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Sting in the tail: swine flu returns

24 March 2011

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Meirion R Evans

Regional Epidemiologist
Communicable Disease Surveillance Centre,
Public Health Wales

Meirion is chair of the Health Protection Committee of the Faculty of Public Health and a member of the UK Scientific Pandemic Influenza Advisory Committee. He worked for many years as a consultant in communicable disease control and a district immunisation coordinator. He is married with two children. His passion is chocolate and his penance is hill-walking

Richard J Roberts

Head, Vaccine Preventable Disease Programme
Public Health Wales

Richard has been a member of the UK Joint Committee on Vaccination and Immunisation since 2003. He specialised in vaccines following experience in practice and health protection. Evangelical about vaccination and life in general, he is married with three children. His father was a GP in Cardiff for 40 years

In some ways, it was no different to many other flu seasons. It started a little earlier than usual, lasted 6-8 weeks and then faded away. Only this time it was due to a return of the swine flu, the A(H1N1) influenza virus. That meant that something else was different as well. This flu strain caused more illness in those under 35, rather than in older people. There were stories of younger people falling seriously ill and of intensive care units full of people with flu.

But in spite of media and parental demands for flu vaccine for children under five, statistics showed it was not healthy young children who were being worst affected, but young adults in clinical risk groups and pregnant women. Most patients who were admitted to hospital or who died had not had a flu jab. And the supply of seasonal flu vaccine ran out.

So what happened?
Early in the season, demand for flu vaccine was normal, even rather slow, compared with previous years. Then flu cases rose, media reports multiplied and, by early December when vaccination is usually winding down, there was a rush to get flu jabs.

The government urged people to get protected. GP surgeries ran out of flu vaccine and practices were asked to pool resources. Every dose the manufacturers could supply was ordered and used. Demand was such that by early January the government stock of pandemic flu vaccines was released to meet the late surge. Did we really mess up or was it all unavoidable? The truth, as is often the case, lies somewhere in between.

The annual flu immunisation programme takes a lot of planning. GPs order flu vaccine supplies up to 12 months ahead of the next flu season. Some supplies are available on ‘sale or return’, but otherwise practices have to bear the cost of any unused vaccine. This requires a pragmatic approach, usually based on the number of doses used in the previous season.

This year’s unprecedented late surge in demand meant that most vaccine had already been used up, some on target groups and the remainder on anyone else who wanted to be immunised. The Department of Health, who for many years have run high-profile publicity campaigns in advance of the season, decided not to in 2010, perhaps relying on the high profile of the H1N1 pandemic.

While media reports highlighted tragic individual cases of flu, especially in healthy children, these were rare and the Joint Committee on Vaccination and Immunisation based its advice on objective evidence about flu admissions and deaths. They advised that vaccinating those in identified high-risk groups should remain the priority.

Central issue
Would it help to bring flu vaccine purchasing under the central control of the UK health departments? It works for the childhood immunisation programme, but demand for children’s vaccines is entirely predictable. Central purchasing for flu vaccine would transfer the risk of over or under-ordering from practices to central government. However, it would also deprive practices of income, especially from the purchase reimbursement differential, and this would need to be equitably addressed. It could be offset by providing incentives, such as rewards for practices that make improvements in flu vaccine uptake or achieve uptake targets.

Ultimately, the big challenge is how we make sure that more patients get protected from flu. The UK has good flu uptake rates compared to most other countries, but around one in four of those 65 and over, and one-half of the under-65s, miss out each year (see Figure 1), leaving them vulnerable to the serious consequences of a bad bout of flu.(1) Also, there are still wide variations in flu uptake rates between practices.(2)


Proactive planning
Next year we can do better. First, we need actively to invite younger people in clinical risk groups who are most at risk if swine flu returns again. Vaccine orders must reflect efforts to increase uptake. Second, the best efforts of practice staff can be undermined if there is a lack of awareness of or confidence in the vaccine, which is where the government has its part to play. But the main determinant of vaccine uptake will continue to be what your practice can do to better protect your patients.

The scientific evidence shows that it helps if your practice has an active approach to planning, and someone to co-ordinate things. Relying on publicity, posters or prescription reminders is not enough. There should also be outreach initiatives to reach patients who do not routinely visit the practice (eg, written or telephone reminders, home visits) and measures to improve access to immunisation (eg, walk-in clinics, satellite clinics).(3,4) Above all, it’s important to approach the flu immunisation programme as a team effort. Guides on how to plan effectively are available.(5) Now is the time to start.

1. Begum F, Pebody R. Seasonal influenza vaccine uptake among the 65 years and over and under 65 years at risk in England. London: Department of Health; 2010. Available at:…
2. Doran T, McCann R. Obstacles to influenza immunization in primary care. J Public Health Med 2001;23:329-34.
3. Sarnoff R, Rundall T. Meta-analysis of effectiveness of interventions to increase influenza immunization rates among high-risk population groups. Med Care Res Rev 1999;55:432-56.
4. Thomas RE, Russell ML, Lorenzetti DL. Systematic review of interventions to increase influenza vaccination rates of those 60 years and older. Vaccine 2010;28:1684-701.
5. Meredith N, Cottrell SL for the Vaccine Preventable Disease Programme. A Flu Campaign Guide for General Practice. Cardiff: Public Health Wales; 2010. Available at: