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					                                                                                            Enclosure 18



                                          NHS WALSALL BOARD
Subject                              Swine Flu Vaccination: NHS Walsall Employees
Report From                          Dr Christopher Chiswell, SpR Public Health
                                     Anthony Jackson, Emergency Planning Manager
Date of Meeting                      25 March 2010

AIM OF REPORT

Provide an update on the NHS Walsall staff vaccination plan to date, and provide
information to allow the board to issue an assurance to the Strategic Health Authority on
the approach taken to date, and future plans for swine flu vaccination.


EXECUTIVE SUMMARY

Ian Dalton, national director of flu resilience has asked all NHS Trust Boards to review
their staff vaccination rates and programmes, and provide assurance that they have met
an appropriate performance standard.

NHS Walsall has achieved a vaccination uptake rate of 46%.
 This is the 4th highest PCT rate in the West Midlands, approximately ten percentage
  points above the West Midlands average.
 It ranks 39th out of 151 PCTs, as of the end of January 2010.
 The national average rate of uptake amongst PCT staff is around 38%.

NHS Walsall has provided a wide range of communications to staff, including leaflets, a
payslip message, a website, video, team briefs and regular road show sessions. 28
Vaccination drop in or pre-booked sessions have been held at 11 sites.

Vaccine remains available through Walsall Manor Hospital Occupational Health
Department, and new starters to the Trust continue to be offered vaccination. Further
uptake work amongst other staff is difficult, due to the declining case numbers and
prominence of swine flu within the local community.

A wider vaccination report is being prepared, and this will provide lessons learnt from the
vaccination programme, that will inform seasonal flu planning for 2010/11, as well as
planning for future pandemics.


RECOMMENDATION(S)
1) That the NHS Walsall Trust Board provides assurance to the West Midlands Strategic
Health Authority that adequate measures have been taken in Walsall to deliver a staff
vaccination programme, and that it is satisfied with uptake rates achieved, and future
plans for additional pandemic vaccine delivery

2) That the NHS Walsall Trust Board review the wider report on the Swine Flu vaccination
programme in Walsall when it is made available

Board Action Required (please tick)                 Approval [ ]   Assurance [ ]
    Walsall Teaching Primary Care Trust                                        www.walsall.nhs.uk
IMPLICATIONS
Priorities (please tick)                    Comment
- Health Service not Illness Service [  ] Vaccination of staff ensures that swine flu virus
                                            is not passed from infected staff members to
                                            patients, particularly during subclinical infection
                                            periods.
- Evidence-based Excellence            [ ]
- Alliances the Key to Success         [ ]
- Listening to Local People            [ ]
- True Choices, Accessible Services [ ]
- Hitting the Hard Targets             [ ]
Risks                                       Unvaccinated staff can pass virus to others.
                                            Potential risk of serious complications or death
                                            in a patient associated with an unvaccinated
                                            staff member
Resource                                    Ongoing swine flu vaccination is provided
                                            within current Occupational Health services
                                            agreements.
Environment
Equality Impact Assessment
Impact on Health Inequalities
Engagement (eg PPI, Clinical, Non-Clinical)
Legal
Timescales and Implementation               Assurance to SHA needs to be provided by
                                            31st March 2010
Review

Key Standard(s) for Better Health             C4a: Vaccination reduces the risk of patients,
                                             other staff, and visitors, from acquiring swine
                                             flu. Staff members who are vaccinated cannot
                                             catch swine flu, and cannot therefore pass it on
                                             to others.
WCC Competency                               Competency 1: The Staff vaccination
                                             campaign was part of a wider programme to
                                             deliver vaccine across NHS services in
                                             Walsall. Development of the PCT model,
                                             including the communications package, has
                                             supported other health providers within the
                                             borough. Public Health, through the strategic
                                             group, has led the borough wide delivery of
                                             swine flu vaccine

Author                                       Dr Christopher Chiswell, SpR Public Health
Director Checked (Initials)                  SR
Date Received by Board Secretary             3.03.2010




