(Refer to current and relevant SmPC (Great Britain or Northern Ireland) and online Green Book guidance for additional details)
Prophylaxis of influenza in individuals identified as requiring influenza vaccination or those requesting vaccination.
To reduce morbidity and mortality from influenza.
Valid consent has been obtained from the patient/carer who does not want to consult with their GP and would prefer to access vaccination from the PGD user.
Patients 6 months of age and over (N.B. product specific age exclusions must be followed – see ‘Description of vaccine’).
Individuals falling inside the NHS vaccination criteria may be vaccinated under this PGD so long as they are NOT within any of the ‘Exclusion criteria’ for this PGD and they are aware they are entitled to receive the vaccine free from an NHS service provider.
For further information regarding NHS eligibility, National flu immunisation programme plan 2023 to 2024 - GOV.UK (www.gov.uk)
Patients for whom no valid consent has been received.
Patients under 6 months of age (N.B. product specific age exclusions must be followed –
see ‘Description of vaccine’).
Hypersensitivity to the active substance(s) or to any of the excipients or trace residuals in the selected influenza vaccine. See section 2 and 6.1 of the relevant Summary of Product Characteristics (SmPC).
Patients that have experienced a systemic allergic reaction (e.g., anaphylaxis) to a previous influenza vaccine.
Patients less than 2 years of age that have had a severe anaphylactic reaction to egg requiring intensive care.
Patients who have already received a flu vaccine during the season, with the exception of children between 6 months and 8 years of age in clinical risk group and who have not received an influenza vaccine previously. For further details, see ‘Frequency of administration’.
Individual is acutely unwell and/or has a fever (≥38°C). In this case vaccination should be postponed until the patient has recovered.
Has an evolving neurological condition. (With an evolving neurological condition, immunisation should be deferred until the neurological condition has resolved or stabilised).
Patients who are immunosuppressed due to disease or treatment.
Patients that have experienced a systemic allergic reaction (e.g., anaphylaxis) to eggs or to egg proteins (e.g., ovalbumin).
Patients who are receiving salicylate therapy.
Patients with severe asthma or active wheezing. This includes a history of active wheezing in the past 72 hours or those who have increased their use of bronchodilators in the previous 72 hours.
Patients that have received influenza antiviral agents in the last 48 hours.
Pregnant or breast-feeding individuals.
Patients with unrepaired craniofacial malformations.
Patients with heavy nasal congestion.
Protection against flu (1) (2) (3) (4) (5)
Influenza vaccines are not effective against all possible strains of influenza virus and will only provide protection against those strains of virus (and closely related strains) from which the vaccine is prepared. Furthermore, a protective immune response may not be elicited in all patients who are vaccinated.
Influenza vaccines should be given with caution to patients with thrombocytopenia or any coagulation disorder (including those taking anticoagulants) since bleeding may occur following intramuscular administration to these patients (1) (2) (3) (4) (5). It is recommended that the appropriate healthcare professional (e.g., GP) is consulted prior to injection, to determine if intramuscular injection is suitable and if vaccination should be scheduled shortly after the patient receives their medication/treatment to reduce bleeding. If the vaccine is offered, the patient/carer should be informed about the risk of bleeding from the injection.
Patients on stable anticoagulation therapy, including patients on warfarin who are up- to-date with their scheduled International Normalised Ratio (INR) testing and whose latest INR was below the upper threshold of their therapeutic range, can receive intramuscular vaccination. If in any doubt, the clinician responsible for prescribing or
monitoring the patient’s anticoagulant therapy should be consulted prior to injection (6).
Influvac® sub-unit Tetra and quadrivalent influenza vaccine (Sanofi Pasteur) may alternatively be administered by the subcutaneous (SC) route to individuals with bleeding disorders (N.B. There is a lack of evidence that subcutaneous injection is any safer than intramuscular injection in individuals taking anticoagulants, and injection by this route is more likely to cause local reactions) (2) (3) (7). Healthcare professionals who are not professionally competent to perform SC injections should refer the individual(s) to a suitable alternative provider.
