Human Vaccines & Immunotherapeutics

ISSN: 2164-5515 (Print) 2164-554X (Online) Journal homepage: http://www.tandfonline.com/loi/khvi20

Seasonal influenza immunization program outside general practice: An evaluation Sally Morrison-Griffiths & Liz Gaulton To cite this article: Sally Morrison-Griffiths & Liz Gaulton (2016) Seasonal influenza immunization program outside general practice: An evaluation, Human Vaccines & Immunotherapeutics, 12:1, 248-251, DOI: 10.1080/21645515.2015.1099770 To link to this article: http://dx.doi.org/10.1080/21645515.2015.1099770

Accepted author version posted online: 13 Nov 2015.

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Date: 02 April 2016, At: 05:05

REVIEW Human Vaccines & Immunotherapeutics 12:1, 248--251; January 2016; © 2016 Taylor & Francis Group, LLC

Seasonal influenza immunization program outside general practice: An evaluation Sally Morrison-Griffiths1,* and Liz Gaulton2 1

Addaction; St Helens, UK; 2Public Health & Wellbeing; St. Helens Council; St. Helens, UK

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Keywords: chronic disease, drug users, immunisation, influenza

With the support of our local Public Health and NHS England teams, we developed a pathway of care to provide seasonal influenza vaccination to our heroin dependent service users. 340 of the 515 service users receiving opioid substitution treatment (OST) were offered the vaccination in the 2014/15 influenza season and 205 accepted it. A further 29 service users received the vaccination elsewhere. With over 50% of those on OST prescriptions known to have a diagnosed chronic condition, such as liver or respiratory disease, this was a worthwhile health intervention in a population that is known to be “hard to reach.” In addition to the potential benefit to the individuals who received the seasonal influenza vaccination, there was also an opportunity to provide health advice and information surrounding chronic disease management. Service user feedback overwhelmingly supported the provision of seasonal influenza vaccination within Drug and Alcohol services.

Background and Aims This pilot study aimed to improve the uptake of seasonal influenza vaccination in an area of high deprivation, targeting a ‘hard to reach’ population of heroin users. There is evidence to suggest that patients from a deprived area have a slightly lower vaccination rate.1 The borough of St Helens in Merseyside has a population of just over 176,000 and the Index of Multiple Deprivation (IMD) ranked St Helens the 51st most deprived local authority in England (out of 326) in 2010. The IMD is the most widely adopted measure of deprivation taking into account factors such as employment, housing, health and disability, education and training.2 The most likely chronic conditions to increase during the winter months in St Helens are respiratory diseases. In each winter between 2008 and 2011, respiratory disease deaths increased by over 60% compared to non-winter months. In St Helens, deaths from influenza and pneumonia have been significantly higher than the England average between 2004 and 2011.3 The purpose of the national influenza immunisation program is to protect those at most risk of serious illness or death should they develop influenza. *Correspondence to: Sally Morrison-Griffiths; Email: sallymorrison-griffi[email protected] Submitted: 09/10/2015; Accepted: 09/19/2015 http://dx.doi.org/10.1080/21645515.2015.1099770

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Addaction is a third sector charitable organization and is the current sole service provider for those with substance misuse problems within the borough of St Helens. There are over 1000 service users in treatment with Addaction at any one time with a range of substance misuse problems including alcohol, heroin, crack cocaine, cannabis and stimulants. There are just over 500 service users on an opioid substitution therapy (OST) prescription i.e. methadone or buprenorphine, for heroin addiction. Although there are a high number of heroin injectors in St Helens, one of the harm reduction methods employed in the treatment of heroin users is to encourage them to ‘smoke’ (or inhale) heroin rather than inject it, as injecting is a much riskier practice. Recently however, there is evidence to suggest that smoking heroin may be contributing to earlier onset chronic respiratory disease, in particular chronic obstructive pulmonary disease (COPD). A significant number of heroin users also smoke tobacco. A recent questionnaire survey of service users in nearby Liverpool found that most respondents had at least one symptom suggestive of airways disease, although only 17% had actually received spirometry for diagnosis.4 Injecting drug use carries with it the risk of contracting blood borne viruses including HIV, hepatitis B and hepatitis C. The majority of new cases of hepatitis C in England and Wales are due to injecting drug use. In St Helens, over 50% of those on OST carry antibodies for hepatitis C and just 34% are infected with chronic hepatitis C. This is close to national figures.5 Chronic infection with hepatitis C leads to liver fibrosis, cirrhosis, hepatocellular carcinoma and death. It is a treatable condition but unfortunately, due to the chaotic lifestyle of many drug users and the stigmatisation of addiction often they do not access treatment.6 In February 2014, an audit of 185 service users’ case notes in St Helens found that over 50% of individuals on OST had been diagnosed with a chronic disease that would make them eligible for the seasonal influenza vaccination. This information was elicited from the GP Patient Summary, routinely requested when a service user enters treatment. However, as noted previously, many drug users do not attend their GP despite symptoms of a possible chronic disease so it is probable that the actual number is much higher. The two most common chronic diseases diagnosed were chronic respiratory disease (asthma or COPD) and liver disease [n D 58 and 54 respectively]. Some individuals had both conditions. At the same time, a review of the deaths in service found that there were 15 deaths between the 22 months of April 2012 (when Addaction took over the service) and January 2014. The

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Table 1. Cause of death in service users Cause of death

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Unknown Respiratory disease Liver disease Ischaemic heart disease Overdose (heroin)

Number 7 3 2 2 1

average age was 51 y old (range D 34–69) and the cause of death is shown in Table 1. Public Health England (North West) and NHS England (Merseyside Area Team) set up a pilot scheme with the aims of improving the uptake of the seasonal influenza vaccination in ‘hard to reach’ groups for the 2014/15 season in St Helens. The service specification provided a clear, robust clinical pathway for healthcare professionals outside of General Practice to proactively advocate, promote and administer the vaccine. Service design Following a series of meetings between the local Public Health team, NHS England Merseyside Area team and Addaction, a service specification was produced and Addaction signed up to provide the service to those service users on a prescription for OST. Addaction St Helens has a clinical team of 3 doctors and 3 nurses and the plan was for nurses to incorporate the administration of the influenza vaccine into their routine nursing practice. The nurses are experienced in vaccination administration as they regularly administer hepatitis A and B vaccines to service users. All doctors and nurses attended a ‘Flu Update’ to ensure their knowledge and skills were up to date. It was decided to offer the influenza vaccination to all service users on a prescription for OST rather than the whole service user population for the following reasons:  Individuals on a prescription were well known to us and regularly attended the service to pick up their prescriptions  We had more knowledge about their chronic disease status in most cases (although we did not have the chronic disease information on all of our service users as it is not always possible to get this information from the GP)  Some individuals are not aware of their own chronic disease diagnoses  There is a higher level of morbidity and mortality in this group of service users due to their high risk drug taking behavior and the effects of heroin and crack cocaine on physical health  These individuals are less likely to visit their GP than the general population  If the program was a success we could consider rolling it out to all service users in the future  Bronchopneumonia is a common cause of hospital admission among those who smoke heroin and crack cocaine It was decided that the vaccination be offered to all individuals on OST because of the likelihood of under-diagnosis of respiratory and liver conditions in this group, and also because of the

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greater risk factors leading to complications of influenza such as homelessness, poor nutrition and general self-neglect. There is evidence that heroin and crack cocaine users present late to the GP or to hospital and this may be due to previous poor experiences of healthcare environments, fear of stigmatisation for being on treatment for heroin addiction or due to chaotic lifestyles.6 All service users on OST have a keyworker who sees them every 2 weeks to provide psychosocial interventions and issue their prescription for OST. Service users are seen every 3 months for review by the prescribing doctor and every 6 months for a nurse-led health review. Therefore, in order to try and reach as many service users as possible within the vaccination program timeframe, it was necessary to enlist the help of keyworkers to accompany their clients to the nurse drop-in clinics for the flu vaccination. This was achieved by providing educational sessions and frequent reminders to staff and managers from the clinical team. It took longer than anticipated to organize the necessary paperwork that needed to be signed off in order to safely and effectively initiate this new service, so the program did not start until the end of October 2014. Each individual who accepted the vaccination was given preand post-vaccination advice and a patient information leaflet (PIL). Each individual who declined to take up the offer of vaccination was given health advice and a PIL and were signposted to the GP as an option if they changed their mind. All GPs were sent a fax within 24 hours of service users receiving the vaccination.

