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Update on use of antivirals for flu prevention and treatment published (Department of Health, UK, December 20 2012)
[Source: Department of Health, United Kingdom, full PDF document: (LINK). Edited.]
Richmond House 79 Whitehall London SW1A 2NS
Gateway reference: 18573 / 17 December 2012
From the Chief Medical Officer and the Chief Pharmaceutical Officer
For action
Dear Colleague
1. INFLUENZA SEASON 2012/13 ? USE OF A NTIVIRAL MEDICINES
The most recent surveillance data indicate that there is now a substantial likelihood that people, including children in schools, presenting with an influenza-like illness are infected with an influenza virus.
GPs may now prescribe at NHS expense, antiviral medicines for the prophylaxis and treatment of influenza, in accordance with NICE guidance and Schedule 2 to the National Health Service (General Medical Services Contracts) (Prescription of drugs etc) Regulations 2004), commonly known as the Grey List or Selected List Scheme (SLS).
In November 2010, Schedule 2 to the National Health Service (General Medical Services Contracts)(Prescription Drugs etc) Regulations 2004, was amended to include pregnant women amongst the list of people 'at clinical risk' from seasonal flu and eligible to receive antiviral medicines at NHS expense prescribed by General Practitioners. General Practitioners should note the information on use in pregnancy in the Summary of Product Characteristics of both antiviral medicines.
The above Regulations were further amended in April 2011, which give GPs the discretion to prescribe antiviral medicines, if in their clinical judgement, they believe that it is appropriate to prescribe an antiviral medicine for a person aged under 65 years of age, who is not in one of the identified clinical at-risk groups but is at risk of developing medical complications from influenza. This discretion is to be guided by the Chief Medical Officer on an annual basis.
Chief Medical Officer (CMO) guidance on prescribing of antiviral medicines for people not in the identified at-risk groups, for 2012-13
GPs should prescribe antiviral medicines only if they consider the patient to be at risk of developing complications if not treated. This will also help to ensure that there are enough antiviral medicines in the supply chain to meet, in a timely manner, the needs of patients who are eligible for treatment and who are suffering symptoms of influenza.
Further information on the at-risk groups and patients who are eligible for treatment at NHS expense with either oseltamivir (Tamiflu) or zanamivir (Relenza) can be found in Part XVIIIB of the Drug Tariff (Drugs, Medicines and Other Substances that may be ordered only in certain circumstances) available at: http://www.ppa.org.uk/ppa/edt_intro.htm
NICE guidance
NICE guidance is relevant to all clinicians (primary and secondary care). However, clinicians in secondary care are not subject to the ?Grey List? restrictions that GPs are, for prescribing of antiviral medicines. They can therefore use their clinical judgment to prescribe antiviral medicines, including for those not in the 'at risk' groups.
For clinicians treating hospitalised patients with suspected influenza, rapid laboratory confirmation with subtype identification is advised to support patient management.
The ?Grey List?, which is included within the Drug Tariff, restricts GPs to only prescribe antiviral medicines to specified people who are listed in the Drug Tariff. i.e. the clinical at risk groups, pregnant women, people over the age of 65 years and those people under 65 years of age who are at risk of developing medical complications
The full NICE guidance on the use of antiviral medicines can be accessed at: http://guidance.nice.org.uk/TA168 for treatment, and http://guidance.nice.org.uk/TA158 for prophylaxis.
Advice for prescribers for endorsing prescriptions
Prescribers are reminded to endorse all prescriptions for oseltamivir (Tamiflu) and zanamivir (Relenza), with the reference ?SLS?. Community pharmacies are only able to dispense oseltamivir and zanamivir at NHS expense, if the prescriber endorses the prescription with ?SLS?.
Liaison with manufacturers and wholesalers
The Department of Health is in regular contact with manufacturers and wholesalers to ensure that there are adequate quantities of antiviral medicines in the supply chain.
We would urge pharmacies not to over order stocks of antiviral medicines.
Over ordering could result in shortages in the supply chain. It is, however, important that oseltamivir and zanamivir for adults are taken within 48 hours of onset of symptoms.
Children 5 years and over and under 13 years of age should take zanamivir within 36 hours of onset of symptoms, to obtain maximum benefit.
Prescribing for children over the age of one year.
Wherever possible, for children over the age of one year and for adults who are not able to swallow capsules, the appropriate strength of capsules should be prescribed. The contents of the capsules can be emptied and added to a suitable sugary diluent. Ideally, the suspension should be restricted for children under 1 year of age. This will support the continuity of supply of the liquid form of oseltamivir for this age group.
