Flu vaccination: increasing uptake

The outcomes that matter most

Uptake of flu vaccination by people in eligible groups, and its acceptability to them.

The quality of the evidence

Advantages and disadvantages of using a multicomponent approach to increase flu vaccination

To improve uptake, the committee noted the importance of both increasing demand for flu vaccination among target groups (for example, through awareness raising, using education to overcome informational barriers or sending reminders), and addressing 'supply' factors (for example, prompts to providers to increase offers of vaccination). Accessibility and convenience of vaccination provision were consistent themes highlighted in reviews of the qualitative evidence and expert testimonies [Evidence review 2: Q-ES1.4, Q-ES1.5. Evidence review 3: Q-ES 2.3. Evidence review 4: Q-ES3.6. EP1, EP2, EP3, EP4, EP5, EP6]. A key advantage of a multicomponent approach is that it can address demand and supply factors simultaneously.

The committee acknowledged that it may be difficult to identify what specific interventions within a multicomponent approach are more or less effective in promoting uptake. This may affect the ability of programme leaders to modify and improve the approach to increase uptake of flu vaccination over successive vaccination seasons.

The outcomes that matter most

Uptake of flu vaccination by people in eligible groups, and its acceptability to them.

The quality of the evidence

There was some quantitative evidence supporting the effectiveness of provider education as part of a multicomponent approach to improving uptake of flu vaccination among eligible groups. There were 10 evidence statements relating to largely non-UK-based studies in which provider education explicitly formed part of the intervention being evaluated. The study populations included children not in clinical risk groups [Evidence review 2: ES123.3], pregnant women, and children and adults in clinical risk groups [Evidence review 3: SR-ES1.1; ES123.2, ES123.3, ES123.5; SR-ES123.5, SR-ES123.6, SR-ES123.7, SR-ES123.8, SR-ES123.9], and covered a range of healthcare settings. Certainty in the evidence was variable; most was rated low or very low quality. Reasons for downgrading included risk of bias (mostly observational studies), high levels of heterogeneity in pooled analyses of data, and imprecision of effect estimates in smaller studies. In 9 of the 10 evidence statements there was a reported increase in flu vaccination uptake; in 6 cases this was a clinically important increase (5% or more relative to control group or pre-intervention uptake) [Evidence review 3: SR-ES1.1; ES123.2, ES123.3; SR-ES123.5, SR-ES123.6, SR-ES123.9].

There was more available evidence on the effectiveness of education or awareness-raising interventions aimed at eligible people (or their parents, in the case of children) rather than healthcare providers. In this context, education was often combined with other interventions such as written or text message reminders. Various interventions were outlined and in many cases there was a lack of specific detail (the term 'educational materials' was frequently used).

Eighteen evidence statements generated across evidence review 2 [ES1.1/4, ES1.2, ES3.2] and evidence review 3 [ES1.1, ES1.2, ES3.1, ES3.2, ES3.3, ES123.3, ES123.4; SR-ES1.1, SR-ES1.2, SR-ES3.8, SR-ES123.3, SR-ES123.6, SR-ES123.7, SR-ES123.8, SR-ES123.9], again relating to largely non-UK-based studies and covering a range of healthcare settings and populations, included an educational element targeted at the person eligible for flu vaccination. Eleven of the 18 statements reported an increase in vaccination uptake that, in 8 cases was clinically important [Evidence review 2: ES1.1/4. Evidence review 3: ES3.2, ES123.3; SR-ES1.1, SR-ES1.2, SR-ES123.3, SR-ES123.6, SR-ES123.9]. There was generally low or very low certainty in the evidence, with downgrading due to risk of bias (mostly observational studies), high levels of heterogeneity in pooled analyses of data, and imprecision of effect estimates.

Qualitative evidence highlighted that access to information was essential to parents making vaccination decisions on behalf of their children, and for people with chronic health conditions [Evidence review 2: Q-ES1.1. Evidence review 3: Q-ES2.2]. People's perceptions of personal risk differ, and these need to be ascertained and addressed by healthcare providers, along with concerns about flu vaccine safety and effectiveness and misconceptions, for example that vaccination can give people flu [Evidence review 2: Q-ES1.1, Q-ES1.2. Evidence review 3: Q-ES2.1, Q-ES2.2].