Results The total number of service users who were on OST when we started the seasonal influenza vaccination program was 515. 340 (66%) of service users on OST were offered the vaccination. Of the 340 service users offered the influenza vaccination, 205 accepted (60%) and 106 declined (31%). Twenty-nine service users had already received the vaccination elsewhere (9%) (Table 2). Where possible, we recorded the chronic diseases of the service users. This information was gained either from our own records as we provide the detection, diagnosis and referral for blood borne viruses, or from a copy of the GP Patient Summary (if available). For those where we either had no diagnosis or we were unsure of diagnosis we recorded ‘immunosuppression’ or ‘other’ as agreed in the original meetings.

Table 2. Number of service users taking up offer of influenza vaccination October 2014-March 2015 Service users eligible Offered Accepted Declined Already received vaccine

515 340 205 106 29*

*14 – pharmacist, 10 – GP, 1 – prison, 4 - not sure

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Table 3. Chronic diseases Chronic disease Liver Respiratory Ischaemic heart disease Kidney disease Cancer Type I DM Stroke HIV Immunosuppression/other Total

Number 54 50 (COPD D 26, asthma D 24) 4 2 2 1 1 1 95 210*

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*(Total is greater than 205 as some individuals had more than one chronic disease).

The results were similar to the audit conducted in February 2014 and found that 110 of the 205 service users who accepted the influenza vaccination had one or more chronic disease (54%) with chronic liver disease being the most common condition (26%) followed by chronic respiratory disease (24%) (Table 3). Most of the chronic liver disease was related to chronic infection with hepatitis C, although 2 individuals had alcohol-related liver disease. The average age of those who accepted the influenza vaccination and those who refused it was the same at 41 y old. 26% of those accepting the vaccination were female and 74% were male. This gender split reflects the number of males and females in service for heroin and crack cocaine addiction on our database. It is known that more males than females enter treatment for heroin addiction throughout Europe.7 We asked 132 of the service users accepting the vaccination whether they had been vaccinated in previous years. 100 stated that they had not and 32 stated that they had previously received it from their GP. Service user feedback In April 2015, we conducted a survey to elicit the opinions of service users to being offered the seasonal influenza vaccine in Addaction Drug and Alcohol Service. We handed out 60 questionnaires randomly and there were 51 respondents (85%). Of the 51 respondents, 23 self-reported that they had a chronic condition (45%), 25 did not (49%) and 3 were not sure (6%). The majority of the 23 respondents who did state that they had a chronic condition, most identified a respiratory condition (65%, nD14); 30% (nD7) had chronic liver disease. Of these individuals, one had both respiratory and liver disease. Two respondents had ‘other’ chronic diseases. Of the 51 survey respondents, 21 (41%) stated that they had received the influenza vaccination at Addaction; 20 of those were satisfied with the information they received about the vaccination and one did not answer the question. None of the 21 who received the vaccination suffered from any adverse reaction. Only 8 of the 21 vaccinated at Addaction had been vaccinated in previous years (5 in their GP surgery, 2 in prison and one was not sure where). Thirty respondents did not have the influenza vaccination at Addaction. Ten respondents replied that they had not been offered it, 7 had one at their GP Practice, 8 did not feel they needed it or did not want it, 2 had it at the pharmacy and 3

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did not answer the question. A total of 44 (86%) of the 51 respondents felt that it was a positive thing that Addaction offered the seasonal influenza vaccination, 6 were not sure or did not answer and one respondent replied ‘no’; 14 (61%) of the 23 respondents who identified having a chronic disease did not have the vaccine. Ten (20%) of the respondents stated that they had been previously hospitalised with pneumonia or a respiratory problem. Of those, 3 had not had the influenza vaccination in the 2014/15 y and 7 had. Of the 7, 2 had it at Addaction, 4 at their GP surgery and one at a pharmacy. The results of this questionnaire survey suggest that service users were satisfied with the seasonal influenza vaccination being offered at their Drug and Alcohol Service and satisfied with the information given to them. However, over a third of service users were not offered the vaccine, which suggests that staff need to be more proactive in promoting it. This is particularly important as over 60% of those who self-identified with a chronic disease did not have the vaccine.

