CLINICAL COMMISSIONING GROUP PRIMARY CARE COMMITTEE EXECUTIVE SUMMARY

Primary Care Committee Agenda Item 7.1 CLINICAL COMMISSIONING GROUP PRIMARY CARE COMMITTEE EXECUTIVE SUMMARY SHEET DATE: 4 th July 2017 TITLE OF PAPER: Influenza Vaccination 2016-17 EXECUTIVE Chris Morris RESPONSIBLE: Contact Details: Ext: Email: AUTHOR (if different from Jacqui Seaton (Head of Medicines Management) above) Contact Details: Ext:580434 Email: jacquiseaton@nhs.net CCG OBJECTIVE: To improve commissioning of effective, safe and sustainable services, which deliver the best possible outcomes, based upon best available evidence For Information For decision For performance monitoring EXECUTIVE SUMMARY The aim of this paper is to provide PCC with background information about the annual flu vaccination programme. The paper provides information about the flu virus, the vaccine and the people that the vaccine is targeted at. The appendix contains a number of tables that provide further insight into the local uptake of the flu vaccine during 2016/17 flu season. FINANCIAL IMPLICATIONS: EQUALITY & INCLUSION PATIENT & PUBLIC ENGAGEMENT: LEGAL IMPACT: CONFLICTS OF INTEREST RISKS/OPPORTUNITIES: RECOMMENDATIONS: The national flu vaccination programme is funded by NHS England (including the cost of the vaccines) N/A N/A N/A No conflicts of interest to declare Healthcare practitioners managing the flu programme should make sure that individuals of all ages in at-risk groups have the opportunity to receive flu vaccine. There is also a role for doctors and specialist nurses in secondary care, health visitors, pharmacists, midwives and other caregivers to raise awareness of flu vaccine as part of the care pathway for people in clinical risk groups PCC is asked to note the content of this report and support joint working between the CCG (managers and clinicians), NHS England, the Local Authority and providers of pharmaceutical services to enhance the opportunities for vaccination and improve uptake of the vaccine during the 2017/18 flu season. Jacqui Seaton, Head of Medicines Management May 2017 Page 1

CLINICAL COMMISSIONING GOVERNANCE BOARD REPORT Influenza Vaccination Programme 2016-17 Background information Flu immunisation is one of the most effective interventions immunisers can provide to reduce both the risk of death and serious illness from flu, and the pressures on health and social care services during the winter. Flu is an acute viral infection of the respiratory tract. It is a highly infectious illness which spreads rapidly in closed communities. It is transmitted by droplets, aerosol, or through direct contact with the respiratory secretions of someone with the infection. Even people with mild or no symptoms can infect others. The incubation period is the time between exposure to the flu virus and when signs and symptoms first appear. This is generally 1-5 days (average 2-3 days), though this may be longer especially in people with immune deficiency. For healthy individuals, flu is an unpleasant but normally self-limiting disease with recovery usually within two to seven days. Common symptoms include: Sudden onset of fever, chills, headache, muscle and joint pain and extreme fatigue Dry cough, sore throat and stuffy nose In young children gastrointestinal symptoms such as vomiting and diarrhoea may occur Common complications include: Bronchitis Otitis media (children) Sinusitis Secondary bacterial pneumonia Less common complications include: Meningitis, encephalitis, meningoencephalitis Primary influenza pneumonia The risk of most serious illness is highest in children under 6 months, pregnant women, older people and those with underlying health conditions. These groups are at greater risk of complications from flu such as bronchitis or pneumonia. Flu during pregnancy may be associated with perinatal mortality, prematurity, smaller neonatal size and lower birth weight. There are three types of flu virus, A, B and C. A viruses cause outbreaks most years and are the usual cause of epidemics B viruses tend to cause less severe disease and smaller outbreaks mostly in children C viruses cause minor respiratory illness only Influenza A virus has two antigens on the surface - Haemagglutinin (H) and Neuraminidase (N). An antigen is any substance that causes the immune system to produce antibodies against it. Changes in the surface antigens (H & N) result in the flu virus constantly changing. Antigenic drift refers to minor changes (natural mutations) in the genes of flu viruses that occur gradually over time. Antigenic shift describes the combination of two or more different strains of flu virus. This abrupt major change results in a new subtype. Immunity from previous flu Jacqui Seaton, Head of Medicines Management May 2017 Page 2

