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1 WORCESTERSHIRE 2011/12 FLU PLAN DR ASHIS BANERJEE, PUBLIC HEALTH DEPARTMENT NHS WORCESTERSHIRE, AUGUST 2011

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3 Table of Contents 1. Objectives Background Seasonal Flu vaccine eligibility Performance and targets Delivery of flu immunisations Submission of surveillance data Other vaccine issues Antivirals Roles and responsibilities Action Plan Appendix 1: SF immunisation uptake in patients Appendix 2: SF immunisation uptake in HCWs Appendix 3: GP flu vaccine stock assurance exercise, June Appendix 4: Groups eligible for SF vaccine... 19

4 1. Objectives 1.1. The strategic objectives of the 2011/12 Worcestershire flu plan are: Vaccinating at least 75% of eligible patients with the seasonal flu vaccine before the virus starts to circulate Improving and maximizing seasonal flu uptake in NHS Health Care Workers (HCWs) that have direct patient contact Offering antiviral medicines to patients in at-risk groups for the treatment of flu in line with National Institute for Health and Clinical Excellence (NICE) guidance 1.2. There may be increased demand for services and increased levels of staff absenteeism due to flu and other illnesses during the winter period. Planning to ensure that the NHS is well prepared for these circumstances is undertaken by the Worcestershire Capacity Management Group. These business continuity arrangements are outside the scope of this report. 2. Background 2.1. Flu is characterised by cough, rhinorhhea, fever, chills, headache and muscle aches. Complications include bronchitis or pneumonia. Those at risk of more severe illness include the elderly, pregnant women, diabetics, immunocompromised patients and those with underlying lung, heart, kidney, liver, or neurological disease The flu virus is highly contagious and is easily passed from person-to-person when an infected person coughs or sneezes. Transmission can also occur by touching contaminated surfaces The Seasonal Flu (SF) vaccine provides protection against three strains of flu including the swine flu variant that led to the global pandemic in The flu virus is constantly changing and therefore patients at continuing risk need to have the vaccine every winter Flu epidemics typically occur each winter sometime between November and March, lasting about 6 to 10 weeks and peaking at around the fourth week of the outbreak. The flu vaccine can take up to 2 weeks to work. It is important therefore for patients to get vaccinated as early as possible The flu vaccine can prevent flu. In the elderly, it is less effective in prevention but can reduce the risk of complications and death In HCWs, the vaccine protects staff and their families as well as the vulnerable patients they care for Most flu patients will make a speedy recovery and will only need analgesia, adequate hydration and rest at home. 3

5 2.8. Antivirals (AVs) can be used to treat or prevent flu. They are only used once flu is circulating in the community and only in those at increased risk of complications of the disease. The Department of Health (DH) will inform NHS Worcestershire (NHSW) if and when circulating flu levels mean that AVs are indicated. Antiviral treatment can reduce the length of illness and reduce the risk of complications. 3. Seasonal Flu vaccine eligibility 3.1. The following groups are eligible for the SF vaccine: people aged 65 years and over; all those aged 6 months or over in a clinical risk group (Appendix 4); pregnant women; people living in long-stay residential care homes or other long-stay care facilities where there is a risk of high morbidity and mortality; household contacts of immunocompromised patients based on a risk assessment by the GP; those who are in receipt of a carer s allowance, or the main carer, or the carer of an elderly or disabled person whose welfare may be at risk if the carer falls ill; frontline health and social care workers. 4. Performance and targets 4.1. DH has set the following targets for flu immunisation in 2011/12: % uptake in those aged 65 and over; % uptake for eligible patients aged less than 65. DH states that a reasonable trajectory would be 60% uptake in 2011/12, 70% in 2012/13 and 75% in 2013/ These are challenging targets given uptake in 2010/11 in Worcestershire was 73.3% for the elderly and 52.2% for those aged less than There is no explicit target for HCW uptake but the CMO letter of March 2011 states that every employer should have plans to significantly improve uptake 4.4. A full analysis of flu uptake results is presented in Appendices 1 and 2. 4

