Guidance

National flu immunisation programme 2023 to 2024 letter

Updated 3 July 2023

Please refer to the Statement of amendments to annual flu letter published on 3 July 2023 for changes to the NHS influenza immunisation programme 2023 to 2024.

Planning for the 2023 to 2024 flu vaccination programme

Dear colleagues,

Seasonal flu vaccination remains a critically important public health intervention and a key priority for 2023 to 2024 to reduce morbidity, mortality and hospitalisation associated with flu at a time when the NHS and social care will be managing winter pressures whilst continuing to recover from the impact of the coronavirus (COVID-19) pandemic. The delivery of the NHS flu immunisation programme over recent seasons has been both ambitious and challenging as we sought to offer protection to as many eligible people as possible, exceeding the World Health Organization (WHO) target for those aged 65 years and above for a third season running.

This letter sets out guidance for the 2023 to 2024 season, including the cohorts and next steps for regions and providers to take. Further guidance will follow on how the flu programme should be aligned to any autumn COVID-19 vaccination programme.

Cohort eligibility

The programme provides direct protection to those at higher risk of flu associated morbidity and mortality, including older people, pregnant women, and those in clinical risk groups and is guided by advice from the Joint Committee on Vaccination and Immunisation (JCVI), an independent departmental expert committee. In addition, based on the JCVI 2012 recommendation, a vaccination programme for children using live attenuated influenza vaccine (LAIV) provides individual protection to the children and reduces transmission to the wider population.

The below groups will be eligible for a flu vaccine from 1 September 2023:

• those aged 65 years and over
• those aged 6 months to under 65 years in clinical risk groups (as defined by the Green Book, chapter 19 (Influenza))
• pregnant women
• all children aged 2 or 3 years on 31 August 2023
• primary school aged children (from Reception to Year 6)
• those in long-stay residential care homes ^{[footnote 1]}
• carers in receipt of carer’s allowance, or those who are the main carer of an elderly or disabled person
• close contacts of immunocompromised individuals
• frontline workers in a social care setting without an employer led occupational health scheme including those working for a registered residential care or nursing home, registered domiciliary care providers, voluntary managed hospice providers and those that are employed by those who receive direct payments (personal budgets) or Personal Health budgets, such as Personal Assistants

All frontline health care workers, including both clinical and non-clinical staff who have contact with patients, should be offered a flu vaccine as part of the organisations’ policy for the prevention of the transmission of flu to help protect both staff and those that they care for. Social care workers directly working with people clinically vulnerable to flu should also have the flu vaccine provided by their employer. There are circumstances where frontline staff, employed by specific social care providers without access to employer led occupational health schemes (see cohort eligibility above), can access the vaccine through the NHS free of charge.

Eligible school aged children (including those in clinical risk groups) will be offered immunisation by the school age immunisation service. However, general practices should continue to invite eligible school aged children in clinical risk groups for flu vaccination to ensure that they can access a vaccine before flu starts to circulate, where school sessions may be scheduled for later in the season or have been missed.

An expansion to secondary school-aged children (Years 7, 8, 9, 10 and 11) is being considered. Should this be confirmed, further guidance will follow.

Providers are expected to deliver a 100% offer to eligible groups. Providers should aim to equal or exceed last season’s (2022 to 2023) uptake particularly in clinical risk groups, children aged 2 and 3 years old, and pregnant women (see Appendix 1). Providers should also ensure they have robust plans in place for tackling health inequalities for all underserved groups.

With healthcare workers, one of the quality indicators in the 2023 to 2024 Commissioning for Quality and Innovation (CQUIN) is a goal of vaccinating over 75% of staff, reflecting the importance of vaccinating staff both for their own protection and to reduce transmission to vulnerable patients.

Timing

Vaccination should be given in sufficient time to ensure patients are protected before flu 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 flu season or when patients newly at-risk present, such as pregnant women who may not have been pregnant at the beginning of the vaccination period. Late vaccines can also provide some protection into the following season. The decision to vaccinate should take into account the fact that the immune response to vaccination takes about 2 weeks to fully develop.

For school-aged cohorts, providers should ensure they commence vaccinations as early as possible after the flu vaccine becomes available and complete by 15 December to provide early protection, reduce transmission to the wider population and ensure minimal impact on routine immunisations in the spring.

As with the school-aged programme in order to provide early protection and reduce transmission to the wider population, GP practices should prioritise vaccination of 2- and 3-years olds with LAIV over vaccination of adult cohorts; and commence as early as possible after the flu vaccine becomes available.

