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This publication is available at https://www.gov.uk/government/publications/national-flu-immunisation-programme-plan/national-flu-immunisation-programme-2021-to-2022-letter
17 July 2021
The national influenza immunisation programme 2021 to 2022
Last year saw the roll out of the biggest NHS influenza vaccination programme ever, with the aim of offering protection to as many eligible people as possible during the coronavirus (COVID-19) pandemic. We would like to extend a huge thank you to all those involved for your hard work during very challenging times which led to the best influenza vaccine uptake rates ever achieved.
As a result of non-pharmaceutical interventions in place for COVID-19 (such as mask-wearing, physical and social distancing, and restricted international travel) influenza activity levels were extremely low globally in 2020 to 2021. As a result, a lower level of population immunity against influenza is expected in 2021 to 2022. In the situation where social mixing and social contact return towards pre-pandemic norms, it is expected that winter 2021 to 2022 will be the first winter in the UK when seasonal influenza virus (and other respiratory viruses) will co-circulate alongside COVID-19.
Seasonal influenza and COVID-19 viruses have the potential to add substantially to the winter pressures usually faced by the NHS, particularly if infection waves from both viruses coincide. The timing and magnitude of potential influenza and COVID-19 infection waves for winter 2021 to 2022 are currently unknown, but mathematical modelling indicates the 2021 to 2022 influenza season in the UK could be up to 50% larger than typically seen and it is also possible that the 2021 to 2022 influenza season will begin earlier than usual.
Influenza vaccination is therefore an important priority this coming autumn to reduce morbidity and mortality associated with influenza, and to reduce hospitalisations during a time when the NHS and social care may also be managing winter outbreaks of COVID-19.
The national influenza immunisation programme aims to provide direct protection to those who are at higher risk of influenza associated morbidity and mortality. Groups eligible for influenza vaccination are based on the advice of the Joint Committee on Vaccination and Immunisation (JCVI) and include older people, pregnant women, and those with certain underlying medical conditions.
Since 2013, influenza vaccination has been offered to children in a phased roll-out to provide both individual protection to the children themselves and reduce transmission across all age groups to protect vulnerable members of the population.
The expanded influenza vaccination programme that we had last year will continue in 2021 to 2022 as part of our wider winter planning when we are likely to see both influenza and COVID-19 in circulation. This means that as a temporary measure the offer for 50 to 64 year olds will continue this year to protect this age group, as hospitalisation from COVID-19 also increases from the age of 50 years onwards.
As a temporary measure, the programme will also be extended this year to 4 additional cohorts in secondary school so that all those from years 7 to year 11 will be offered vaccination. Vaccinating children reduces transmission of influenza and JCVI have recommended that expanding into secondary schools would be cost-effective, particularly if COVID-19 is still circulating .
Therefore, those eligible for NHS influenza vaccination in 2021 to 2022 are:
- all children aged 2 to 15 (but not 16 years or older) on 31 August 2021
- those aged 6 months to under 50 years in clinical risk groups
- pregnant women
- those aged 50 years and over
- those in long-stay residential care homes
- close contacts of immunocompromised individuals
- frontline health and social care staff employed by:
- a registered residential care or nursing home
- registered domiciliary care provider
- a voluntary managed hospice provider
- Direct Payment (personal budgets) and/or Personal Health Budgets, such as Personal Assistants.
All frontline health and social care workers are expected to have influenza vaccination to protect those they care for. A separate communication will follow about staff vaccination.
The influenza chapter in ‘Immunisation against infectious disease’ (Green Book), which is updated periodically, gives detailed descriptions of the groups outlined above and guidance for healthcare workers on administering the influenza vaccine.
Vaccines for the national immunisation programme
Influenza viruses change continuously and the World Health Organization (WHO) monitors the epidemiology of influenza viruses throughout the world, making recommendations about the strains to be included in vaccines, with recommendations now confirmed for 2021 to 2022.
