Camden - Flu Education and Shared Learning Event · • Influenza activity started in January 2019 and peaked in weeks 5 and 6. • Influenza like illness (ILI) rates were considerably

By Carolyn Matthews

Workforce, Education and Provider Development Manager

14th August 2019

12.00 – 14.30

Swiss Cottage Surgery, London, NW3 3NP

Camden - Flu Education and Shared Learning Event

Introduction

Welcome to 2019/20

Camden's Flu Education and Shared Learning Event

This event is to give key stakeholders an opportunity to meet each other, listen and ask questions.

With the aim of improving patient health, increasing flu vaccination uptake and myth bust.

Presentations by:

Time Title Name

12.00 Introduction and Welcome Carolyn Matthews

Workforce Education and Provider

Development Manager

12.05 Neighbourhood Outcome Target Cynthia Mkandawire – Senior Commissioning

Manager

12.10 Resources and Information for Camden Practices

Medicine Management

Ey Cheung – Medicines Management

12.20 Accessing Data on Flu immunisation provided by

community pharmacists

Pritpal Thind – Director of Sonar Informatics

Ltd

12.50 Seasonal Influenza in Camden Khalida Aziz NHSE Imms. team and Chris Salt

– Immunisation Commissioning Officer

13.30 Epidemiology and how the virus strains are

identified and included

Dr Aparna Keegan – Assistant Director of

Public Health, Camden and Islington Public

Health

14.10

Shared Learning – Good Practice

Improving Flu Immunisations: lessons learnt

Practices

Susan Sinclair

Chief Executive Officer

14.25

AOB

Carolyn Matthews – Workforce Education

and Provider Development Manager

Neighbourhood Outcome Target

Cynthia Mkandawire

Senior Commissioning Manager

Primary Care Team

Neighbourhood Outcome Target

KPI

KPI Target

Vaccination

Apr-19 Min. Threshold Max. Threshold

Camden CCG 68.2% 75.0%

CHE 63.8% 70.0% 75.0%

NW3 71.9% 70.0% 75.0%

NW5 71.3% 70.0% 75.0%

South 71.1% 70.0% 75.0%

KPI

KPI Target

Vaccination

Apr-19 Min. Threshold Max. Threshold

Camden CCG 45.7% 52.5%

CHE 44.8% 47.0% 52.5%

NW3 45.1% 47.0% 52.5%

NW5 47.2% 47.0% 52.5%

South 46.5% 47.0% 52.5%

[C_INF_21] Percentage of flu vaccination uptake for people aged 65 and over

[C_INF_21] Percentage of flu vaccination uptake for people aged 65 and over

[C_INF_22] Percentage of flu vaccination uptake for people within the at risk population

[C_INF_22] Percentage of flu vaccination uptake for people within the at risk population

63%

41%

In 2019/20, GP practices are being incentivised to

increase uptake of seasonal influenza vaccination for

people aged 65+ and under 65 in identified eligible

groups.

The following targets have been introduced:

• 75% uptake of people aged 65 and over

• 52.5% uptake for people within the at risk population

The targets are set at GP neighbourhood-level –

Payment will be made at the end of the year based on

practices’ collective achievement.

Total budget allocation for seasonal influenza is £50k.

Resources and Information forCamden Practices

Medicine Management

E .Y. Cheung

Deputy Head of Medicines Management

NICE Medicines and Prescribing Associate

Medicines Management Team | NHS Camden Clinical Commissioning Group

• Flu page on GP website

• Vaccine Updates

• Prescribing Matters – MMT newsletter

Resources & Information for Camden Practices

Resources for Camden Practices

Medicines Management Team

[email protected]

020 3688 1788

mailto:[email protected]

Accessing data on flu immunisation provided by community pharmacists

Pritpal ThindDirector

Sonar Informatics Limited, 9 Goldhawk Road,London W12 8QQ

Sonar service for GP’s 2018 - 2019

London Vaccination Service

Dmirs

London Vaccination service

Pharmacy Area

Sonar – SCR PDs and 111 integration

London Vaccination service 2017-8

GP Area

Click to view and Acknowledge Notification

Click to Notify Pharmacy that Patient is not ours

Sample GP – Flu Notification Email

Notification Actions


CCG Area

Main reports

Patient Survey

Survey Question

Answers


Patient Appointments


Live Statistics

Visit:www.sonarhealth.org/london-vacc

Influenza Vaccination Programme 2019/2020

Khalida Aziz

(Immunisation Commissioning Manger NCL)

43 |

• To increase vaccination uptake rates in clinical ‘at risk’ groups (6 months to 64 years) to 50%

• To increase vaccination uptake rates of >65s in London to 2018/19 national level of 71.3%

• To increase vaccination uptake rates of pregnant women to 2018/19 national level of 45%

• To increase delivery of child ‘flu vaccination services across all primary school year groups and increase uptake to >50%

• To attain 40% national standard for age 2 and age 3 child ‘flu vaccinations in general practice

• To streamline the time-consuming multiple reporting processes on ‘flu vaccination rates during ‘flu season

Aims:

