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Influenza

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What is covered

This interactive flowchart covers how to increase uptake of the free flu vaccination among people who are eligible. It describes ways to increase awareness and how to use all opportunities in primary and secondary care to identify people who should be encouraged to have the vaccination. It also covers post-exposure prophylaxis and treatment of influenza for at-risk groups.

Updates

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on influenza in an interactive flowchart

What is covered

This interactive flowchart covers how to increase uptake of the free flu vaccination among people who are eligible. It describes ways to increase awareness and how to use all opportunities in primary and secondary care to identify people who should be encouraged to have the vaccination. It also covers post-exposure prophylaxis and treatment of influenza for at-risk groups.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Flu vaccination: increasing uptake (2018) NICE guideline NG103
Amantadine, oseltamivir and zanamivir for the treatment of influenza (2009) NICE technology appraisal guidance 168

Quality standards

Quality statements

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

NICE has produced resources to help implement its guidance on:

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Supporting information

People who care informally on an unpaid basis for a family member or friend have the right to discuss with their local council what their own needs are, separate to the needs of the person they care for. The assessment covers anything the carer thinks would help them with their own health or with managing other aspects of their life. The council will use the information to decide what help it can offer.
Include prompts about people's eligibility for flu vaccination in electronic patient records or in medical notes (for example, by putting reminder stickers in antenatal notes).
A brief intervention involves oral discussion, negotiation or encouragement, with or without written or other support or follow-up. It may also involve a referral for further interventions, directing people to other options, or more intensive support. Brief interventions can be delivered by anyone who is trained in the necessary skills and knowledge. These interventions are often carried out when the opportunity arises, typically taking no more than a few minutes for basic advice.

Clinical risk groups

People who have a medical condition that means they are more likely to develop potentially serious complications from flu. People in these groups are eligible for free flu vaccination and are specified in the Green Book and the annual flu letter. At the time of publication of this guidance, the groups are:
  • chronic respiratory disease, such as asthma (requiring use of inhaled or systemic steroids, or with previous exacerbations needing hospital admission), chronic obstructive pulmonary disease, or bronchiectasis
  • chronic heart disease
  • chronic kidney disease (stage 3 or above)
  • chronic liver disease
  • chronic neurological disease such as Parkinson's disease, motor neurone disease, or a learning disability
  • diabetes
  • a weakened immune system caused by disease (such as HIV/AIDS) or treatment (such as chemotherapy or high-dose corticosteroids)
  • asplenia or conditions that can lead to dysfunction of the spleen, such as sickle cell disease or coeliac disease
  • morbid obesity (adults with a BMI of 40 or over).

Clinical risk groups

People who have a medical condition that means they are more likely to develop potentially serious complications from flu. People in these groups are eligible for free flu vaccination and are specified in the Green Book and the annual flu letter. At the time of publication of this guidance, the groups are:
  • chronic respiratory disease, such as asthma (requiring use of inhaled or systemic steroids, or with previous exacerbations needing hospital admission), chronic obstructive pulmonary disease, or bronchiectasis
  • chronic heart disease
  • chronic kidney disease (stage 3 or above)
  • chronic liver disease
  • chronic neurological disease such as Parkinson's disease, motor neurone disease, or a learning disability
  • diabetes
  • a weakened immune system caused by disease (such as HIV/AIDS) or treatment (such as chemotherapy or high-dose corticosteroids)
  • asplenia or conditions that can lead to dysfunction of the spleen, such as sickle cell disease or coeliac disease
  • morbid obesity (adults with a BMI of 40 or over).

Eligible group

People who are eligible for free flu vaccination in the NHS, as outlined in the Green Book. For the purpose of this guidance, the specific eligible groups considered were:
  • children and adults aged 6 months to 64 years in a clinical risk group (as listed in the annual flu letter)
  • pregnant women
  • people in receipt of a carer's allowance
  • people who are the main informal carer of an elderly or disabled person whose welfare may be at risk if the carer falls ill.
In addition, flu vaccination with live attenuated intranasal vaccine is recommended for all children aged 2 to 17 years who are not in a clinical risk group. This programme is being implemented in a phased roll-out, starting with the youngest first. At the time of publication (August 2018), the universal 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.