                                               2
Context
On 27th January 2010, Ian Dalton, National Director of NHS Flu Resilience, wrote
to all Primary Care Trusts detailing the current swine flu situation, and the next
steps required by health care providers. As well as detailing the closure of the
National Pandemic Flu Service, it highlighted the importance of achieving adequate
health care worker vaccination rates within the NHS. Specifically, he requested that
Boards of all NHS organisations

       “Review their uptake data formally and by 31 March 2010, and assure
       themselves that their healthcare worker vaccination programmes have
       met an appropriate performance standard compared to other NHS
       organisations”


Staff Vaccination: Preparation & Delivery
Vaccination of clinical staff was identified as a high priority during early stages of
planning by the vaccination subgroup of the NHS Walsall Swine Flu Strategic
Group. Effective vaccination gives staff confidence to work in environments with
exposure to patients with suspected swine flu, decreases staff absence, and
prevents staff-to-patient and staff-to-staff transmission. The wide symptom profile
of H1N1 Influenza (in contrast to seasonal influenza) meant staff could continue to
work without realising they were infective to others. Vaccination prevents an
individual catching flu, and therefore stops passing the virus on to people in their
care who are much higher risk of severe disease.

Although the vaccine was licensed through approved routes, there were significant
national and local concerns regarding safety. Many clinical staff were familiar with
high profile health scares, including a ‘flu vaccine in the 1970s that had been linked
to increased rates of Guillain Barré Syndrome (a severe neurological condition).
There was also sceptical national media coverage of the vaccine. Local anecdotal
evidence suggested that staff felt that the risk posed by H1N1 was marginal, and
that it was outweighed by the perceived risk of a new vaccine (however
unsupported that risk was by evidence).

In response to these concerns, Public Health has led an information and health
promotion campaign, in partnership with PCT, Community Health and Acute Trust
teams. There were several key elements to this response;

          Consistent messages on indications and safety profile

          Signposting to tiered information, from basic Questions and Answers to
          full referenced and peer reviewed literature

          Open and honest engagement with staff (for example recognition of
          frequency of side effects).

          Direct recognition of common fears and concerns, with appropriate
          responses

          Multiple media delivery of message, via presentation, intranet and
          internet communication, leaflets, posters and targeted events

                                       3
          Availability of specialist public health staff to handle direct enquiries

          Keeping senior staff educated and informed to represent vaccine at all
          possible opportunities

          Close management of figurehead negative opinions, including one-to-
          one conversations where necessary

          Maintaining the importance of basic preventative measures, such as
          hand hygiene and self-isolation if symptomatic

The delivery of this programme varied during the campaign. Early messages
focussed on the vaccine being prepared and developed. Once information on the
scope of the staff vaccination campaign was available, these messages were
integrated into vaccine administration training events throughout October. This
aimed to give vaccinators confidence in the programme, and to begin spreading
information throughout the organisation.

As vaccination sessions were confirmed, these messages were delivered to a
wider audience through NHS staff team briefs held at four sites across the
borough. On 13th November, a swine flu section was opened on the NHS Walsall
website, that included links to questions and answers, and relevant downloads.
Online media was extended to include videos produced by the Strategic Health
Authority as these became available in mid November. They remain viewable at
www.walsall.nhs.uk/swineflu/staffvideo.asp

The department of health launched a range of communication materials to support
the staff vaccination campaign in November. Printed four-side A5 leaflets using the
national ‘Swine Flu: If you can’t catch it, you can’t pass it on’ messages were
printed within a forty-eight hour turnaround and distributed to all PCT sites. A4
posters were also included in these packs and prominently displayed. On 25 th
November, all staff received a DL size leaflet attached to their payslip

Visuals were designed to support the consistent message that the staff vaccination
programme not only protected the individual, but helped ensure that they did not
pass the virus on to vulnerable people in their care. They included signposting to
the trust Intranet to identify vaccination sessions.

Sessions for NHS Walsall staff were delivered through the Occupational Heath
Services contract with Walsall Manor Hospital. Drop in sessions were held at
several venues during November, commencing on 17th November.