Syncope (fainting) can occur following, or even before, any vaccination as a psychogenic response to the needle injection. This can be accompanied by several neurological signs such as transient visual disturbance, paraesthesia and tonic-clonic limb movements during recovery. It is important that procedures are in place to avoid injury from faints
(8).
Patients that are immunosuppressed due to disease or treatment, including asplenia or dysfunction of the spleen, or HIV infection (regardless of CD4 count), may not produce a sufficient protective antibody response following vaccination (9).
Specialist advice may be required - see the Green Book chapters 6 & 7:
https://www.gov.uk/government/publications/contraindications-and-special- considerations-the-green-book-chapter-6
https://www.gov.uk/government/publications/immunisation-of-individuals- with-underlying-medical-conditions-the-green-book-chapter-7
The anterolateral aspect of the thigh may be used as injection site in children from 6 months through 35 months, though the deltoid muscle may be used if muscle mass is adequate.
Healthcare professionals who are not professionally competent to perform injections in the thigh should refer the individual(s) to another suitable alternative provider if injection in the anterolateral aspect of the thigh is required.
(including any relevant action to be taken)
(including any relevant action to be taken)
For patients with allergy to latex, check with the manufacturer prior to administration of any vaccine regarding its latex content.
Deferral of administration of Fluenz® Tetra should be considered for patients with nasal congestion (see ‘Exclusion criteria’), as there are no data on the effectiveness of Fluenz® Tetra in these patients and it might impede delivery of the vaccine. If appropriate, an alternative injectable influenza vaccine should be offered.
Inactivated influenza vaccines may be administered to pregnant or breast-feeding women if it is considered that the potential benefit outweighs any possible risk to the foetus or infant (7). For more information, refer to the SmPC (section 4.6) for the vaccine being administered. Please note that pregnant or breast-feeding patients are excluded from Fluenz® Tetra vaccination (10).
Patients aged 65 years and older (11) (12)
Patients aged 65 years and older should be offered adjuvanted quadrivalent influenza vaccine or Supemtek®. Where these are not available, consider signposting the patient to another provider for vaccination. Cell-based quadrivalent influenza vaccine may be considered as an acceptable alternative and is preferable to standard egg-culture influenza vaccines.
For patients that have experienced a severe anaphylaxis to egg requiring intensive care, only the egg free vaccines (cell-based quadrivalent influenza vaccine and Supemtek®) can be offered under this PGD. Where these vaccines are not available, the patient should be excluded and referred for specialist assessment. (N.B. product specific age exclusions must be followed – see ‘Description of treatment’).
For adult patients with a history of allergic reactions to egg not requiring intensive care, vaccination can be offered with an inactivated influenza vaccine with an ovalbumin content less than 0.12 micrograms/ml (equivalent to 0.06 micrograms for 0.5 ml dose)
(7).
For further advice on immunisation in patients with egg allergy, see Green book Chapter 19.
(including any relevant action to be taken)
In theory, healthcare professionals may have low level exposure to LAIV viruses during administration of the vaccine and/or from recently vaccinated patients. As a precaution, very severely immunosuppressed individuals should not administer Fluenz® Tetra. Other healthcare workers who have less severe immunosuppression or are pregnant, should follow normal clinical practice to avoid inhaling the vaccine and ensure that they themselves are appropriately vaccinated (7). Further guidance can be found on Green Book Chapter 19.
Where Fluenz® Tetra is to be administered, vaccine recipients should be informed that Fluenz® Tetra is an attenuated live virus vaccine and has the potential for transmission to immunocompromised contacts. Vaccine recipients should attempt to avoid, whenever possible, close association with severely immunocompromised individuals (e.g., bone marrow transplant recipients requiring isolation) for 1-2 weeks following vaccination. Peak incidence of vaccine virus recovery occurred 2-3 days post-vaccination in Fluenz® Tetra clinical studies. In circumstances where contact with severely immunocompromised individuals is unavoidable, the potential risk of transmission of the influenza vaccine virus should be weighed against the risk of acquiring and transmitting wild-type influenza virus (10).
Patients/carers should be informed that Fluenz® Tetra contains porcine gelatine. If the patient/carer does not wish for Fluenz® Tetra to be administered, the healthcare professional should offer an alternative vaccine that does not contain gelatin.
NHS guidance recommends the use of an injectable cell-based quadrivalent influenza vaccine (QIVc) as an alternative for healthy children whose parents object to Fluenz® Tetra.
Patients who have already received seasonal influenza vaccination during the season are excluded from further vaccination. However, children under nine years who are in clinical risk groups and have not received influenza vaccine previously may be offered a second dose of influenza vaccine (after at least 4 weeks) in line with official guidelines (7).
For patients with other health conditions, the risks and benefits of vaccination should be weighed on an individual basis.
Healthcare professionals must not delegate their responsibility and they have the right to refuse vaccination to eligible patients based on their own clinical judgement. Where there is doubt, vaccination should not be initiated until the patient has sought advice from the appropriate healthcare professional.
Prior to administration and where indicated, medication that the patient is using should be checked for product interactions using the British National Formulary (BNF) and SmPC. This includes checking that the patient’s medication does not suggest conditions that are excluded from vaccination under this PGD.
Fluenz® Tetra should not be administered to children and adolescents receiving salicylate therapy. Salicylates should not be used in children and adolescents for 4 weeks after vaccination unless medically indicated as Reye’s syndrome has been reported following the use of salicylates during wild-type influenza infection (10).
It is recommended not to administer Fluenz® Tetra until 48 hours after the cessation of influenza antiviral therapy. Administration of influenza antiviral agents within two weeks of vaccination may affect the response of Fluenz® Tetra (7).
The risk to the patient of not being vaccinated must be considered.
If administration is postponed, arrange a future date for vaccination as appropriate.
Discuss with patient and document the reasons for exclusion from vaccination under the PGD.
If the patient has consented, refer them to their GP and/or inform their GP.
Signpost to other services if appropriate.
Advise about the disease and its transmission, about hand hygiene and avoiding influenza, how to recognise it and what to do if influenza is contracted.
Ensure patient/carer fully understands the risks of declining vaccination.
Advise the patient/carer about the protective effects of the vaccine.
Explain NHS eligibility for vaccination where appropriate.
Reschedule vaccination if appropriate.
Document the reasons for declining vaccination and any action taken, including advice given to the patient in their medication record.
Advise about the disease and its transmission, about hand hygiene and avoiding influenza, how to recognise it and what to do if influenza is contracted.
2. Description of vaccine | |||||
Name, strength & formulation of drug | |||||
Supplier | Name of product | Composition | Pharmaceutical form | Excipients | Age indications |
AstraZeneca UK Ltd | Fluenz® Tetra | LAIV Influenza vaccine (live attenuated) | Nasal spray, suspension | 2-17 years | |
Seqirus UK Ltd | Adjuvanted quadrivalent influenza vaccine▼ | aQIV Adjuvanted quadrivalent influenza vaccine (egg grown, surface antigen, inactivated, adjuvanted with MF59C.1) | Suspension for injection in pre- filled syringe | For adjuvant, see section 2 of the SmPC | 65 years and over |
Seqirus UK Ltd | Cell-based quadrivalent influenza vaccine▼ | QIVc Quadrivalent Influenza vaccine (surface antigen, inactivated, prepared in cell cultures) | Suspension for injection in pre- filled syringe | 2 years and over | |
