Transcript Influenza Training Webinar 2016-17 - GP-one

Influenza Training Webinar
2016-17
What is flu?
• Flu is a highly infectious viral illness and can
cause serious disease
• People with mild or no symptoms can still infect
others
• Incubation period 1-3 days (average 2-3 days)
though may be longer, especially in hosts with
immune deficiency
Influenza update 2016/17
Complications of flu
• Common:
– Bronchitis
– Otitis media (children)
– Sinusitis
– Secondary bacterial pneumonia
• Less common:
– Meningitis, encephalitis
– Primary influenza pneumonia
• Most serious illness is seen in neonates,
pregnant women, older people and those in
clinical risk groups
Influenza update 2016/17
Influenza update 2016/17
2016/17 vaccine composition
Trivalent vaccines will contain the following three
viruses:
• A/California/7/2009 (H1N1)pdm09-like virus
• A/Hong Kong/4801/2014 (H3N2)-like virus
• B/Brisbane/60/2008-like virus.
It is recommended that quadrivalent vaccines
containing two influenza B viruses contain the above
three viruses and a B/Phuket/3073/2013-like virus.
None of the influenza vaccines for the 2016/17 season
contain thiomersal as an added preservative
Influenza update 2016/17
Flu epidemiology
Influenza-like illness consultation rate per 100,000 practice population in Welsh
sentinel practices
Source Vaccine Preventable Disease Programme Public Health Wales
Influenza update 2016/17
Burden of influenza season 2015/16
• >9,887 patients diagnosed by GPs to have flu-like
illness
• 807 patients in hospital confirmed to have influenza
• 125 patients in intensive care units (ICU) in Wales
were confirmed with influenza
• This season, confirmed cases of influenza were seen
in all age-groups, children (<15y) and adults aged
45y to 64y accounted for half of all cases
• 20 outbreaks reported to PHW (in hospitals,
residential homes nurseries and an army barracks)
• Much lower level of seasonal excess mortality than
last year
Influenza update 2016/17
Seasonal influenza vaccine effectiveness (VE)
• Efficacy calculated at between 50-60% for adults aged 1865yrs, Lower efficacy in elderly although immunisation shown
to reduce incidence of severe disease including
bronchopneumonia, hospital admissions and mortality
• End of season overall adjusted VE of the 2015-2016 influenza
vaccine in preventing medical consultation in primary care
with a laboratory confirmed Influenza like illness (ILI) across
the UK was 52.4%
Pebody et al. Effectiveness of seasonal influenza vaccine in preventing
laboratory –conformed influenza in primary care in the United Kingdom:
2015/16 mid-season results. Euro Surveill. 2016;21 (13):pii=30179
Influenza update 2016/17
The National Influenza
Immunisation Programme 2016/17
• Eligibility
– In 2016-17 the following groups are eligible for flu vaccination:
– those aged 65 years and over
– those aged six months to under 65 years in clinical risk groups
– pregnant women
– those in long-stay residential care homes
– carers and third sector carers
– members of voluntary organisations providing emergency first aid
– community first responders
– all two and three year olds (age on 31 August 2016)
– All children in reception class and year 1,2 and 3 in primary school
– In addition, all health and social care workers with direct patients/client
contact should be offered flu vaccine by their employer
A more detailed list can be viewed in the Welsh Health Circular (2016) 039
Influenza update 2016/17
Individuals over the age of 65 years
Individuals aged 65 years
of age and over who catch
flu are about twenty times
more likely to die than
individuals under 65 years
of age who get flu.
(Pebody et al, 2010)
©Leah Milinship
Influenza update 2016/17
People with certain underlying chronic
health conditions from 6 months of age
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Chronic respiratory disease
Chronic heart disease
Chronic kidney disease
Diabetes
Asplenia or splenic dysfunction
Pregnancy
Chronic liver disease
Chronic neurological disease
Immunosuppression
Morbidly obese (class lll obesity)
–
(BMI) of 40 or more
Source: Green Book chapter 19 - Influenza
Influenza update 2016/17
Individuals who have chronic
liver disease are around 48
times more likely to die if they
catch flu than someone with
no underlying health condition
Individuals with neurological
disease are around 40 times
more likely to die if they catch
flu
Individuals who are
immunosuppressed are around
47 times more likely to die if
they catch flu
Trends in seasonal influenza immunisation uptake in
patients aged 65 years and over and in those aged six
months to 64 years in clinical risk groups, Wales, 2008/09 –
2015/16.