Presentation title

44 |

• To assure that all general practices are prepared for the extra demand and capacity that ‘flu vaccinations place on winter primary care services

• To increase uptake amongst frontline health care workers to 80% including primary care staff

• To improve access to vaccinations for London’s homeless population by bringing vaccinations to them via pharmacy, general practices that specialise in caring for the homeless populations and voluntary organisations that do outreach work

Presentation title

45 |

• At a minimum, annual reported rates are to exceed 2017/18 levels for seasonal influenza and child influenza vaccinations

• Reduction in number of hospitalised cases of seasonal influenza

• Minimisation of influenza like illness (ILI) consultations in general practices

Measures of success

Presentation title

46 |

• Low to moderate levels of influenza activity were observed in the community with circulation of influenza A (H1N1)pdm09 followed by A (H3N2) later in the season.

• Influenza activity started in January 2019 and peaked in weeks 5 and 6.

• Influenza like illness (ILI) rates were considerably lower than in 2017/18 (see figure 1).

• Peak admission rates of influenza to hospital and ICU were similar or slightly lower than seen in 2017/18 but higher than all other seasons since 2010/11. Impact of A(H1N1) was predominantly seen in 15 to 44 (39.8%) and 45 to 65 (19.8%) age groups.

• Numbers of outbreaks were down from 2,149 in 2017/18 nationally to 1,340 nationally in 2018/19.

• The majority of outbreaks (69.6%) occurred in care homes, 14.9% in hospitals and 11.8% in schools. Regionally, the majority of outbreaks occurred in the South West region (16.4%) followed by the South East and North West regions (15.2% and 14.6% respectively).

• Overall, vaccine effectiveness in 2018/19 was 44.3% (CI 26.8, 57.7).i The aTIV for over 65s was higher at 62% (3.4, 85). In 2017/18 the vaccine effectiveness was 25-52% against any influenza in Europe.

Summary of Influenza season 2018-19

Presentation title

47 |

Figure 1:ILI consultation rates for London compared to England for 2018/19 and 2017/18

Presentation title

48 |

Ages 2 and 3 years

• There is a national ambition for minimum 40% uptake in 2-3 year olds (which is offered in general practice) and 50-65% for school years Reception to Year 5.

• Figure 2 illustrates the uptake in London compared to England for the years 2016/17, 2017/18 and 2018/19. London declined for age 2 slightly in 2018/19. Both are below national averages and national ambitions.

• Throughout London, uptake for child ‘flu vaccine for 2 and 3 year olds is low despite efforts every year from the public health commissioning team to visit poor performing practices (those performing less than 10%) to support them. These visits have however considerably reduced the number of practices performing less than 10% from 155 in 2016/17 in to 88 in 2018/19.

• Three CCGs achieved the lower threshold of 40%. These were Bromley (46% for age 3), Greenwich (46% for age 3) and Kingston (43%).

• Interestingly, when looking at this season’s reception children (who were aged 3 last year), their uptake rate doubled once offered in schools – a pattern also seen for 2017/18, suggesting that a main contributing factor to poor uptake is service related.

Child ‘Flu Vaccination Uptake

Presentation title

49 |

Figure 2:Age 2 and 3 Child ‘Flu vaccination rates for London compared to national for 2016/17, 2017/18 and 2018/19 (up to end January 2019)

Presentation title

Source: PHE (2019)

50 |

• Figure 3 illustrates London’s cumulative uptake for all school year groups for 2018/19 compared to the previous flu season and the national ambition.

• Figure 4 compares London’s uptake across the school year groups for 2018/19 to the previous two ‘flu seasons. Uptake has increased year on year.

• For 2018/19, London exceeded the lower threshold of the national aspirations for Reception, Years 1-2 (i.e. >50%).

• The decline in uptake across age groups - e.g. 53.7% in Reception in 2018/19 compared to 44.6% in Year 5 – is not attributable to a decline as child age. The proportion of children in Year 5 is similar the proportion of that same cohort when they were in Year 4 in 2017/18 and Year 3 in 2016/17 (although there was an improvement in uptake in this cohort in 2018/19 compared to previous years). This is consistent with the literature in that uptake of child ‘flu vaccine is associated with previous ‘flu vaccination. As a result, SAV providers are encouraged to ensure good uptake in Reception so that this is maintained throughout primary school

Primary School Children

Presentation title

51 |

Figure 3Cumulative uptake for the primary school programme for London 2018/19 compared to previous year and national ambition

Presentation title

52 |

Figure 4:Comparison of child flu uptake across all healthy child age groups in London for 2018/19 compared to previous ‘flu seasons

Presentation title

Reception Year 1 Year

2 Year 3

Year 4

Year 5

London 2018/19

53.7% 52.7% 50.2% 48.9% 46.5% 44.6%

London 17/18

51% 49% 48% 45% 41% n/a

London 16/17

n/a 45% 43% 42% n/a n/a

Source: PHE (2019)

53 |

• Despite improvements in London’s ‘flu vaccination rates for 2016/17 and 2017/18, the trend was not continued for 2018/19 for adult vaccinations.