These clinics were initially for members of staff identified as being higher priority,
who were invited to attend first by letter. This was to ensure that early clinics were
not overwhelmed. This initial system was not effective, and the identification of
front line staff was not precise. For example, lower priority staff within a team had
received an invite when patient contact staff had not. A rapid decision was taken by
the vaccination subgroup to remove this letter-only restriction, and a wider
message was sent out inviting all staff who fulfilled the national criteria to attend a
vaccination session.

Uptake at these sessions was limited, with approximately twenty staff attending
each two hour session. As with many trusts, it was identified that swine flu vaccine
remained a relatively low priority to many staff. Efforts were made to ensure further
                                          4
vaccine sessions were available at multiple sites, including the Star Quality event
on 27th November 2009. Residual capacity from the Social Care vaccination
programme was also released and made available to all NHS staff.

Specific teams that were reluctant to take up vaccine were also contacted and had
the opportunity to discuss concerns with a member of the Public Health team.

Despite only moderate initial uptake, the trust maintained sustained opportunities
for vaccination, and uptake rates consistently increased through November and
December.




                                         5
Staff Vaccination: Outcomes
After the conclusion of main vaccination programmes across the West Midlands,
the trust had delivered vaccination to 45.8% of eligible front line clinical staff. These
figures do not include any members of staff who were vaccinated by their own GP
because they were in a clinical at risk group.

The trust had achieved the fourth highest rate of vaccination in the West Midlands
region on 19th January 2010, ten percentage points above the regional average.

                                  Staff Vaccine Uptake NHS Walsall vs. West Midlands PCT Average
                     50


                     40


                     30
    % Uptake




                     20

                                                                                                                   NHS Walsall
                     10
                                                                                                                   WM Average

                      0
                            09


                                         09


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                                                                                                            0


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                                                                                15




                                                                                Submission Date

The national range of trust vaccination rates is very wide, with PCTs achieving
uptake rates between 18% and 92%, as of 31 st January 2010. However, the
majority of PCTs have rates that are within a much narrower range. The figure
shows the distribution of these uptake rates by PCT, and Walsall’s location on the
upper quartile line.
                                                                                                                                  PCT
                                                                                                                                  25th Percentile
                      aH1N1 (swine) flu vaccine uptake by PCT (31.01.10)                                                          50th Percentile
                                                                                                                                  75th Percentile
                    100%


                    80%
 % Vaccine Uptake




                    60%
                                                                                                                NHS Walsall


                    40%


                    20%


                     0%
                            151                      Vaccination rate by England PCT, ranked by ascending uptake                                    1




                                                                                         6
NHS Walsall is ranked 39th out of 151 PCTs for which data was available, with an
uptake rate just above the 75th percentile. The overall England average uptake rate
was 38%, as of 31st January 2010. SHAs are undertaking targeted work with trusts
with low vaccination rates, and this average may rise slightly.

The flowchart included in the appendix details the full range of appointments
offered to staff in November and December. Sessions were organised at eleven
different sites.

Vaccine is still available through Occupational Health, and the NHS Walsall Swine
Flu micro-site is maintained to provide information to any staff member who still
wishes to access vaccine. Staff briefings continue to highlight that swine flu
vaccine is still available to members of staff who are in the relevant groups.

Vaccine of General Practice staff
To extend flexibility to GP staff, Public Health confirmed to all surgeries that
vaccine could be taken from stock held at the surgery and used for the vaccination
of staff who met the clinical or social care definitions. No payment was attached to
vaccination administered via this route.

The trust received comments via practice manager representatives that certain
non-clinical staff, including receptionists, felt that they should also be eligible for
vaccine. The national strategy focused on vaccinating staff members who could
pass the virus on through close clinical contact, and the assessment had been that
receptionists did not have this contact. However, the Royal College of General
Practitioners made recommendations that practices could use unused doses from
multi-dose vaccine vials to vaccinate individuals who were not eligible, providing no
eligible patients were available.

Public Health was not able to fully endorse this approach, as it contradicted
Department of Health guidance. However, surgeries were not penalised if they
adopted this strategy, providing they could give assurance that patient care was
not compromised, and that vaccine bookings were not manipulated to create
unused vaccine stock.

Approximately 85 General Practice employees were vaccinated via this route, at 17
general practices.

