Health Departments. Immunisation against Infectious Disease. London: HMSO, Ashley J, Smith T, Dunnell K. Deaths in Great Britain associated with the influenza epidemic of 1989/90. Pop Trends 1991: 65: Ahmed AH, Nicholson KG, Nguyen-Van-Tam JS. Reduction in mortality associated with influenza vaccine during epidemic. Lancet 1995; 346: Fleming DM, Watson JM, Nicholas S, Smith GE, Swan AV. Study of the effectiveness of influenza vaccination in the elderly in the epidemic of using a general practice database. Epidemiol Infect 1995; 115: Nicholson KG. Immunisation against influenza among people aged over 65 living at home in Leicestershire during winter BMJ 1993; 306: Warren SS, Nguyen-Van-Tam JS, Pearson JCG, Modeley RJ. Practices and policies for influenza immunisation in old people's homes in Nottingham (UK) during season: potential for improvement. J Pub Health Med 1996; 17: Connolly AM, Salmon RL, Lervy B, Williams DR. What are the complications of influenza and can they be prevented? Experience from the 1989 epidemic of H3N2 influenza A in general practice. BMJ 1993; 306: Ahined AH, Nicholson KG, Nguyen-Van-Tam JS, Pearson JC. Effectiveness of influenza vaccine in reducing hospital admissions during the epidemic. Epidemiol Infect 1997; 118: