CCG Governing Board Meeting

CCG Governing Board Meeting Date of Meeting: 20 th July 2012 Agenda Item: Subject: Reporting Officer: Paper 19 (viii) Seasonal influenza immunisation programme report September 2011- March 2012 Christine Khiroya, Lead Nurse Health Protection/ Immunisation and Vaccination. Purpose of the Paper: To Inform the committee of the work undertaken by NHS HMR to plan and deliver the 2011/12 Seasonal Influenza Immunisation Campaign and the outcomes achieved. Governance: Link to PCT Strategic Objectives Improving health and well being. Health Protection All age all cause mortality Resolution: To approve To support Recommendation The committee to be aware of the issues and challenges covered within this report Key implications for the following: Financial Key Financial Implications: Has this paper been approved by the Finance Department? If YES: Name and Job Title of member of the Finance Department If NO what process has been agreed for financial sign off? Page 1 of 10 State budget here Yes / No / N/A

Value for Money Risk Legal Workforce Seasonal influenza vaccination is a safe and cost effective way of protecting at risk populations from Influenza and related secondary complications such as bronchitis and pneumonia which also cause excess demand on health services during the winter period. Reduced incidence of hospitalisations and costs associated. Failure to meet the DH national targets attributed to this programme result in failure to protect our vulnerable populations leading to increased morbidity and mortality in the target groups and increased pressure on primary and secondary care. The planning and delivery for the flu programme relies on cooperation and participation from commissioning staff who lead the programme and provider staff in primary and secondary care to promote and deliver an effective programme. Equality Impact Assessment: Included in Paper yes no n/a Comments Patient and Public Involvement Clinical Engagement Parties/ Committees consulted It is planned to involve patients reps in flu planning for 2012/13 National DES, local LES, LMC support Jane Rossini, Director of Public Health, Bernadine O Sullivan, Consultant in Public Health Influenza Group Page 2 of 10

Annual seasonal influenza vaccination programme 1. Introduction The paper informs the CCG of the 2011/12 seasonal influenza vaccination campaign including: A breakdown on the target groups Practice performance Recommendations for the forthcoming seasonal influenza immunisation programme and the associated challenges. The aim of the influenza vaccination campaign is to reduce morbidity and mortality from influenza. The peak GP influenza-like illness consultation rates were the lowest on record in England and Wales during 2011-12. Clinical indices of activity peaked in February 2012 with community syndromic indicators not breaching any early warning thresholds during the season. In Pennine Acute Trust (PAT) for the period 1 st September to 31 st January there were no deaths associated with influenza. HMR Data indicates that during the same period there were three hospital admissions where influenza was the primary diagnosis (GP registered patients). In 2011/12 Influenza A(H3N2) was the dominant subtype detected with virological activity corresponding to clinical activity. Influenza B viruses were also detected, though a smaller proportion was reported compared to 2010/11. Few A(H1N1)pdm09 viruses were detected (HPA Surveillance of influenza and other respiratory pathogens in the UK; April 2012). It is recommended that vaccines for use in the 2012/13 influenza season contain the following viruses: an A/California/7/2009 (H1N1)pdm09- like virus, an A/Victoria/361/2011 (H3N2)-like virus and a B/Wisconsin/1/2010-like virus This report outlines the work undertaken by NHS HMR to plan and deliver the 2011/12 seasonal influenza immunisation campaign and recommendations for 2013/12. The campaign 2011/12 Outcomes: 40,231 influenza vaccinations were administered to the target populations in the five month period 01/09/11-31/01/12, an increase of 3,450 from the same period 2010/11 The national target for the vaccination of 65 years and over population is 75%. NHS HMR achieved 78.2 %, an increase on the previous years campaign of 3% Uptake in the under 65 at risk population: 57.5%, an increase of 3.5% on the previous year. Uptake in frontline health care workers: GP practices 75.8 % an increase of 35.8% on the previous year. Pennine Care NHS Foundation Trust : 55%, PAT : 58.8%, NHS HMR commissioning staff: 56%, comparisons to previous year data not possible This year six practices took part in a pilot to offer pulse palpitation to patients over 65 to diagnose atrial fibrillation (AF), a major cause of stroke Challenges: Achieve all national targets attributed to the annual seasonal influenza vaccination programme Improve and sustain influenza vaccine uptake in those aged 65 years and over Increase uptake of the vaccine in those aged under 65 years in clinical at risk groups Identification and vaccination of pregnant women Data collection Increase frontline staff uptake of the vaccination Lack of national campaign Improve communication between providers Avoid duplication of work Successes: Increased vaccine uptake in all target populations Improved national ranking in target populations Support of practices in preparation for and through the programme Communication Plan produced Page 3 of 10

Midwives promoting and delivering influenza vaccination Collaboration of all services Successful pilot of AF pulse checks 2. Body of report Influenza is an acute viral infection of the respiratory tract. Because of the changing nature of the virus the World Health Organization (WHO) monitors the epidemiology of influenza internationally, making recommendations annually about the strains to be included in the vaccines for the forthcoming winter. Influenza is an important cause of morbidity and mortality, in particular in the elderly and those with underlying chronic disease. Studies have estimated that in epidemic years influenza has caused up to 12,000 excess deaths. Influenza and related secondary complications such as bronchitis and pneumonia also cause excess demand on health services during the winter period. Influenza vaccination has been recommended in the UK since the 1960 s with the aim of directly protecting those in clinical at risk groups with their consequent higher risk of serious morbidity and mortality. In 2000 this programme was extended to include all those people aged 65 years and over. The influenza vaccine is a safe and effective vaccine which protects and prevents transmission of influenza. The seasonal influenza vaccination programme is delivered to the majority of patients via GP practices under the Directed Enhanced Service (DES) issued by the Department of Health. NHS HMR supplemented this with a Local Enhanced Service (LES) which this year incorporated a stretch target of 80% for the 65 year and over population and a further target of 60% for those in a clinical at risk group, inline with the national trajectory target for this population. Payment arrangements under the DES scheme apply to target populations who are immunised by 31 st March in the relevant financial year. Contractors will have needed to develop satisfactory registers of the at risk population to be immunised, many of which will be in place as a result of participating in the Quality and Outcomes Framework. In 2011 Immunisation was recommended for: o All those aged 65 years and over o All those aged over 6 months in the following risk groups: Chronic Respiratory disease including asthma that requires continuous use of inhaled or systemic steroids or with previous exacerbations requiring hospital admission. Chronic heart disease Chronic renal disease Diabetes to include those controlled by insulin and oral hypoglycaemics Immunosuppression Chronic liver disease Chronic neurological disease o o o o Pregnant women Frontline health and social care staff directly involved in patient care Those who are the main carer for an elderly or disabled person whose welfare may be at risk if their carer falls ill. Vaccinations should be given at the GP s discretion Those living in long stay residential care homes or other long stay facilities In addition: GPs should consider on an individual basis the clinical needs of their patients Planning Flu is an unpredictable and recurring pressure that the NHS faces during the winter. Each year NHS HMR prepare for the capricious nature of influenza. The initial phase of the campaign in 2011 consisted of a public health awareness campaign. Activity commenced in July with a practice event coordinated by public health in partnership with primary care and the communications department. The communications department at NHS HMR designed, in collaboration with practices and the immunisation lead, a communications pack for all HMR practices and additionally distributed leaflets/posters across HMR footprint. Information was also circulated in the media. Pharmacies within the area publicised the campaign and alerted patients to attend their GP by displaying posters & leaflets. They also attached small credit sized cards to all dispensed prescriptions advising patients to contact their GP/pharmacist to make an appointment for their vaccine. Road shows across the conurbation were also held in September. Page 4 of 10

The Chief Medical Officer s guidance, national DES, local LES and information about the web-based reporting system was issued to every practice. All practices were offered ongoing advisory support which included clinical and organisational support. Any additional correspondence from the DH was cascaded in a timely manner. Monthly uptake reports were also cascaded. Midwives were trained to administer the vaccine and a pathway was commissioned. District Nurse Teams liaised with GPs to provide immunisations to eligible housebound clients on their caseload. Nine pharmacists across four sites within the PCT are trained to administer influenza vaccinations and offer influenza vaccinations opportunistically to under 65 at risk groups Vaccine supply It is the service provider s responsibility to order sufficient vaccine. Stocks of vaccine should be held and monitored at each site and stored as per national guidelines. NHS HMR held a very limited supply of stock which enabled support of practices throughout the programme. For the forthcoming programme the DH are once again seeking assurance from practices, clusters and NHS North West that sufficient vaccine stock has been ordered. Delivery The vaccination programme commences from the first delivery of the vaccine normally towards the end of September. Although eligible groups are targeted throughout the period from September to January, best practice is to ensure the vaccine in administered early in the season. This was achieved by the majority of practices. Data collection DH collects uptake data on a monthly basis. Data is uploaded on to IMMFORM web reporting site on the planned dates. This is dependant upon the practice clinical computer system. Upload can be automatic (only available for practices with EMIS LV and Vision) or manual (data entry by supported by primary care). Plans are in place to support all practices to input their own data as per the DES Obtaining the uptake data from practices within the time deadline requires considerable knowledge, skill, time and effort. 100% of NHS HMR practices (with ICT support from the PCT) provided and uploaded the mandatory data within the stipulated time frames. Uptake analysis in the target populations: 65 years and over NHS HMR exceeded the national target of 75% (national average 74%) achieving 78.2% uptake and ranked:- 6 th Nationally 4 th NHS North West 4 th Greater Manchester The overall trend since 2005 for NHS HMR within this population is increasing uptake of vaccination (see table 1). The pandemic season of 2009/10 was an exception and the 2% drop was consistent with national trends. Under 65 years in a clinical at risk group The NHS was asked to plan to reach uptake of 60% for people aged under 65 years in clinical risk groups, as a first step to reaching uptake of 75% by 2013/14. Uptake in this population was 57.7%, an increase of 3.5% on the previous year and above the national average of 50.3% and ranked:- 11 th Nationally 6 th NHS North West 4 th Greater Manchester It is disappointing that overall vaccine uptake for this group did not reach 60% last season. The overall trend since 2005 for NHS HMR within this population is increasing uptake of vaccination (see Table 1) Page 5 of 10