Vaccination of Hospital Staff
Walsall Manor Hospital Occupational Health were responsible for delivering
vaccine to staff in the at risk groups. NHS Walsall supported this by providing
education resources and advice, and by being a point of contact for any enquiries.
The hospital achieved uptake rates of 55% as of 31st January 2010. The highest
West Midlands rate was achieved by Birmingham Children’s Hospital with 85%.


Forward Opportunities
The Chief Medical Officer wrote to Primary Care Trusts on 18th February 2010
detailing forward plans for the swine flu vaccination programme. Trusts have been
asked to continue delivering vaccination to at risk clinical groups, the under 5s, and
health and social care staff until the seasonal flu vaccine becomes available next
winter.

                                           7
Currently recognised risks for further development of the H1N1 pandemic are;

          Mutation to a more virulent strain that re-establishes within the UK

          A ‘third wave’ of cases, although this is felt decreasingly likely

          Based on evidence from previous pandemics, H1N1 is likely to be the
          dominant seasonal flu strain for the next few years. Its severity, and at
          risk groups are unknown. There is potential for an early onset of
          seasonal flu next winter

          Imported cases. Southern Hemisphere flu seasons continue through the
          UK summer. Travellers may bring virus back in to local populations that
          do not have sufficient herd immunity to prevent propagation of a local
          outbreak

          H5N1 virus is still present in South East Asia, and the risk of a novel
          emergent pandemic strain is not altered by the current pandemic

These factors mean that NHS Walsall has an ongoing responsibility for ensuring
appropriate local protection. This includes reinforcing messages about personal
hygiene precautions, self isolation if flu symptoms develop, and vaccination if
within at risk groups. Achieving further uptake in the vaccine programme is made
difficult by the public perception of the waning of the pandemic. Despite over 40
million doses of vaccine given without changes in the risk profile, there is still
residual perception of risks, and the decreasing potential benefit makes it harder to
promote individuals to receive vaccination.

Staff Vaccination
No vaccination communications were made from mid January to mid February.
This was to provide clear space for the closure of the National Pandemic Flu
Service and to ensure staff did not receive two, potentially contradictory,
messages. Staff vaccination continues to be available through occupational health
at Walsall Manor Hospital, and preparations are being made for vaccine availability
to be highlighted at NHS Walsall induction sessions. Further web communications
will be sent to all staff in March, highlighting core messages on vaccine safety and
the need for ongoing vaccine uptake. No further funding will be available beyond
2009/2010 from the Department of Health to support further uptake work.


Summary
NHS Walsall has achieved above region and above England rates of vaccination
uptake. It has provided good access to information sources and verbal advice, and
a range of clinics across several sites and times. Although demand for vaccine has
now fallen, vaccine is still available through Manor Hospital Occupational Health
Department, and from April, all new starters to NHS Walsall will receive an invite to
attend for vaccination.

The Strategic Swine Flu Group, and the Vaccination Subgroup have supported the
programme throughout 2009 and 2010, and in their final meetings agreed that the
actions that have been taken as appropriate and adequate for the delivery of swine
flu vaccine to NHS staff.
                                           8
A wider report on the vaccination programme across Walsall, including lessons
learnt and recommendations for future practice, is currently being completed by
Public Health.



Recommendation
That the NHS Walsall Trust Board provides assurance to the West Midlands
Strategic Health Authority that adequate measures have been taken in Walsall to
deliver a staff vaccination programme, and that it is satisfied with uptake rates
achieved, and future plans for additional pandemic vaccine delivery.




Attachments
1) Timeline of vaccination campaign in Walsall (overleaf)