Prescribing for children under one year of age
Tamiflu is not licensed for use in children under one year of age for seasonal influenza. Prescribing of oseltamivir for this age group for seasonal influenza, should be based on the judgment of the clinician, after considering the risks and benefits of treatment.
2. INCREASING UPTAKE OF FLU VACCINE
The increase in flu activity also highlights the need to ensure maximum protection through vaccination for those most-at risk. It is therefore essential that over 65s, under 65s at risk and pregnant women are protected against the complications from flu that they are at high risk of experiencing.
The latest national flu vaccine uptake figures show that, coverage is similar to last year. As at 9 December, the uptake rates for both the age 65 and over population, and the under 65s with clinical conditions group was one percentage point lower than last year. Uptake among pregnant women was 11.5 percentage points higher than last year.
We recognise, and are very grateful for, the excellent work that many health professionals have done to strive to vaccinate as many people as possible in the risk groups. It is important to take this opportunity to highlight the ongoing importance of GP practices and other health professionals continuing to strive towards achieving high uptake of the seasonal flu vaccine among relevant patients and their own frontline healthcare workers.
GPs have a particularly important role to play. Research conducted last year by the University of Sheffield identified a number of key factors which distinguished those GP practices which achieved high vaccine uptake. These factors included simple steps such as making sure that practices identified and called in patients with a clinical condition that may put them more at risk of the effects of flu. The full set of factors, which are known as the ?GP Checklist?, can be found at Annex B of the CMO?s annual flu letter of 3 May 2012: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_133963.pdf
Yours sincerely
Professor Dame Sally C Davies, Chief Medical officer and Chief Scientific Adviser / Dr Keith Ridge, Chief Pharmaceutical Officer
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Richmond House 79 Whitehall London SW1A 2NS
Gateway reference: 18573 / 17 December 2012
From the Chief Medical Officer and the Chief Pharmaceutical Officer
For action
- General Practitioners
- Chief Executives of Strategic Health Authorities
- Chief Executives of Primary Care Trusts
- Chief Executives of NHS Trusts
- PCT Directors of Public Health
- SHA Flu Leads
- SHA Winter Leads
- Community Pharmacists
- PCT Immunisation and Flu Co-ordinators
- Medical Directors of NHS Trusts
- Directors of Maternity Services
- Directors of Nursing
- Chief Pharmacists/Pharmaceutical Advisers of PCTs
- Chief Pharmacists of NHS Trusts
- Lead Nurses at PCTs
- Regional Directors of Public Health
- Royal College of Physicians
- Royal College of General Practitioners
- Royal Pharmaceutical Society
- Pharmacy Voice
- Pharmaceutical Services Negotiating Committee
- Faculty of Pharmaceutical Medicine
- Royal College of Paediatrics and Child Health
- Faculty of Public Health
- Royal College of Obstetrics and Gynaecology
- Royal College of Nursing
- Royal College of Midwives
- British Medical Association
- Community Practitioners and Health Visitors Association
- Chairs Infection Control Committees
- Consultants in Communicable Disease Control
- Accident and Emergency Departments
- All Pharmacists
- Nurses
- Midwives
- Obstetricians
- GP Practice Nurses
- Health Visitors
- Chief Executives of NHS Foundation Trusts
- Monitor - Independent Regulator of NHS Foundation Trusts
- Occupational Health Departments
- Directors of Infection and Prevention Control
- Nursing and Midwifery Council
- NHS Employers
Dear Colleague
1. INFLUENZA SEASON 2012/13 ? USE OF A NTIVIRAL MEDICINES
The most recent surveillance data indicate that there is now a substantial likelihood that people, including children in schools, presenting with an influenza-like illness are infected with an influenza virus.
GPs may now prescribe at NHS expense, antiviral medicines for the prophylaxis and treatment of influenza, in accordance with NICE guidance and Schedule 2 to the National Health Service (General Medical Services Contracts) (Prescription of drugs etc) Regulations 2004), commonly known as the Grey List or Selected List Scheme (SLS).
In November 2010, Schedule 2 to the National Health Service (General Medical Services Contracts)(Prescription Drugs etc) Regulations 2004, was amended to include pregnant women amongst the list of people 'at clinical risk' from seasonal flu and eligible to receive antiviral medicines at NHS expense prescribed by General Practitioners. General Practitioners should note the information on use in pregnancy in the Summary of Product Characteristics of both antiviral medicines.
The above Regulations were further amended in April 2011, which give GPs the discretion to prescribe antiviral medicines, if in their clinical judgement, they believe that it is appropriate to prescribe an antiviral medicine for a person aged under 65 years of age, who is not in one of the identified clinical at-risk groups but is at risk of developing medical complications from influenza. This discretion is to be guided by the Chief Medical Officer on an annual basis.