Viatris (formerly Mylan) | Influvac® sub- unit Tetra | QIVe Quadrivalent Influenza vaccine (egg grown, surface antigen, inactivated) | Suspension for injection in pre- filled syringe | 6 months and over | |
Sanofi Pasteur | Quadrivalent influenza vaccine | QIVe Quadrivalent influenza vaccine (egg grown, split virion, inactivated) | Suspension for injection in pre- filled syringe | 6 months and over | |
Sanofi Pasteur | Supemtek®▼ | QIVr Quadrivalent influenza vaccine (recombinant, prepared in cell culture) | Suspension for injection in pre- filled syringe | 18 years and over | |
Sucrose
Dipotassium phosphate
Potassium dihydrogen phosphate
Gelatin (porcine, Type A)
Arginine hydrochloride
Monosodium glutamate monohydrate
Water for injections
Sodium chloride
Potassium chloride
Potassium dihydrogen phosphate
Disodium phosphate dihydrate
Magnesium chloride hexahydrate
Calcium chloride dihydrate
Water for injections
Sodium chloride
Potassium chloride
Potassium dihydrogen phosphate
Disodium phosphate dihydrate
Magnesium chloride hexahydrate
Water for injections
Sodium chloride
Potassium chloride
Potassium dihydrogen phosphate
Disodium phosphate dihydrate
Magnesium chloride hexahydrate
Calcium chloride dihydrate
Water for injections
Sodium chloride
Potassium chloride
Potassium dihydrogen phosphate
Disodium phosphate dihydrate
Water for injections
Polysorbate 20 (E432)
Sodium chloride
Sodium phosphate monobasic, monohydrate
Sodium phosphate dibasic, dodecahydrate
Water for injections
For a full list of excipients, see section 2 and 6.1 of the relevant SmPC.
For information regarding the ovalbumin content of each vaccine, see government guidance.
Vaccines labelled with a black triangle (▼) are subject to additional monitoring (see reporting procedure of adverse reactions).
2. Description of vaccine – continued | ||
Legal status | ||
Dose/dose range | Name of product | Dose |
Fluenz® Tetra | 0.2 ml (administered as 0.1 ml per nostril) | |
Adjuvanted quadrivalent influenza vaccine▼ | 0.5 ml | |
Cell-based quadrivalent influenza vaccine▼ | 0.5 ml | |
Quadrivalent Influvac® sub-unit Tetra | 0.5 ml | |
Quadrivalent influenza vaccine | 0.5 ml | |
Supemtek®▼ | 0.5 ml | |
Use of PGD outside terms of SmPC | 6 months to under 9 years (N.B. product specific age exclusions must be followed) who are in clinical risk groups. This advice may differ from SmPC advice (7). | |
Route/method of administration | on co-administration with other vaccines (10). | |
Frequency of administration | ||
Follow up / minimum or maximum period | ||
POM – Prescription Only Medicine
This PGD covers vaccination in England, Scotland, Wales and Northern Ireland. Please note that Northern Ireland may have a separate SmPC from Great Britain and guidance may differ. Please refer to the relevant SmPC for more information.
Although healthcare professionals have the right to refuse vaccination even where a patient is eligible, they cannot override PGD exclusions.
A second dose of influenza vaccine may only be offered under this PGD to children aged
The vaccine should be inspected for any foreign particulate matter and /or for any variation of physical aspect prior to administration. If either is observed the vaccine should not be administered (3) (5).
For intramuscular injection, the preferred site of injection is the deltoid muscle of the upper arm. The vaccine must not be injected intravenously, subcutaneously or intradermally and must not be mixed with other vaccines in the same syringe (1) (4) (5). Influvac® sub-unit Tetra and Quadrivalent Influenza vaccine (Sanofi Pasteur) may alternatively be administered by the subcutaneous route to individuals with bleeding disorders (2) (3).
For patients with bleeding disorders, a fine needle (equal to 23 gauge or finer calibre) should be used for the vaccination, followed by firm pressure applied to the site (without rubbing) for at least 2 minutes. Alternatively, vaccination with Influvac® sub-unit Tetra or quadrivalent influenza vaccine (Sanofi Pasteur) can be given by subcutaneous injection to reduce risk of bleeding (see cautions) (6).
