Flu Immunisation Programme 2019/20 - PowerPoint Presentation

Flu Immunisation Programme 2019/20Northern Ireland

AcknowledgementsPHA would like to acknowledge PHE for permission to adapt their slides and materials for use in Northern Ireland. Adapted for use by Immunisation/Vaccination Team (PHA, Northern Ireland)

Influenza / Flu Overview Is an acute viral infection of the respiratory tract Is highly infectious & spreads rapidly in closed communities Can be spread by people with mild / no symptoms Usually occurs most often in an 8-10 week period during the winter

Influenza viruses There are 3 types of influenza viruses: A viruses Causes the majority of seasonal flu cases and is always the cause of pandemics Animal reservoir – wildfowl, also carried by other mammals B viruses Associated with low-level sporadic disease Burden of disease mostly in children Predominantly found in humans C viruses Minor respiratory illness only

Flu A virus Two surface antigens: Haemagglutinin (H) Neuraminidase (N) Genetic material (RNA) in the centre Two Surface Antigens There are 18 different types of H and 11 different types of N

Flu A virus Two surface antigens: Haemagglutinin (H) Neuraminidase (N) Genetic material (RNA) in the centre Two Surface Antigens There are 18 different types of H and 11 different types of N e.g. H3N2 or H1N1

Antigenic Drift minor changes (natural mutations) in the genes of flu viruses that occur gradually over time Antigenic Drift

Antigenic Shift Two or more different strains combine. This abrupt major change results in a new subtype. Immunity from previous flu infections/vaccinations may not protect against the new subtype, potentially leading to a widespread epidemic or pandemic Antigenic Shift

Features of flu easily transmitted by droplets, small-particle aerosols and by hand to mouth/eye contamination from a contaminated surface or respiratory secretions of infected person people with mild or no symptoms can still infect others incubation period 1-5 days (average 2-3 days) though may be longer especially in people with immune deficiency 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 be seen

Possible complications of flu Common : bronchitis o titis media (children), sinusitis secondary bacterial pneumoniaLess common:meningitis, encephalitis, meningoencephalitisprimary influenza pneumoniaRisk of most serious illness is higher in children under six months older peoplethose with underlying health conditions such as respiratory disease, cardiac disease, long-term neurological conditions or immunosuppressionpregnant women (flu during pregnancy may be associated with perinatal mortality, prematurity, smaller neonatal size and lower birth weight) 10

Flu epidemiology 11 Primary Care ILI Consultation Rates (NI) 2018/19

National Flu Vaccination Programme Late 1960s : recommended to directly protect those in clinical risk groups at a higher risk of influenza associated morbidity and mortality 2000 : flu vaccine policy extended to include all people aged 65 years or over 2010 : pregnancy added as a clinical risk category for routine flu immunisation 2013 : pre-school 2 years + and all primary school children

Eligibility for 2019/20 flu vaccine programme Unchanged from 2018/19 programme Details can be found in: Department of Health (NI) CMO Letter 2019/20 www.gov.uk/government/publications/influenza-the-green-book-chapter-19 However list of eligible groups is not exhaustive Clinical judgement should be applied to take account risk of flu exacerbating any underlying disease as well as the risk of serious illness from flu itself 13

Eligibility for 2019/20 flu vaccine programme All individuals aged 65 years or over Individuals aged six months to under 65 years in a clinical risk group All children aged 2 – 11 years (pre-school and primary school) Individuals living in long-stay residential care homes or facilities (does not include prisons, young offender institutions / halls of residence) Main carers of an elderly / disabled personChild contacts of very severely immunocompromised individualsHealth & social care staff in direct contact with patients / clients

Clinical risk groups The national flu immunisation programme 2017/18

Clinical risk groups The national flu immunisation programme 2017/18

Vaccine Uptake Targets 2019/20 Eligible Group Uptake Ambition Aged 65 and over 75% Aged under 65 “at clinical-risk” 75% Pregnant women 60% Pre-school children aged 2 years / over 60%Primary school aged children (P1-P7)75%Trust –employed frontline Health Care Workers≥50%Trust- employed frontline Social Care Workers≥40%