infections/vaccinations may not protect against the new subtype, potentially leading to a widespread epidemic or pandemic. Because of the changing nature of flu viruses, the World Health Organization (WHO) monitors their epidemiology throughout the world. Each year the WHO makes recommendations about the strains of influenza A and B which are predicted to be circulating in the forthcoming winter based on information about the circulating viruses and epidemiological data at that time. These strains are then included in the flu vaccine developed that year. Flu viruses circulate every winter with most flu activity usually occurring between September and March. The impact of flu on the population varies from year to year. How much flu is seen is influenced by changes in the virus that, in turn, influence the proportion of the population that may be susceptible to infection and the severity of the illness. There are two main types of flu vaccine available - inactivated and live. Flu vaccines contain either three (trivalent) or four (quadrivalent) different flu viruses. A list of the influenza vaccines available in the UK is published ahead of the flu season in the annual flu letter for England. Flu vaccine efficacy is usually around 50-60% for adults aged 18-65 years. It is lower in the elderly although immunisation has been shown to reduce the incidence of severe disease including bronchopneumonia, hospital admissions and mortality. Mismatches between the components in the vaccine and circulating viruses do occur from time to time and this explains why vaccine effectiveness varies. In most recent years, flu vaccines have closely matched the influenza A viruses circulating during the flu season, the 2014/15 flu season being a rare exception. It is important to remember that flu vaccination remains the best way to protect people from flu. When antigenic drift does occur, vaccination is still recommended as some degree of protection may be offered against the drifted strain. In addition, the vaccine should also still offer protection against the other strains in the vaccine (more than one strain of flu virus circulates each flu season). Who should the flu vaccine be targeted at? Morbidly obese patients The Joint Committee of Vaccination and Immunisation (JCVI) have advised that morbid obesity (defined as BMI 40+) should be considered as a risk factor for flu vaccination. This advice was based on the observation that those with morbid obesity were found to be at higher risk of hospitalisation and death following pandemic flu infection. Many in this patient group are already eligible for flu vaccination due to complications of obesity that place them in another risk category. Pregnant women There is good evidence that pregnant women are at increased risk from complications if they contract flu. In addition, studies show that having flu during pregnancy may be associated with premature birth and smaller birth size and weight. Flu vaccination during pregnancy not only reduces these risks, it also provides passive immunity against flu to infants in the first few months of life through antibodies passing across the placenta. Studies on the safety of flu vaccine in pregnancy show that inactivated flu vaccine can be safely and effectively administered during any trimester of pregnancy. No study to date has demonstrated an increased risk of either maternal complications or adverse fetal outcomes associated with inactivated flu vaccine. Jacqui Seaton, Head of Medicines Management May 2017 Page 3

Children The extension of the annual seasonal flu vaccination programme to children aims to substantially lower the public health impact of flu by: Providing direct protection to vaccinated children thus preventing a large number of cases of flu in children Providing indirect protection to others by lowering flu transmission from children to other children, to adults and to those in the clinical risk groups of any age Children are the main source of flu transmission in the population. Reducing flu transmission in the community should avert many cases of severe flu and flu-related deaths in older adults and people with clinical risk factors. People in clinical risk groups The flu vaccine is offered free of charge on the NHS to anyone with a serious long-term health condition including: Chronic (long-term) respiratory diseases, such as severe asthma, chronic obstructive pulmonary disease (COPD), or bronchitis Chronic heart disease, such as heart failure Chronic kidney disease at stage three, four or five Chronic liver disease Chronic neurological disease, such as Parkinson's disease or motor neurone disease or learning disabilty Diabetes Problems with the spleen for example, sickle cell disease or if the spleen has been removed or is not working properly A weakened immune system due to disease (such as HIV and AIDS), or treatment (such as cancer treatment) The list of risk groups is not exhaustive, and the healthcare practitioner should apply clinical judgment to take into account the risk of flu exacerbating any underlying disease that a patient may have, as well as the risk of serious illness from flu itself. Flu vaccine should be offered in such cases even if the individual is not in the clinical risk groups specified above. Increasing flu vaccine uptake in clinical risk groups is important because of the increased risk of death and serious illness if people in these groups catch flu Health and social care workers Frontline health and social care workers have a duty of care to protect their patients and service users from infection. Flu outbreaks can occur in health and social care settings with both staff and their patients/service users being affected when flu is circulating in the community. It is important that health and social care workers protect themselves by having the flu vaccine, and, in doing so, they reduce the risk of spreading flu to their patients, service users, colleagues and family members. Vaccination of healthcare workers against flu has been shown to significantly lower rates of flulike illness, hospitalisation and mortality in the elderly in long-term healthcare settings. It also reduces the transmission of flu to vulnerable patients, some of whom may have impaired immunity and consequently may not respond well to their own immunisation. Vaccination of health and social care workers also helps reduce the level of sickness absenteeism that can jeopardise the NHS and care services. This is essential in the winter when pressures on these services increase, and staff vaccination will contribute to keeping the NHS and care services running. Jacqui Seaton, Head of Medicines Management May 2017 Page 4