Qualitative evidence also suggested that providers may themselves have differing risk–benefit perceptions depending on their own clinical or personal experience [Evidence review 3: Q-ES2.1, Q-ES2.2, Q-ES2.5]. Other studies highlighted that people deciding whether to have a flu vaccination place importance on the perceived strength of their healthcare provider's endorsement of the flu vaccine [Evidence review 3: Q-ES2.4], and that they want to trust that the advice they are given is credible and delivered for their own health benefit without any conflict of interest (for example, to get incentive payments) [Evidence review 2: Q-ES1.3]. Providers and people in eligible groups may be aware that flu vaccine effectiveness varies, and this may work as a barrier to uptake. Although it is not possible to predict before a flu season how well the available vaccine and circulating strains of the virus will be matched, the committee were keen to note that the flu vaccine has generally been a good match and continues to provide the best protection for those at greatest risk from flu and its complications.

The evidence reviewed reinforced the committee's decision to recommend raising and sustaining awareness not only in eligible groups, but also in those who commission and deliver vaccination programmes. Encouraging use of professional minimum standards vaccination training will help to reduce variation in professional attitudes and ensure consistency of message delivery.

The committee was satisfied that the majority of evidence favoured using information and education to raise and sustain awareness of flu vaccination as a means of increasing uptake. They agreed it was important to target both healthcare providers and people in clinical risk groups. Based on their knowledge of this kind of approach in the UK and the generally positive direction of effect across studies in the evidence reviews, the committee felt the evidence could be extrapolated to all eligible groups specified in the Green Book and across health and social care settings, provided that individual needs underpin any information given as part of an intervention.

Advantages and disadvantages of raising awareness to increase flu vaccination

Raising and sustaining awareness – both among those with responsibility for providing and administering flu vaccination and those eligible for vaccination – should reduce barriers to offering, providing and accepting it.

Using opportunistic approaches, including brief interventions or brief advice, is in line with the principles of Making Every Contact Count and the NHS Five Year Forward View and should result in increased efficiency of service provision and access.

Raising awareness as a means of encouraging more people to be vaccinated needs to be coupled with interventions to ensure there are adequate supplies of flu vaccine to meet increased demand, and that appropriate and convenient access arrangements are in place. Otherwise there is a risk of deterring people from further engaging with vaccination services.

The outcomes that matter most

Uptake of flu vaccination by people in eligible groups, and its acceptability to them.

The quality of the evidence

In relation to increasing offers of flu vaccination, the committee considered ways in which people who are eligible can be identified ('case-finding'), and interventions to ensure that vaccination services are accessible to those who are offered them.

Case-finding can be done opportunistically or systematically. The published evidence related mainly to systematic approaches using provider prompts embedded in healthcare records. This evidence is considered separately in the section on patient records.

Expert testimony highlighted the importance of using both opportunistic and systematic approaches to case-finding as a means of increasing opportunities to offer flu vaccination. Face-to-face interactions in primary care (including community pharmacy) provide opportunities to identify and offer vaccination to eligible people. Periodic searches of computer records can be undertaken in general practice to identify unvaccinated new patients or people who have recently become eligible (for example, people who are recently diagnosed with a condition that places them in a clinical risk group, or women with a newly confirmed pregnancy) [EP6].

Other strategies for case-finding should be considered for eligible people who may not be identifiable using existing general practice systems. The committee noted that carers are a difficult group to identify because their carer status may not be routinely recorded in GP records [EP1]. Other expert testimony highlighted that chronic liver disease is associated with the highest risk of flu-related mortality but lowest rates of vaccination uptake across all clinical risk groups specified in the Green Book. Prevalence of chronic liver disease is high among people who abuse drugs and alcohol, who may be in more regular contact with specialist services and pharmacies than with GPs [EP2]. People sleeping rough have a high prevalence of chronic respiratory illness and are usually not in regular contact with statutory healthcare services [EP3]. The committee was keen to promote links between vaccination providers and other local organisations, such as those assessing and supporting carers, specialist drug and alcohol services, community pharmacies and voluntary groups working with carers or people who are homeless to identify eligible people and offer (or signpost them to) vaccination services.

Qualitative evidence highlighted that perceived availability and accessibility are significant barriers to or facilitators of uptake among eligible groups who are offered a flu vaccination [Evidence review 2: Q-ES1.4, Q-ES1.5. Evidence review 3: Q‑ES2.3].

Fourteen evidence statements related to effectiveness studies in which access had been improved for target populations by providing vaccination services more frequently or at more convenient times or locations. The published evidence ranged from moderate to very low quality, with the majority being of very low certainty and from non-UK settings. Reasons for downgrading included risk of bias, high levels of heterogeneity in pooled analyses of data, and imprecision of effect estimates. Eight of these evidence statements reported an increase in vaccination uptake, which was clinically important in 6 cases, among populations that included children not in clinical risk groups [Evidence review 2: ES123.1/4] as well as adults and children with clinical risk factors and pregnant women [Evidence review 3: SR-ES2.2, SR‑ES123.1, SR-ES123.3, SR-ES123.5, SR-ES123.9]. The majority of studies lacked specific detail about how access to vaccination services had been improved by the intervention, which made it difficult for the committee to make recommendations. One study that reported an increase in uptake compared year-round flu vaccination for children with asthma with appointments offered only during the flu season, which the committee agreed was not applicable to the UK [Evidence review 3: SR-ES2.2]. The committee discussed another before-and-after study that reported no clear improvement in uptake when 2 additional Saturday clinics were offered to children with asthma at the start of the flu vaccination season [Evidence review 3: SR-ES 2.1]. The committee felt this relatively small US-based study did not support the qualitative evidence or their own experience of the importance of out-of-hours access, particularly for people in work or education. Expert testimony confirmed that GP practices offering weekend access have been able to achieve vaccination of hundreds of patients in 1 day. This had the added benefit that it was outside usual practice hours, so reducing impact on the winter pressure for GP appointments [EP6].

In England, community pharmacies are able to provide flu vaccinations to eligible adults. Studies in which community pharmacies were part of extended access arrangements did not show increased uptake among target populations [Evidence review 1: ES2.1. Evidence review 3: ES2.1, ES2.2, ES123.1]. However, the committee noted that people of working age in clinical risk groups who are relatively well but need regular prescription medication, and carers in particular, may be more likely to use community pharmacies as a convenient alternative to GP vaccination services. This was confirmed by expert testimony relating to carers [EP1].

The committee concluded that increasing identification of eligible people and providing sufficient routes of access to meet the needs of different groups (including out-of-hours opportunities for people with work commitments) are key to increasing vaccination uptake, as is ensuring that supplies are sufficient to meet demand. The empirical evidence linking extended hours to increased uptake was inconsistent, but the committee felt it important to provide convenient access to as many eligible people as possible.

Organisations are encouraged to use clinical systems to systematically identify people who are eligible for free flu vaccination and record uptake. Flu vaccination providers should plan to exceed the previous year's uptake when ordering supplies.

1.4.1 to 1.4.6

The committee agreed that most people who are particularly vulnerable to the complications of flu, or who are eligible for other reasons, are likely to be in regular contact with their GP surgery or local community pharmacy and know the staff. These routine contacts provide ideal opportunities to speak to people about flu vaccination. The evidence showed that making sure invitations to eligible people are personalised to their circumstances also helps to increase vaccination uptake. If eligible people are not in regular contact with primary care services, or have particular concerns about flu vaccination, using peers as local 'flu champions' providing information that is accessible and appropriate to the target group may help promote uptake.

1.4.7 to 1.4.9

Some people at high risk from flu and its complications visit hospital outpatients or other secondary care clinics more regularly than their GP. Existing hospital systems could be used to identify them, raise awareness and encourage them to have a free flu vaccination while they are there if this is a locally agreed route for offering vaccinations. There is evidence that this is most effective when the vaccination offer is tailored to their condition and made by a healthcare practitioner they know.

1.4.10

In both primary and secondary care, incorporating prompts in electronic health records helps to remind health and social care staff to offer flu vaccination to people who are eligible when they attend for appointments. Using already available systems to set these reminders helps the care provider raise awareness of and offer vaccination.

The outcomes that matter most

Uptake of flu vaccination to people in eligible groups and its acceptability to them.

The quality of the evidence

Call ('vaccination due') and recall ('vaccination overdue') interventions delivered using various formats are frequently used in UK primary care to remind people of their eligibility for free flu vaccination. The committee reviewed the published evidence on the effectiveness of such interventions, which was mostly from non‑UK studies and ranged from high to very low quality, with the majority being of low quality. Reasons for downgrading included risk of bias, high levels of heterogeneity in pooled analyses of data, and imprecision of effect estimates.

As a single intervention strategy, there was no evidence that reminders delivered as text messages (with or without an educational element) increased flu vaccination uptake among eligible groups by a clinically important amount (5% or more, compared with control or pre-intervention uptake rates) [Evidence review 2: ES3.1, ES3.2, ES3.3. Evidence review 3: ES3.3, ES3.4a; SR-ES3.8]. However, call and recall methods using more personalised approaches (such as letters, postcards or personal telephone calls) appear to be more effective. There were 7 evidence statements relating to the use of such approaches among people from clinical risk groups, of which 5 reported an important increase in flu vaccination uptake [Evidence review 3: ES3.2; SR-ES3.1, SR-ES3.2, SR-ES3.3, SR-ES3.5]. The committee noted that in 3 of the 5 cases the target population was children, suggesting that parents may be more amenable to personalised messages about the protective health benefits of vaccination when their children are in clinical risk groups than are adults who themselves have clinical risk factors. When reminders formed part of a multicomponent approach, an important increase in vaccination uptake was reported [Evidence review 3: SR-ES123.1, SR-ES123.3, SR-ES123.9], although 1 UK-based study that targeted children aged 2 to 4 years who were not in a clinical risk group found no increase in uptake when practices incorporated text messaging into a multicomponent approach [Evidence review 2: ES123.2]. The committee noted qualitative evidence that for parents of preschool children, a personal invitation from a healthcare professional is important for making a decision about vaccination [Evidence review 2: Q-ES1.9]. Other qualitative evidence further highlighted that people are more likely to trust advice and offers of vaccination that come from healthcare professionals they know, and that it is important for messages to be delivered with conviction [Evidence review 3: Q-ES2.4].