Every year JCVI reviews the latest evidence on influenza vaccines and recommends the type of vaccine to be offered to patients. Providers should ensure that they have ordered adequate supplies of the recommended vaccines for their different adult patient groups, as set out in 2 letters from NHS England and Improvement (NHSEI) on 3 February and on 1 April 2021 .
In summary the recommended vaccines are:
- for those aged 65 years and over – the adjuvanted quadrivalent influenza vaccine (aQIV), with the cell-based quadrivalent influenza vaccine (QIVc) or the recombinant quadrivalent influenza vaccine (QIVr) offered if aQIV is unavailable
- for under-65s (including those at risk, pregnant women and 50 to 64 year old cohort) offer QIVc or QIVr, as an alternative if these are not available, the egg-grown quadrivalent influenza vaccine (QIVe) should be considered for use
Public Health England (PHE) procures vaccines for the children’s programme and these can be ordered through Immform. The live attenuated influenza vaccine (LAIV) should be offered to eligible children aged 2 years and over, unless contraindicated. QIVc, which is now licensed for all children aged 2 years and above, will be available to order for children in at risk groups who are contraindicated to receive LAIV, and as an alternative offer for children aged 2 and over whose parents object to LAIV on the ground of its porcine gelatine content. Children in clinical risk groups aged 6 months to less than 2 years should be offered QIVe.
LAIV is offered to children as it is generally more effective in the programme than the injected vaccines. It is also easier to administer and considered better at reducing the spread of influenza to others, who may be vulnerable to the complications of influenza.
In order for providers to receive payment for administration and reimbursement of vaccine they will need to use the specific influenza vaccines recommended in the NHSEI letters referred to above.
Last season due to supply constraints the alternative offer for children whose parents or guardians objected to LAIV on grounds of porcine gelatine content was only able to be made from November onwards. This season no supply constraints are anticipated and the alternative offer should be made routinely from the start of the season where applicable.
Achieving high vaccine uptake levels
Last season saw the most successful programme ever. Despite the challenges due to the COVID-19 pandemic, at the end of February 2021 NHS services had vaccinated a record 80.9% of those aged 65 years and over in England. This is the highest uptake ever achieved for this group and exceeds the WHO uptake ambition of 75%. For frontline healthcare workers, 2 and 3 year olds, and at risk groups the highest ever recorded levels of influenza vaccine uptake were also achieved.
All providers should have planned their influenza vaccine ordering to at least equal the high levels of uptake achieved in 2020 to 2021. The ambitions we are setting for the 2021 to 2022 programme are set out below. We want to build on the momentum of last year’s achievements and the successful roll-out of the COVID-19 vaccination programme, achieving even higher uptake this year. You many need to order additional vaccine to support you in reaching these ambitions.
The high ambitions reflect the importance of protecting against flu this winter and should be regarded as a minimum level to achieve. The different ambitions across the cohorts reflect what is regarded as achievable so, for instance, for those aged 65 and over the high ambition reflects the already high uptake levels achieved last year whereas for school-aged children the large expansion into secondary school this year will be challenging in itself.
Table 1. Vaccine uptake ambitions in 2021 to 2022
|Eligible groups||Uptake ambition|
|Routine programme for those at risk from influenza|
|Aged 65 years and over||At least 85%, reflecting the World Health Organization (WHO) target for this group.|
|Aged under 65 ‘at risk’, including pregnant women||At least 75% in all clinical risk groups|
|Aged 50 to 64 years||At least 75%|
|Preschool children aged 2 and 3 years old||At least 70% with most practices aiming to achieve higher.|
|School-aged children||At least 70% to be attained across all eligible school years.|
|Reducing levels of inequality|
|All ages||No group or community should have a vaccine uptake that is more than 5% lower than the national average. See paragraph 18 for more details.|
|Health and social care workers|
|Frontline health care workers||100% offer with an 85% ambition|
|Frontline social care workers||100% offer with an 85% ambition[footnote 1]|
In 2020 to 2021, published monthly data included a breakdown by ethnic group for the first time, and this was included in the 2020 to 2021 annual report and this will continue in 2021 to 2022. Other inequalities work led by PHE will continue to monitor and enhance the tools available and will include data on Index of Multiple Deprivation (IMD) which can be used to provide the best measure of relative deprivation as a snapshot in time (see Appendix I). We need to ensure those who are living in the most deprived areas, from ethnic minority and other underserved communities, have equitable uptake compared to the population as a whole. It will therefore require high quality, dedicated and interculturally competent engagement with local communities, employers, faith and advocacy groups. Providers are expected to ensure they have robust plans in place for tackling health inequalities for all underserved groups to ensure equality of access.