6 5. Delivery of flu immunisations 5.1. GP Practice arrangements The patient flu immunisation programme is delivered exclusively through GP practices. All GP practices in Worcestershire have offered flu immunisations in previous years and all practices are expected to offer the service again in 2011/ Flu immunisation is a Directly Enhanced Service (DES) for GP practices. As part of the DES, practices need to identify eligible patients, have a robust call and reminder system, administer flu vaccinations, record details of vaccines administered and provide NHSW with data for performance management purposes. It is an outcome based DES and practices are paid 7.64 per dose of seasonal flu vaccine administered. Each practice is responsible for offering the vaccine to all its eligible patients with no exemptions for housebound patients GP practices generally receive delivery of vaccines from the end of September. Practices use a variety of methods to alert patients that they will need flu immunisation. The DES specifies the need for a robust call and reminder system but does not provide explicit minimum requirements such as all patients having to receive a letter or phone call. Call and reminder systems used by practices include letters, phoning patients or providing reminders at the bottom of repeat prescriptions. Most immunisation activity is concentrated from the beginning of October to the middle of November. Practices may organise special drop-in flu clinics including Saturday sessions Practices are also responsible for procurement of flu vaccine. Practices should order sufficient vaccines from manufacturers to meet national flu immunisation targets and are to offer flu vaccination to their own practice staff. Practices are able to reclaim the cost of vaccines administered to their registered patients by claiming this through the Prescription Pricing Division (PPD) with the cost met by NHSW. The PPD reimbursement to practices is higher than the money that practices pay manufacturers to buy the vaccine Following vaccine supply problems in 2010/11, West Midlands SHA has asked NHSW to seek assurance that practices have ordered sufficient vaccines to meet the DH targets. Practices may be wary of over-ordering vaccines as they are only paid through the PPD for vaccines administered although some manufacturers may allow some unused stock to be returned. The results of a stock assurance exercise are shown is in Appendix 3. Further assurance will be sought from practices following a poor response rate from the initial survey Housebound patients GP practices need to offer flu immunisations to housebound patients under the DES requirements. In the 2010/11 flu season, there was an agreement that District Nurses would provide flu immunisations to housebound patients if the patient was already on their caseload. The DES payment in these cases went to the former Worcestershire 5

7 PCT Provider Services rather than to GP practices. Arrangements for 2011/12 need clarification Patients not registered to GP practices Patients not registered to a GP practice can still get the flu vaccine if they are in an atrisk group. They could register with a practice as a temporary or permanent patient. Alternatively they could get the flu vaccine through the Worcester Walk-In Health Centre without registering Pregnant women Pregnant women can be a particularly difficult group to target. They have only recently become eligible to have the vaccine and unlike most other eligible patients, most will not have been offered the flu vaccine previously. It is important therefore to explain the rationale of the vaccine to pregnant women and make access to immunisation services as easy as possible In addition, GP practices have some difficulty in identifying pregnant women from their registered patients due to technical issues Public Health has therefore been working with Maternity Services from Worcestershire Acute Hospitals NHS Trust (WAHT) and the plan is to inform pregnant women of the importance of flu immunisation at antenatal midwifery sessions through a NHSW leaflet for pregnant women. In addition, work is underway to see if Maternity Services can provide practices with lists of pregnant women to facilitate identification of eligible patients Staff NHS Employers have a responsibility to offer flu immunisation to all HCWs that have direct patient contact. In Worcestershire, all NHS occupational flu immunisations are offered by Worcestershire Occupational Health (OH) & Well-being service which is part of WAHT. In reality OH generally offers flu immunisation to all staff rather than just those with direct patient contact Each health-care provider has a contract with WAHT for provision of flu immunisations to NHS staff. For GP practice staff, the contract is between the NHSW and WAHT on behalf of all the practices. This also includes provision of flu immunisations to community pharmacy staff that contract with NHSW HCWs with direct patient contact that work for private organisations (eg: nurses in a nursing home) should be offered the flu vaccine but the responsibility for provision lies with the employer and not the NHS. Non-NHS HCWs cannot get the flu vaccine from their GP practice unless they also have a non-occupational indication. 6