The committee believed strongly that reminders should be proactive. Not everyone who is eligible for free flu vaccination will visit their GP surgery regularly, so it is not sufficient to rely on posters in waiting rooms to remind them. The committee discussed the equivocal evidence on the effectiveness of text messaging to call and recall people for flu vaccination, which they felt may be perceived by the recipient as too impersonal or lacking conviction. They agreed that, if possible, reminders to eligible people should be personalised and come from a healthcare professional they know, either in person or in writing. The committee acknowledged that digital formats may be more acceptable to some population groups than others but were keen to recommend that if they are used, they should include links to additional useful information, including options for seeking further face-to-face advice and for booking an appointment to have their flu vaccination.

The committee also considered expert testimony that supported the use of peers to inform and invite people who are not in contact with primary care services for vaccination, such as people who are homeless [EP3]. They discussed that this approach could be extended to engage people who may have concerns about flu vaccination for religious reasons, as highlighted in another expert's testimony [EP6]. For example, some parents of children eligible for flu vaccination may be reluctant for their child to take up the offer because the nasal spray that is used to vaccinate children contains a gelatine additive derived from pork, so may be considered 'forbidden' in certain faiths. In such situations, it may be worth trying to engage peers or community leaders to work with local healthcare providers to provide information and support that people feel able to trust, in a language that is accessible and appropriate to them.

The majority of published evidence considered by the committee was from the USA, where there is no distinction between primary care and secondary care that equates to the UK healthcare context. However, the committee noted there was low-quality evidence from studies in which interventions implemented in specialist healthcare settings had successfully improved vaccination uptake among children having treatment for different forms of cancer [Evidence review 3: ES123.3] and, although with greater uncertainty in the effect, among people with end-stage renal disease who were having treatment in dialysis centres [Evidence review 3: ES123.5].

In relation to UK secondary care, the committee reviewed expert testimony about people with chronic liver disease. This highlighted that these people are at high risk of flu-related morbidity and mortality but currently have the lowest rates of vaccination uptake in primary care; also that they may be more likely to have regular contact with specialist hospital clinics or other services (such as drug and alcohol services) [EP2]. The committee agreed this may also apply to other eligible groups, including those with chronic neurological or kidney disease, people who are immunocompromised due to a medical condition or ongoing treatment, and pregnant women attending hospital antenatal appointments. This offers opportunities to provide flu vaccination in secondary care to people who may otherwise not access vaccination through primary care. Existing hospital systems could be used to identify and prompt offers of vaccination to anyone attending a routine appointment during the flu season who remains unvaccinated. However, the committee were keen to underline that vaccination in secondary care needs to be done in line with local commissioning agreements. Also, arrangements should be in place to ensure that anyone who is opportunistically offered vaccination in secondary care can access it easily, because qualitative evidence suggests people are put off if they have to arrange a further appointment or go to another location to get the flu vaccine [Evidence review 3: Q-ES2.3].

The committee drew on evidence from qualitative studies with pregnant women highlighting the importance of a personalised invitation from a known professional involved with their antenatal care [Evidence review 3: Q-ES2.4]. They discounted evidence from a number of small, low-quality studies that found no difference in vaccination decision-making among pregnant women when messages about flu vaccination were framed either 'negatively' (in terms of risks of remaining unvaccinated) or 'positively' (in terms of the benefits both to mother and baby of protection against flu both during pregnancy and after birth). There was contradictory evidence from other qualitative studies suggesting that pregnant women respond more readily to offers of vaccination when the benefits to their baby are clearly communicated [Evidence review 3: Q-ES2.6]. The committee felt this corresponded with other evidence already outlined suggesting that parents of children in clinical risk groups respond well to personalised interventions encouraging vaccination of their children. Given that flu vaccination rates are currently very low in young children, particularly babies and infants with clinical risk factors that put them at highest risk from flu, the committee felt it is important that providers help parents make decisions about flu vaccination by not only outlining the potential risks of not vaccinating but also the benefits – appealing to the parental instinct to nurture and protect their child's health.