Discussion The results described here show that over half of individuals attending treatment for drug addiction have been diagnosed with a chronic disease making them eligible to receive the seasonal influenza vaccine, but that many do not attend their GP to receive it. There are likely to be many more individuals who remain undiagnosed due to poor engagement with health services and to the high number of risk factors involved in heroin addiction. Over a third of current and ex-injecting drug users in St Helens have chronic hepatitis C. In addition to smoking heroin and crack cocaine, most service users smoke cigarettes, increasing the risk of developing COPD. A large number of heroin users are malnourished and suffer psychosocial problems such as homelessness, poverty, unemployment and mental health issues. All of these factors may increase the risk of morbidity and mortality related to influenza. Public Health England’s ‘Green Book’ identifies an increased risk of mortality from influenza in those with chronic disease (60% vs 40% without a chronic disease) with an age-related relative risk of 7.4 for chronic respiratory disease and 48.2 for chronic liver disease.8 There is no evidence to suggest that prior heroin use affects the response to the vaccine.9 The average age of those in treatment for heroin addiction is 51, which may explain why some service users felt that they were not at risk from the complications of influenza and declined the vaccine, being in a younger age group to many of those in the general population with chronic disease. These barriers can be overcome by education of both staff and service users through posters, leaflets and integrating the offer of vaccination into their current treatment plans. The results of the service user survey showed that a significant majority of users felt that it was a positive thing that Addaction were offering the vaccine. Interestingly, 7 out of the 10 individuals who had been hospitalised in the past with a chronic respiratory condition had taken up the offer of the 2014/15 influenza vaccine. This may have been because they were consequently aware that they were at high risk for the complications of influenza.

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This pilot study shows that the seasonal influenza vaccination can be safely and effectively administered outside General Practice to improve uptake in a population of high morbidity, high mortality and high deprivation index.

Conclusions A significant number of individuals accessed the seasonal influenza vaccination who otherwise may not have done. The high number of service users with chronic liver disease and chronic respiratory disease makes this population a

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References 1. Coupland C, Harcourt S, Vinogradova Y, Smith G, Joseph C, Pringle M, Hippisley-Cox J. Inequalities in uptake of influenza vaccine by deprivation and risk group: time trends analysis. Vaccine. 2007; 25 (42):7363-71; PMID:17884258; http://dx.doi.org/ 10.1016/j.vaccine.2007.08.032 2. St Helens Public Health Annual Report (2013) ‘Better health together’ Liz Gaulton, director of public health. Available at:http://www.sthelens.gov.uk/media/570573/ 1301345_public_health_annual_report_10-final.pdf. 3. St Helens Joint Strategic Needs Assessment Update. Executive summary, St helens public council and st helens clinical commissioning group. 2013. Available at: http://www.sthelens.gov.uk/media/500228/st_helens_js na_2013_executive_summary.pdf.

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worthwhile target for this health promotion activity. There were no recorded hospital admissions or deaths from respiratory disease among those who had received the seasonal influenza vaccination. There was one recorded hospital admission (bronchopneumonia) and no deaths recorded for respiratory disease among those who had declined the seasonal influenza vaccination.

Disclosure of Potential Conflicts of Interest

No potential conflicts of interest were disclosed.

4. Tridimas A, Archer T, Rehman Z, Oelbaum S, Burhan H.. The prevalence of self-reported respiratory symptoms amongst patients attending a drug dependency clinic. Thorax, December 2013; Supplement 111 (P126): 126. Available at: https://www.brit-thoracic.org. uk/document-library/learning-hub/winter-meeting2013/winter-meeting-2013-abstract-book/ 5. Advisory Council on the Misuse of Drugs.The Primary prevention of hepatitis C among injecting drug users, the home office. 2009. Available at: https://www.gov.uk/ government/uploads/system/uploads/attachment_data/ file/119144/acmdhepcreport2.pdf. 6. Jones R, Simonson P and Singleton N. Experiences of stigma – everyday barriers for drug users and their families. London: UKDPC. 2010. Available at: http://www. ukdpc.org.uk/publications.shtml#Stigma_reports.

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7. Solis M. Heroin abuse: breaking the cycle. The Pharmaceutical J 2015; 294:7868 8. The Green Book, Chapter 19, The Home Office. 2013. Available at: https://www.gov.uk/government/publica tions/influenza-the-green-book-chapter-19 9. Iorio AM, Alatri A, Francisci D, Preziosi R, Neri M, Donatelli I, Castrucci MR, Biasio LR, Tascini C, Iapoce R, et al. Immunogenicity of influenza vaccine (1993-94 winter season) in HIV-seropositive and -seronegative exintravenous drug users. Vaccine 1997; 15:97-102; PMID:9041673; http://dx.doi.org/10.1016/S0264410X(96)00057-6

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Seasonal influenza immunization program outside general practice: An evaluation.

With the support of our local Public Health and NHS England teams, we developed a pathway of care to provide seasonal influenza vaccination to our her...
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