- 28 Oct 2020
This year, the seasonal flu vaccination programme takes on new significance. We expect the onset of seasonal flu within the next 2 or 3 months. Covid-19 will still be in circulation. Both infections present with similar symptoms. Cough, temperature, tiredness and muscle soreness are common to both conditions. Loss of taste or smell is the only presenting symptom unique to Covid-19. It is likely, therefore, that it will be difficult to distinguish, clinically, between the two conditions in patients seeking medical advice. To support safe and effective management of Covid-19 patients, it is essential we do all we can to minimise the impact of influenza in the coming winter. This paper outlines proposals for the seasonal flu vaccination programme.
1. Flu vaccination should be available to a wider range of people
The demands on primary care staff of this year's flu vaccination programme will be considerable and they will need support from health boards and HSCPs. In previous years, the vaccine has been offered to those over 65, those with health problems that increase the risk of serious complications if they contracted flu, health and care workers, pregnant women and all children of primary school age. More people will be eligible to receive the vaccine and the aim will be to immunise considerably greater numbers of those eligible.
This year, it is proposed that the eligible groups should be expanded to include those over 55. The UK Government has, apparently, purchased a larger number of doses than usual. Health Boards should plan for both an extended range of people being immunised and a greater increase in uptake. Typically, we might see 50-60% of the eligible population receiving the vaccine. This year, we should aim for a significantly higher percentage of the general population and, at least, 90% of health and care home staff receiving it. It is unlikely sufficient vaccine will be available at the beginning of the programme to cover such an expanded target population. Phasing of the programme will be necessary with priority groups being vaccinated first and other groups being vaccinated as more doses become available. If more doses become available, it should be offered to those over 50.
If the aim is to start vaccination at the beginning of October, health and care workers should come first with the elderly and those shielding with serious risk factors coming soon after. As more doses become available, a further phase of vaccinations can be planned. If they have not already done so, Health Boards should be asked to urgently assess the number of doses of vaccine they will need to cover both the expanded list of people eligible and to provide for much greater uptake within the eligible groups. They should plan for 2 or 3 phases of the campaign and begin to draw up lists of who will be invited and when.
2. Strategies to enhance uptake
The annual uptake of flu vaccine can be anywhere between 40% and 60% of those who are offered it. This year, we will need a concerted information campaign to increase uptake to a level which protects the NHS from being overloaded with patients who have serious complications of flu and reduces demand on a system which may have to cope with increased numbers of Covid-19 cases. There are a number of possible strategies.
1. Compulsion: We can find evidence of only two countries using compulsion as a strategy this year. South Africa has made flu vaccination compulsory for all health care workers and Australia has made vaccination essential for anyone entering an elderly care home. This includes all visitors, volunteers, staff and health care workers. Health care workers in primary care and hospitals are not required to be vaccinated.
Discussion with a wide range of groups suggests that compulsory vaccination of health care workers in Scotland might have an adverse impact on overall uptake within the population. Some health care professions might see compelling people to have a vaccine as being contrary to the principle of informed consent and, therefore unethical. The risk is that they would make their objections public, thereby undermining the confidence of the population at large in the programme. There are already a number of people in every community who refuse the vaccine and one often hears the complaint that "the vaccine gave me the flu." It can't of course but any strategy which involves government compulsion seems likely to encourage debate which might bring the "anti-vaxxers" to the fore and make it more difficult to persuade the general population of the safety and efficacy of the vaccine.
2. A heart and minds approach: The approach most likely to produce a high uptake of vaccination is one which appeals to the community spirit which was so obvious during the initial phase of the pandemic. "Protect the NHS" was a slogan which produced public support for compliance during lockdown. If we had, as part of the campaign, a similar approach which encouraged uptake of the vaccine not only to protect our fellow citizens but also to ease the burden an NHS which was still coping with the demands of Covid, then we might see a considerable increase in vaccination uptake across all sectors of society, including health care workers. The General Medical Council requires doctors to act in the best interests of their patients. A reminder that getting vaccinated against flu would be an important way of keeping patients safe would encourage uptake. Discussion on this point with the BMA in Scotland suggests that they would publicly back such an approach and would encourage their members to be vaccinated. We should also ask the other professional bodies such as the RCN and those organisations representing Allied Health Professionals to show their support. Maintaining public confidence in the vaccination process and the support the health professions have for it will be critical for the next vaccination programme which will be to protect against Covid-19
This approach has been discussed with colleagues in some of the advisory committees that have been set up during the pandemic. It is widely supported as having the potential to be the most effective way of increasing uptake.