8 The Worcestershire Occupational Health & Well-being service generally offers a series of drop-in clinics to NHS staff at WAHT locations as well as some work place based sessions. Each provider needs to negotiate and specify the level of service expected from OH services Public media campaign DH has stated that there will be no national mass media campaign for flu vaccination due to a lack of evidence of effectiveness. There will however be a hygiene campaign once flu is circulating which will aim to promote good respiratory hygiene and therefore reduce acquisition and transmission of the virus It is not clear what if any media material will be made available to NHSW. DH generally produces a patient leaflet that can be downloaded from their website. Leaflets and posters are not routinely provided to NHSW or GP practices. Some practices use advertising material provided by vaccine manufacturers The advice from the NHSW communications team is that mass advertising is unlikely to be cost-effective but it would be worthwhile to undertake radio interviews and distribute press releases during the campaign. 6. Submission of surveillance data 6.1. GP practices submit data on flu immunisation uptake in patients on a monthly basis via the DH IMMFORM website based on the schedule below. A minority of practices in Worcestershire have an automated real time upload of data from their practice systems onto IMMFORM. Other practices need to input the data manually. Table 1: Schedule for GP practice submission of patient flu immunisation surveillance data Period covered Data collected (exact deadlines for submission are still awaited from DH) All immunisation administered up to end October 2011 Nov 2011 All immunisation administered up to end November 2011 Dec 2011 All immunisation administered up to end December 2011 Jan 2012 All immunisation administered up to end January 2012 Feb

9 6.2. Each NHS Trust needs to provide HCW uptake data to DH via the IMMFORM website. It is the responsibility of each NHS Trust to collate and submit uptake data to DH. NHSW has a responsibility for ensuring timely and complete submissions by working with the SHA in performance managing this aspect of the programme GP practices that immunise their own practice staff can provide NHSW with details of immunisations administered via a GP data entry tool on IMMFORM. NHSW will collate details of GP practice staff that have had the flu vaccine. Information will be collected from OH and from GP practices (eg: via the GP reporting tool on IMMFORM). NHSW will submit the collated GP practice uptake data onto IMMFORM. 7. Other vaccine issues 7.1. There are a number of flu vaccines available to GP practices. Intanza is a flu vaccine that is administered intradermally whereas all other flu vaccines are given intramuscularly. Intanza is more expensive than other flu vaccines but there is no convincing evidence that it is more effective or more suitable for any patient groups. Intanza is not approved by the Area Prescribing Committee (APC) for use in Worcestershire. NHSW wrote to practices in September 2010 discouraging use of Intanza and stating that its use would not be supported by the 2011/12 SF DES Preflucel is a new egg-free SF vaccine. It is the first time that an egg free SF vaccine has been available which means that those that have severe egg allergies can now be immunised with the vaccine. GP practices will need to be given guidance on the use of Preflucel NHSW has ordered 2000 doses of SF vaccine at approximately 8000 cost which were earmarked for Maternity Services but are not now required. Work will need to be done on deciding on the best way of discarding of these vaccines eg: cancel the order if possible, sell and transfer to an immunisation provider or hold some stock as a local contingency measure. 8

10 8. Antivirals 8.1. Once flu levels in the community reach a critical threshold, DH will inform all PCTs in the country that AVs can now be prescribed for prevention and treatment of flu in patients at increased risk of serious complications if they acquire the disease Patients generally need to start AV treatment within 36 to 48 hours of onset of flu symptoms for them to be effective Once NHSW is informed that AV prescribing has been triggered, it will inform all community pharmacies and dispensing doctor practices via fax on the same working day. The communication will ask them to assure themselves that they are able to order AVs from their wholesalers in a timely manner and to inform NHSW of any concerns Community pharmacies and dispensing doctor practices generally have two deliveries per day. Unless AV demand is high, most will not have AVs in stock. Patients presenting with prescriptions for AVs will therefore typically have to wait until the next scheduled delivery for their drug. Practices will be advised to inform patients that they should contact pharmacies by telephone to avoid unnecessary extra journeys to get the AVs GP practices will be asked to inform NHSW if patients are having difficulty in acquiring AVs in a timely manner DH has a national reserve of AVs that can be sent to wholesalers if there are problems with supply of the drug. 9