GP practices and school-based providers must actively invite 100% of eligible individuals (for example, by letter, email, phone call, text) and ensure uptake is as high as possible. The benefits of influenza vaccination among all eligible groups should be communicated and vaccination made as accessible as possible. Community pharmacy service providers do not have a fixed patient list from which to undertake call and recall activities. However, they should proactively offer influenza vaccination to any patient they identify as being eligible to receive it should the patient present in the pharmacy for any reason.
NHSEI will be recommissioning of a National Call and Recall service for the 2021 to 2022 season. This national call and recall service will supplement rather than replace local contractual call and recall mechanisms which must still continue as contracts dictate.
Frontline health and social care workers
All frontline health and social care workers should receive a vaccination this season. This should be provided by their employer, in order to meet their responsibility to protect their staff and patients and ensure the overall safe running of services. Employers should commission a service which makes access easy to the vaccine for all frontline staff, encourage staff to get vaccinated, and monitor the delivery of their programmes.
For healthcare workers providers should use the current definition as set out in chapter 12 of the Green Book.
As in previous years, NHS Trusts should complete a self-assessment against a best practice checklist which has been developed based on 5 key components of developing an effective flu vaccination programme. The completed checklist should be published in public board papers at the start of the flu season (see Appendix H).
Where employee-led occupational health services are not in place NHSEI will continue to support vaccination of social care and hospice workers employed by registered residential or domiciliary care providers as well as those employed through Direct Payment and/or Personal Health Budgets to deliver domiciliary care to patients and service users. Vaccination will be available through community pharmacy or their registered general practice. This scheme is intended to complement, not replace, any established occupational health schemes that employers have in place to offer flu vaccination to their workforce.
Since last year, the Community Pharmacy Seasonal Influenza Advanced Service Framework enables community pharmacies to vaccinate both residential care or nursing home residents and staff in the home setting in a single visit.
Good practice guidance material can be found at Increasing Health and Social Care Worker Flu Vaccinations: Five Components and marketing resources will be available to download and order from the PHE Campaign Resource Centre.
Influenza and COVID-19 vaccination
Booster vaccines for COVID-19 are currently under consideration, with trials underway to ascertain whether co-administration of COVID-19 and influenza vaccines will be permissible, subject to the advice of JCVI. Early evidence on the concomitant administration of COVID-19 and influenza vaccines used in the UK, supports the delivery of both vaccines at the same time where appropriate.
Planning for influenza vaccination should continue as usual for this autumn, with further advice issued should co-administration with COVID-19 vaccination be recommended so that where appropriate both vaccines could be given at the same time.
Vaccination should be given in sufficient time to ensure patients are protected before influenza starts circulating. If an eligible patient presents late for vaccination it is generally appropriate to still offer it. This is particularly important if it is a late influenza season or when newly at risk patients present, such as pregnant women who may not have been pregnant at the beginning of the vaccination period. The decision to vaccinate should take into account the fact that the immune response to vaccination takes about 2 weeks to fully develop.
Last year the school age immunisation national service specification had a requirement that, to provide early protection, the provider would complete the influenza vaccination as early as possible after the influenza vaccine became available and at the latest by 15 December for all eligible children. In order to facilitate the service expansion alongside the continuation and catch up of the routine school age immunisation programmes this season the completion date for school age influenza vaccinations has been extended until the end of January 2022 although providers are encouraged to complete as soon as possible.