Patients aged 65y and over
68.3%
48.5%
50.0%
49.7%
51.1%
2011-12
2012-13
2013-14
63.5%
67.7%
2010-11
Patients aged under 65y at risk
65.7%
67.7%
68.0%
66.6%
59.5%
49.1%
49.3%
46.9%
Influenza update 2016/17
2015-16
2014-15
2009-10
2008-09
40.8%
Summary of influenza uptake rates in patients aged 65
years and over and six months to 64 years at risk, by
individual risk group, Wales, 2015/16.
2015-16 summary data
65y and older
Younger than 65y at risk
Diabetes
Immunosuppression
Chronic kidney disease
Chronic respiratory disease
Chronic heart disease
Neurological conditions
Chronic liver disease
Morbidly obese
Pregnant women
Carers
Influenza update 2016/17
66.6%
46.9%
62.3%
55.9%
51.2%
46.4%
46.7%
44.6%
40.6%
34.8%
75.6%
49.1%
Benefits of flu vaccine
for mother and infant
• Risk of serious illness and death
from flu is higher in pregnant
women.(1)
• Influenza vaccine given to pregnant
women is 91.5% effective in
preventing hospitalisation of their
infants from influenza in the first
six months of life.(2)
1.Pebody Ret al (2010) Pandemic influenza A (H1N1) 2009 and mortality in the
United Kingdom: risk factors for death, April 2009 to March 2010.
Eurosurveillance 15(20): 19571.
2.Benowitz I, et al. Influenza vaccine given to pregnant women reduces
hospitalization due to influenza in their infants. Clin Infect Dis 2010; 51
(12):1355-61
Influenza update 2016/17
Childhood programme 2016/17
The following age groups of children
will be eligible for flu vaccine in
2016-17:
• All children aged between two
and seven years on 31 August
2016 (children born on or
between 1st September 2008 and
31st August 2014)
A more detailed list can be viewed in
the Welsh Health Circular (WHC
(2016) 039)
Influenza update 2016/17
© Public Health Wales
Childhood programme 2016/17
Delivery location: Primary care
• GPs should actively invite and offer
nasal spray flu vaccine to all
registered patients aged two and
three years old on 31st August
2016
Dates of birth from:
1st September 2012 to
31st August 2014
inclusive
Influenza update 2016/17
Childhood programme 2016/17
Delivery location: Primary schools
• Children in reception class and
school years 1, 2 and 3
will be offered flu vaccination in
school via the school nursing
service
• For practical reasons all children in
these school years should be
offered vaccination irrespective of
their date of birth
Influenza update 2016/17
Children’s flu programme 2016/17
school programme exemptions:
• Parents of children in the school
cohort who do not attend a
school where flu vaccine is
offered should contact their GP
to obtain their vaccine (aged 4 to
7 years on 31st August 2016)
This includes:
• A small amount of four year olds
who have not started
mainstream school
• Home educated children
• Some independent schools
Influenza update 2016/17
©Leah Milinship
Uptake of flu vaccine in children
2015/16
• Uptake of influenza immunisation in children
aged two to three years was 44.4%
• Uptake of influenza immunisation in primary
school cohort (reception class, year 1 and 2)
was 63.4%
• No specific target will be set for children’s flu
vaccination until the programme is more
established
Influenza update 2016/17
Who else needs the flu vaccine?
People who could give the illness to someone
who is vulnerable or who would leave a
vulnerable person at risk if they were ill
• Health and social care workers with patient/client contact
• Residents of long-stay care facilities such as residential
homes and nursing homes
• Anyone who is the main carer for a vulnerable person (this
doesn’t include parents of healthy children)
• Third sector/voluntary carers
• Members of certain voluntary organisations who may be
involved in the provision of care at mass gatherings. This
includes members of the British Red Cross and St John
Ambulance
• Community first responders
Influenza update 2016/17
Healthcare workers
• Patients can infect healthcare workers.