The committee reviewed evidence for provider prompts embedded in patient medical records as an intervention to increase uptake of flu vaccination. There were 8 evidence statements relating to use of provider prompts – either as a single intervention or, more usually, combined with other approaches to increasing vaccination uptake [Evidence review 2: ES3.4. Evidence review 3: SR-ES3.4, SR‑ES3.7, SR-ES3.9, ES123.3, SR-ES123.1, SR-ES123.7, SR-ES123.9]. Seven of these statements reported an increase in vaccination uptake. This was clinically important (an increased uptake of 5% or more, compared with the control or pre‑intervention level), in 6 of the 7 evidence statements. The evidence was of variable quality with most rated of low or very low certainty. Reasons for downgrading included risk of bias (mostly observational studies), high levels of heterogeneity in pooled analyses and imprecision of effect estimates. The settings included primary and secondary care. Populations included children not in clinical risk groups [Evidence review 2: ES3.4], as well as adults and children with clinical risk factors and pregnant women [Evidence review 3: SR-ES3.4, SR-ES3.7; ES123.3; SR-ES123.1, SR-ES123.9]. One study suggested that timing of prompts may be important, with a greater increase in uptake when provider prompts were activated later in the flu season (January to February) compared with earlier (October to December).

Advantages and disadvantages of increasing uptake among eligible groups in primary and secondary care

Primary care is the main setting in which flu vaccinations are given in the UK. Most people who are eligible for free flu vaccination are already registered with a GP, so it is relatively easy to use the systems already in place in primary care to implement interventions to increase uptake, such as case-finding and using provider prompts. Sending reminders to eligible people that they are due or overdue (call/recall) their flu vaccination is a useful means of sustaining awareness across successive flu seasons. However, this needs contact information to be kept up to date in patient records.

Face-to-face interactions are an opportunity to raise awareness and encourage uptake. However, some people who are eligible for flu vaccination may not be in regular contact with primary care and may remain unvaccinated, which is why the committee were keen to also include recommendations for increasing uptake in secondary care. Systems are in place to enable the identification of people receiving specialist treatment for health conditions that make them eligible for free flu vaccination so that the vaccine could be offered. However, vaccination needs to be available and easily accessible on‑site, and to be organised in line with local patient group directions or enhanced services arrangements that have been agreed with commissioners.

Embedding provider prompts in health records is likely to be a more consistent and efficient method of identifying eligible people and increasing offers of flu vaccination than opportunistic approaches to case-finding. It is relatively easy to implement because systems are already in place. For example, prompts for flu vaccination could be established through coding from previous hospital admissions or primary care records and automatically generated in electronic case records. However, a disadvantage of prompts is that they are often used for many aspects of healthcare delivery, and run the risk of practitioners getting 'prompt fatigue'.

The outcomes that matter most

Uptake of flu vaccination by people in eligible groups, and its acceptability to them.

The quality of the evidence

Qualitative evidence highlighted that providers need to feel that they can trust in the accuracy of computerised prompts and patient records, which should be maintained and updated in a consistent and timely fashion [Evidence review 2: Q-ES1.6]. The committee agreed that this is an important issue given the inclusion of recommendations in this guideline to extend vaccination provision to other settings to increase uptake, including schools (as part of the universal programme for vaccinating children), community pharmacies, secondary care and social care settings.

The committee reviewed very low- to moderate-quality evidence showing that audit and feedback interventions are associated with increases in flu vaccination when delivered individually or as part of a multicomponent strategy to increase uptake in clinical risk groups. The committee agreed there was some uncertainty in the size of effect because of study quality, or because it was difficult to be sure how much of the effect in multicomponent approaches was due specifically to audit, monitoring and feedback activities. However, the consistent direction of effect for the majority of patients enabled the committee to make recommendations.

The committee also heard expert testimony from a practice nurse [EP6] who leads on increasing uptake in a general practice and also supports flu vaccination campaigns across her region for the clinical commissioning group. She stated that using audit and monitoring enabled them to improve their targeting of particular clinical groups in which uptake was low. It also helped her to spot any other general practices in her region that may need advice or support.

Published evidence on audit and feedback and the impact of QOF on increasing uptake is mixed. One study showed that practice audits increased uptake in some clinical risk groups but not others [Evidence review 3: ES3.4b], although the committee agreed that the difference in impact between clinical risk groups may be due to relatively low numbers of post-splenectomy patients (in whom no significant effect was found) compared with other groups studied (coronary heart disease and diabetes).