Recommended vaccines

Every year the JCVI reviews the latest evidence on flu vaccines and advises the type of vaccine to be offered to different age groups. A list of all influenza vaccines marketed in the UK (including details of ovalbumin content) is available on GOV.UK.

Adult vaccines eligible for reimbursement

No changes were recommended by JCVI for adult flu vaccines for 2023 to 2024. Providers should ensure that they have ordered adequate supplies of the recommended vaccines to vaccinate all eligible individuals included within this letter.

Contractual requirements for all commissioned NHS flu vaccination providers will state that to receive payment for flu vaccination and reimbursement of flu vaccine they will need to use the specific flu vaccines outlined below for the appropriate cohort - see the summary poster aide memoire on the vaccines for 2023 to 2024. Please note that commissioners will actively reclaim any payments made for the incorrect vaccine administered. The GP and Community Pharmacy enhanced specifications will be updated and published shortly following usual engagement with professional bodies.

With the exception of frontline workers in certain social care settings (see above), please be aware the vaccination of all other frontline health care staff will not be reimbursed and does not qualify for a payment.

The following vaccines will be reimbursed for adults in the 2023 to 2024 programme:

Those aged 65 years and over	Those aged 18 to 64 years in eligible groups
Adjuvanted quadrivalent influenza vaccine (aQIV) / recombinant quadrivalent influenza vaccine (QIVr) Cell-based quadrivalent influenza vaccine (QIVc) – only when every attempt to use aQIV or QIVr has been exhausted – evidence of this may be requested by the commissioner before reimbursement is agreed	Cell-based quadrivalent influenza vaccine (QIVc) / recombinant quadrivalent influenza vaccine (QIVr) Egg-grown quadrivalent influenza vaccine (QIVe) -only when every attempt to use QIVc or QIVr has been exhausted – evidence of this may be requested by the commissioner before reimbursement is agreed

For those aged 18 to 64 years in eligible groups, QIVc and QIVr should be prioritised for these cohorts. There is a potential advantage to using flu vaccines which do not use eggs in the manufacturing process (cell-culture or recombinant) compared with egg-cultured flu vaccines, due to the possible impact of “egg-adaptation” on the effectiveness of flu vaccines, particularly against A(H3N2) strains.

Due to manufacturing processes and commissioning arrangements, some vaccines may only be available in limited quantities or batches of vaccine may be subject to delay. Therefore, it is recommended that orders are placed with more than one manufacturer to ensure providers receive sufficient stock. Providers should remain flexible when scheduling vaccination sessions and be prepared to reschedule if necessary.

Providers should only purchase alternative vaccines to the ones recommended above if all attempts to secure the recommended first line vaccines have failed. Providers may be asked to provide evidence to show this upon request from their commissioner.

As in previous years, aQIV may be offered ‘off-label’ to those who become 65 years of age before 31 March 2024.

Children’s vaccines

UK Health Security Agency (UKHSA) supplies all flu vaccines for the children’s programme and these will be available to order through ImmForm and are not reimbursable. The following vaccines will be available to order:

Children aged 6 months to less than 2 years in clinical risk groups	Children aged 2 to less than 18 years in clinical risk groups; 2 to 3 years, and those in eligible school age cohorts
Cell-based quadrivalent influenza vaccine (QIVc), Seqirus (offered off-label)	Live attenuated influenza vaccine (LAIV), Fluenz® Tetra Cell-based quadrivalent influenza vaccine (QIVc) where LAIV is contraindicated or otherwise unsuitable (for example parents object to LAIV on the grounds of its porcine gelatine content)

LAIV is the vaccine of choice for the childhood flu programme for those aged 2 years and over. 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 flu to others, who may be vulnerable to the complications of flu. LAIV should be offered unless it is medically contraindicated or otherwise unsuitable (including objection to LAIV on the grounds of its porcine gelatine content).

JCVI recommended that an egg-grown quadrivalent influenza vaccine (QIVe) is also suitable for use in children aged 6 months to under 2 years and for those aged 2 to less than 18 years if QIVc is not available. However, this vaccine is not being supplied by UKHSA via its ImmForm website.

As in previous seasons, ordering controls will be in place for Fluenz® Tetra in 2023 to 2024 to enable UKHSA to balance vaccine availability and demand appropriately across the programme. The latest information on ordering controls and other ordering advice for UKHSA supplied flu vaccines will be featured on the ImmForm news page both prior to and during the flu vaccination period. Information will also be featured in Vaccine update and disseminated via the National Immunisation Network as appropriate. It is strongly advised that all parties involved in the provision of flu vaccines to children ensure they remain up to date with this information at all times until the end of the 2023 to 2024 programme.