Healthcare workers are at risk of
occupationally acquired flu.
• Healthcare workers can infect
patients. Several studies show patients in
risk groups such as the elderly are at
increased risk of catching and dying from
flu if cared for by unvaccinated staff
• Vaccination of healthcare workers against
flu is a World Health Organisation
recommendation. It has been policy in the
United Kingdom since 2000
Influenza update 2016/17
Types of flu vaccines
Two main types of vaccine available:
• Inactivated – by injection
• Live - by nasal application
• None of the flu vaccines can cause clinical influenza in those
that can be vaccinated
• Trivalent: flu vaccines contain two subtypes of Influenza A
and one type B virus
• Quadrivalent vaccines contain two subtypes of Influenza A
and two B virus types*
• As quadrivalent vaccines may be better matched and therefore
may provide better protection against the circulating B
strain(s) than trivalent flu vaccines, the live intranasal vaccine
offered to children aged 2yrs and over is a quadrivalent
vaccine
*Quadrivalent inactivated flu vaccine only authorised for children aged 3 years and older
Influenza update 2016/17
Live Attenuated Influenza Vaccine (LAIV)
• Fluenz® Tetra is the recommended flu vaccine for children
between the ages of 2 and 17 unless it is contraindicated
• Live attenuated influenza vaccine (LAIV) provides good
protection against flu for children*JCVI statement on the nasal
spray vaccine
• It may offer some protection against strains not contained in the
vaccine as well as to those that are
• It is cold adapted, so it replicates in the cooler nasal mucosa but
not at body temperature in the lungs. It cannot cause a systemic
flu illness
• Fluenz® Tetra contains 4 (two A and two B) influenza virus strains
as directed by WHO
Image source: AstraZeneca UK Ltd
Influenza update 2016/17
Contraindications to flu vaccines
None of the influenza vaccines should be given to those who have
had:
• Confirmed anaphylactic reaction to a previous dose of the vaccine
• Confirmed anaphylactic reaction to any component of the vaccine
(except ovalbumin)
The live attenuated flu vaccine should not be given to children who
are:
• Clinically severely immunodeficient due to conditions or
immunosuppressive therapy:
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Acute and chronic leukaemias
Lymphoma
HIV infection not on highly active antiretroviral therapy
Cellular immune deficiencies
High dose corticosteroids
• Receiving salicylate therapy
• Known to be pregnant
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Precautions to flu vaccines
• Acutely unwell:
defer until recovered
• Heavy nasal congestion:
defer live intranasal vaccine until resolved or consider
inactivated flu vaccine
Use with antiviral agents against flu:
• The live intranasal vaccine (Fluenz® Tetra) should not be
administered at the same time or within 48 hours of cessation
of treatment with flu antiviral agents
• Administration of flu antiviral agents within two weeks of
administration of Fluenz® Tetra may adversely affect the
effectiveness of the vaccine
Influenza update 2016/17
Severe asthma or active wheezing
• Live flu vaccine is not recommended for children who are
currently taking or have been prescribed oral steroids in the last
14 days
• Children currently taking a high dose inhaled steroid Budesonide >800 mcg/day or equivalent (e.g. Fluticasone > 500
mcgs/day) should only be given live flu vaccine on the advice of
their specialist
As these children are a defined flu risk group, those who cannot
receive LAIV should receive an inactivated flu vaccine
• Vaccination with Fluenz® Tetra should be deferred in children
with a history of active wheezing in the past 72 hours or those
who have increased use of bronchodilators in the previous 72
hours. If not improved after a further 72 hours then inactivated
flu vaccine should be offered to avoid delaying protection in this
high risk group
Influenza update 2016/17
Egg allergy - adults
• Most flu vaccines are prepared from flu viruses grown in
embryonated hens eggs-the final vaccine products contains
varying amounts of egg (as ovalbumin)
• Adults with egg allergy can be immunised in any setting using
 an inactivated flu vaccine with an ovalbumin content less than 0.12
µg/ml (equivalent to <0.06 µg for 0.5 ml dose)
• Adults with either severe anaphylaxis to egg which has