In 2 studies looking at the impact of QOF, 1 showed that pay-for-performance targets increased flu vaccination rates in a target clinical risk group of people with coronary heart disease compared with control conditions of chronic obstructive pulmonary disease, diabetes and stroke [Evidence review 3: ES3.5]. The other showed that removing pay-for-performance targets (in a condition previously incentivised) did not result in the uptake rate decaying over the 8‑year study period, with uptake rate being maintained at over 75%, which is above the national target. In 2 multicomponent studies that included audit and feedback, a cluster-randomised controlled trial indicated education plus audit increased vaccination in clinical risk groups [Evidence review 3: ES123.2]. This was supported by a retrospective cohort of 6 years' repeated measures after the intervention showing provider feedback combined with education and nurse standing orders (PGD) increased and maintained uptake compared with baseline [Evidence review 3: SR-ES123.6]. The committee acknowledged the overall quality of the evidence was very low to moderate, but felt this was to be expected given the evidence is driven by the quality improvement cycle. They agreed that the consistency and in some cases durability of effect over time, in real-world circumstances, reduced any uncertainty resulting from study quality.

Expert testimony on increasing uptake in healthcare workers also highlighted the importance of monitoring and feedback because it encouraged staff to accept the vaccination and helped to show senior managers that the campaign was working. Evidence on feedback as an intervention to increase uptake in health and social care staff is mixed. One study showed it was a component in a successful approach on hospital wards and in outpatient clinics to increase uptake [Evidence review 4: ES45.10]. However, this was not the case in a before-and-after study in which director-level feedback was a component in a multicomponent approach [Evidence review 4: ES45.9]. The committee considered the inconsistency in the evidence, including the small numbers in the study that showed no effect and the fact that uptake had been corroborated with lab-confirmed cases of flu in the other study. Based on this, along with the expert testimony, the committee considered feedback to be a key component that should be recommended as an important approach to support increasing uptake. Additionally, the recent introduction of a CQUIN to increase uptake meant that monitoring and using feedback to improve programmes was likely to become increasingly important to meet targets, and to show that these targets have been met.

Advantages and disadvantages of audit, monitoring and feedback

Overall, the committee agreed that healthcare records can be used effectively to identify and increase offers of flu vaccination to eligible groups. However, it is important that patient records are accurate and up to date to ensure all vaccinations are included in uptake data and that people are not inadvertently vaccinated more than once in a season. The committee confirmed that, although not in itself likely to be harmful to the person, over-vaccination will incur unnecessary costs and increase the burden of any associated short-term side effects such as pain, swelling or redness at the injection site.

If eligible people are vaccinated in settings other than their own GP surgery, poor information transfer may waste time and resources if practices invite and remind people unnecessarily, or booked flu clinic appointments go unused. Mechanisms for sharing information across providers need careful planning and oversight to minimise data loss.

Audit, monitoring and feedback activities are useful for needs assessment, enabling a practice to determine where extra effort or resources may be needed to increase uptake among particular groups. Monitoring uptake will also help in planning activities as well as in ordering and maintaining stock; this will have a knock-on effect of reducing inefficiency by reducing potential waste and allowing effort to be focused on targeting the most needed groups.

Recording why people decline vaccination helps to identify barriers and adapt interventions to address and overcome those issues in future activities or campaigns. However, this needs to be done accurately and consistently to support a better understanding of barriers to vaccination.

Payments will offset the resource impact of campaigns to increase vaccination uptake in some organisations, such as GP surgeries, community pharmacies and NHS trusts. This may motivate organisations to increase uptake and encourage staff to succeed, which in turn may improve job satisfaction if incentive targets are reached.

The social care sector and some NHS organisations may be disadvantaged by a current lack of systems to collect flu vaccination data and by the lack of payment by results incentivisation to increase uptake among staff. Resource impact from implementing the recommendations may therefore be greater in the social care sector in particular.

The outcomes that matter most

Uptake of flu vaccination by people in eligible groups, and its acceptability to them.

The quality of the evidence

There was a lack of published effectiveness evidence relating to interventions to increase uptake among carers. Very-low-quality evidence from 1 non‑UK observational study suggested that a recommendation from a respected person may positively affect carers' uptake of flu vaccination [Evidence review 1: ES1.1]. Other very-low-quality evidence from the UK suggested that extending access by offering vaccination services in community pharmacies does not increase uptake among carers, although they may be more likely than other eligible populations to opt to use pharmacies as a convenient out-of-hours alternative to GP vaccination services [Evidence review 1: ES2.1]. This was confirmed by expert testimony relating to carers [EP1].