Vaccination of Clinical Risk Groups i ncreasing flu vaccine uptake in clinical risk groups is important because of increased risk of death and serious illness from flu despite those with liver disease and chronic neurological disease having some of the highest mortality rates , they have low flu vaccine uptake rate compared with those in other clinical risk groupsvaccine uptake for all those in clinical risk groups needs to improve - particularly in those with chronic liver and neurological disease

Pregnant women All pregnant women should be offered the inactivated flu vaccine by their G.P. irrespective of the stage of pregnancy p regnant women at increased risk from complications of flu flu during pregnancy associated with premature birth and smaller birth size and weightflu vaccination during pregnancy provides passive immunity against flu to infants in the first few months of lifestudies on 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

Rationale for vaccinating children against flu Extension of the seasonal flu vaccination programme to all children aims to appreciably lower the public health impact of flu by : providing direct protection thus preventing a large number of cases of flu infection in children providing indirect protection by lowering flu transmission from children: to other childrento adultsto those in the clinical risk groups of any age 20 The national flu immunisation programme 2018/19

Health and social care workers duty of care to protect patients and service users from infection Flu vaccine reduces transmission of flu to: HSCW vulnerable patients, who may have impaired immunity and not respond well to immunisation, and other service usersColleagues and family memberssignificantly lowers rates of flu-like illness, hospitalisation and mortality in elderly in long-term healthcare settingsreduces sickness absences and contributes to delivery of Health and Social Care services during winter pressures

When to vaccinate vaccinate as soon as vaccine available so people are protected when flu begins to circulate in the communityTry to vaccinate by December before flu circulation peaks however continue to offer vaccination from throughout the season especially if level of flu activity is highRemember that immune response following flu vaccination takes about two weeks to develop fullyprotection afforded by the vaccine thought to last at least one influenza seasonhowever, as antibody levels likely to reduce in subsequent seasons and there may be changes to circulating strains from one season to next, annual revaccination is important 22

Start of 2019/20 programme Official launch 1 st October 2019 All Practices should receive initial deliveries of injectable flu vaccines before end September Nasal flu vaccine for children can be ordered from 1 st October Can start clinics once have received vaccine Leaflets expected to be delivered by first week in September Leaflets can be downloaded from PHA web-site PGDs available from end of August

Types of Flu Vaccines Inactivated vaccines (by injection)Egg-based Quadrivalent Inactivated Vaccine (QIVe) Sanofi Pasteur Quadrivalent Inactivated vaccine Adjuvant Trivalent Inactivated Vaccine (aTIV) Fluad Cell-based Quadrivalent Inactivated Vaccine (QIVc) Flucelvax tetraLive Attenuated Influenza Vaccine (nasal application)Quadrivalent LAIV Fluenz tetra

The only trivalent vaccine used in Northern Ireland is Fluad (aTIV) which is the vaccine of Choice for > 65 year olds. WHO recommends that trivalent flu vaccines for 2019/20 contain: Flu Vaccine composition 2019/20

The only trivalent vaccine used in Northern Ireland is Fluad (aTIV) which is the vaccine of Choice for > 65 year olds. WHO recommends that trivalent flu vaccines for 2019/20 contain: an A/Brisbane/02/2018 (H1N1)pdm09-like virus an A/Kansas/14/2017 (H3N2)-like virus a B/Colorado/06/2017-like virus (B/Victoria/2/87 lineage) and Flu Vaccine composition 2019/20

Quadrivalent vaccines for use in the 2019/20 northern hemisphere influenza season: Fluenz Tetra (LAIV), Sanofi Pasteur Quadrivalent Inactivated Vaccine (QIVe) and Flucelvax Tetra (QIVc) contain : Flu Vaccine composition 2019/20

Quadrivalent vaccines for use in the 2019/20 northern hemisphere influenza season: Fluenz Tetra (LAIV), Sanofi Pasteur Quadrivalent Inactivated Vaccine (QIVe) and Flucelvax Tetra (QIVc) contain: an A/Brisbane/02/2018 (H1N1)pdm09-like virus an A/Kansas/14/2017 (H3N2)-like virus a B/Colorado/06/2017-like virus (B/Victoria/2/87 lineage) and a B/Phuket/2073/2013-like virus (B/Y amagata/16/88 lineage Flu Vaccine composition 2019/20