11 9. Roles and responsibilities Organization NHSW Public Health Department NHSW Primary Care Department WAHT Worcestershire Health and Care NHS Trust Roles and responsibilities Co-ordinate the 2011/12 patient flu immunisation campaign Oversight of the NHS OH flu immunisation campaign. NHSW has a role in assuring itself that all commissioned providers of healthcare have robust arrangements for provision of flu immunisation to staff. Provision of information to GP practices and NHS OH services before and during the campaign To clarify NHSW policies to professionals, patients, NHS organizations and the general public. To work with NHS Trusts and GP practices to ensure that accurate and comprehensive surveillance data is submitted in a timely manner. This may for example be through providing clarification on data requirements and through following up GP practices who have failed to meet submission deadlines. To facilitate communications messages to patients and NHS staff in order to maximize uptake eg: myth busting, provision of briefing sheets etc. To reduce the risk of vaccine shortages through assurance that adequate vaccine stocks have been ordered. To minimize the effects of any vaccine shortages eg: through facilitating sharing of vaccines between practices or requesting access to the national reserve stocks To ensure that robust arrangements are in place to increase and maximize uptake of flu immunisations by GP practice staff To ensure that robust arrangements are in place to increase and maximize uptake of flu immunisations by all NHS staff in Worcestershire To submit uptake data for WAHT staff to DH as per DH requirements To inform NHSW as early as possible of any vaccine issues such as likely shortages or clinical incidents/errors To ensure that robust arrangements are in place to increase and maximize uptake of flu immunisations by practice staff To submit uptake data to DH as per DH requirements (WHCT) GP Practices Pharmacies / Dispensing Pharmacies To provide a flu immunisation service to registered patients as per DES requirements To submit patient flu vaccine uptake data to DH via IMMFORM as per DH requirements To submit details of all practice staff immunised by the GP practice to NHSW preferably via the GP reporting tool on IMMFORM To inform NHSW as early as possible of any vaccine issues such as likely shortages or clinical incidents/errors To ensure timely availability of AVs once NHSW alerts pharmacies that AVs are indicated 10

12 10. Action Plan Action Date Who 1. Draft LES/DES including groups not covered by DES Complete SB 2. PGD to be prepared Complete SL 3. NHSW to seek further assurance that GP practices have ordered sufficient flu vaccines 4. Provision of a briefing sheet to maternity services that can be handed out to pregnant women at antenatal clinics giving details of why flu vaccination is important and where women can get the vaccine 5. Write to all NHS employers reminding them of their responsabilities and guidance on best practice in provision of occupational flu immunisations Sept 2011 Aug 2011 August 2011 AB AB/PP 6. Consider arrangements for practices to immunise their own staff August 2011 AB/JL 7. Clarify role of District Nurses in imunising housebound patients August 2011 WHCT 8. Clarify contractual arrangements for GP practices immunising their own August 2011 JL staff 9. Discuss arrangemnents for residents not registeed with GPs with the Worcester Walk-in Centre 10. Consider options for 2000 SF vaccines ordered by NHSW which are now surplus to requirement 11. Letter to all GPs including clarity on responsabilities: a. Housebound patients b. Those in long term care c. Robust call and reminder systems d. Intanza / Preflucel e. Carers f. Responsability on submission of surveillance data 12. Provision of lists of pregnant women to GP practices to aid practices in inviting pregant women for flu immunisation August 2011 August 2011 Sept 2011 Sept Develop media plan September Check with OH that surveillance systems are in place (eg: eligible vs offered) 15. Write to all care homes encouraging them to arrange flu immunisation for staff September 2011 Sept GP practices to provide flu immunisations for registered patients Oct 2011 Feb OH to provide flu immunisations to NHS staff Oct 2011 Feb 2012 AB AB SB AB AB/PP AB/TG AB AB/JM GP pracs OH 18. Cascade of DH guidance to practices and OH as required. Responding to queries from professionals. Briefings and promotion of the flu camapign including myth busting. Ongoing till Feb Submission of surveillance data to DH Oct 2011 Feb 2012 AB Providers AB Ash Banerjee SB Sue Bosworth SL Sue Lunec PP Patti Paine JL Jonathan Leach TG Tom Grove JM Jonathan Monks 11

13 Flu immunisation uptake in eligible patients aged < 65 Flu immunisation uptake in the elderly Appendix 1: Seasonal Flu immunisation uptake in patients Figure 1: Seasonal Flu immunisation uptake: Worcestershire and England: 2000/01 to 2010/11 75% WHO target for elderly 70% Worcestershire England WM 65% Year Figure 2: Seasonal Flu immunisation uptake: Worcestershire and England: 2000/01 to 2010/11 80% 75% 70% 65% 60% DH 2012/13 target DH 2012/13 target DH 2011/12 target 55% 50% 45% 40% Worcestershire England WM 35% 30% 25% 2006/7 2007/8 2008/9 2009/ /11 Year 12