The committee also noted issues raised by the expert relating to carer identification, because carer status is not routinely recorded in GP records and many informal carers do not recognise themselves as such. They agreed that community and primary care staff, such as community nurses, may be well placed to identify informal carers and assess their eligibility for flu vaccination – for example, during home visits to the person they are caring for. If a patient group direction or enhanced service arrangement has been agreed with local commissioners, nurses could offer vaccination to eligible carers. Alternatively, nurses could signpost carers to local primary care vaccination services, including any community pharmacies participating in the flu vaccination scheme.

The committee discussed at length evidence from economic modelling (outlined in more detail in the section below on cost effectiveness and resource use) and concluded that it is not cost effective to increase uptake of flu vaccination in all carers. It is important to target people who care for someone who may need to be admitted to hospital, or need alternative statutory care arrangements, if the carer falls ill with flu and is unable to look after them, or if risk of transmission for those who can't or won't be vaccinated is high, or for people for whom the flu vaccine is less efficacious, such as those who are immunocompromised.

Advantages and disadvantages of offering carers a flu vaccination

Carers are in close contact with people who are potentially at greater risk from flu. Carers have an important role; if they fall ill it can be detrimental to those they care for. In addition, they may pass the virus on to the person they care for. If the person being cared for has a weakened immune system they are still susceptible to the flu virus even if they have had the flu vaccine, because it works less well in this group. Increasing flu vaccination in carers can help sustain continuity of care and reduce the chances of onward transmission. However, the provider needs sufficient information to exercise clinical judgement on an individual carer's eligibility for flu vaccination, which should be based on the vulnerability of the person they look after.

The outcomes that matter most

Uptake of flu vaccination by health and social care staff, and its acceptability to them.

The quality of the evidence

The quantitative evidence relating to interventions to increase flu vaccination uptake among health and social care staff was of variable quality, with most rated low or very low. Downgrading was largely due to risk of bias and imprecision of effect estimates. In pooled analyses there was evidence of serious or very serious heterogeneity, which the committee agreed would be expected given the differences between study populations in the types of staff and the lack of standardisation of interventions and comparators across studies. The majority of studies were conducted outside the UK and covered a range of health and social care settings.

The committee noted that most studies included in the review examined combinations of interventions or their additive effects rather than a single approach, with staff education or awareness raising, and the provision of more flexible access (including off‑site or out-of-hours access) forming almost universal components. There was a clinically important increase in vaccination uptake (of 5% or more compared with the control or pre-intervention rate) in 19 out of 20 evidence statements in which a multicomponent approach was evaluated [Evidence review 4: ES45.1, ES45.2, ES45.3, ES45.4, ES45.5, ES45.6, ES 45.7, ES45.8, ES45.9, ES45.10, ES45.11; SR-ES45.1, SR-ES45.2, SR-ES45.3, SR-ES45.4, SR-ES45.5, SR-ES45.6, SR-ES45.7, SR-ES45.8].

There was conflicting evidence from subgroup analyses on the effect of interventions among staff with direct or indirect patient contact [Evidence review 4: SR-ES4.6, SR-ES45.7; ES45.7; SR-ES45.8], with different professional roles [Evidence review 4: ES45.7], or working in different care settings [Evidence review 4: SR-ES4.5]. The committee noted that the Green Book recommends vaccination of all health and social care staff who have direct involvement with patient or client care, and that responsibility for providing occupational flu vaccination rests with employers.

There was evidence that mandatory vaccination (with or without mask-wearing policies for those declining a flu vaccine) is the most effective lever of uptake among health and social care staff [Evidence review 4: ES4.6, ES4.7; SR-ES4.7, SR-ES4.8]. However, the committee expressed concerns about the challenges that mandatory vaccination of staff would have, including qualitative evidence indicating that such policies can negatively affect staff morale and undermine autonomy [Evidence review 4: Q-ES3.8, Q-ES3.9].

The committee acknowledged the concerns of policy makers and senior managers to reduce staff absenteeism. They believed that these concerns can be met by evidence that non-mandatory multicomponent interventions are also effective. This in turn will reduce transmission of flu in health and social care premises. This was confirmed by a study that found a significant decrease in the proportion of laboratory-confirmed flu cases among health and social care staff after implementation of a multicomponent vaccination programme [Evidence review 4: ES45.10].