Eligible groups

People who are eligible for free flu vaccination in the NHS, as outlined in the Green Book. For the purpose of this guidance, the specific eligible groups considered were:
  • children and adults aged 6 months to 64 years in a clinical risk group (as listed in the annual flu letter)
  • pregnant women
  • people in receipt of a carer's allowance
  • people who are the main informal carer of an elderly or disabled person whose welfare may be at risk if the carer falls ill.
In addition, flu vaccination with live attenuated intranasal vaccine is recommended for all children aged 2 to 17 years who are not in a clinical risk group. This programme is being implemented in a phased roll-out, starting with the youngest first. At the time of publication (August 2018), the universal 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.

Underserved groups

This term is used in this guidance to mean adults and children from any background who are 'underserved' if their social circumstances, language, culture or lifestyle (or those of their parents or carers) make it difficult to:
  • recognise they are eligible for flu vaccination (for example, they have an undiagnosed clinical condition)
  • access health services
  • attend healthcare appointments.
The groups classified as underserved in this guidance are:
  • people who are homeless or sleep rough
  • people who misuse substances
  • asylum seekers
  • Gypsy, Traveller and Roma people
  • people with learning disabilities
  • young people leaving long-term care.

Rationale and impact: offering vaccination

Rationale

Many potential opportunities are being missed to offer eligible people a free flu vaccination during contacts with health, social care and other statutory and voluntary services. There is evidence that using existing systems to offer flu vaccination and extending the way services are provided can encourage more people to be vaccinated. An expert told the committee that all organisations that can reach eligible people need to work together to ensure this happens.
The committee also agreed that being flexible with the hours when GP surgeries or other providers offer flu vaccination would enable people to come for vaccination at a time convenient for them. There was limited evidence that this improves vaccination rates but it was also supported by expert testimony.
There is evidence that vaccine supply can also affect uptake. People who request the vaccination may not return if it is not available immediately.

Impact

Using every opportunity to offer and provide flu vaccination will increase uptake among people who need it because they are particularly vulnerable to the complications of flu. Although this may increase costs in the short term, the committee agreed that it is likely to be cost effective.
For more information see the evidence discussion for offering vaccination in the NICE guideline on flu vaccination: increasing uptake.

Rationale and impact: raising awareness

Rationale

Not all health and social care staff know who is at greatest risk from flu, so they are not offering it to everyone who is eligible. There is evidence that training and educating health and social care staff improves vaccination rates. The evidence also showed that people in eligible groups who understand why flu vaccination is particularly important for them are more likely to be vaccinated. Professionals need to explain the benefits of vaccination and address people's misconceptions about it. The committee also agreed that it is important to make sure people know that flu vaccination is free if they are eligible.
There was some evidence that working with other statutory and voluntary organisations might be effective in raising awareness about vaccination and its benefits, although there is currently a lack of empirical evidence in this area.

Impact

Current practice is variable in GP surgeries where most flu vaccination is given. Practices with high vaccination uptake are likely to be delivering services in line with these recommendations already; those practices with lower levels of vaccination uptake will be able to make a big impact by putting these recommendations into practice.
For more information see the evidence discussion for raising awareness in the NICE guideline on flu vaccination: increasing uptake.

Rationale and impact: encouraging uptake in primary care

Rationale

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.
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.

Impact

General practices that have signed up to the service specification for flu vaccination are required to proactively call and recall eligible patients. Computerised systems are already in place to do this, however the way it is carried out is variable. GP surgeries will need to ensure that they personalise and tailor their invitations for vaccination.
A key element of the recommendations is to make the most of face-to-face interactions to offer and deliver vaccination. This may need additional time and resources initially. However, a personalised approach tailored to the person's situation is more likely to engage them with the flu vaccination programme. Embedding prompts in these eligible patients' healthcare records to remind providers to invite them for vaccination each flu season could avoid additional appointments and save costs in the longer term.
The lack of a national service specification for secondary care means that some areas don't have local enhanced services agreements to deliver vaccination and will need to set these up. Procedures for recognising and treating adverse reactions, the purchase and appropriate cold-chain storage of flu vaccine supplies, and ensuring that the setting used to administer vaccinations is appropriate are all issues that need to be taken into account when setting up these agreements with secondary care providers.
For more information see the evidence discussion for increasing uptake among eligible groups in primary and secondary care in the NICE guideline on flu vaccination: increasing uptake.