14 1.1 Uptake in the elderly peaked locally and nationally in 2005/06 when coverage was 75.6% in Worcestershire and 75.3% in England. The DH target for flu immunisation in the elderly is 75%. This was achieved in Worcestershire only in 2005/06 and 2006/ Coverage in Worcestershire has generally been slighter higher than the national coverage and moderately higher than the regional results. In 2010/11, the uptake in the elderly was 73.3% which was slightly higher than the uptake in the previous year and higher than the regional and national results. 1.3 Uptake in younger groups has increased steadily rising from 30.1% in 2006/07 to 52.6% in 2009/10.Uptake in Worcestershire has generally been very similar to the national and regional results In 2010/11 the uptake fell for the first time from 52.6% to 52.0%. This trend was also seen in regional and national results although the fall in coverage was less pronounced in the Worcestershire results. Table 2: Seasonal Flu uptake by locality: Worcestershire, 2010/11 Locality Elderly (aged 65+) Aged < 65 n % n % R&B % % WF % % SW % % ALL % % 1.4 Seasonal flu uptake was consistently highest in Wyre Forest, intermediate in South Worcestershire and lowest in Redditch & Bromsgrove. In Wyre Forest there was 75.1% uptake in the elderly and 55.6% uptake in eligible patients aged less than

15 Flu immunisation uptake Figure 3: Seasonal Flu immunisation uptake by GP practice: Worcestershire, 2010/11 100% 90% 80% 70% 60% Aged 65+ Aged < 65 50% 40% 30% Practices ordered from lowest to highest uptake Table 3: Seasonal Flu immunisation uptake by GP practice: Worcestershire, 2010/11 Age group Range Mean uptake in 10% practices with highest covearge Mean uptake in 10% practices with lowest covearge Difference in uptake between high and low uptake practices % to 87.5% 82.4% 64.2% 1.28 < % to 84.4% 67.5% 42.2% There is considerable variation in flu immunisation coverage between GP practices with the greatest variation being for immunisation in those under 65 years of age where uptake in high uptake practices (defined as the 10% of practices with the highest uptakes) was 67.5% compared to 42.2% in low uptake practices (defined as the 10% of practices with the lowest uptakes). 14

16 Appendix 2: Seasonal Flu immunisation uptake in Health Care Workers Table 4: Flu immunisation uptake in HCWs: Worcestershire and comparators, 2010/11 Doctors Nurses Professionals Support staff ALL frontline HCWs Provider n Uptake n Uptake n Uptake n Uptake n Uptake GP practices % % N/A N/A % % WPCT Provider % % % % % WAHT % % % % % WMHP % % % % % ALL % % % % % WM N/A N/A N/A N/A N/A N/A N/A N/A % Eng N/A N/A N/A N/A N/A N/A N/A N/A % GP + WPCT % % % % % WHCT % % % % % Figure 4: Flu immunisation uptake in HCWs: Worcestershire, 2010/11 60% 50% 40% 30% 20% 10% 0% 2009/ /11 GP pracs WPCT WAHT WMHP 2009/10 8.1% 22.5% 28.3% 28.2% 2010/ % 27.1% 51.9% 40.2% 70% 60% 50% 40% 30% 20% 10% 0% GP practices WPCT Provider WAHT WMHP Doctors Nurses Profs Support 15

17 2.1 Flu immunisation uptake in HCWs has traditionally been low. Up to 2008/09, the Department of Health only collected data on uptake in HCWs in Acute Trusts. In 2008/09, HCW uptake in England was 16.5% based on submissions from 53% of Acute Trusts in the country. There was no submission from WAHT in that year. 2.2 The 2009/10 flu season coincided with the pandemic flu period and led to more robust data collection and significantly increased uptake in HCWs compared to previous years. The uptake nationally in all HCWs across all NHS Trusts including PCTs and Mental Health Trusts was 26.4% in 2009/10 and increased further to 34.7% in 2010/ In Worcestershire, uptake was 29.4% in 2009/10 and 42.8% in 2010/11. The 2010/11 Worcestershire results were higher than both the regional and national results. 2.4 The greatest increase in 2010/11 was in GP practice staff where coverage increased from 8.1% to 40.5%. This may partly be explained by better data collection protocols being in place in 2010/11. The reported uptake in 2009/10 may have been an underestimate of the true uptake. 2.5 The uptake in WAHT increased from 28.3% to 51.9% and that in WMHP from 28.3% to 40.2%. 2.6 The least marked increase in uptake was for WPCT Provider staff where uptake increased from 22.5% to 27.1%. 2.7 Flu immunisation uptake was highest in GPs (56.3%) and lowest in PCT community nurses (19.0%). 16