Co-administration

Providers are encouraged to align delivery of the flu vaccination programme with other commissioned vaccination programmes for which the patient may be eligible (for instance shingles, pertussis, or pneumococcal vaccines) where it is clinically acceptable, operationally feasible, and where the patient is content. Where co-administration may not be feasible providers must make every effort to encourage individuals to take up the offer of every vaccine they are eligible for.

Please refer to the Green Book, chapter 19 (Influenza) for further clinical information for healthcare professionals regarding flu vaccination and documents linked from this letter’s annexe. Further information on the programme can also be found at Annual flu programme.

Data collection

UKHSA publish the national Official Statistics on vaccine coverage for frontline healthcare workers (HCWs), school aged children and eligible GP registered patients that are used to formally evaluate the programme year-on-year, are quoted in the public domain and reported to the WHO. These data collections are managed through the ImmForm website. Providers should ensure they complete these data returns through ImmForm during the appropriate time windows throughout the season. See appendix 2.

Monthly data collections (frontline HCWs, school aged children and eligible GP registered patients) will take place over 5 months (for HCWs and GP patients (November to March publication) and 4 months for schools (November to February publication) during the 2023 to 2024 flu immunisation programme.

NHS Trusts delivering vaccinations must use an NHS-endorsed Point of Care (PoC) system for vaccination event data capture, which will feed back to relevant systems, such as the service user’s GP record, and national and local reporting tools. Primary care providers must use their relevant systems for vaccination event data capture and where required share the vaccination event details with the service user’s registered practice.

Further information

Further information can be found in the Annexe A and separate appendices at National flu immunisation programme plan 2023 to 2024.

Yours sincerely,

Dr Thomas Waite, Deputy Chief Medical Officer for England

Dr Mary Ramsay, Director of Public Health Programmes, UK Health Security Agency

Steve Russell, National Director for Vaccinations and Screening, NHS England

Any enquiries regarding this publication should be sent to: immunisation@ukhsa.gov.uk and phco.fluops@nhs.net

For operational immunisation queries, providers should contact their regional NHSE Public Health Commissioner.

Annexe A: resources to support the programme

Healthcare practitioners should refer to the influenza chapter in ‘Immunisation against infectious disease’ (the ‘Green Book’) for further detail about clinical risk groups advised to receive flu immunisation and advice on contraindications and precautions for the flu vaccines.

Information for healthcare practitioners about the childhood flu programme and the inactivated flu vaccines, and links to an flu vaccination training slide set and the flu vaccination e-learning programme will be available on the Annual flu programme webpage and the e-learning for healthcare Flu Immunisation web page.

UKHSA will develop PGDs that will be available prior to commencement of the programme at Immunisation patient group direction (PGD) templates and Community Pharmacy Seasonal Influenza Vaccine Service. A national protocol for inactivated flu vaccines will also be available.

Resources for the public facing marketing campaign to encourage take-up amongst eligible groups and for adaptable assets for NHS and social care organisations to use in their own staff vaccination campaigns will be available from the Campaign Resource Centre.

UKHSA produces a range of flu publications including leaflets, template invitation letters, template informed consent forms and posters, with leaflets translated into 29 and provided in braille, British Sign Language, large print, simple text for those with low literacy, and easy read for those with a learning disability. Leaflets remain an effective way of communicating the need and the benefits of having a vaccine and inform the consent process. It is important that people receive a leaflet in a format that meets their needs. The leaflets and resources are all available to download and many can also be ordered free of charge.

There is UKHSA guidance on the use of antiviral medicines for the treatment and prophylaxis of seasonal flu. Antiviral medicines can only be prescribed by GPs and non-medical prescribers in primary care during the flu season, once a Central Alerting System (CAS) Alert has been cascaded to GP practices and community pharmacies by the Chief Medical Officer (CMO) and Chief Pharmaceutical Officer authorising the prescribing and supply of antiviral medicines at NHS expense. The statutory prescribing restrictions that apply to primary care do not apply in secondary care. Hospital clinicians can continue to prescribe antiviral medicines for patients whose illness is confirmed or clinically suspected to be due to flu, in accordance with UKHSA guidance for the treatment of complicated flu. Enrolment in the REMAP-CAP influenza platform trial is encouraged and will strengthen our knowledge base for treating influenza.

A table showing influenza vaccine uptake over the last 5 years is available from Appendix 1.

Further information on UKHSA data collection for official statistics is available from Appendix 2.

1. Includes other long-stay care facilities where rapid spread is likely to follow introduction of infection and cause high morbidity and mortality (this does not include, for example, prisons, young offender institutions, university halls of residence) ↩