• Rates are lower than last year across the ‘at risk’ groups of over 65s, clinical ‘at risk’ groups and pregnant women. Rates of health care workers remained stable.

• This year’s uptake was impacted by a mild winter and low circulation of influenza.

• Predominantly the rates were affected by the confusion over the vaccine to be offered to over 65s with late national planning to introduce the new vaccine, difficulties with manufacturing large volumes at short notice resulting in late and staggered deliveries of aTIV.

• All CCGs in London performed below national standards of 70-75% for over 65s and 50-55% for clinically at-risk groups.

• The best performers for >65s were Tower Hamlets (70%), Bromley (68.7%) and Sutton (67.9%). The worst were Kensington & Chelsea (57.3%), Croydon (56.8%) and Hammersmith & Fulham (56%).

• The best performers for clinical ‘at risk’ groups were Tower Hamlets (49.7%), Harrow (47.4%) and Barking & Dagenham (45.8%). The worst were Bexley (35.3%), Haringey (32.9%) and Hammersmith & Fulham (31.4%).

Adult Vaccination Uptake rates

Presentation title

54 |

• The best performers for pregnant women were Tower Hamlets (47%), Wandsworth (46.5%) and Kingston (44.4%). The worst were City & Hackney (31.4%), Hounslow (31.4%) and Enfield (28.2%).

• These figures may not include all flu vaccinations offered in maternity units nor the vaccinations provided in pharmacy. For London, 211,320 vaccinations were offered in pharmacy. Of these, 200,353 vaccinations were to the at-risk groups and over half were to people aged 65 and older. The majority of ‘flu vaccinations are provided in Hillingdon, Ealing, Wandsworth, Croydon, Bromley, Greenwich, Newham, Redbridge and Barnet (all in excess of 8,000).

• In relation to ‘at risk’ groups, 20,000 vaccinations were given in pharmacy but not all clinically uploaded onto GP systems (if all were included it would raise the rates by 1.8%)

continued…

Presentation title

55 |

Figure 5:Comparison of adult vaccinations for London and England 2013-14 to 2018-19

Presentation title

2013-2014

2014-2015

2015-2016

2016-2017

2017-2018

2018-2019

65+ years London England

70% 73.2%

69.2% 72.7%

66.2% 71.0%

65.1% 70.4%

66.9% 72.6%

63.9% 71.3%

<65 years London England

52% 52.3%

49.8% 50.3%

43.6% 45.1%

47.1% 48.7%

45.4% 48.9%

42.5% 46.9%

Pregnant women London England

35.9% 39.8%

39.9% 44.1%

38.5% 42.3%

39.6% 44.8%

41.1% 47.2%

38.9% 45.0%

Healthcare workers London England

41.1% 54.8%

43.2% 54.9%

39.4% 49.5%

55.4% 63.0%

64.1% 68.7%

63.7% 70.3%

56 |

Khalida Aziz: Immunisation Commissioner (NCL)

Influenza uptake in NCL 2018/19

Presentation title

57 |

Aged 65 and Over

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

North CentralLondon STP

NHS Barnet CCG NHS Camden CCG NHS Enfield CCG NHS Haringey CCG NHS Islington CCG 2018-19 HighestCCG - London(NHS TOWER

HAMLETS CCG)

2018-19 HighestCCG - National

(NHS RUSHCLIFFECCG)

2018-19 uptake - Aged 65 and over Target London England

Eligible Vaccinated 2017-18 uptake Eligible Vaccinated 2018-19 uptake

ENGLAND 10,235,150 7,424,047 72.5% 10,349,256 7,221,565 69.8%

London 1,071,626 717,146 66.9% 1,096,610 700,655 63.9%

North Central London STP 179,021 120,865 67.5% 182,913 116,859 63.9%

NHS Barnet CCG 57,615 39,011 67.7% 58,827 38,032 64.7%

NHS Camden CCG 25,199 18,250 72.4% 25,743 17,572 68.3%

NHS Enfield CCG 43,728 29,710 67.9% 44,625 28,414 63.7%

NHS Haringey CCG 30,647 19,134 62.4% 31,474 18,880 60.0%

NHS Islington CCG 21,832 14,760 67.6% 22,244 13,961 62.8%

2018-19 Highest CCG - London

(NHS TOWER HAMLETS CCG) 17,902 12,528 70.0%2018-19 Highest CCG - National

(NHS RUSHCLIFFE CCG) 27,274 21,982 80.6%

58 |

Under 65 Years – at risk


ENGLAND 6,833,843 3,341,888 48.9% 6,827,240 3,055,095 44.7%

London 1,048,468 475,725 45.4% 1,084,582 461,380 42.5%


NHS Barnet CCG 41,120 18,377 44.7% 41,992 18,014 42.9%

NHS Camden CCG 26,029 12,417 47.7% 26,507 11,326 42.7%

NHS Enfield CCG 37,742 16,030 42.5% 38,654 15,182 39.3%

NHS Haringey CCG 33,676 13,574 40.3% 40,605 13,313 32.8%




(NHS STOCKPORT CCG) 40,517 24,621 60.8%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%



HAMLETS CCG)


(NHS STOCKPORTCCG)