Rationale and impact: encouraging uptake in secondary care

Rationale

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.
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.

Impact

General practices that have signed up to the service specification for flu vaccination are required to proactively call and recall eligible patients. Computerised systems are already in place to do this, however the way it is carried out is variable. GP surgeries will need to ensure that they personalise and tailor their invitations for vaccination.
A key element of the recommendations is to make the most of face-to-face interactions to offer and deliver vaccination. This may need additional time and resources initially. However, a personalised approach tailored to the person's situation is more likely to engage them with the flu vaccination programme. Embedding prompts in these eligible patients' healthcare records to remind providers to invite them for vaccination each flu season could avoid additional appointments and save costs in the longer term.
The lack of a national service specification for secondary care means that some areas don't have local enhanced services agreements to deliver vaccination and will need to set these up. Procedures for recognising and treating adverse reactions, the purchase and appropriate cold-chain storage of flu vaccine supplies, and ensuring that the setting used to administer vaccinations is appropriate are all issues that need to be taken into account when setting up these agreements with secondary care providers.
For more information see the evidence discussion for increasing uptake among eligible groups in primary and secondary care in the NICE guideline on flu vaccination: increasing uptake.

Rationale and impact: audit and monitoring

Rationale

Providers and employers need to know whether they are reaching their vaccination targets or whether they need to change the way they are delivering their flu vaccination programme to better protect their patients or vaccinate their staff. According to both evidence and expert testimony, audit, monitoring and feedback help providers and employers to plan for and offer flu vaccination to meet their targets, including for payment by results.
The committee also agreed that if different providers across the system are offering vaccination, it is important for services to share information with each other and keep accurate records of who has been vaccinated. This will ensure general practice uptake figures are accurate and avoid them wasting resources by inviting people for vaccination unnecessarily (leading to missed appointments) or duplicating vaccinations.

Impact

There is inconsistency among GP surgeries in how they record and use data to monitor their progress with flu vaccination during the season. To implement these recommendations some practices will need to improve their record-keeping using clinical software systems so they can monitor whether they are successfully targeting eligible people. Similarly, employers may need to improve their systems for recording and monitoring the vaccination status of staff, because some eligible health and social care staff may not be getting a free vaccination offer from their employer. This may be a particular issue in the social care sector, which has a large number of providers and currently no central requirement to submit data on the uptake of flu vaccination among front-line staff.
Monitoring uptake among eligible groups when vaccination is provided outside general practices in settings that do not have direct access to information technology (IT), or where different IT systems are used, may be a challenge. Mechanisms for sharing information need careful planning and oversight to minimise data loss.
For more information see the evidence discussion for audit, monitoring and feedback in the NICE guideline on flu vaccination: increasing uptake.

Rationale and impact: vaccination for carers

Rationale

If a carer has flu, the welfare of the person they care for may be at risk. There was a lack of evidence on interventions specifically for carers, and health economic modelling showed that increasing uptake among all carers would not be cost effective. The committee agreed that efforts to increase vaccination uptake should target carers who look after people who are particularly vulnerable and who would be at risk of needing hospital or other care if their carer was unwell with the flu. Primary care staff and healthcare professionals working in the community (for example district or specialist nurses or those working in rehabilitation) could be a useful route to identify and offer vaccination to this group, for example during a home visit, if appropriate local agreements were in place.

Impact

Increasing uptake of flu vaccination among eligible carers is not likely to involve a major change to current practice, but the key is for providers to prioritise those carers who look after someone whose health or wellbeing would be at risk if the carer fell ill with flu. This needs clinical judgement and may mean community nurses using home visits to identify and offer vaccination to these particular carers.
For more information see the evidence discussion for flu vaccination in carers in the NICE guideline on flu vaccination: increasing uptake.

