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2018-19 Flu Vaccination Season

Background:

For some of us the complications of this season have been happening around us. To summarise
there are 3 vaccines that we have to administer as part of the flu DES this year. The under 18’s get
the live attenuated nasal spray, the under 65’s get the quadrivalent inactivated (QIV) and the over
65’s get the adjuvanted trivalent inactivated (aTIV). The adjuvant boosts the immune response to
the vaccine in the elderly so although it covers less strains than the QIV the response is better.

This has been a complicated message as last year there was a quadrivalent and a trivalent and the
former probably offered more protection than the latter but was not recommended as cost
effective. I think some may have initially confused the aTIV with the previous trivalent and thought it
would be sensible to give everyone the “better” QIV. However, it has been shown that the aTIV gives
better protection in the over 65’s (especially the over 75’s) than the non-adjuvant vaccines. The
evidence is available here:

https://www.gov.uk/government/publications/flu-vaccination-supporting-data-for-adult-
vaccines/summary-of-data-to-support-the-choice-of-influenza-vaccination-for-adults-in-primary-
care

The problem with aTIV is that there is one supplier (Seqirus) and they are struggling to meet
demand. Practices that were slow to realise they would need QIV and aTIV have been unable to
source any aTIV. Practices and pharmacies who have ordered aTIV will be receiving their ordered
supply in a staggered delivery (40% Sept, 20% Oct, 40% Nov).

As the evidence is robust and this is a public health DES it is not okay to offer the QIV to the over
65’s except in exceptional circumstances (more later). The slight caveat to this might be an elderly
person who has appraised the evidence, is fully informed and requests QIV (they might decide to
swap reduced efficacy for the lower rates of vaccination reactions from the QIV). Consent and
reasons would need to be documented.

Current state of play:

Public Health England (PHE) are stating that across the South West the amount of aTIV ordered by
GPs and pharmacies exceeds the number of over 65’s vaccinated last year. Consequently, there
should be enough for that cohort overall – however it is likely to not all be in the right place at the
right time.

The LMC, PHE and Local Pharmaceutical Committee (LPC) are currently collecting information of who
has what and who has ordered what. You may be approached by us for this information if you have
not already submitted it. The hope is there can then be a bit of mapping of supply to need and some
locality coordinated work. I am not sure supplies will be able to be shipped from one provider to
another as that may breach some regulatory issues but we shall see.

PHE have stated that the usual flu season starts in December and it takes about 2 weeks to raise an
immune response to vaccination. They feel it is safe to delay administering the flu vaccine until the
middle of November and in fact are keen to promote the message that it is never too late for a flu
jab.
Kernow LMC advice to practices:

Submit any information on aTIV and QIV supplies to the LMC if approached.

If you have a supply of aTIV you need to plan a targeted approach to your population. It is possible
Seqirus may not fulfil its orders for reasons beyond their control. In this scenario we need to make
sure that the most likely to benefit get the limited aTIV available. This means that when you receive
your first 40% you need to target over 75’s and the frail housebound. Next come the 65-74’s with at
risk co-morbidity and then the rest as your remaining 20%/40% deliveries come through. In the
background you can run your under 65’s QIV program as usual. Clearly this presents us with a
complex appointment/recall matrix.

If you have no aTIV then we suggest that you crack on with flu clinics for the under 65’s using QIV
and await further guidance from the LMC/PHE over where to direct your over 65’s to get their aTIV.
In terms of what to tell patients at this stage it is tricky as we do not have the full story. A sensible
approach would be to explain there have been some supply problems and the practice is trying to
solve them. In the interim your patients have the choice of contacting their local pharmacy to see if
they have a supply or hanging on for a few weeks whilst you work with NHSE to overcome supply
issues. If we get to November and it is clear there is not enough aTIV being distributed/re-distributed
PHE may declare that there are exceptional grounds for giving the over 65’s QIV. So, it may be you
just end up running later than usual flu clinics for the elderly if Seqirus falls over.

This is an enhanced service and consequently is voluntary but if you are signed up to do it you are
obliged to play by the rules. The problem going forward will be that if the program is always this
complicated the remuneration may not make it commercially viable for practices. We shall see.

Of note the DES includes administering pneumovax so if you are not in a position to give aTIV it
might be worth maximising pneumovax income by checking everyone who should be covered is
(clearly we should do this anyway but you know what I mean).

Will Hynds

Chair Kernow LMC