Flu Vaccine Composition 2019/20 None of the influenza vaccines for the 2019/20 season offered in Northern Ireland contain thiomersal as an added preservative More detailed information on the characteristics of the available vaccines, including age indications can be found in the Influenza chapter of the Green Book (Immunisation against infectious disease) and the product SPCs: FLUAD (aTIV) Fluenz Tetra (LAIV) Sanofi Pasteur Quadrivalent Inactivated Vaccine (QIVe) Flucelvax Tetra (QIVc)

Flu vaccine effectiveness In 2018/19 flu season overall flu vaccine effectiveness was 44.3% 48.6% effective children age 2 to 17 years 44.2% at-risk groups 18 to 64 years 49.9% in 65 years and over 62% in 65 years and over who received aTIV aTIV in > 65 year olds introduced last year following JCVI recommendations (higher vaccine immunogenicity)

31 Which flu vaccine should be used?

Flu Vaccines Available 2019/20

Inactivated Flu Vaccines Fluad ( a TIV) Sanofi Pasteur Quadrivalent Inactivated Vaccine (QIVe) Flucelvax Tetra (QIVc)

Adjuvanted Trivalent Inactivated Vaccine (aTIV) FLUAD ® (Age 65 and over)

Types of flu vaccines - FLUAD ® (aTIV) Has higher immunogenicity & effectiveness than non-adjuvanted, normal doses in the elderly Adjuvant (MF59) added to enhance immune response & counter the effect of immunosenescence aTIV is not suitable for anyone with an egg allergy / Latex allergy Should only be administered I.M. (Needle supplied in box = 25 gauge)

Types of flu vaccines (Trivalent) Only one trivalent vaccine available again this year Adjuvanted Trivalent Inactivated Vaccine (aTIV) = FLUAD® Available to those aged 65 years / over JCVI considers to be more effective & cost-effective than non-adjuvanted vaccines Should be a priority for those 75 years and over aTIV has an excellent safety record No anticipated restricted ordering this year

Administration of FLUAD® Milky-white suspension Intramuscular Injection only Only one dose vaccine Administer single dose of 0.5ml into the deltoid muscle using a 1-inch 25G needle supplied with vaccine (Deltoid)

Sanofi Pasteur Quadrivalent Inactivated Vaccine (QIVe) Licensed from 6 months Children in at-risk groups age 6 months to < 2 years Children age 2 years to < 18 years when Fluenz Tetra (LAIV) is contra-indicated

Sanofi Pasteur Quadrivalent Inactivated Vaccine (QIVe) Adults age 18 to < 65 years Adults age 65+ when FLUAD® (aTIV) is contra-indicated e.g. egg allergy not did not result in anaphylaxis requiring an intensive care admission/ latex allergy

Sanofi Pasteur Quadrivalent Inactivated Vaccine (QIVe) The vaccine available for delivering the flu vaccine programme for frontline healthcare workers Frontline healthcare workers age 65+ may attend G.P. for vaccination (FLUAD®)

Sanofi Pasteur Quadrivalent Inactivated Vaccine (QIVe) S upplied as suspension in pre-filled syringe containing a 0.5ml dose (colourless opalescent liquid) One dose required unless child is in a clinical risk group and < 9 years old and has not previously received a flu vaccineIf second dose required leave at least 4 weeks between vaccinesI.M Deltoid if > 1 yearAnterolateral thigh in infants 6 months- 1 year

Administration of flu vaccines givenby injection Patients taking anticoagulants / with bleeding disorder Individuals on stable anticoagulation therapy (including individuals on warfarin who are up-to-date with their scheduled INR testing and whose latest INR was below the upper threshold of their therapeutic range) can receive intramuscular vaccination if in any doubt, consult with the clinician responsible for prescribing or monitoring the individual’s anticoagulant therapy 42