NHS and social care bodies have a responsibility to ensure, as far as is reasonably practicable, that health and social care workers are free of, and are protected from exposure to infections that can be caught at work. The responsibility for funding and administering seasonal flu vaccine to staff lies with employers. Trusts/ employers must ensure that health and social care staff directly involved in delivering care are encouraged to be immunised and that processes are in place to facilitate and fund this. Uptake figures The tables included in appendix 1 provide information about vaccine uptake in Telford and Wrekin compared with other CCGs across Staffordshire and Shropshire. This information has been provided by NHS England and includes data up to the end of January 2017. According to the figures provided by NHS England, there were 53,331 people who were eligible for flu vaccination during 2016/17 in Telford and Wrekin. 58.4% of our eligible cohort were vaccinated; 93% of these were vaccinated in general practice, 4% were vaccinated in community pharmacy and 1% by other healthcare providers (2% were not assigned to any healthcare provider). Vaccine uptake in Telford and Wrekin is slightly lower than uptake across Staffordshire and Shropshire as a whole (58.4% vs 58.6%). Cohorts where our uptake is below both Shropshire and Staffordshire Area Team figures and England figures (see table 1): People age 65 years and over Children aged 2 years Children aged 4 years During 2016/17 vaccine uptake declined in people age 65 years and over, and in pregnant women compared to uptake during 2015/16 (see table 2 and table 3). Vaccine uptake varies widely between disease groups (see table 4) and by age category for those with an underlying clinical risk factor. Increasing flu vaccination uptake Despite continued efforts to improve uptake, half of the clinical risk group population eligible to receive flu vaccine are still not getting immunised. Vaccine uptake is particularly low in the younger age groups with clinical conditions that put them at most risk of complications from flu. Vaccine uptake needs to increase in all of the target groups, but patients in the clinical risk groups present a particular challenge and we need to work closely with general practice and Public Health colleagues to increase uptake. We need to ensure that all target groups have the opportunity to receive the flu vaccine. There is also a role for doctors and specialist nurses in secondary care, health visitors, pharmacists, midwives and other caregivers to raise awareness of flu vaccine as part of the care pathway for people in clinical risk groups Recommendation PCC is asked to note the content of this report and support joint working between the CCG (managers and clinicians), NHS England, the Local Authority and providers of pharmaceutical services to enhance the opportunities for vaccination and improve uptake of the vaccine during the 2017/18 flu season. Jacqui Seaton, Head of Medicines Management May 2017 Page 5

Appendix 1 Evaluation of the 2016/17 Seasonal Influenza Vaccination Programme Delivery in Staffordshire and Shropshire Seasonal flu vaccine uptake in GP patients: 1 September 2016 to 31 January 2017 https://www.gov.uk/government/statistics/seasonal-flu-vaccine-uptake-in-gp-patients-1-september-2016-to-31-january-2017 Table 1.0: Flu Vaccination Uptake by Local Authority Org Name Local Authority (target %) 65 and over Under 65 (at-risk only) (55%) All Pregnant Women 55% All Aged 2 (40%-60%) All Aged 3 (75%) (40%-60%) Staffordshire 69.3 49.3 48.7 42.4 48.3 35.0 Stoke on Trent 71.9 51.0 42.6 39.4 42.1 32.8 Telford and Wrekin 69.7 52.3 50.1 31.1 42.0 27.6 Shropshire 71.6 52.6 56.4 48.4 49.7 39.6 Shropshire and Staffordshire Area Team 69.9 50.0 48.7 41.3 44.2 34.9 ENGLAND TOTAL 70.5 48.5 44.9 39.0 41.6 33.8 All Aged 4 (40%-60%) All figures are derived from data as extracted from records on GP systems or as submitted by GP practices or Area Teams and CCGs. Data Source: ImmForm website: Registered Patient GP practice data Influenza Immunisation Vaccine Uptake Monitoring Programme Public Health England (PHE) Jacqui Seaton, Head of Medicines Management May 2017 Page 6