    Timeline




                                        9
       Launch Conference                                                                  PCT asked to vacc social care staff                              Phase II Announced                     Amended LES with admin payment accepted
              First Vaccine Subgroup Meeting                                                            Vaccine plan assessment received                   Intranet Message                                         64 practices accept Phase II LES. 2 Refuse
               SHA requests initial plan                                                                               Presentation to LMC                  Letter to social care staff                             Trust begins preparatory work for opted out GP
                     Vacc Subgroup                                                                                       Letter to council re capacity          Intranet Message                                           All practices accept Phase II LES
                      Vacc Subgroup                                                                                       Midwifery Leads Meeting                Community Team Brief (BCC)                                                               Closure of NPFS
                               Initial vaccine assurance submitted                                                              EAPMC Meeting                     Payslip message all staff                                                                            Vacc Subgroup Debrief
                                             Vacc Subgroup                                                                       GP letter re own staff imms           Phoenix Invite to all staff
                                               Risk groups published                                                               Initial Vaccine Delivered              Presentation to health trainers
                                                             Vacc Subgroup                                                              Presentation to LMC               Dental Invite Issued
                                                                      Final vaccine plan submitted                                         Vacc Subgroup                         National negotiations fail on Phase II
                                                                            Vacc Subgroup                                                    Staff Roadshow (DHC)                 SHA assurance re phase II
                                                                             BMA agrees vaccine charge                                       PCT Team Brief (JH)                    Local Phase II LES circulated
                                                                             Social Care Conference                                                 Community Team Brief (LH)           LMC decline initial Phase II LES
                                                                                                         EAPMC Meeting                              Community Team Brief (BHC)
                                                                                                         Vacc Subgroup                               Swine flu microsite launched
                                                                                                               SHA Flu Conference                       Community Team Brief (AM)
                                                                                                                                   DES Released          EAPMC Meeting
06/07/09    20/07/09       03/08/09        17/08/09       31/08/09       14/09/09        28/09/09       12/10/09        26/10/09       09/11/09       23/11/09        07/12/09       21/12/09       04/01/10        18/01/10       01/02/10        15/02/10       01/03/10       15/03/10




                                                                                                                                                                                                                                                                                     10
                                                                                                                                                        Vacc 4-6pm (AM)
                                                                                                                                                          Vacc 4-6pm (WHC)
                                                                                                                                                           Vacc 9-11am (PHC)
                                                                                                                                                               Vacc 12-2pm (DHC)
                  aH1N1 Swine Flu                                                                                                                                Vacc Phoenix (460 slots)
                                                                                                                                                                  Vacc 11-1pm (BV)
                                                                                                                                                                  Vacc 9-4pm Star Quality
                  Vaccination Timeline                                                                      Training Video Launched
                                                                                                                                                                  Vacc Phoenix (40 slots)
                                                                                                                                                                   Vacc Phoenix (40 slots)
                                                                                                                    Pandemrix adult one dose only                    Vacc Phoenix (20 slots)
                                                                                                                        Staff Roadshow (DHC)                           Walsall Council Vacc
                                                                                                                          Staff Roadshow (HHC/AM)                       Vacc Phoenix (460 slots)
                  Key:                                                                                                     Staff Roadshow (BHC)                           Vacc Phoenix (40 slots)
                  AM: Anchor Meadow                                                                                        PGD and comms material released                 Vacc Phoenix (40 slots)
                  BHC: Beechdale HC                                                                                          Staff Roadshow (WHC)                             Vacc Phoenix (20 slots)
                  BV: Blakenall Village                                                                                         Delivery to PCT begins                           Vacc Phoenix (460 slots)
                  BCC: Beechdale Community Centre                                                                                  Staff roadshow (SJC)                           Vacc Phoenix (40 slots)
                  DHC: Darlaston HC                                                                                                                                                Vacc Phoenix (40 slots)
                  JH: Jubilee House                                                                                                                                                  Vacc Phoenix (20 slots)
                  HHC: Harden Health Centre                                                                                                                                           Pandemrix child one dose only
                  LH: Lichfield House                                                                                                                                                   Vacc Phoenix (460 slots)
                  NPFS: National Pandemic Flu Service                                                                                                                                    Vacc Phoenix (40 slots)
                  PHC: Pleck HC                                                                                                                                                           Vacc Phoenix (40 slots)
                  WHC: Willenhall HC                                                                                                                                                        Vacc Phoenix (20 slots)
                                                                                                                                                              PCT led Social Care Vaccinations          PCT Vaccinations via Occupational Health
                                                                                                                                                                              Housebound Vaccinations                     Special School Staff Vacc
                                                                                                                               Phase I Vaccination
                                                                                                                                                                                                                 Phase II Vaccination

				
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