Administration of flu vaccines givenby injection Patients taking anticoagulants / with bleeding disorder Individuals with bleeding disorders may be vaccinated intramuscularly if, in the opinion of a doctor familiar with the individual's bleeding risk, vaccines or similar small volume intramuscular injections can be administered with reasonable safety by this route if the individual receives medication/treatment to reduce bleeding, for example treatment for haemophilia, intramuscular vaccination can be scheduled shortly after such medication/treatment is administered a fine needle (equal to 23 gauge or finer calibre) should be used for the vaccination, followed by firm pressure applied to the site (without rubbing) for at least 2 minutes influenza vaccines licensed for intramuscular or subcutaneous administration may alternatively be administered by the subcutaneous route. Fluad ® and Flucelvax® Tetra are not licensed for subcutaneous administration so should only be administered intramuscularly

Live attenuated influenza Vaccine (LAIV) FLUENZ TETRA (Age 2 to < 18)

Fluenz Tetra® presentation single use prefilled nasal applicator ready to use (no reconstitution or dilution required) nasal spray (suspension) the suspension is colourless to pale yellow, clear to opalescent. Small white particles may be present each applicator contains 0.2ml (administered as 0.1ml per nostril)

Live attenuated influenza vaccine Fluenz Tetra (LAIV) a live attenuated intranasal spray has been shown to be more effective in children compared with inactivated influenza vaccines (administered by injection) it may offer some protection against strains not contained in the vaccine as well as to those that are and has the potential to offer better protection against virus strains that have undergone antigenic drift

Live attenuated influenza vaccine Fluenz Tetra (LAIV) since this vaccine is comprised of weakened whole live virus, it replicates natural infection which induces better immune memory (thereby offering better long-term protection to children than from the inactivated vaccines) i n addition to being attenuated (weakened ), the live viruses in LAIV have been adapted to cold so that they cannot replicate efficiently at body temperatureLAIV has a good safety profile in children aged two years and older

Live attenuated influenza Vaccine (LAIV) Fluenz Tetra Each applicator contains 0.2ml (administered as 0.1 ml per nostril) One dose required unless child is in a clinical risk group and < 9 years old and has not previously received a flu vaccine If second dose required leave at least 4 weeks between vaccines

Administration of L ive Attenuated Influenza vaccine ( LAIV)-Fluenz Tetra It is a live attenuated nasal vaccine and must not be injected d o not attempt to attach a needle LAIV can be administered at the same time as, or at any interval from other vaccines including live vaccinespatient should breathe normally – no need to actively inhale or sniffthe vaccine is rapidly absorbed so no need to repeat either half of dose if patient sneezes, blows their nose or their nose drips following administration

Fluenz Tetra (LAIV) As well as being used for the new programme for healthy children Fluenz Tetra is the vaccine of choice for at risk children aged 2 to 17 years inclusive – except where contraindicated. Sufficient vaccine has been ordered to easily provide for all such children. Majority of fluenz supplies expire at the end of December so plan to complete programme by then and check expiry date before use

Storage of all flu vaccine Efficacy, safety and quality may be adversely affected if vaccines are not stored at the temperatures specified in the licence Flu vaccines must be stored in accordance with manufacturer’s instructions : store between + 2⁰C and + 8⁰C do not freezestore in original packagingprotect from lightCheck expiry dates regularly:the LAIV has an expiry date 18 weeks after manufacture – this is much shorter than inactivated flu vaccinesit is important that the expiry date on the nasal spray applicator is checked before use 51

Vaccine Intervals There is no interval required between live and inactivated flu vaccines If two / more vaccines are given at the same time give in separate limbs / leave at least 2.5 cms between administration sites Fluad should be administered in a separate limb if possible See Chapter 11 The Green Book

There are very few individuals who cannot receive any flu vaccine 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 see precautions) Fluad (aTIV) is contra-indicated in anyone with an egg / latex allergy Note: Always refer to SPC for individual products when deciding which vaccine to give Contraindications (Inactivated Vaccines & LAIV)

The live attenuated flu vaccine ( Fluenz Tetra ) should not be given to children who are: clinically severely immunodeficient due to conditions or immunosuppressive therapy: acute and chronic leukaemias l ymphoma HIV infection not on highly active antiretroviral therapycellular immune deficiencieshigh dose corticosteroidsreceiving salicylate therapy known to be pregnant See subsequent slide for children with acute and severe asthma Contraindications (LAIV)