previously required intensive care, or with both egg allergy
and severe uncontrolled asthma should be referred to
specialists for immunisation in hospital
Influenza update 2016/17
Egg allergy - children
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Children with an egg allergy can be safely vaccinated with
Fluenz® Tetra in any setting (including primary care and
schools)
Those with both egg allergy and clinical risk factors* that
contraindicate Fluenz® Tetra (e.g. immunosuppression) should be
offered an inactivated flu vaccine with a very low ovalbumin content
(less than 0.12 μg/ml)
Children with a history of severe anaphylaxis to egg which has
previously required intensive care, should be referred to
specialists for immunisation in hospital
*Children in a clinical risk group and aged under nine years who have not
been previously vaccinated against influenza will require a second dose
whether given LAIV or inactivated vaccine
Green Book influenza Chapter 19
Influenza update 2016/17
Risk of transmission
• There is the potential for transmission of live attenuated
influenza vaccine virus from the vaccinated person to other
people. This does not pose a risk to most people (including
healthcare workers). However transmission of live
attenuated influenza vaccine virus to very severely
immunocompromised contacts (e.g. bone marrow
transplant patients requiring isolation) following
immunisation with Fluenz® Tetra may pose a risk to them
– Risk is for one to two weeks following vaccination
– Where close contact is likely or unavoidable (e.g.
household members) consider using an inactivated flu
vaccine
– For less severely immunocompromised close contacts,
the benefits of immunisation outweigh any risks
Influenza update 2016/17
Commonly reported adverse reactions
Following inactivated flu vaccine:
• Pain, swelling or redness at the injection site, low grade fever, malaise,
shivering, fatigue, headache, myalgia and arthralgia
•
A small painless nodule (induration) may also form at the injection site
•
These symptoms usually disappear within one to two days without
treatment
Following live attenuated flu vaccine:
• Nasal congestion/rhinorrhoea, reduced appetite, weakness and
headache
•
Rarely, after live or inactivated vaccine, immediate reactions such as
urticaria, angio-oedema, bronchospasm and anaphylaxis can occur
Influenza update 2016/17
Resources -
Welsh Government Posters and leaflets
NHS Wales immunisation leaflets and posters
[email protected]
Phone number: 0845 606 4050
Influenza update 2016/17
Resources -websites
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NHS Direct Wales –primary source of public facing flu information in Wales:
http://www.nhsdirect.wales.nhs.uk/Encyclopaedia/f/article/flujab,seasonal/#Le
aflets
Flu “Frequently Asked Questions”
http://nww.immunisation.wales.nhs.uk/check-the-faqs
Template PGD
http://nww.immunisation.wales.nhs.uk/pgds-psds
Public Health Wales: Influenza page
http://www.wales.nhs.uk/sitesplus/888/page/43745
Influenza vaccination programme intranet page 2016-17
http://nww.immunisation.wales.nhs.uk/flu-2016-17-season
Public Health Wales: Childhood influenza vaccination programme 2016-17
www.publichealthwales.org/childrensfluvaccine
Childhood influenza vaccination programme intranet page 2016-17
http://nww.immunisation.wales.nhs.uk/childhood-influenza-vaccinationprogramm-3
Influenza update 2016/17
Resources -websites
WHO influenza information
• http://www.euro.who.int/en/what-we-do/health-topics/diseasesand-conditions/influenza
Beat Flu
• www.beatflu.org – public facing information, fully endorsed by
Public Health Wales
My Health Text
• My Health Text - supporting free text messaging services for
general practice
Influenza update 2016/17
Resources – e-learning
• Three flu related e-learning resources are
available:
– FluOne (health) - Information for all NHS
Staff
– FluOne (social) - Information for social care
staff (including care home workers)
– FluTwo - Information for immunisers
Influenza update 2016/17
References
1. Osterholm, MT, Kelley, NS, Sommer, A, and Belongia, EA (2012) Efficacy and effectiveness of influenza vaccines: a systematic review and meta-analysis. Lancet Infect Dis. 12(1.1),
36-44.
2. Fleming DM, Watson JM, Nicholas S et al. (1995) Study of the effectiveness of influenza vaccination in the elderly in the epidemic of 1989/90 using a general practice database.