2018-19 uptake - Under 65 at risk Target London England

59 |

Pregnant Women

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%



HAMLETS CCG)


(NHS STOCKPORTCCG)

2018-19 uptake - Pregnant women Target London England


ENGLAND 643,373 303,593 47.2% 559,343 244,260 43.7%

London 134,114 55,138 41.1% 128,161 49,842 38.9%


NHS Barnet CCG 5,555 2,178 39.2% 5,175 1,912 36.9%

NHS Camden CCG 3,220 1,416 44.0% 3,088 1,238 40.1%

NHS Enfield CCG 4,631 1,431 30.9% 4,273 1,206 28.2%

NHS Haringey CCG 4,344 1,521 35.0% 3,983 1,392 34.9%




(NHS STOCKPORT CCG) 3,557 2,495 70.1%

60 |

Children Aged 2


ENGLAND 689,962 290,194 42.1% 675,043 280,629 41.6%

London 123,655 41,030 33.2% 125,101 38,890 31.1%


NHS Barnet CCG 5,290 1,787 33.8% 5,505 1,655 30.1%

NHS Camden CCG 2,481 804 32.4% 2,530 691 27.3%

NHS Enfield CCG 4,822 1,276 26.5% 4,861 1,017 20.9%

NHS Haringey CCG 3,678 1,197 32.5% 3,922 1,202 30.6%

NHS Islington CCG 2,599 817 31.4% 2,628 757 28.8%


(NHS KINGSTON CCG) 2,563 1,094 42.7%2018-19 Highest CCG - National

(NHS NORTH NORFOLK CCG) 1,446 913 63.1%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


NHS Barnet CCG NHS Camden CCG NHS Enfield CCG NHS Haringey CCG NHS Islington CCG 2018-19 HighestCCG - London

(NHS KINGSTONCCG)

2018-19 HighestCCG - National(NHS NORTH

NORFOLK CCG)

2018-19 uptake - Aged 2 Target London England

61 |

Children Aged 3


ENGLAND 695,579 302,356 43.5% 676,640 291,676 43.1%

London 121,481 40,423 33.3% 121,814 39,614 32.5%


NHS Barnet CCG 5,541 1,979 35.7% 5,277 1,789 33.9%

NHS Camden CCG 2,397 865 36.1% 2,444 695 28.4%

NHS Enfield CCG 4,695 1,201 25.6% 4,816 1,151 23.9%

NHS Haringey CCG 3,497 1,168 33.4% 3,748 1,165 31.1%

NHS Islington CCG 2,475 782 31.6% 2,487 701 28.2%


(NHS BROMLEY CCG) 4,460 2,052 46.0%2018-19 Highest CCG - National

(NHS SOUTH WARWICKSHIRE CCG) 2,997 1,936 64.6%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


NHS Barnet CCG NHS Camden CCG NHS Enfield CCG NHS Haringey CCG NHS Islington CCG 2018-19 HighestCCG - London

(NHS BROMLEYCCG)

2018-19 HighestCCG - National(NHS SOUTH

WARWICKSHIRECCG)

2018-19 uptake - Aged 3 Target London England

NHS England and Improvement London Region:

Healthcare Workers (GP Practice Staff) Influenza Vaccination

Uptake

Khalida AzizImmunisation Commissioner (NCL)

63 |

• Seasonal influenza vaccine uptake data will continue to be collected on frontline healthcare workers (HCWs) involved with direct patient care from all NHS Trusts, including Acute, Mental Health, Ambulance, Care and Foundation Trusts. Data will also be collected from GP Practices.

• The Green book has recommended for healthcare workers directly involved in patient care, who should be offered influenza immunisation on an annual basis

• Therefore, it is the responsibility of employers to assess the risks to staff and offer flu vaccination accordingly.

• Cumulative data will be collected on vaccinations administered from 1 September 2018 to the end of the survey month (inclusive of both dates). The data collection will comprise of 5 monthly surveys for October, November, December, January, and February with the collections starting from 1st November through to 13th March.

Background

Presentation title

64 |

Review of HCWs Uptake

Presentation title

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

2014 -15 2015-16 2016-17 2017-18 2018-19

England London

65 |

Review of the London Region: Uptake of the Health Care Worker's Influenza Vaccination Programme