Chief Medical Officer (CMO) guidance on prescribing of antiviral medicines for people not in the identified at-risk groups, for 2012-13
GPs should prescribe antiviral medicines only if they consider the patient to be at risk of developing complications if not treated. This will also help to ensure that there are enough antiviral medicines in the supply chain to meet, in a timely manner, the needs of patients who are eligible for treatment and who are suffering symptoms of influenza.
Further information on the at-risk groups and patients who are eligible for treatment at NHS expense with either oseltamivir (Tamiflu) or zanamivir (Relenza) can be found in Part XVIIIB of the Drug Tariff (Drugs, Medicines and Other Substances that may be ordered only in certain circumstances) available at: http://www.ppa.org.uk/ppa/edt_intro.htm
NICE guidance
NICE guidance is relevant to all clinicians (primary and secondary care). However, clinicians in secondary care are not subject to the ?Grey List? restrictions that GPs are, for prescribing of antiviral medicines. They can therefore use their clinical judgment to prescribe antiviral medicines, including for those not in the 'at risk' groups.
For clinicians treating hospitalised patients with suspected influenza, rapid laboratory confirmation with subtype identification is advised to support patient management.
The ?Grey List?, which is included within the Drug Tariff, restricts GPs to only prescribe antiviral medicines to specified people who are listed in the Drug Tariff. i.e. the clinical at risk groups, pregnant women, people over the age of 65 years and those people under 65 years of age who are at risk of developing medical complications
The full NICE guidance on the use of antiviral medicines can be accessed at: http://guidance.nice.org.uk/TA168 for treatment, and http://guidance.nice.org.uk/TA158 for prophylaxis.
Advice for prescribers for endorsing prescriptions
Prescribers are reminded to endorse all prescriptions for oseltamivir (Tamiflu) and zanamivir (Relenza), with the reference ?SLS?. Community pharmacies are only able to dispense oseltamivir and zanamivir at NHS expense, if the prescriber endorses the prescription with ?SLS?.
Liaison with manufacturers and wholesalers
The Department of Health is in regular contact with manufacturers and wholesalers to ensure that there are adequate quantities of antiviral medicines in the supply chain.
We would urge pharmacies not to over order stocks of antiviral medicines.
Over ordering could result in shortages in the supply chain. It is, however, important that oseltamivir and zanamivir for adults are taken within 48 hours of onset of symptoms.
Children 5 years and over and under 13 years of age should take zanamivir within 36 hours of onset of symptoms, to obtain maximum benefit.
Prescribing for children over the age of one year.
Wherever possible, for children over the age of one year and for adults who are not able to swallow capsules, the appropriate strength of capsules should be prescribed. The contents of the capsules can be emptied and added to a suitable sugary diluent. Ideally, the suspension should be restricted for children under 1 year of age. This will support the continuity of supply of the liquid form of oseltamivir for this age group.
Prescribing for children under one year of age
Tamiflu is not licensed for use in children under one year of age for seasonal influenza. Prescribing of oseltamivir for this age group for seasonal influenza, should be based on the judgment of the clinician, after considering the risks and benefits of treatment.
2. INCREASING UPTAKE OF FLU VACCINE
The increase in flu activity also highlights the need to ensure maximum protection through vaccination for those most-at risk. It is therefore essential that over 65s, under 65s at risk and pregnant women are protected against the complications from flu that they are at high risk of experiencing.
The latest national flu vaccine uptake figures show that, coverage is similar to last year. As at 9 December, the uptake rates for both the age 65 and over population, and the under 65s with clinical conditions group was one percentage point lower than last year. Uptake among pregnant women was 11.5 percentage points higher than last year.
We recognise, and are very grateful for, the excellent work that many health professionals have done to strive to vaccinate as many people as possible in the risk groups. It is important to take this opportunity to highlight the ongoing importance of GP practices and other health professionals continuing to strive towards achieving high uptake of the seasonal flu vaccine among relevant patients and their own frontline healthcare workers.
GPs have a particularly important role to play. Research conducted last year by the University of Sheffield identified a number of key factors which distinguished those GP practices which achieved high vaccine uptake. These factors included simple steps such as making sure that practices identified and called in patients with a clinical condition that may put them more at risk of the effects of flu. The full set of factors, which are known as the ?GP Checklist?, can be found at Annex B of the CMO?s annual flu letter of 3 May 2012: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_133963.pdf
Yours sincerely
Professor Dame Sally C Davies, Chief Medical officer and Chief Scientific Adviser / Dr Keith Ridge, Chief Pharmaceutical Officer
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