Brexit 'Not to Blame for Flu Vaccine Delays'

Edna Astbury-Ward

October 04, 2019

Public Health England estimates that up to 25 million could get the flu vaccination this year if supply can keep up with demand.  

One million more people this year than last will be eligible. The Department of Health and Social Care (DHSC) and Public Health England (PHE) have advised that vaccination should be given in sufficient time to ensure patients are protected before flu starts circulating. However, if, as the vaccine manufacturers are warning, there is going to be a delay of 2 weeks due to distribution, manufacturing and packaging problems then the chances are that flu may be passed from person to person during that time. Symptoms start appearing within 2-4 days of contact.

Children 'Super Spreaders' of Flu

For the first time all primary school children (an extra 600,000) will be offered the nasal spray vaccine (unless contraindicated), which protects against four strains of flu. Children of this age are considered 'super spreaders', so it makes sense to do this in an attempt to increase herd immunity. Professor Yvonne Doyle, Public Health England medical director, expects the childhood programme to be completed by end of November/beginning of December. The Joint Committee on Vaccination and Immunisation (JCVI) recommended the live attenuated influenza vaccine (LAIV) as the vaccine of choice for children.  However, LAIV contains a highly processed form of gelatine (derived from pigs) and some faith groups do not accept the use of porcine gelatine in medical products. As yet there is not an alternative.

Flu vaccines are generally given from September to November as cases of flu peak in the new year. This year the majority of flu vaccines are expected to be in the UK by the end of October. However, one of the suppliers, Sanofi Pasteur, is only able to deliver just under two thirds of the vaccine; delivery of the remaining 35% will commence by November 18th.

Professor Jonathan Van-Tam, Deputy Chief Medical Officer told a news briefing this week that he didn't expect any delays to the delivery of the vaccines for the childhood or over 65's programmes. He added that Matt Hancock, Health Secretary has procured an extra 400,000 doses to be made available should the need arise. When asked the reason for the delay in delivery of some vaccines, he cited that the World Health Organisation (WHO) was not able to make an unequivocal decision for 4 weeks about which strains of the flu virus were to be recommended for manufacture, this together with unprecedented global demand meant that Sanofi could not meet delivery targets for 35% of the batch due for the UK.

Different strains of the flu virus are used in vaccine manufacture each year. Flu viruses change continuously and the WHO monitors the epidemiology of flu viruses throughout the world making recommendations about the strains to be included in vaccines for the forthcoming winter. Normally, the constituents of the flu vaccine used in the northern hemisphere are decided in February by the WHO. However, because this year it has taken longer to identify which strains of the flu virus were to be included this has had a knock-on effect on the production schedule.

Healthcare Workers Uptake

Professor Andrew Goddard, president of the Royal College of Physicians warned earlier in the year: "If there is a significant outbreak, or even an epidemic, it won't just bring more patients to hospitals, GPs, and health clinics … but could also keep the very staff needed to treat them, at home, with sickness levels rocketing at exactly the wrong time." Vaccination is recommended for frontline health and social care workers because it reduces the transmission of infection to vulnerable patients. This should be provided by their employer as part of the organisation's policy for the prevention of the transmission of flu to help protect both staff and those they care for. However, uptake of vaccinations by healthcare workers varies considerably from trust to trust, with the best achieving 90% uptake and the worst 40%. This season PHE intend to tackle this by 'buddying up' poor uptake Trusts with higher uptake Trusts in the hope that they achieve more than 90% uptake.

Medscape News UK asked Professor Doyle why health workers aren't mandated to have the flu vaccine as we do for hepatitis B. She said: "This is a question that is examined regularly and is under scrutiny again at the moment, up to now the response has been that it isn't necessary to be mandatory. In our culture the question is whether mandating would be counter effective or would it boost uptake? We think the buddying system will be more helpful to increase uptake in healthcare workers."

Professor Van-Tam added "there is the element of professional responsibility of clinical staff." He went on: "From a patient perspective you don't want to be in a situation where only 7 out of 10 healthcare workers you meet are vaccinated, you'd like to think 10 out of 10 are vaccinated, so there is a very strong professional responsibility on healthcare workers to be vaccinated."

Flu Vaccine in Pregnancy

Pregnant women have the lowest uptake at 45%. It is likely that concerns about safety and vaccine scepticism may be the reason for this. The DHSC and PHE have advised that flu vaccine can be safely and effectively administered during any trimester of pregnancy and no study to date has demonstrated an increased risk of either maternal complications or adverse foetal outcomes associated with inactivated influenza vaccine.

GPs Role in the Vaccination Programme

Some GP surgeries have already been warned about the delay because GPs are responsible for ordering their own vaccines directly from the manufacturers. GPs, pharmacists and school nurses are responsible for rolling out the flu vaccination programme across the UK so it is vital that they don't find themselves in the same situation as they did last year when some surgeries ran out because of uneven distribution and had to call the Medicines and Healthcare products Regulatory Agency (MHRA) to step in and suspend regulations to redistribute supplies. Groups eligible for flu vaccination are based on the advice of the Joint Committee on Vaccination and Immunisation (JCVI).

Those eligible for flu vaccination in 2019/20

  • All children aged 2 to 10 (but not 11 years or older) on 31 August 2019

  • Those aged 6 months to under 65 years in clinical risk groups

  • Pregnant women

  • Those aged 65 years and over

  • Those in long-stay residential care homes

  • Carers

  • Close contacts of immunocompromised individuals

Which Flu Vaccine Should Be Offered?

This year there are a range of recommended flu vaccines. The following should be offered:

  • Children aged 2 to 17 in an eligible group are offered a live attenuated quadrivalent vaccine (LAIV), given as a nasal spray, unless contraindicated.

  • Adults aged 18 to 64 who are either pregnant, or at increased risk from flu because of a long-term health condition, are offered a quadrivalent influenza vaccine (QIV). The vaccine offered will have been grown either in eggs (QIVe) or cells (QIVc) – both of which are considered to be equally suitable.

  • Adults aged 65 and over will be offered either an adjuvanted trivalent influenza vaccine (aTIV) grown in eggs or a cell grown quadrivalent influenza vaccine (QIVc). Both of which are considered to be equally suitable.

  • Children in at-risk groups aged between 6 months and 2 years old and those in at risk groups who are contraindicated to LAIV must be offered an inactivated (injected) vaccine. This year, PHE has purchased the egg-grown quadrivalent influenza vaccine (QIVe).

This will be the first year that cell-grown vaccines are used. Prof Van-Tam believes that it may help to improve the supply chain if an alternative to egg grown vaccines can be used, because of the complex supply chain logistics involved in egg grown vaccines.

What strains of flu do the vaccines protect against?

  • 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/3073/2013-like virus (B/Yamagata/16/88 lineage).

The adjuvanted vaccine being offered to those aged 65 and over does not include the B/Yamagata strain –B strains usually affect younger age groups.

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