Presentation title

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

2014 -15 2015-16 2016-17 2017-18 2018-19

London Primary Care (Aggreated by CCG) Trusts

66 |

London Trusts: HCWs ‘flu Vaccination Uptake 18/19

NHS England and Improvement London Region: HCWs Review Of Performance To Date

67 |

Uptake in Primary Care

No. of

practices

No. of

forms

completed

% of orgs

respondingNo. %

NHS BARKING AND DAGENHAM CCG 35 3 8.6 53 33 62.3

NHS BARNET CCG 54 6 11.1 161 83 51.6

NHS BEXLEY CCG 24 6 25.0 155 95 61.3

NHS BRENT CCG 56 3 5.4 59 36 61.0

NHS BROMLEY CCG 45 7 15.6 173 103 59.5

NHS CAMDEN CCG 34 0 0.0 0 0

NHS CITY AND HACKNEY CCG 42 2 4.8 61 19 31.1

NHS CROYDON CCG 50 4 8.0 120 72 60.0

NHS EALING CCG 75 3 4.0 50 27 54.0

NHS ENFIELD CCG 36 6 16.7 245 98 40.0

NHS HOUNSLOW CCG 47 1 2.1 19 3 15.8

NHS GREENWICH CCG 35 4 11.4 94 62 66.0

NHS HAMMERSMITH AND FULHAM CCG 29 0 0.0 0 0

NHS HARINGEY CCG 37 0 0.0 0 0

NHS HARROW CCG 33 1 3.0 28 23 82.1

NHS HAVERING CCG 43 3 7.0 93 44 47.3

NHS HILLINGDON CCG 45 2 4.4 41 27 65.9

NHS ISLINGTON CCG 32 5 15.6 114 73 64.0

NHS KINGSTON CCG 21 4 19.0 107 62 57.9

NHS LAMBETH CCG 42 7 16.7 149 94 63.1

NHS LEWISHAM CCG 37 1 2.7 24 11 45.8

NHS NEWHAM CCG 49 4 8.2 54 33 61.1

NHS REDBRIDGE CCG 42 2 4.8 25 18 72.0

NHS RICHMOND CCG 28 4 14.3 94 47 50.0

NHS SOUTHWARK CCG 36 2 5.6 46 12 26.1

NHS MERTON CCG 22 8 36.4 228 105 46.1

NHS SUTTON CCG 23 2 8.7 80 33 41.3

NHS TOWER HAMLETS CCG 34 1 2.9 26 14 53.8

NHS WALTHAM FOREST CCG 41 2 4.9 97 27 27.8

NHS WANDSWORTH CCG 40 6 15.0 133 59 44.4

NHS WEST LONDON CCG 42 3 7.1 59 44 74.6

NHS CENTRAL LONDON (WESTMINSTER) CCG 33 2 6.1 51 13 25.5

Total 1245 105 8.4 3313 1646 49.7

Org Name

Response SummaryNo. of

HCWs with

Direct

Patient

Care

Seasonal Flu doses

given since 1st

September 2018

68 |0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0

NHS BARKING AND DAGENHAM CCG

NHS BARNET CCG

NHS BEXLEY CCG

NHS BRENT CCG

NHS BROMLEY CCG

NHS CAMDEN CCG

NHS CITY AND HACKNEY CCG

NHS CROYDON CCG

NHS EALING CCG

NHS ENFIELD CCG

NHS HOUNSLOW CCG

NHS GREENWICH CCG

NHS HAMMERSMITH AND FULHAM CCG

NHS HARINGEY CCG

NHS HARROW CCG

NHS HAVERING CCG

NHS HILLINGDON CCG

NHS ISLINGTON CCG

NHS KINGSTON CCG

NHS LAMBETH CCG

NHS LEWISHAM CCG

NHS NEWHAM CCG

NHS REDBRIDGE CCG

NHS RICHMOND CCG

NHS SOUTHWARK CCG

NHS MERTON CCG

NHS SUTTON CCG

NHS TOWER HAMLETS CCG

NHS WALTHAM FOREST CCG

NHS WANDSWORTH CCG

NHS WEST LONDON CCG

NHS CENTRAL LONDON (WESTMINSTER) CCG

Seasonal Flu doses given HCWs in Primary Care since 1st

September 2018 (%)

69 |

• Before the start of the season:

• HCW lead Commissioner will communicate to CCG flu leads the time table for submitting monthly data on Immform.

• HCWs can be vaccinated from the 1st September or when the vaccination has been received by the practice.

• During the ‘flu season:

• HCWs lead Commissioner will send out monthly reminders to CCG Flu Leads for uploading data onto Immform

• Those practices that have not submitted data on time will be escalated to CCG Flu Lead and Primary are Commissioner and internally at NHS E/I

After season: HCWS Lead Commissioner will send a briefing paper to CCG Leads regarding Uptake for Primary Care.

Proposed Delivery Plan

Dr Aparna Keegan

Assistant Director, Camden And Islington Public Health

14 August 2019

Influenza Epidemiology and the Vaccine

Influenza Epidemiology 2018/19- London/ England

Influenza Vaccine Challenges

Vaccine Effectiveness 2018/19

Vaccine Eligible Populations 2019/20

Vaccine Uptake 2018/19

Nice Guidance- Flu Vaccination: Increasing Uptake

Content

GP Consultation 2018/19- London

Hospital Admissions 2018/19- London & England

Hospital Admissions 2018/19- England

Microbiology 2018/19- London

Outbreaks 2018/19- England

From the beginning of the season (starting in week 40, 01 October 2018), 59

acute respiratory outbreaks have been reported in London by week 18.

Excess mortality- England

Key Messages 2018/19 Flu season

• In the 2018 to 2019 season, low to moderate levels of influenza activity were observed in the community with circulation of influenza A(H1N1)pdm09 followed by influenza A(H3N2) in the latter part of the season.

