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The prevention and treatment of viral respiratory disorders

A briefing from the Board of Science
September 2007

Vaccination and treatment
There are two main ways to treat the influenza virus. These are the administration of a vaccine or an antiviral drug.

Vaccination
Influenza vaccination gives good protection against influenza, and lasts for one year. The vaccine is made from the strain of influenza virus that is expected in the coming winter; because the prevalent strain tends to be different each year it is important to get yearly immunisation to ensure protection.

Healthcare professionals have a vital role to play in combating the risk of influenza. This includes ensuring that vaccinations are available to those people in at-risk groups, and that these are taken up. This importance is reflected in the inclusion of influenza immunisation as part of the new General Medical Services (GMS) contract, covered by a Directed Enhanced Service (DES). Under this contract GPs have agreed to compile a list of at-risk patients eligible for influenza immunisation, provide them with vaccinations, and immunise, at their discretion, people not in at-risk groups when requests are made. For more information see the section on GP contractual agreement.

The BMA general practitioners committee (GPC) has produced guidance about payments for influenza vaccinations, [see reference 46] the aim of which is to bring to GPs’ attention, information about prices for vaccination and their responsibilities under the new contract.

Vaccination is particularly important for groups at increased risk of infection, these include:

• young people
• people aged 65 and over
• those with serious medical conditions such as:
  - chronic neurological disease
  - chronic respiratory disease
  - chronic heart disease
  - chronic renal disease
  - chronic liver disease
  - diabetes mellitus
  - immunosuppression due to disease or treatment
• people living in long-stay residential care homes or 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 prisons, young offender institutions, university halls of residence etc)
• people who are the main carer for an elderly or disabled person, and health and social care professionals. These should be given on an individual basis at the GP’s discretion in the context of other clinical risk groups in their practice. [see references 47 and 48]

The uptake of the influenza vaccination has been followed in those aged 65 and over since 2000/01, and in at-risk groups since 2004/05 (for more information see the DH website). It is important that all
sections of the population are educated in ways to stop the spread of viruses, of particular importance are children, at-risk groups and the elderly, as they are most susceptible.

Research shows a particularly low uptake of influenza vaccination among black and minority ethnic (BME) communities. [see reference 49] In order to combat this trend, in 2005 the NHS published Flu immunisation campaign 2005 local action pack to help with the organisation of local flu immunisation awareness campaigns. The document includes the following information and advice:

• an overview of the campaign
• advice on gathering case studies and spokespeople
• information on distributing campaign materials
• ideas for local events and networking
• ways to reach BME groups
• good ideas from previous years
• advice on using the local media
• template press releases for the launch and hard to reach audiences. [see reference 49]

Antivirals
The publication Guidance on the use of oseltamivir and amantadine for the prophylaxis of influenza (NICE, 2003), examines the use of antiviral drugs where it is known that influenza type A or B are circulating in the community. A review of this document is under way and new guidance is due for publication in October 2008. The current guidance states that ‘vaccination is the most effective way of preventing illness from influenza, and the drugs described in this guidance are not a substitute for vaccination’. Antiviral drugs such as oseltamivir and amantadine are recommended for use in at-risk patients who are not effectively covered by vaccination, and have been exposed to someone with influenza-like illness (ILI). People not effectively covered by vaccination include those:

• who have not been vaccinated
• whose vaccination is contraindicated, or has yet to take effect
• whose vaccination has been carried out but the vaccine is not well matched to the strain of influenza virus circulating. [see reference 13]

These drugs act independently of vaccination, and provide additional barriers to the influenza virus where the vaccine is not efficacious. It is not known how well antiviral drugs would perform in pandemics. [see reference 13] The British Medical Journal (BMJ) recently reported advice from the Japanese health authorities that the prescription of the antiviral drug oseltamivir could be connected to psychological problems in teenagers, after two 14 year olds committed suicide. Fifty two other deaths globally (14 in children or adolescents) have been associated with the same drug. GPs have been urged to be cautious when prescribing the drug. [see reference 50] In the UK oseltamivir is classified as a ‘black triangle’ drug, meaning it remains under intensive surveillance. For more information on black triangle drugs and pharmacovigilence see Reporting adverse drug reactions: a guide for healthcare professionals (BMA, 2006). [see reference 51]

GP contractual agreement
Under the DES, each Primary Care Trust (PCT) must enter into arrangements with primary medical services contractors to provide immunisation to patients.
GPs are be reimbursed for the vaccine used at the list price agreed by the Prescription Pricing Division (PPD). Personal administration fees are available for flu immunisation given as part of the programme.

Under the new GMS contract [c] the following are agreed:

1. ‘PCTs must enter into arrangements with a primary medical services contractor to provide seasonal influenza immunisation to at-risk patients in line with national directions.
2. Annual influenza immunisation is provided as part of a DES. As part of these arrangements, the provider is required to compile a register of at-risk patients eligible for vaccination. The contractor is entitled to an item of service fee under the DES and a Personal Administration fee under the Statement of Financial Entitlements (SFE 17.4). However, if the contractor wrote an NHS prescription for the influenza vaccination for dispensing by a pharmacy, instead of supplying the vaccine itself, the only fee payable would be that due under the DES. Nothing would be due under the SFE (SFE 17.7).
4. Where a person not in the high risk group requests an influenza vaccination, the decision to immunise is based on the GP’s clinical judgement. There is no DES payment for this use if the vaccine, but if the contractor supplies and administers the vaccine a payment would be due under the SFE (17.4).
5. Providing a flu vaccination as a “private treatment” by a contractor in relation to one of their registered patients would be a breach of contract. Any contractor offering a private flu vaccination service for their own registered patients is immediately in breach of their contract whether or not the private charge relates to the prescription or the administration of the vaccine or both.
6. Under the current system, contractors can cross-refer patients so that practice A provides private flu vaccinations for patients of practice B and vice-versa. However, if there were any financial adjustments between the practices this could be seen as a breach of contract. In these circumstances, there is no DES payment and no SFE payment.

(The arrangements for the annual influenza programme apply to at-risk patients in line with national directions, who are immunised by 31 March in the relevant financial year. GMS and PMS contractors are expected to provide the service at the nationally agreed benchmark item of service prices of £7.51 for 2007/08).’ [see reference 47]

[c] While the GP contracts of the devolved nations are all different the health outcomes are the same. The benchmark service prices for 2007/08 for the influenza programme are £7.51 throughout the UK.