Precautions to vaccination

Acutely unwell: defer until recovered Heavy nasal congestion: defer live intranasal vaccine until resolved or, if the child is in a risk group, consider inactivated flu vaccine to provide protection without delay Use with antiviral agents against flu :live flu vaccine (LAIV) should not be administered at the same time or within 48 hours of cessation of treatment with flu antiviral agentsadministration of flu antiviral agents within two weeks of administration of LAIV may adversely affect the effectiveness of the vaccine 56 Precautions to flu vaccines

Acute and severe asthma New guidance for 2019 from JCVI based on recent data C hildren with asthma on inhaled corticosteroids may safely be given LAIV irrespective of the dose prescribed LAIV is not recommended for children and adolescents currently experiencing an acute exacerbation of symptoms including - those who have had increased wheezing and/or - needed additional bronchodilator treatment in the previous 72 hours Such children should be offered a suitable inactivated influenza vaccine to avoid a delay in protectionchildren who require regular oral steroids for maintenance of asthma control, or have previously required intensive care for asthma exacerbation should only be given LAIV on the advice of their specialist As these children may be at higher risk from influenza infection, those who cannot receive LAIV should receive a suitable inactivated influenza vaccineChildren with significant asthma and aged under nine years who have not been previously vaccinated against influenza will require a second dose (of either LAIV or inactivated vaccine as appropriate).

Egg allergy – adults m ost flu vaccines are prepared from flu viruses grown in embryonated hens’ eggs – the final vaccine products contains varying amounts of egg (as ovalbumin) a dults 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 <0.06µg for 0.5ml dose) e.g. Sanofi Pasteur Quadrivalent Inactivated flu vaccine (QIVe) / Flucelvax Tetra (QIVc)adults with severe anaphylaxis to egg that has previously required intensive care should be offered Flucelvax Tetra (QIVc) unless contra-indicated e.g. latex allergy-Available by submitting form to Movianto if requiredSee CMO Letter annex 1 for table containing flu vaccines for 2019/20

Egg allergy – children c hildren with an egg allergy can be safely vaccinated with the LAIV in any setting (including primary care and schools) children who have required admission to intensive care for a previous severe anaphylaxis to egg should be given LAIV in a hospital setting / if 9 years / older and LAIV contra-indicated for other reasons can be considered for Flucelvax Tetra (QIVc) in any settingIf < 9 years there is no licensed egg-free vaccine available

Egg allergy – children those with both egg allergy (without anaphylaxis requiring intensive care admission) and clinical risk factors that contraindicate LAIV (e.g. immunosuppression) should be offered an* inactivated flu vaccine with a very low ovalbumin content (less than 0.12μg/ml) e.g. Sanofi Pasteur Quadrivalent Inactivated VaccineEgg-allergic children with asthma can receive LAIV if their asthma is well-controlled (see previous slide on severe asthma)*Children in a clinical risk group and aged under nine years who have never previously received influenza vaccine will require a second dose, one month after the first dose, whether given LAIV / inactivated vaccine

Flu Vaccines with Low Ovalbumin Content / Egg-free The following vaccines, available for the 2019/20 flu season, have a very low ovalbumin content (< 0.12μg/ml – equivalent to < 0.06μg for a 0.5ml dose) and may be used safely in individuals with egg allergy Supplier Name of product Vaccine type Age indicationAstraZeneca UK LtdFluenz Tetra Live attenuated, nasal (quadrivalent)From 24 months to less than 18 years of ageSanofi Pasteur VaccinesQuadrivalent Influenza Vaccine (Split Virion, inactivated) Split virion inactivated virusNote: This vaccine is only available for the school delivered flu programmeFrom 6 months Sequiris Flucelvax TetraQuadrivalent Influenza Vaccine (Cell Grown-QIVc) From 9 years

theoretical potential for transmission of live attenuated virus to immunocompromised contacts risk is for one to two weeks following vaccination e xtensive use of the live attenuated influenza vaccine in US – no reported instances of illness or infections from the vaccine virus among immunocompromised patients inadvertently exposed to vaccinated childrenhowever, where close contact with very severely immunocompromised patients (e.g. bone marrow transplant patients requiring isolation) is likely or unavoidable (e.g. household members) consider an appropriate inactivated flu vaccine instead Risk of Transmission of Live Vaccine Virus