• These were genetically and antigenically similar to the Northern Hemisphere 2018 to 2019 A(H1N1)pdm09 and A(H3N2) vaccine virus strains

• Influenza transmission resulted in high impact on secondary care in terms of hospitalisations and ICU admissions.

• Overall influenza vaccine effectiveness in 2018 to 2019 against a laboratory confirmed infection resulting in a primary care consultation was 44.3% (95% CI 26.8% to 57.7%)

Challenges in producing the influenza vaccine

• 3 types of Influenza: A, B and C.

• Type A is the most dangerous; can cause serious disease / can triggers worldwide pandemics. Type B causes a less severe illness, but it has never led to a worldwide pandemic. Type C causes mild disease. Influenza A and B are the two types of influenza viruses that cause epidemic human disease. Influenza A(H1N1) viruses, influenza A(H3N2) viruses, and influenza B viruses co-circulate globally.

• Type A is also much more complex than the other types of flu virus.

• On the surface of each Influenza A virus there are proteins (haemagglutinin and neuraminidase referred to as H and N) that help the virus to invade cells. There are 18 known different types of the H protein, and 11 known different types of the N protein.

• This means there are 198 different possible varieties of Influenza A – from H1N1 (the Swine Flu virus) to H18N11. Not all of these types are known to infect humans, but there are still a lot of options when it comes to designing the annual flu vaccine.

• Influenza B viruses are separated into two distinct genetic lineages (Yamagata and Victoria) but are not categorized into subtypes.

• In addition, the flu virus can change quickly and easily.

• Each of the 144 types of Influenza A can undergo ‘antigenic drift’ – a process of genetic change that leads to even more variety within each type. Two different virus strains can even combine their genetic material to make a new sub-strain (this process is called ‘antigenic shift’, and is what led to the new Swine Flu virus in 2009).

• Influenza B viruses undergo antigenic drift less rapidly than influenza A viruses.

Challenges in producing the influenza vaccine

• Each year’s flu vaccine is made to give the best protection against the strains of flu that are expected to circulate in the coming season.

• However, decisions about what to put in the flu vaccine have to be made six months before the flu season starts.

• Every February in the Northern Hemisphere, the World Health Organization (WHO) reviews the types of flu that have been circulating in all parts of the world and chooses the ones which will go in the vaccine for the following autumn. Vaccine production starts in March to be released in the UK in September – but it also gives the flu virus time to change before vaccination starts in the autumn.

• In about 9 out of 10 years the vaccine matches the strains causing illness that winter, but sometimes the flu virus changes in ways that are not expected. This means that sometimes the flu vaccine may not be a good match for all the strains of flu that are circulating.

• The viruses for flu vaccines was usually grown in hen’s eggs.

• This is a slow process, and can lead to something called ‘egg adaptation’. The flu virus strain starts to adapt to the conditions in the egg, leading to changes in the virus. This is another reason that the flu vaccine may not always match the circulating strains of flu.

• A cell-based flu vaccine was developed as an alternative to the egg-based manufacturing process

• The influenza viruses used in the cell-based vaccine are grown in cultured cells of mammalian origin instead of in hens’ eggs. Cell culture technology is potentially more flexible than the traditional technology, which relies upon adequate supply of eggs.

• In addition, the cell-based flu vaccine that uses cell-based candidate vaccine viruses (CVVs) has the potential to offer better protection than traditional, egg-based flu vaccines as a result of being more similar to flu viruses in circulation.

Vaccine Effectiveness 2018/19

* First season of introducing a newly licensed adjuvantedinfluenza vaccine (aTIV) for those aged 65+ years.

• The vaccine effectiveness and cost-effectiveness of influenza vaccine depends upon thecomposition of the vaccine, the circulating strains, the type of vaccine and the age of theindividual being vaccinated. Even if its less effective- may still reduce severity.

• Overall influenza vaccine effectiveness in 2018 to 2019 against a laboratory confirmedinfection resulting in a primary care consultation was 44.3% (95% CI 26.8% to 57.7%).

• Protection varies for different age groups and also against different strains of the virus;better protection against influenza A(H1N1)pdm09, there was reduced VE against A(H3N2).

• Immunosenescence with age. The JCVI, recommended the introduction of the adjuvantedtrivalent vaccine for over 65s in the 2018-19. aTIV provided significant protection for those65+ year olds. There is a significantly higher list price TIV-HD - is not eligible forreimbursement under the NHS flu vaccination programme.

• JCVI noted that with QIVc the evidence of superior effectiveness was not of sufficient qualityto express a preference at this time over other flu vaccines currently recommended in over65s and at risk groups under 65.

• Due to variation in vaccine effectiveness it reinforces the importance of vaccinating childrenand healthcare workers, both of whom can help to stop the spread of flu in at riskpopulations.

Recommended Vaccines for 2019/20

WHO Recommended composition of influenza virus vaccines for use in the 2019-2020 northern hemisphere influenza season (updated on 21 March 2019).

It is recommended that egg based quadrivalent vaccines for use in the 2019-2020 northern hemisphere influenza season contain the following:

• 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).