18 Appendix 3: GP flu vaccine stock assurance exercise June 2011 Scenario Description No. practices Adequate stock Inadequate stock ordered No response 1 75% uptake in elderly + 50% others (at risk, carers, practice staff) % elderly + 60% others % elderly + 70% others % elderly + 75% others All GP practices in Worcestershire were asked if they had ordered adequate flu vaccines to meet a range of scenarios based on DH targets for flu immunisation in 2011/ All scenarios include 75% uptake in those aged 65 or over. DH states uptake in those aged less than 65 should be 75% but a reasonable trajectory would be 60% uptake in 2011/12, 70% in 2012/13 and 75% in 2013/14. Scenario 1 is close to current performance and scenarios 2, 3 and 4 relates to improved performance in line with DH targets. 3.3 Flu uptake in 2011/12 is unlikely to be greater than that shown in scenario 1 or out of 38 practices that responded have adequate vaccines ordered to cope with this level of demand. 3.4 There are some concerns over the following findings: No assurance was received from 30 practices. It is possible that practices least likely to respond to the survey are those who have under ordered vaccines If the vaccine is very popular uptake may reach the levels seen in scenario 3 or 4 and around a third of responding practices have inadequate stock for scenario There is some clinical flexibility in deciding which patients need a flu vaccine it is important therefore that practices follow the national guidelines closely so that only those likely to benefit from immunisation are given the vaccine and stocks are maintained 3.5 The survey also asked practices about their call and reminder systems. The results demonstrated that practices use a variety of methods to call/recall patients only 2 practices stated that they did not either write or telephone eligible patients. 3.6 Practices were asked about any support they would welcome from NHSW. The results showed practices would welcome a timely local media campaign and some also suggested financial support in contacting patients. 17

19 Table 5: Call and reminder systems for flu immunisations Call systems Yes No Other Blank Letter certain groups only eg: non-attendees of first clinic, at risk groups, those not phoned Phone call or Text only for certain groups or circumstances eg: non- attendees, pregnant women, for booking appointment time Notes tagged at risk groups only 29 Posters 38 1 None 29 Table 6: Support requested from GP practices Support requested from practices No. practices Media campaign especially to start in September and advertise GP clinics 13 PCT to fund postage for writing out to patients 6 PCT to hold local reserve of vaccines at no financial risk to practices 2 Target pregnant women eg: get midwives to immunise 2 Lobby for a national media campaign 2 Help with home visits 1 Ensure occupational system is in place for NHS staff 1 18

20 Appendix 4: Groups eligible for the Seasonal Flu vaccine 4.1 Seasonal flu vaccinations are currently offered free of charge to the following at-risk groups: people aged 65 or over; all pregnant women; chronic (long-term) respiratory disease, such as severe asthma, chronic obstructive pulmonary disease (COPD) or bronchitis; chronic heart disease, such as heart failure; chronic kidney disease at stage 3, 4 or 5; chronic liver disease; chronic neurological disease, such as Parkinson's disease or motor neurone disease; diabetes; a weakened immune system due to disease (such as HIV/AIDS) or treatment (such as cancer treatment); people living in long-stay residential care homes or other long-stay care facilities where rapid spread is likely to follow introduction of infection and cause high morbidity and mortality. This does not include, for instance, prisons, young offender institutions, or university halls of residence people who are in receipt of a carer s allowance, or those who are the main carer of an older or disabled person whose welfare may be at risk if the carer falls ill; frontline health and social care workers. 4.2 The list above is not exhaustive and decisions should be based on a practitioner s clinical judgement. 4.3 Consideration should also be given to the vaccination of household contacts of immunocompromised individuals, i.e. individuals who expect to share living accommodation on most days over the winter and therefore for whom continuing close contact is unavoidable. 19