Table 1 Pregnant women NHS HMR achieved 45.6% uptake exceeding the national average of 27.4% ranked:- 4 th Nationally 4 th NHS North West 4 th Greater Manchester (there was less than 1% differential between those ranked 2 nd, 3 rd and 4 th) However, there were national data issues pertaining to the baseline denominator for this data. Uptake of the influenza vaccination increased within this population (see Table 2) Table 2 Practice performance 65 years and over Twenty six practices achieved the NHS HMR stretch target of 80% or above, an increase of eight from the previous year. Six practices achieved between 75% and 79.9% giving a total of thirty two achieving the national target or greater, an increase of six from the previous year. Of the seven (a decrease of six) practices who failed to reach national target four were above 70%. This is illustrated in Table 3 (overleaf). The Pearson Correlation Coefficient between deprivation (ID2007) and vaccinations of those aged 65 and over indicates a significant positive correlation. Therefore, there is a pattern evident in the data that practices with higher deprivation saw a higher uptake in the acceptance of the vaccination, see Table 4 Page 6 of 10

Table 3 Table 4; Demographic cluster analysis Page 7 of 10

Under 65 years at risk Twenty four practices reached or exceeded the national target of 60%. Of the fifteen practices who failed to achieve the target ten achieved between 50-59.9%. One practice failed to achieve above 40%. Please see Table 5 for influenza vaccination uptake per GP practice across HMR. The Pearson Correlation Coefficient between deprivation (ID2007) and vaccinations of those under 65 in an at risk group indicates a very weak correlation. Therefore, there is no significant pattern between uptake and deprivation evident from the data see Table 6. Table 5 Table 6; Demographic cluster analysis Page 8 of 10

Pregnant women: Five practices achieved or exceeded 60% and a total of twenty three practices achieved above 40% (see Table 7). A total of 1,324 vaccines were administered in comparison with 403 the previous year (see Table 2). Local midwives were commissioned and trained to deliver influenza and a pathway devised. A local evaluation concluded that this has had a positive impact on the uptake of the influenza vaccination within this target population and NHS North evaluation supported this by advocating the inclusion of midwives in commissioned pathways for this target population. Table 7 Frontline health care workers The DH stipulates that it is the employer s responsibility to ensure maximum uptake in staff groups. All NHS HMR employed staff were offered influenza immunisation. NHS HMR reported uptake amongst GP practice frontline staff was 76.1%, an increase of 38% from the previous year. The DH has stated that lead commissioners should seek assurance from their providers that immunisation programmes for frontline health and social care workers improve upon their current uptake. Conclusion The seasonal influenza vaccination programme 2011/12 was a well planned campaign. All departments within NHS HMR involved in the programme should be commended for their collaboration at a time of transition. Many new innovations were developed through the team, such as the practice influenza guide. The locally designed LES achieved its aim of offering an incentive to practices to maximise uptake of the vaccine in the targeted populations. Sharing non anonymised information with practices had a positive effect in the motivation of practices. The team plan to build upon this year s achievement to rise to the challenges in the forthcoming programme. Planning for 2012/13 is underway. The pilot scheme for offering pulse palpitation will be rolled out to all practices in 2012/13. 3. Assessment of risk The PCT campaign was successful in that it exceeding the national target and improved the uptake in the 65 year and over population. If NHS HMR had not instigated the LES, this target would not have been achieved. Practices who failed to achieve target will be contacted and a recovery plan developed with them for the 2012/13 programme. Uptake in the under 65 at risk population falls short of the WHO target of 75%. This puts targeted populations at danger of influenza and the resulting clinical complications. Page 9 of 10

Pregnant women are a target population for seasonal influenza vaccination. The process by which this group is identified and targeted requires appraisal to maximise uptake in this group Commissioned provider services must ensure adequate provision of seasonal influenza vaccine for their frontline HCW. 4. Next steps NHS HMR needs to continue to work with practices, staff and local targeted populations to support the national seasonal influenza programme to ensure that the local population is protected. To learn from the previous year s engagement in order to maximise uptake in groups of patients designated as high risk groups by the DH. This also applies to all identified staff groups. Appraise the local delivery plan Review provider frontline staff vaccination action plans Ensure a clear communication strategy Lessons learnt workshop to be held share good practice for Practices Partnership working across the borough to ensure all aspects of this programme are delivered Build on this year s achievements 5. Recommendations/Resolution required Clinical commissioners are asked to support the influenza plan moving forward for 2012-13. Christine Khiroya: Lead nurse health protection/ immunisation and Reporting Officer: vaccination Page 10 of 10