Seasonal flu vaccine uptake in GP patients: 1 September 2016 to 31 January 2017 Data taken from immform https://portal.immform.dh.gov.uk/datacollections/datacollections/current-surveys/flu-data-collections/uptake-summary/ccg-list-flu- 2017.aspx?userSpecific=false&orgcode=Q60&hash=79c992c0c54692f9f4432b14fb88d6aabbe9632f4e81c8f7617a0991c27e30fd 2016/17 Seasonal influenza vaccine uptake in 65 plus, under 65 (at risk) pregnant cohorts, and children aged 2,3,4 years in each area team compared to 2015/16 uptake in the same week. (Week Ending Sunday 29 Jan 2017) Table 2.0. 2016/17 Flu Vaccination uptake compared to 2015/16 activity Org Name 65 and over Under 65 (at-risk only) (55%) All Pregnant Women (55%) All Aged 2 (40%- 60%) All Aged 3 All Aged 4 (40%-60%) (75%) (40%- 60%) NHS CANNOCK CHASE CCG 67.4 49.4 53.2 35.1 38.2 29.6 NHS EAST STAFFORDSHIRE CCG 69.5 46.1 41.0 44.8 46.6 38.2 NHS NORTH STAFFORDSHIRE 69.2 49.7 48.0 34.2 38.1 29.6 CCG NHS SHROPSHIRE CCG 70.8 51.9 56.7 47.3 49.0 38.2 NHS SOUTH EAST STAFFS AND SEISDON PENINSULAR CCG 71.3 49.5 50.0 50.3 50.1 42.0 NHS STAFFORD AND 68.2 48.0 46.9 45.0 43.2 35.6 SURROUNDS NHS STOKE ON TRENT CCG 72.0 51.3 43.2 39.2 42.7 33.5 NHS TELFORD AND WREKIN CCG 68.2 51.3 50.4 33.9 44.3 32.2 Shropshire and Staffordshire Area Team 69.9 50.0 48.7 41.3 44.2 34.9 ENGLAND TOTAL 70.5 48.5 44.9 39.0 41.6 33.8 Jacqui Seaton, Head of Medicines Management May 2017 Page 7

Orange Uptake % is less than 5% below same time last year Green Uptake % is equal to or better than same time last year Red - Uptake % is 5% or more below than same time last year Overall across Staffordshire and Shropshire the flu vaccination coverage is equal to or better than same time last year with only a small decrease in 65+ years cohort, mirroring the national trend. A summary of the changes in percentage vaccination coverage is provided in table 3 below. Jacqui Seaton, Head of Medicines Management May 2017 Page 8

Table 3. Percentage Change in seasonal flu vaccination uptake for between 2016/17 and 2015/16 CCG Code Org Name 65 and over Summary of Flu Vaccine Uptake % Under 65 (atrisk only) All Pregnant Women All Aged 2 All Aged 3 England -0.6 3.6 2.5 3.5 3.8 3.9 All Aged 4 Q60 Staffordshire & Shropshire -0.4 3.7 2.4 2.7 3.2 1.1 04Y NHS CANNOCK CHASE CCG -0.9 4.4 7.1 3.5 4.4 4.1 05D NHS EAST STAFFORDSHIRE CCG -0.6 2.5-2.6 3.6 3.1-5.5 05G NHS NORTH STAFFORDSHIRE CCG -1 3.5 3.2 0.6 1.5-0.3 05N NHS SHROPSHIRE CCG -0.2 2.8 1.1-0.2 1-0.2 05Q NHS SOUTH EAST STAFFS AND SEISDON PENINSULAR CCG -0.9 1.6 6.9 6.1 3.3 2.8 05V NHS STAFFORD AND SURROUNDS CCG 0.7 4.2 6.7 6.4 3.2 3.7 05W NHS STOKE ON TRENT CCG 0.2 6.1 2 3.7 5.3 0.7 05X NHS TELFORD AND WREKIN CCG -1.4 3.2-3.6 0.7 3.9 3.2 CCG highest increase/lowest decrease uptake CCG highest decrease in uptake Jacqui Seaton, Head of Medicines Management May 2017 Page 9