Vaccine eligible populations

In 2019/20 the following are eligible for flu vaccination:

• all children aged two to ten (but not eleven years or older) on 31 August 2019

• those aged six 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

•Recommended for frontline health and social care workers (provided by employers) – 2019/20 CQUIN target 60-80%

•In 2019/20, NHS England will continue to support vaccination of social care and hospice workers

Rationale for Vaccine Eligible Populations

• Older Adults (65+):

• people 65 years and older are at greater risk of serious complications from the flu compared with younger healthy cohorts

• Greatest burden of disease: est 70% and 90% of seasonal flu-related deaths have occurred in people 65 years and older and between 50% and 70% of seasonal flu-related hospitalizations have occurred among people in that age group.

• At Risk Groups <65+:

• Among children and adults aged 6 months to 64 years who are in a clinical risk group, the average age-adjusted risk of flu-related death is 11 times greater than for those not in a clinical risk group.

• Considerable variation between the different target groups: higher relative risk (RR) of flu-related death is associated, with chronic liver disease (RR=48.2), immunosuppression (RR=47.3) and chronic neurological disease (RR=40.4). For other clinical groups, the age-adjusted relative mortality risks are: chronic renal disease, RR=18.5; chronic heart disease, RR=10.7; chronic respiratory disease, RR=7.4; diabetes, RR=5.8; and pregnant women RR=7.0.

• Children:

• In 2012, the JCVI recommended extending the flu programme to children to protect them and those they are in contact with esp at risk groups and older adults.

• Children with influenza remain infectious for longer than adults (up to two weeks), and they are also more likely to pass on the infection (due to poorer hand hygiene than adults).

• Studies have demonstrated good impact and is cost-effective- vaccinating children against flu is a good way to reduce flu-related illness, GP visits, hospital admissions and deaths for the whole community.

• The best results have been achieved in areas of the UK where all primary school age children are offered the vaccine, and where uptake of the vaccine is high.

Rationale for Vaccine Eligible Populations

• Pregnant women:

• There is strong evidence that pregnant women have a much higher risk of serious illness as a result of flu, compared with the general population. The risks are highest in the last three months of pregnancy.

• US studies of the H1N1 (‘Swine Flu’) pandemic in 2009 found that pregnant women were four times as likely to develop serious illness and up to five times as likely to be admitted to hospital, compared with the general population. As a result of the evidence from this pandemic, pregnant women were added to the list of groups considered to be at higher risk from seasonal flu.

• In the UK between 2009 and 2012, flu was the cause of death for 36 women who died during pregnancy or shortly afterwards. It is estimated that half of these deaths could have been prevented by flu vaccination. See the 2014 summary report from MBRRACE-UK. Between 2012 and 2014 there was a fall in deaths of pregnant women from flu, but this was mainly due to low rates of flu in the UK during this period.

• There is also strong evidence that catching flu in pregnancy has an effect on the unborn baby. Babies born to women who have hadflu are up to four times more likely to be born prematurely and to have a low birth weight. This may be because flu infectionproduces an inflammatory response in the body which can trigger premature labour. Flu in pregnancy can even lead to stillbirth or death in the first week of life. Flu vaccination during pregnancy provides protection against flu in infants in the first few months of life

• Frontline HCW:

• Frontline healthcare workers are more likely to be exposed to the influenza virus, particularly during winter months when some of their patients will be infected.

• It has been estimated that up to one in four healthcare workers may become infected with influenza during a mild influenza season -a much higher incidence than expected in the general population.

• Influenza is a highly transmissible infection. The patient population found in hospital is much more vulnerable to severe effects. Healthcare workers may transmit illness to patients even if they are mildly infected.

Vaccine Uptake- GP Patients

69.4

43.9

38.6

54.2

39.7

28.2

65.4

44.4

37.9

55.5

39.1

32.4

72.0

48.0

43.7

60.2

45.2 44.9

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

65 and over Under 65 (at-risk only) Pregnant women and NOT ina clinical risk group

Pregnant women IN a clinicalrisk group

All Pregnant women All 2 and 3 year olds(combined)

% V

acci

ne

Up

take

Eligible Population

Vaccine Uptake in GP Patients 1/9/18- 28/2/19

Camden London England

Vaccine Uptake- Primary School Children

52.8

48.3 48.2

43.5 44.5

39.1

46.1

53.7 52.750.2 48.9

46.544.6

49.4

64.3 63.661.5 60.4

58.356.5

60.8

0

10

20

30

40

50

60

70

Reception (age 4-5) Year 1 (age 5-6 yrs) Year 2 (age 6-7 yrs) Year 3 (age 7-8 yrs) Year 4 (age 8-9 yrs) Year 5 (age 9-10 yrs) Total (reception to Yr 5)

% V

acci

ne

Up

take

School Year

Vaccine Uptake in Primary School Children (1/9/18-31/1/19)

Camden London England

Vaccine Uptake- HCW

0.0

20.0

40.0

60.0

80.0

100.0

120.0

2018/19 All Frontline HCWs All Doctors Qualified Nurses (including GP PracticeNurses