Exposure of healthcare workers to live attenuated influenza vaccine viruses (Fluenz) theoretically there may be some l ow level exposure to the vaccine viruses for those administering LAIV and/or from recently vaccinated patients risk of acquiring vaccine viruses from the environment is unknown but probably low the vaccine viruses are cold-adapted and attenuated and therefore unlikely to cause symptomatic influenza in the US there has been extensive use of LAIV:-No transmission of vaccine virus in healthcare settings has been reported-No reported instances of illness or infections from the vaccine virus among healthcare workers inadvertently exposedas a precaution, very severely immunosuppressed individuals should not administer LAIVother healthcare workers who have less severe immunosuppression or are pregnant, should follow normal clinical practice to avoid inhaling the vaccine and ensure that they themselves are appropriately vaccinated

Inadvertent administration of LAIV if an immunocompromised individual receives LAIV, the degree of immunosuppression should be assessed i f patient is severely immunocompromised, antiviral prophylaxis should be consideredotherwise they should be advised to seek medical advice if they develop flu-like symptoms in the four days following administration of the vaccineif antivirals are used for prophylaxis or treatment, patient should also be offered inactivated flu vaccine in order to maximise their protection in the forthcoming flu season (this can be given straight away) 64

Commonly reported adverse reactions Following inactivated flu vaccine: pain , swelling or redness at the injection site, low grade fever, malaise, shivering, sweating, fatigue , headache, myalgia and arthralgia a small painless nodule may also form at the injection sitethese symptoms usually disappear within one to two days without treatmentFollowing 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 65

66 Reporting suspected adverse reactions All serious suspected reactions following flu vaccination should be reported to the Medicines and Healthcare products Regulatory Agency using the Yellow Card scheme at http://yellowcard.mhra.gov.uk / All of the inactivated quadrivalent flu vaccines carry a black triangle symbol (▼) ( a s do all vaccines during the earlier stages of their introduction)This is to encourage reporting of all suspected adverse reactions

Please, Please, PLEASE Don’t Over Order Movianto will deliver next working day Will deliver as often as needed Only order what you need for next week This avoids: Vaccine being left over at end of campaign Vaccine can’t be taken back once it has been delivered Large losses if fridge breaks down Flucelvax Tetra can only be ordered by contacting Movianto directly with details of why vaccine is being ordered

Details for 2019/20 - In schools All Primary School children (P1 – P7 inclusive) will be offered the vaccine in school; Includes “at risk” children as well as healthy children; DOB range: 02/07/2008 – 01/07/2015 – GPs should NOT invite these children for vaccination even those in risk groups Fluenz Tetra® will be offered to most children – those for whom contraindicated but who can receive injected vaccine will be offered injected vaccine in school; No mop-up service and if vaccine is missed in school / second vaccine required, the parent / guardian will be advised by school nursing team to contact G.P.

Details for 2019/20 - General Practice All pre-school children aged 2 years and over on 1 September 2019 should be actively invited for flu vaccination. (DOB range: 02/07/15 – 01/09/17) Pre-school children who turn 2 between 1/9/19 and 30/12/19 can be offered vaccination if requested by parents Children of all ages in risk groups – invited as normal – except those in any year in Primary School or a special school who will be offered vaccine in school DOB: 02/07/2008 – 01/07/2015 Post-primary school children in clinical risk groups should be identified and actively invited for vaccination in primary care Children who missed vaccine in primary school / who require second vaccine (clinical risk group + < 9+never previously received flu vaccine)

Primary school children GPs DO need to vaccinate School health teams will visit each school once only – no mop-up of those absent on day of visit; Parents will be advised to contact GP if require vaccine – particularly important for “at risk” children; A few children will require a second vaccine after 4 weeks – again parents will be advised to contact GP for this; Onus is on parents to contact GP, but should be facilitated if request is made Normal fee payable for all such children vaccinated by GP (Both “healthy” and “at risk”)

Resources The Green Book: Influenza Chapter DH CMO letter seasonal influenza 2019/20 Flu patient information leaflets Flu healthcare worker’s factsheet PHA flu page