How to Deliver the Joint Flu and COVID-19 Vaccination Programmes

Dr Toni Hazell Discusses the Vital Role of Primary Care in Rolling Out the Flu and COVID-19 Vaccination Programmes this Autumn

My 17 years as a GP seem to be marked by the cycle of flu vaccination seasons—every year, as we plan our main ‘flu jab Saturday’, I’m surprised that it has come around again so soon, and I have to remind myself who should be offered which vaccine, and where in the fridge the different types are kept.

Last year, we dealt with an expanded flu cohort to include all over 50s, along with the additional challenges of social distancing. For the 2021–2022 flu season, there are also COVID-19 vaccinations to take into account—boosters and third doses of the primary course for immunosuppressed patients. This article will provide an overview of the flu vaccination campaign for 2021–2022, and discuss what is currently known about the COVID-19 booster campaign, an area in which information is constantly changing.

Each year, flu vaccinations are formulated anew, in an attempt to match the strains that are likely to be circulating in the upcoming flu season. We don’t find out until after the flu season has finished how well the vaccination matched the circulating strains, and this varies from year to year. There are concerns that the flu season this year may begin earlier than usual, and that there could be up to 50% more cases than usual.¹ This is presumably due to reduced immunity as less people contracted flu during the periods of lockdown,¹ making it all the more important that we get on top of flu vaccination as soon as possible, even if we have to work around delays in the delivery of vaccines.²

Who is Eligible for Flu Vaccination?

Broadly speaking, a patient may be eligible for their flu vaccination for one or more of four reasons—their age, their occupation, their household contacts, or their medical history. Box 1 lists those who are eligible for an NHS flu vaccination in the 2021–2022 season.

Recommended Flu Vaccines

Those of a similar vintage to me might look back with fondness to the days when every patient had the same flu vaccine. However, for the past few years, the type of vaccine offered differs depending on the patient. This is to do with a phenomenon known as immunosenescence, in which the number and effectiveness of B and T cells reduces with age, while levels of pro-inflammatory cytokines increase.⁵ For this reason, all those aged 65 years and over are offered an adjuvanted flu vaccine, as it is more effective for this age group than the standard vaccine, which does not contain an adjuvant.^1,4

Table 1 shows the first choice of vaccine for each group of patients who are eligible for the flu vaccination.¹

Table 1: Summary of Flu Vaccines for Each Eligibility Group¹

The Live Attenuated Flu Vaccine

The live attenuated influenza vaccine (LAIV) is a live vaccination and therefore cannot be given to children who are immunocompromised as a result of disease or medication.^1,4 Conditions which are a contraindication to use of LAIV are listed in Box 2.^4–8

Concerns About Transmission of the Vaccine Virus

Parents have been known to enquire about whether a child who has the LAIV can ‘shed’ the live vaccine, and whether this would be dangerous if they have a household contact who is immunocompromised. It is possible that such queries may become more common this year, because there is more awareness about the group of household contacts of immunocompromised people, as they are now entitled to a flu vaccine based solely on their contact status.¹

Public Health England (PHE) says that the risk is largely theoretical and that there have been no reported cases of illness or infection from household contacts of children vaccinated with LAIV.⁹ It advises: ‘Where close contact with very severely immunosuppressed contacts (for example, household members) is likely or unavoidable, however, consideration should be given to using an appropriate inactivated flu vaccine instead.’⁹ The PHE guidance does not define ‘very severely immunosuppressed’, but a patient group direction for LAIV gives an example of someone who is isolating after a bone marrow transplant.^9,10 The majority of families can be reassured that it is safe for their child to have the LAIV.

Offer Information Tailored to Cultural and Social Needs

In recent years, there has been some publicity about religious groups pointing out that porcine gelatine is used in the manufacturing process of the LAIV. The gelatine degrades and is not present in the vaccine itself, but some individuals in Muslim and Jewish faith groups have expressed unhappiness at the use of this vaccine in their children. If this concern is expressed to you, there are various resources available that give opinions from Muslim and Jewish scholars that using this vaccine does not break religious law.^11–14 If a parent is still unwilling to allow their child to have the LAIV, but would accept an injectable vaccine, then one should be offered.¹ For the first time this year, this is the case from the very start of the flu season, both for children in an at-risk group and those being offered the vaccine on the basis of their age alone.¹

Flu Vaccines and Egg Allergy

Another query that is frequently brought to GPs’ attention is the question of egg allergy; it is a common urban myth that anyone with an egg allergy should not have a flu vaccination. This is not entirely correct—it is only an issue for those adults or children who have an egg allergy that has previously required admission to intensive care. Influenza: the green book, chapter 19 advises that children in this situation should have their LAIV vaccination in hospital, and adults should be referred to a specialist for assessment with regard to receiving immunisation in hospital.⁴