65 and Over Across Staffordshire and Shropshire uptake is below the National ambition target of 75%, but mostly in line with the England average of 70.5% Under 65 and at risk From table 1.0 it can be seen that flu uptake across the area is below national Standard of 55% but in line with the national average, however when broken down into groups of patients with different conditions (table 4.0) there is clear variation in uptake of the vaccination between clinical risk groups. Diabetic patients appear to have high uptake as an overall group whilst patients who are asplenic or experience dysfunction of the spleen display the lowest uptake. Table 4.0 Chronic diseases flu uptake (data taken from Immform) At risk Chronic respiratory Chronic kidney Chronic liver diabetes immunosuppressed Neurological disease CANNOCK 48.1 55.8 49.6 62.6 58.4 50 37.5 EAST STAFF 43.9 54.8 48.3 66 56.4 48.2 39.7 NORTH Staff 50.3 54.1 51.5 62.5 52.6 49.3 39.6 SHROPSHIRE 51.8 54.1 50.4 64 58.4 52.3 43.8 SOUTH EAST 48.6 59.6 43.9 63.4 60.6 51.6 44 STAFFORD AND SURROUNDS STOKE ON TRENT TELFORD AND WREKIN 47.3 55.9 47.6 59.5 58 49.6 38 52.4 60.3 43.8 64.1 54.4 50 42.8 51.3 57 46 64.1 56.4 50.5 38.2 Jacqui Seaton, Head of Medicines Management May 2017 Page 10 Asplenic or dysfunction of the spleen All Pregnant women Unable to meet the national ambitious target however there was overall improvement in the Staffordshire and Shropshire Area from the previous year s achievement.

Health care workers uptake of flu vaccination- (Trust/Area Team) 2016-17 Data Source https://portal.immform.dh.gov.uk/datacollections/datacollections/current-surveys/flu-data- Collections/Home/Flu-Collections-Home.aspx Table 9.0 Flu Monthly HCWs (Trust/Area Team) 2016-17 Organisation %Uptake 2015/16 %Uptake 2016/17 Change in uptake Shropshire and Staffordshire area team health care workers National ambition 75% 61.4 56.3-5.1% Shropshire community health NHS trust 68.4 72.4 4% Staffordshire and Stoke on Trent partnership NHS trust 51.3 69.8 18.5% University hospital of North Midlands NHS Trust 75.9 81.2 5.3% The Robert Jones And Agnes Hunt Orthopaedic Hospital NHS Foundation Trust North Staffordshire Combined Healthcare NHs Trust 41.4 48.5 7.1% 53.2 79.7 26.5% South Staffordshire And Shropshire Healthcare 53.2 66.4 13.2% NHS Foundation Trust Shrewsbury And Telford Hospital NHS Trust 43.3 70.6 27.3% Total 60.7 72.7 12% Across the Area the uptake in HCWs varies from 48.5 % to 81.2 % with an average of 72.7% which is just below the national target. Overall in majority of the areas the uptake has increased from same time last year Jacqui Seaton, Head of Medicines Management May 2017 Page 11