Rationale and impact: vaccination programmes

Rationale

Flu-related illness places a strain on NHS resources every winter because many of the people whose health is most at risk from flu – as well as the staff who come into contact with them – are not vaccinated. Evidence showed that the most effective way to encourage people to have a flu vaccination every year is to use a combination of interventions. The committee agreed there is no single intervention that can improve both how likely vaccination is to be offered and also the likelihood that people will accept vaccination. Based on their knowledge of practice in the UK, the committee agreed with experts who said that organisations need to work closely together to achieve this, an approach that was supported by evidence on collaborative multi-agency working and leadership.

Impact

The recommendations will help to reduce current variation in practice. For example, vaccination uptake among eligible groups in general practice can range from 15 to 100%. The greatest resource impact is therefore likely to be for those practices that are less active in promoting flu vaccination uptake. But the cost impact should be relatively small compared with the reduction in mortality and morbidity associated with flu. In addition, there are opportunities to gain incentive payments by results which may offset organisational costs.
For more information see the evidence discussion for a multicomponent approach in the NICE guideline on flu vaccination: increasing uptake.

Rationale and impact: staff vaccination

Rationale

Health and social care staff are in daily contact with people who are susceptible to infection, and they could transmit flu to vulnerable people at risk of serious complications. Staff may not know they are eligible for a free vaccination through occupational health, or may not realise it may help protect their patients, family and co-workers. Evidence suggests that actions to encourage staff to be vaccinated do work. Programmes involving a combination of actions, such as awareness raising, education and flexible services were effective and acceptable. Although the evidence was uncertain in some cases, the committee recommended a range of interventions so that organisations can tailor their approach to local needs, targeting demand (by increasing awareness, education and incentives) and supply (for example using mobile carts and off-site or out-of-hours access).

Impact

Implementing the recommendations will have a bigger impact in some organisations than others. Current variation in practice is partly because different incentives operate across the health and social care sectors. It may also be easier to provide vaccination for staff in some organisations than others. For example, a GP surgery already has access to flu vaccine supply and the skills to deliver the vaccination to staff. A social care provider may need to contract an occupational healthcare provider to carry out vaccination, or set up a scheme to help employees access community pharmacy flu vaccination.
For more information see the evidence discussion for employers of health and social care staff in the NICE guideline on flu vaccination: increasing uptake.

Glossary

(this covers 24 hour accommodation with either non-nursing care (for example, a residential home) or nursing care)
(people who receive a carer's allowance or who are the informal 'main carer' of an older or disabled person whose welfare may be at risk if the carer falls ill; this definition is in line with the Green Book, which recommends offering the flu vaccination on the basis of clinical judgement, regardless of whether the person receives a carer's allowance)
(people who receive a carer's allowance or who are the informal 'main carer' of an older or disabled person whose welfare may be at risk if the carer falls ill; this definition is in line with the Green Book, which recommends offering the flu vaccination on the basis of clinical judgement, regardless of whether the person receives a carer's allowance)
(a strategy where 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)
(a set of multiple interventions implemented together to increase flu vaccination uptake; these target both demand (for example, increasing awareness of eligibility and the reasons why vaccination is beneficial) and supply (for example, creating more opportunities for vaccination, such as increasing the offer by professionals)
(approaches to reach underserved groups in which people with lived experience (for example, people who have been homeless, or who are from particular cultural backgrounds) work alongside health and social care professionals to provide information that is accessible and appropriate to the target group, acting as local 'flu champions' to promote awareness and uptake among their peers)
(the day-to-day healthcare given by a healthcare provider: typically this provider acts as the first contact and principal point of continuing care for patients within a healthcare system, and coordinates other specialist care that the patient may need; in the UK, people access primary care services through local general practice, community pharmacy, optometrist, dental surgery and community hearing care providers)
(staff who are allowed to administer the flu vaccination, or affiliated staff (for example general practice staff who log patient demographics and could therefore see who satisfies Green Book criteria)
(often acute healthcare (elective care or emergency care) provided by medical specialists in a hospital or other secondary care setting; patients are usually referred by a primary care professional such as a GP)
(organisations with legal responsibility at a national or local level for the provision, commissioning, regulation or improvement and oversight of government-funded health and care services)

Paths in this pathway

Pathway created: August 2018 Last updated: August 2018

© NICE 2018. All rights reserved. Subject to Notice of rights.

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