Children with a lesser degree of egg allergy can be safely vaccinated with LAIV in any setting. Adults with an egg allergy, and children who also have another condition which contraindicates LAIV, should be vaccinated with an inactivated flu vaccine that has a very low ovalbumin content of less than 0.12µg/ml.⁴ The ovalbumin content can be checked on the PHE website; this year, many of the commonly used brands are either egg free, or fit into the low ovalbumin content category.¹⁵

Coordinating the COVID-19 Vaccination Programme Alongside Flu Vaccinations

Finally, we need to consider how the flu vaccination programme will fit in with COVID-19 booster vaccinations. There are two groups that are eligible for a third COVID-19 vaccine this winter.

Third Primary Dose for Individuals With Severe Immunosuppression

A group of patients who are severely immunocompromised aged 12 years and over are being offered a third primary dose of a COVID-19 vaccine, due to concerns that they may not have mounted a strong immune response to the first two doses.^16,17 It is preferred that those in this group who are aged 18 years or over are given an mRNA vaccine (Pfizer–BioNTech or Moderna), even if they had the AstraZeneca–Oxford University vaccine for their first two doses; the Pfizer–BioNTech vaccine is preferred for those aged 12–17 years.¹⁶ The AstraZeneca–Oxford University vaccine should only be given as the third dose to patients for whom it was the primary course, and when it is necessary to facilitate delivery that would otherwise be difficult.¹⁶ This may be relevant for some individuals in nursing homes or those who are housebond.

Decisions on eligibility for a third dose, and the timing of it, should be made by the patient’s specialist,¹⁶ so any queries received in primary care should be directed towards secondary care. General principles include the fact that the third dose should ideally be given at least 8 weeks after the second dose, and delayed, if possible, for a period of 2 weeks after a period of immunosuppression, such as after chemotherapy, in addition to the time required for clearance of the therapeutic agent.¹⁶  If this is not possible, consideration should be given to vaccination during a treatment holiday or when immunosuppression is lowest, such as between doses of treatment.¹⁶  

Delivering Booster Vaccinations

The second group eligible for another dose of COVID-19 vaccine is those who were in priority groups 1–9 for the primary course; they should all be offered a booster vaccination at least 6 months after receiving their second dose of a COVID-19 vaccine. This includes:¹⁸

• those living in residential care homes
• all adults aged 50 years or over
• front-line health or social care workers
• all those aged 16–49 years with underlying health conditions that put them at higher risk of severe COVID-19 (this broadly corresponds to those who have always been offered a flu vaccination), and adult carers
• adult household contacts of immunosuppressed individuals.

The preference is for this group to receive the Pfizer–BioNTech vaccine, regardless of which brand was given for the primary course. Data suggest that it should be well tolerated and provide a strong booster response.¹⁸ If this is not possible, then a half dose of the Moderna vaccine can be offered, with the AstraZeneca–Oxford University vaccine being given only to those who cannot have an mRNA vaccine due to allergies or other contraindications.¹⁸

Helpfully, the COVID-19 and flu vaccines can be given on the same day.¹⁸ Whether this actually happens will depend on how things work in each individual area; in some areas, COVID-19 vaccination is happening at GP surgeries, but in many places the logistics mean that COVID-19 vaccinations are mainly at larger centres which may not be able to co-administer the flu vaccine.

As well as third doses and boosters, vaccine centres continue to give first and second doses to adults who may have initially been vaccine hesitant and are now changing their minds, as well as a first dose to all 16- and 17-year-olds. Recently, it has also been announced that all 12–15-year-olds will be offered one dose of the COVID-19 vaccine, although these will primarily be given in school.¹⁹

This is unlikely to be the end of the story as the Joint Committee on Vaccination and Immunisation is still reviewing emerging data—we probably have more to learn about immunity to COVID-19 for different population groups, so watch this space as time goes on.

Summary

The flu vaccine is being offered to all adults who are 50 years or over, as well as the usual groups who are offered it due to their occupation or co-morbidities. Most children of school age will receive the nasal flu vaccine in school but a small number will need the injection if they have a contraindication to live vaccines. Egg allergy is not a contraindication for the flu vaccination and it is very rare for a patient to need vaccination in hospital due to an egg allergy. The primary COVID-19 vaccination programme is continuing, along with boosters for eligibility groups 1–9, and a third primary dose for those who are significantly immunosuppressed.

Dr Toni Hazell

Portfolio GP, Tottenham, London