Distribution of Flu Vaccination Activity across Providers January 2017 https://portal.immform.dh.gov.uk/datacollections/datacollections/current-surveys/flu-data-collections/home/flu-collections- Home.aspx Summary of flu vaccination Org Code 04Y 05D 05G 05Q 05V 05W 05N 05X Org Name Patients registered No. vaccinated No. of patients vaccinated in their GP Practice % of patients vaccinated in their GP Practice No. of patients who received the Flu vaccine in Pharmacies % of patients who received the Flu vaccine in Pharmacies Vaccination given by other healthcare providers % of patients received vaccinated by other healthcare providers NHS CANNOCK CHASE CCG 41163 25189 23472 57.0 1170 2.8 254 0.6 NHS EAST STAFFORDSHIRE CCG 34114 20525 19118 56.0 974 2.9 270 0.8 NHS NORTH STAFFORDSHIRE CCG 72720 45290 41043 56.4 3126 4.3 531 0.7 NHS SOUTH EAST STAFFS AND SEISDON PENINSULAR CCG 68384 42671 40617 59.4 1479 2.2 327 0.5 NHS STAFFORD AND SURROUNDS CCG 49032 30869 29272 59.7 1172 2.4 272 0.6 NHS STOKE ON TRENT CCG 86771 54333 48959 56.4 3743 4.3 583 0.7 NHS SHROPSHIRE CCG 109192 71776 68193 62.5 2640 2.4 715 0.7 NHS TELFORD AND WREKIN CCG 53331 33165 31144 58.4 1354 2.5 336 0.6 STAFFORDSHIRE & SHROPSHIRE 514707 323818 301818 58.6 15658 3.0 3288 0.6 Jacqui Seaton, Head of Medicines Management May 2017 Page 12

Distribution of Flu Vaccination Activity across Providers January 2017 https://portal.immform.dh.gov.uk/datacollections/datacollections/current-surveys/flu-data-collections/home/flu-collections- Home.aspx Jacqui Seaton, Head of Medicines Management May 2017 Page 13

Distribution of vaccine uptake (%) across providers including patients who have refused/declined vaccine: patients in clinical at risk groups aged 6months- 65years) 100.0 90.0 80.0 70.0 60.0 50.0 40.0 30.0 20.0 10.0 0.0 % of patients refused/declined vaccine % of patients received vaccinated by other healthcare providers % of patients received Flu vaccine in pharmacies % vaccinated in their GP Practice Jacqui Seaton, Head of Medicines Management May 2017 Page 14

Jacqui Seaton, Head of Medicines Management May 2017 Page 15

School based flu vaccination delivery Data source https://portal.immform.dh.gov.uk/datacollections/datacollections/current-surveys/flu-data-collections/home/flu- Collections-Home.aspx and Provider reports for activity during the 2016/2017 season Staffordshire and Stoke on Trent Partnership NHS Trust Fluenz Uptake 2016/17 Table 5.0 Staffordshire School Based Fluenz Uptake 2016/17 Year Group Year 1 Year 2 Year 3 Total Denominator 9855 9927 9549 29331 Doses Administered 6201 6239 5914 18354 Percentage Uptake 62.9% 62.8% 61.9% 62.57%% Table 6.0 Stoke on Trent School Based Fluenz Uptake 2016/17 Year Group Year 1 Year 2 Year 3 Total Denominator 3486 3270 3269 10025 Doses Administered 1943 1810 1754 5507 Percentage Uptake 55.7% 55.4% 53.7% 54.93% Total targeted = 39356 Total delivered = 23861 Overall Uptake= 60.62% Jacqui Seaton, Head of Medicines Management May 2017 Page 16

Shropshire Community Health NHS Trust Fluenz Uptake 2016/17 Table 7.0 Telford & Wrekin School Based Fluenz Uptake 2016/17 Year Group Year 1 National standard 40-65% Year 2 National standard 40-65% Year 3 Total Denominator 2357 2347 2357 7061 Doses Administered 1403 1465 1375 4243 59.52% 62.42% 58.33% 60.09% Table 8.0 Shropshire School Based Fluenz Uptake 2016/17 Year Group Year 1 Year 2 Year 3 Total National standard 40-65% National standard 40-65% National standard 40-65% Denominator 3105 3074 3121 9289 Doses Administered 2121 2120 2099 6340 68.30% 68.96% 67.25% 68.25% Total targeted = 16,346 Total delivered = 10,583 Overall Uptake = 64.74% All LA and Independent schools participated in the delivery of the programme so clinical teams are confident of 100% offer to eligible children. Figures are of vulnerable groups outside of mainstream education i.e. special schools. Children unwell on the day of vaccination delivery in school and unable to be vaccinated safely were provided with letters for parents to contact for community clinic appointment. Mop Up community clinics held end December and January for second and any missed doses. Jacqui Seaton, Head of Medicines Management May 2017 Page 17