Very low‑ to low-quality evidence indicated that declination policies were an effective approach [Evidence review 4: SR-ES4.4, SR-ES4.8, SR-ES 45.5, SR-ES 45.8; ES45.3, ES45.4, ES45.5, ES45.6, ES45.11]. A declination policy requires employees to submit a mandatory written statement stating that they have refused an offer of flu vaccination and citing their reasons why. A systematic review and meta-regression found that declination policies had an independent effect on flu vaccination uptake that was greater, on the whole, than all other types of intervention except mandatory vaccination [Evidence review 4: SR-ES 4.8]. Although the quality of the evidence was limited, the quantity and overall consistency of effect suggested that declination policies could work well. However, qualitative evidence indicated that employees have mixed feelings about declination policies, and stakeholder consultation on the draft version of this guideline revealed some resistance to the idea. The committee reconsidered the evidence in light of stakeholder feedback, noting that the studies included in the meta-regression analysis evaluating declination statements were all conducted in a US or Japanese setting, where organisational culture and employment relations are likely to differ markedly from the UK.

The committee also reconsidered evidence from a randomised controlled trial comparing an 'opt‑in' with an 'opt‑out' flu vaccination strategy for healthcare workers, conducted in 1 tertiary care provider in the Netherlands [Evidence review 4: ES4.8]. Participants in the opt‑out group were emailed with a pre-scheduled appointment for flu vaccination, which could be changed or cancelled by following a web link. In the opt‑in condition, participants received an email explaining that they had to book an appointment if they wanted to get vaccinated. The investigators failed to detect a statistically significant effect of either strategy on vaccination uptake, but because there were only 61 participants in each group it is likely the study was underpowered to detect a significant difference. However, healthcare workers in the opt‑out group were more likely than those in the opt‑in group to have an appointment for flu vaccination, which in turn increased the probability of them getting vaccinated (RR 1.70; 95% CI 0.85 to 3.41).

The committee concluded that an opt‑out strategy better respects individuals' autonomy, specifically the right to choose whether or not to accept a medical intervention, and may therefore be considered more acceptable than a declination policy for encouraging flu vaccination among front-line health and social care staff. The committee discussed the importance of involving staff representatives in developing a flu vaccination policy to minimise any negative impact on morale. The committee also agreed that it would not be appropriate to ask employees in an identifiable way to state their reasons for opting out of voluntary flu vaccination. However, it would usefully inform future flu vaccination campaigns if organisations could survey staff anonymously about their vaccination decision-making.

Expert testimony on increasing uptake in healthcare workers [EP4, EP5] further supported the approaches recommended by the committee based on the evidence. The experts considered audit and monitoring systems to be particularly important to help them plan their activities effectively and understand how they were progressing and whether changes were needed. The experts also stated that a multicomponent approach was important to ensure they were targeting the breadth of the workforce, because different members might be reached more effectively by different approaches. They indicated that assigning a lead and flu champions, involving media and other publicity activities along with keeping staff abreast of progress via feedback were all useful and important aspects. The experts also noted that staff incentives proved popular. Another key factor was to ensure that access to vaccination was carefully considered. One expert described taking the vaccination service to eligible staff as a useful strategy. Using mobile vaccination carts and making them available in high footfall areas such as the staff canteen, and around shift switchover times on wards, all made it more convenient for eligible staff to take up the offer of vaccination [EP5]. This testimony aligned with the qualitative and quantitative evidence considered by the committee. The committee highlighted that the recently introduced CQUIN would act as a significant lever for increasing vaccination rates among hospital-based staff for the foreseeable future.

The committee acknowledged that although the recommendation outlines a selection of interventions, it is difficult to specify what configuration would maximise any effect. They were satisfied that the recommendations outline an effective approach that can be tailored to local needs.

Advantages and disadvantages of offering health and social care staff a flu vaccination

Increasing vaccination uptake in health and social care staff will reduce the risk of transmission and offer protection to those they come into contact with who may be more susceptible to infection. It also has the potential to reduce sickness absence and increase the continuity of care that they provide.

Raising awareness in healthcare staff about eligibility for flu vaccination and its efficacy should increase the identification of eligible groups and their subsequent vaccination, thus reducing transmission and associated mortality and morbidity.

The committee has not made recommendations about mandatory flu vaccination policies. They have recommended the adoption of a full participation vaccination strategy, with nationally agreed opt‑out criteria. Nationally agreed opt‑out criteria are needed to ensure consistency of approach. The committee believes they should be developed with the involvement of staff representatives. A full participation strategy is one in which a range of approaches are used to maximise uptake and in which the expectation is that all front-line staff should be vaccinated. The full participation approach includes agreed mechanisms enabling staff to opt out if they wish.

An opt‑out strategy is potentially more acceptable for employment relations. But it offers less opportunity than a declination policy to engage with health and social care staff who decline vaccination in order to target support and education to overcome barriers, such as needle phobia, or misinformation about the flu vaccine's safety and effectiveness.