All other professionally qualified clinicalstaff

All Support Staff

% V

acci

ne

Up

take

Professional Group

Seasonal Flu Vaccine Uptake in Frontline Healthcare Workers - NHS England Trusts (1/9/18-28/2/19)

CAMDEN & ISLINGTON MENTAL HEALTH AND SOCIAL CARE TRUST CENTRAL AND NORTH WEST LONDON NHS FOUNDATION TRUST

MOORFIELDS EYE HOSPITAL NHS FOUNDATION TRUST ROYAL FREE LONDON NHS FOUNDATION TRUST

UNIVERSITY COLLEGE LONDON HOSPITALS NHS FOUNDATION TRUST THE WHITTINGTON HOSPITAL NHS TRUST

Nice Guidance (NG103) Flu vaccination: increasing uptake published August 2018

Increasing uptake among eligible groups in primary care

Inform and invite children and adults in eligible groups . When inviting people for flu vaccination:• Ensure the invitation comes from a healthcare practitioner that they know• Tailor it to the person's situation• Include information about the risks of not being vaccinated• Include educational messages to help overcome barriers

Use written reminders (including text messages, letters and email), phone calls from staff or an auto dialler, social media, or a combination of methods, to contact people in eligible groups whose immunisations are due ('call') or overdue ('recall').

For invitations and reminders using digital media:• Link to further information on trusted websites (see NHS Choices) and enable the person to ask for further information• Provide a prompt (for example, a hyperlink) so the person can make an appointment online• Encourage people to find out more during face-to-face interactions, such as with their health visitor or pharmacist

Consider using peer-led approaches for inviting people in underserved groups who are eligible for flu vaccination.

Shared Learning

Are there any Practices here today who would like to:

• Share any lessons learnt?

• Share how they have increased uptake over the years?

Improving Flu Immunisations: lessons learntSusan Sinclair | Chief Executive OfficerMay 2019

London’s largest provider of Primary Care services

The flu problem: System perspective

• Vaccine preventable

• Significant cause of mortality and morbidity

• Significant driver of GP and Hospital attendances

5,611 hospitalised 3,214 ICU admissions 314 confirmed deaths120/100,000

GP consultations (2010/11)

The flu problem:Primary Care perspective

Time limited High volume Resource intensive Operationally challenging

The flu problem:Patient access to vaccination

Repeat attendances

Reservation’s required

Inconvenient

Patient groups

CARERS/ PREGNANT

Suffer for longerSuperspreaders!

Highest risk of poor outcomesNew vaccines= better immunity

Most vulnerable to severe disease following influenza

4X more likely to develop serious illness 5X more likely to be admitted to hospital,

2015/16 performance

Root Cause Analysis

• Not enough real time information

• Poor understanding of cohorts

• Numbers too high to work without weekly plan

• Data visibility low

• To Plan

• To Monitor

• Spot Variance

• To Share

Data

Creating appropriate targets and trajectories

Providing Support and monitoring

Agile interventions

if required

Leadership and

communications

capacity building through Medical Assistant Roles

Flu special measures!

Appropriate targets trajectories to give

weekly bite sized targets

Improvement approach

Leadership, support and monitoring

Multichannel communication throughout season

Medical assistants

- Offering new roles and training to staff

- Care Certificate qualified & signed off

- Clinically led Classroom and Practice based training

- Supervised for post training sign-off

- Working to PSD and protocol, under supervision

Flu Trajectory

Approach to manage vaccine availability

Letters sent out early for over 65’s

Settling off of targets, to allow more focus on difficult to convince patients

More graduated start

Realistic Stretch target

Start date reflects vaccine delivery

Big focus around half term

Realistic Stretch target

Linear trajectory

Letters

Flu analytics

Recall & Delivery

– Text weekly – Calls– Letters early– Clinician call

– Text weekly – Calls to reach target– Letters if needed

– Text– Calls – Letters

– Text– Calls– Carers health checks

and open days

Opportunistic immunisation an important facet of programme

Range of clinic types:- Walk in- anytime - Extended hours- Clinics with walk in- Appointments- Home visits

CARERS/ PREGNANT

Leadership and communications

1,777 more patients immunised

Influenza immunisation coverage compared to England average

0%

10%

20%

30%

40%

50%

60%

70%

80%

Over 65 Under 65 02/03 Preg

Flu Year on Year data ATM

2015/16 2016/17 2017/18 2018/19 London

Lessons learnt

• Data is key

• Different cohorts need different approaches

• Really important to localise to what your population will/ won’t do

• Long process at hard time of year- make it enjoyable and ensure staff understand patient & system benefits

• Order early and understand delivery schedule

What would help going forward

• The earlier the better for vaccinations- Christmas is often a hard stop to the season

• Restrictions on childhood imms

• Over 65’s shortage of supply and supply timeline

• Understanding of system supply= pharmacies??

Thank you

Cohort size

AOB

Do you have any questions?

If you think of any queries or questions you think of later please contact me on the following email address and

I will put together an FAQ to send out

[email protected]

mailto:[email protected]

Documents

Camden - Flu Education and Shared Learning Event · • Influenza activity started in January 2019 and peaked in weeks 5 and 6. • Influenza like illness (ILI) rates were considerably