Parents of any child at risk from influenza because of an underlying medical condition can choose to receive influenza vaccination in general practice, especially if the parent does not want their child to have to wait for the school vaccination session (which may be one of the later sessions). GP practices should invite these children for vaccination, making it clear that parents have the option to have their child vaccinated in general practice.
List of appendices
Detailed planning information is set out in the following appendices:
Appendix A: groups included in the national influenza immunisation programme
Appendix B: service specifications
Appendix C: recommended influenza vaccines
Appendix D: vaccine supply and ordering
Appendix E: training resources, patient group directions (PGDs), protocols and patient facing information
Appendix F: children’s influenza vaccination programme
Appendix G: pregnant women
Appendix H: healthcare worker flu vaccination best practice management checklist
Appendix I: Data collection
Appendix J: Antiviral medicines
We would like to take this opportunity to thank you all for your hard work in delivering the influenza immunisation programme. We have some of the best influenza vaccine uptake rates in Europe and we achieved record levels in 2020 to 2021. This winter, it remains a key intervention to reduce pressure on the NHS and social care.
This Annual Influenza Letter has the support of the Chief Pharmaceutical Officer, the NHS Chief Nursing Officer for England and the Public Health England Chief Nurse.
Prof Chris Whitty
Chief Medical Officer for England
Prof Yvonne Doyle
Public Health England, Medical Director and Director for Health Protection
Prof Stephen Powis
NHS England and NHS Improvement, National Medical Director
Any enquiries regarding this publication should be sent to: email@example.com. For operational immunisation queries, providers should contact their local screening and immunisation team.
Links to other key documents
Vaccine Update – PHE monthly newsletter
PHE Flu Immunisation Programme page on GOV.UK
PHE Campaign Resource Centre – Help Us Help You campaign
Clinical commissioning groups clinical leads
Clinical commissioning groups accountable officers
General Practitioners Committee
Pharmaceutical Services Negotiating Committee
NHS England and NHS Improvement regional directors
NHS England and NHS Improvement regional medical directors
NHS England and NHS Improvement regional chief nurses
NHS England and NHS Improvement regional directors of commissioning
NHS England and NHS Improvement regional directors of primary care and public health
NHS England and NHS Improvement heads of public health commissioning
NHS England and NHS Improvement heads of primary care
Sustainability and Transformation Partnership (STP) primary care leads
Integrated Care System (ICS) primary care leads
PHE centre directors
Screening and immunisation leads
Chief executives of NHS trusts and foundation trusts
Heads of nursing of NHS trusts and foundation trusts
Heads of midwifery of NHS trusts and foundation trusts
Chief pharmacists of NHS trusts and foundation trusts
Directors of public health
Local authority chief executives
NHS regional chief pharmacists
Chairs of health and wellbeing boards
Allied Health Professionals Federation
Community Practitioners and Health Visitors Association
Nursing and Midwifery Council
Royal College of Midwives
Royal College of Nursing
Academy of Medical Royal Colleges
Royal College of Anaesthetists
Royal College of Physicians
Royal College of Surgeons
Royal College of Obstetricians and Gynaecologists
Royal College of General Practitioners
College of Emergency Medicine
Faculty of Occupational Medicine
Royal College of Pathologists
Royal College of Ophthalmologists
Royal College of Paediatrics and Child Health
British Medical Association
Royal Pharmaceutical Society
Association of Pharmacy Technicians UK
Company Chemist’s Association
National Pharmacy Association
Local Government Association
Association of Directors of Adult Social Services
Council of Deans of Health
General Medical Council
General Pharmaceutical Council
Faculty of Public Health
Association of Independent Multiple Pharmacies
UK Homecare Association (UKHCA)
Skills for Care
Association of Directors of Adult Social Services
Care Association Alliance
Care Provider Alliance
Voluntary Organisations Disability Group
National Care Forum (NCF)
National Care Association (NCA)
Local Government Association
In addition to occupational health schemes, all frontline social care workers can access a free vaccination from their GP or local pharmacy through the complementary scheme. ↩