Epidemiol Infect 115: 581–9
3. Wright PF, Thompson J, Vaughn WK et al. (1977) Trials of influenza A/New Jersey/76 virus vaccine in normal children: an overview of age-related antigenicity and reactogenicity. J
Infect Dis 136 (suppl): S731–41.
4. Mangtani P, Cumberland P, Hodgson CR et al. (2004) A cohort study of the effectiveness of influenza vaccine in older people, performed using the United Kingdom general practice
research database. J Infect Dis 190(1): 1–10.
5. Pebody, R et al. (2015) Low effectiveness of seasonal influenza vaccine in preventing laboratory-confirmed influenza in primary care in the United Kingdom: 2014/15 mid-season
results. Eurosurveillance. 20. Issue 5. www.eurosurveillance.org/ViewArticle.aspx?ArticleId=21025
6. Immunisation against infectious disease (‘the Green Book’) Chapter 19 ‘Influenza’. Updated 21 May 2015. Available at: https://www.gov.uk/government/organisations/public-healthengland/series/immunisation-against-infectious-disease-the-green-book
7. Public Health England. Surveillance of influenza and other respiratory viruses in the United Kingdom: winter 2014 to 2015. Published May 2015. Available at:
https://www.gov.uk/government/statistics/annual-flu-reports
8. Morgan OW, Bramley A, Fowlkes A, et al. Morbid obesity as a risk factor for hospitalization and death due to 2009 pandemic influenza A(H1N1) disease PLoS One. 2010 Mar 15;5(3)
9. Fezeu L, Julia C, Henegar A, Bitu J et al. Obesity is associated with higher risk of intensive care unit admission and death in influenza A (H1N1) patients: a systematic review and
metaanalysis. Obes Rev. 2011 Aug;12(8):653-9
10. Van Kerkhove MD, WHO Working Group for Risk Factors for Severe H1N1pdm Infection. Risk factors for severe outcomes following 2009 influenza A (H1N1) infection: a global pooled
analysis. PLoS Med. 2011 Jul;8(7):e1001053
11. Public Health England. Influenza immunisation programme for England GP patient groups. Data collection survey. Season 2014 to 2015. Available at:
https://www.gov.uk/government/statistics/seasonal-flu-vaccine-uptake-in-gp-patients-in-england-winter-season-2014-to-2015
12. Neuzil KM, Reed GW, Mitchel EF et al. (1998) Impact of influenza on acute cardiopulmonary hospitalizations in pregnant women. Am J Epidemiol. 148:1094-102
13. Pebody R et al. (2010) Pandemic influenza A (H1N1) 2009 and mortality in the United Kingdom: risk factors for death, April 2009 to March 2010. Eurosurveillance 15(20): 1957
14. Pierce M, Kurinczuk JJ, Spark P et al. (2011) Perinatal outcomes after maternal 2009/H1N1 infection: national cohort study. BMJ. 342:d3214.
15. McNeil SA, Dodds LA, Fell DB et al. (2011) Effect of respiratory hospitalization during pregnancy on infant outcomes. Am J Obstet Gynecol. 204: (6 Suppl 1) S54-7.
16. Omer SB, Goodman D, Steinhoff MC et al. (2011) Maternal influenza immunization and reduced likelihood of prematurity and small for gestational age births: a retrospective cohort
study. PLoS Med. 8: (5) e1000441.
17. Benowitz I, Esposito DB, Gracey KD et al. (2010) Influenza vaccine given to pregnant women reduces hospitalization due to influenza in their infants. Clin Infect Dis. 51: 1355-61.
18. Eick AA, Uyeki TM, Klimov A et al. (2010) Maternal influenza vaccination and effect on influenza virus infection in young infants. Arch Pediatr Adolesc Med. 165: 104-11.
Influenza update 2016/17
Acknowledgements
• This resource was prepared by the Vaccine
Preventable Disease Programme, Public Health
Wales to support the influenza vaccination
programme 2016/17
• Some information has been adapted for use by
kind permission from colleagues in Public
Health England
Influenza update 2016/17
Copyright Public Health Wales © 2016