Where two or more injections need to be administered at the same time, they should be given at separate sites, preferably in different limbs. If more than one injection is to be given in the same limb, they should be administered at least 2.5cm apart (13).
In children 6 months through 35 months, the preferred sites for intramuscular injection are the anterolateral aspect of the thigh (if suitably trained), or the deltoid muscle if muscle mass is adequate (see ‘Cautions’).
Fluenz® Tetra immunisation must be carried out by nasal administration as a divided dose in both nostrils (do not inject Fluenz® Tetra). For instructions on administration, see section 6.6 of the SmPC. Refer to section 4.5 of the Fluenz® Tetra SmPC for information
Single dose annually.
Children aged 6 months to under nine years who are in clinical risk groups and have not received an influenza vaccine previously, may be offered a second dose of the vaccine at least 4 weeks later, in line with official recommendations. For additional details, refer to the green book, chapter 19: https://www.gov.uk/government/publications/influenza-
Single dose annually (see ‘Frequency of administration’).
Follow local SOP on adverse reactions and their management.
(14): Chills; hyperhidrosis; induration; local reactions; pain.
Elderly patients might be more susceptible to side-effects (14).
Emergency equipment must be available including immediate access to epinephrine (adrenaline) 1:1000 for intramuscular (IM) injection. Please refer to resuscitation council guidelines.
Healthcare professionals should confirm with patients that they are fit to leave the premises after a period of observation. Patients should not leave if they are feeling at all unwell without speaking to the healthcare professional.
The onset of anaphylaxis is rapid, typically within minutes, and its clinical course is unpredictable with variable severity and clinical features. Due to the unpredictable nature of anaphylactic reactions, it is not possible to define a particular time period over which all patients should be observed following immunisation to ensure they do not develop anaphylaxis.
In the event that the patient exhibits signs of anaphylaxis after injection, healthcare professionals must seek urgent medical attention.
Advise the patient to consult their GP if there is a severe local reaction at the injection site, if they have a fever or if any other serious symptoms develop.
For a comprehensive list of all warnings, cautions and potential adverse reactions, refer to the current BNF, current and relevant SmPCs (Great Britain or Northern Ireland) and the Green Book - Immunisation against infectious disease.
Report to GP if appropriate & document in patient’s medication records.
Follow local SOP for reporting of adverse events.
Black triangle products (▼) are subject to additional monitoring.
All suspected adverse reactions must be reported via the Yellow Card scheme to the MHRA or on the website at https://yellowcard.mhra.gov.uk/
An adverse reaction should be reported even if it is not certain that the medicine has caused it, if it is well recognised, or if other drugs were given at the same time.
Further information is available online from https://yellowcard.mhra.gov.uk/
Explain protection level expected from vaccine. Advise patients that not all those who receive the vaccine will be fully protected, and the vaccine only protects against infections for which it has been developed.
Provide a patient information leaflet and discuss as required.
Provide advice on and explain potential warnings.
Advise on possible side effects and their management. If the symptoms do not resolve and/or the patient experiences other severe symptoms, they should be advised to contact their GP, NHS 111 or visit A&E.
Advise about the disease and its transmission, about hand hygiene and avoiding influenza, how to recognise it and what to do if influenza is contracted.
Provide patient with a record of vaccination.
In all cases manual records including any risk assessment forms or computerised records should include:
̵ Patient’s name, address and date of birth;
̵ Name of immuniser;
̵ Dose, site and route of injection;
̵ Date of administration;
̵ Brand name, batch number & expiry date of vaccine;
̵ Confirmation that there are no contraindications; that side effects have been discussed; support literature given (if applicable) and any other advice given;
̵ That valid informed consent was given prior to administration;
̵ Details of any adverse reactions and actions taken;
̵ Signature and printed name and designation (in black ink) for paper records. For computer records, ensure data authentication of practitioner delivering care.
GP may be notified, if the patient has consented for personalised information to be shared.
Pharmacy/clinic records should be stored in line with relevant legislation and local policies. Generally, records should be kept for 8 years in adults and until 25 years of age in children.
Policies and procedures must be in place for providing a private vaccination service including cold chain management, sharps disposal, needlestick injury, consent, record keeping and training requirements.
Pharmaceutical refrigerator (or validated cool box for storing vaccines if running an
“offsite” clinic).
Resuscitation kit, including immediate access to 1:1000 epinephrine (adrenaline).
Access to medical support (this may be via telephone).
Disposal - equipment used for vaccination, including used vials or ampoules, should be disposed of at the end of a session by sealing in a proper, appropriately sized puncture- resistant ‘sharps’ box (UN-approved, BS 320).
Be familiar with and have online access to the latest edition of the Green Book, noting that clinical guidance may change and that the Green Book is frequently updated.
Be aware of current clinical recommendations and be able to undertake administration (where applicable) and discuss any issues that may arise.
Have been trained and assessed as being competent in the delivery of this medicine covered by this PGD.
Maintain their skills, knowledge and professional level of competence in this area according to their individual code of professional conduct.
Possess appropriate professional indemnity.
Agree to work within the terms of the implementing PGD.
Be aware of medicine handling, storage and administration guidelines.
Regularly check BNF/BNFC / Green Book for contraindications, cautions and interactions. The superintendent/clinical lead of the implementing pharmacy/clinic will be responsible for:
Providing adequate up-to-date clinical resources.
Ensuring that staff using the PGD, have access to up-to-date resources.
Ensuring that staff have received adequate training in all areas relevant to this PGD.
All staff involved in the implementation of this PGD should participate in adequate and appropriate Continual Professional Development to ensure procedures follow the most up to date clinical guidance.
Consultations carried out under the authorisation of this PGD should be completed in a private space, physically closed off from interruption such as a pharmacy consultation room, in order to ensure patient confidentiality.
The following should be available:
Safe storage areas for medicines and equipment
Clean and tidy clinical rooms that allow confidentiality and patient privacy
Copies of the current PGD
Access to a current BNF and Green Book
All health risk assessment, advice and medicine supply record forms should be stored in the pharmacy/clinic and will be audited by the implementing pharmacy/clinic in order to analyse service delivery. If the service is deemed insufficient, management staff, the superintendent/clinical lead and implementing healthcare professional will be informed and an action plan drawn up to remedy the service.
Prior to the administration and/or supply of a medicine, consent must be obtained, preferably written, from the patient, and documented either in the patient’s medical records/notes or on an administration form.
If a patient’s fitness and suitability cannot be established, supply should be deferred.
There is no legal requirement for consent to be in writing but written consent serves to record the decision and the discussions that have taken place.
Consent - either written or verbal - is required at the time of each supply.
Consent remains valid unless the patient who gave it withdraws it. If there is new information between the time consent was given and when the supply is offered, including new evidence of risk, new medicines becoming available or where there is a significant change in the patient’s condition, it may be necessary for the patient to reconfirm their consent.
Written and verbal information should be available in a form that can be easily understood by the person who will be giving the consent. Where English is not easily understood, translations and properly recognised interpreters should be used in order that they can make informed consent.
The attendance of a patient for the supply/administration of treatment after an invitation to attend for this purpose may be viewed as acceptance that the patient may have the treatment/administration.
Patients should also be informed about how data on the supply will be stored, who will be able to access that information and how that data may be used.
Where consent is either refused or withdrawn, this decision must be documented.
Consent obtained before the occasion upon which a patient attends for the supply/administration is only an agreement for the patient to be included in this instance and does not mean that consent is in place for each future supply/administration.
For a comprehensive list of all warnings, cautions and potential adverse reactions, refer to the current BNF and SmPCs.
Summary of Product Characteristics; Adjuvanted Quadrivalent Influenza Vaccine (Surface Antigen, Inactivated) Seqirus suspension for injection in pre-filled syringe Influenza vaccine, Adjuvanted with MF59C.1. emc (Great Britain). [Online] 21 June 2023. [Cited: 27 July 2023.] https://www.medicines.org.uk/emc/product/12881/smpc.
Summary of Product Characteristics; Influvac sub-unit Tetra. emc (Great Britain). [Online] 17 July 2023. [Cited: 27 July 2023.] https://www.medicines.org.uk/emc/product/9381.
Summary of Product Characteristics; Quadrivalent Influenza Vaccine (split virion, inactivated), suspension for injection in pre-filled syringe. emc (Great Britain). [Online] 17 August 2022. [Cited: 27 July 2023.] https://www.medicines.org.uk/emc/product/666/smpc.
Summary of Product Characteristics; Supemtek solution for injection in pre-filled syringe. emc (Great Britain). [Online] 06 January 2023. [Cited: 27 July 2023.] https://www.medicines.org.uk/emc/product/12761.
Summary of Product Characteristics; Cell-based Quadrivalent Influenza Vaccine (Surface Antigen, Inactivated) Seqirus suspension for injection in pre-filled syringe. emc (Great Britain). [Online] 10 July 2023. [Cited: 27 July 2023.] https://www.medicines.org.uk/emc/product/12882/smpc.
Chapter 14a; COVID-19 - SARS-CoV-2. The Green Book. [Online] 27 April 2023. [Cited: 27 July 2023.] https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1057798/Greenbook-chapter-14a- 28Feb22.pdf.
Chapter 19; Influenza. The Green Book. [Online] 16 September 2022. [Cited: 27 July 2023.] https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/931139/Green_book_chapter_19_ influenza_V7_OCT_2020.pdf.
Chapter 8: Vaccine safety and the management of adverse events following immunisation. The Green Book. [Online] 20 March 2013. [Cited: 27 July 2023.] https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/147868/Green-Book-Chapter-8- v4_0.pdf.
Chapter 7; Immunisation of individuals with underlying medical conditions. The Green Book. [Online] January 2020. [Cited: 27 July 2023.]
https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/857279/Greenbook_chapter_7_I mmunsing_immunosupressed.pdf.
Summary of Product Characteristics; Fluenz Tetra nasal spray suspension Influenza vaccine (live attenuated, nasal). emc (Great Britain). [Online] 28 July 2021. [Cited: 15 July 2022.] https://www.medicines.org.uk/emc/product/3296.
National flu immunisation programme plan 2023 to 2024. GOV.UK. [Online] 03 July 2023. [Cited: 27 July 2023.] https://www.gov.uk/government/publications/national-flu-immunisation-programme-plan.
JCVI, Advice on influenza vaccines for 2023/24. App box. [Online] 30 November 2022. [Cited: 27 July 2023.] https://app.box.com/s/t5ockz9bb6xw6t2mrrzb144njplimfo0/file/1079253178131.
Chapter 4; Immunisation procedures. The Green Book. [Online] June 2021. [Cited: 27 July 2023.] https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/147915/Green-Book-Chapter- 4.pdf.
Influenza vaccine. BNF; The National Institute for Health and Care Excellence. [Online] [Cited: 27 July 2023.] https://bnf.nice.org.uk/drugs/influenza-vaccine/.
1. Flu. NHS. [Online] September 05, 2022. [Cited: July 27, 2023.] https://www.nhs.uk/conditions/flu/.
Chapter 6; Contraindications and special considerations. The Green Book. [Online] October 26, 2017. [Cited: July 27, 2023.] https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/655225/Greenbook_chapter_6.pd f.
Patient Group Direction; Medicines practice guideline [MPG2]. National Institute for Health and Care Excellence. [Online] March 27, 2017. [Cited: July 27, 2023.] https://www.nice.org.uk/Guidance/MPG2.
Competency framework for health professionals using Patient Group Directions. National Institute for Health and Care Excellence. [Online] January 4, 2018. [Cited: July 27, 2023.] https://www.nice.org.uk/guidance/mpg2/resources.