Context

Guidance

Each winter hundreds of thousands of people see their GP and tens of thousands are hospitalised because of flu. Deaths attributable to flu are estimated to range from around 4,000 to 14,000 per year, with an average of around 8,000 per year (Public Health England and the NHS prepare for unpredictable flu season).

Flu vaccination has been recommended in the UK since the late 1960s. Everyone aged 65 and over, those who are the main carer of an older adult or person with a disability, anyone aged 6 months to 64 years in a clinical risk group that puts them at a higher than average risk of illness and death linked to flu, and all pregnant women are offered free vaccination as part of the Public Health England and NHS England national programme. In addition, the Joint Committee on Vaccination and Immunisation has recommended extending flu vaccination to children to reduce transmission in the community and reduce the number of cases of flu-related illness and death among older adults.

At the time of publication (August 2018), the universal flu vaccination programme is available for children aged 2 to 9 years (up to school year 5). Preschool children (aged 2 and 3 years) should be vaccinated in general practice. Older children (from reception age) are being vaccinated by local healthcare teams working with schools. Once the programme has been rolled out to all primary-school-aged children, it will be reviewed to assess whether to continue the extension into secondary schools. Decisions about further roll-out to include older year groups will be notified in the annual flu letter.

In addition to the groups already mentioned, the Health and Safety at Work Act (1974) makes employers responsible for offering the flu vaccination to health and social care staff who have direct care responsibilities.

Among people aged 65 or over, annual uptake of free NHS flu vaccination is relatively high and consistent, at around 70 to 75%. For this reason, this group was not included as a target population for increasing uptake in the scope for this guideline.

Among people under 65 who are in clinical risk groups, uptake is lower and more variable: 49% overall in 2017/18, ranging from 39% in patients with morbid obesity (with a BMI of 40 or over) and 41% in patients without a spleen or with splenic dysfunction, to 65% in patients who have diabetes. Uptake is particularly low among babies and infants (aged 6 months to under 2 years) who are in a clinical risk group: the vaccination rate in 2017/18 was only 21%. Uptake increased among preschool children in a clinical risk group (52% of those aged 2 to under 5 years), but then dropped off again among those of school age (44%). Among children not in a clinical risk group, uptake of the universal flu vaccination programme was 43% for 2‑year‑olds and 44% for 3‑year‑olds. Among pregnant women, flu vaccination uptake was 47% in 2017/18, whereas for people under 65 years who are registered as a carer by their GP, uptake was 40% (Public Health England's seasonal flu vaccine uptake in GP patients in England: winter 2017/18).

In England, 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. However, this masks considerable variation between the different target groups. A much higher relative risk (RR) of flu‑related death is associated, for example, 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.

In England 69% of healthcare workers in NHS trusts and area teams with direct patient contact were vaccinated in 2017/18, an increase from 63% the previous year (Public Health England's seasonal flu vaccine uptake in healthcare workers in England: winter 2017/18).

This guideline considers interventions to increase flu vaccination uptake in children aged 2 to 17 years (to take account of any future roll-out of the current children's universal vaccination programme); children and adults aged between 6 months and 64 years who are in clinical risk groups (see the Green Book), or adults who are morbidly obese (with a BMI of 40 or over); pregnant women, carers, and front-line health and social care staff, in line with the national flu immunisation programme plan 2022 to 2023.

See the guideline scope for more details.