3. We need an accurate data collection system.
All the staff involved in vaccination programmes have pointed to the lack of an effective system for knowing who has or has not been vaccinated. Such data would allow those who have failed to take up the offer to be identified and followed up with further appointments. If, as seems likely, there will be phasing of different groups of people being vaccinated, accurate systems for identifying those still to be vaccinated will be necessary. Knowing who has been vaccinated against flu might also help in the management of patients presenting with symptoms. Someone with a cough and temperature who has been vaccinated against flu might be more likely to have Covid-19 and be managed more appropriately. Some Health Boards apparently had better data collection than others and they should work together to establish such a Scotland wide system as a matter of urgency.
4. Where should flu vaccination take place?
In previous years, vaccination was carried out in GP surgeries. GPs would usually advertise locally that vaccination was available, and they might arrange a session in which a great many patients were vaccinated. This year, for several reasons, a different approach is necessary.
The Royal College of General Practitioners has offered guidance on facilities suitable for large scale vaccination programmes. The first concern is safety. Social distancing remains in force and many GP surgeries have small waiting areas which would struggle to contain the numbers of patients being vaccinated. Most countries are planning to provide vaccination in more suitable sites such as large clinics where a significant number of patients can be seen. At present, staff wear full PPE in their interactions with patients. However, given the brief interaction involved in vaccination, it might be possible to limit PPE requirements simply to a mask and visor and have the person administering the vaccine wash their hands between patients. The four UK countries are presently discussing this. Different points of entrance and exit which are clearly signed should be established.
Some countries have used drive through systems although these have problems if the outdoors area has limited access to power since vaccine cannot then be stored at a suitable temperature. There was no enthusiasm for such arrangements in the group.
The use of Covid Assessment Centres for vaccination was discussed and discounted since there would be a risk of spreading infection. An important requirement would be that patients with symptoms should not attend for vaccination until the symptoms had settled.
Staff availability is likely to be an issue with the greater numbers of people to be vaccinated. It has been suggested that retired NHS staff should be asked back to help deliver the programme
5. What can the experience of winter in the southern hemisphere tell us to expect?
Most Southern hemisphere countries have been successful in increasing vaccine uptake. They have obtained greater numbers of doses than usual and this should indicate to us that the required number of doses needs to be calculated and procured very quickly.
The flu season in Southern countries has, in fact been very quiet. This may be partly as a result of the success of the vaccination programme but, more likely, it has been due to the precautions taken against Covid-19. Social distancing, wearing masks, hand washing etc are all effective against the spread of airborne viruses such as flu. The experience of the Southern Hemisphere tells as that existing advice about suppression of Covid-19 should continue into the winter.
6. Recommended actions
Boards are well ahead with preparing their winter plans and most will be already thinking about these issues. It might be helpful if, instead of 14 different territorial boards coming up with plans, there was an improvement collaborative approach in which they shared ideas and implemented those which were most effective. Professor Jason Leitch has indicated his support for such an approach
Health Boards and their Public Health Departments should be asked to collate numbers of people in the target groups for vaccination. They need to assess the numbers of doses they need and begin to plan a phasing of vaccination in the event that there is insufficient available at the start of the season which is, at most 2 months away.
Health Boards and their primary care groups need to plan where vaccination can safely and conveniently take place. Small facilities which do not allow for social distancing are unsuitable and some groups of GPs are likely to want access to larger facilities which can handle a greater throughput safely.
The demands of this programme on primary care staff will be considerable and ways of enhancing the complement of individuals available to administer the programme need to be discussed.
Data collection as to who has been invited and who has had the vaccine needs to be accurate and centrally collected within each Health Board. Central support for such a system would be essential
A public information campaign needs to be prepared. Based on an appeal to support the NHS and to keep citizens safe at a time of Covid risk, the Campaign should include support from professional organisations to their members. This is best coordinated centrally.