Which patients in my practice are eligible for seasonal influenza vaccination, and how should I prioritise clinical risk groups this winter?

For England / an NHS GP practice in Manchester and the current seasonal flu programme, the Green Book says flu vaccine should be offered to: all people aged 65+, everyone aged 6 months+ in clinical risk groups, children in the annual children’s programme, residents in long-stay residential care, and certain other groups such as pregnant women, carers, household contacts of immunosuppressed people, and people experiencing homelessness. [1]

Who is eligible in your practice

1) Age-based eligible patients

• Age 65 years and over. [1]
• Children in the children’s flu programme; the exact age/school cohorts are set in the annual flu programme letter for that season. [1]

2) Clinical risk groups, aged 6 months and over

Offer flu vaccination to patients with any of the following risk groups:

• Chronic respiratory disease
  e.g. COPD, bronchiectasis, cystic fibrosis, interstitial lung fibrosis, pneumoconiosis, BPD; asthma needing continuous/repeated inhaled or systemic steroids or with prior hospital exacerbations. [1]
• Chronic heart disease / vascular disease
  e.g. congenital heart disease, hypertension with cardiac complications, heart failure, IHD needing follow-up/regular medication, AF, PVD, VTE history. [1]
• Chronic kidney disease
  CKD stage 3, 4 or 5, chronic kidney failure, nephrotic syndrome, kidney transplant. [1]
• Chronic liver disease
  Cirrhosis, biliary atresia, chronic hepatitis. [1]
• Chronic neurological disease
  Stroke/TIA, neuromuscular or neurological disease compromising respiration; the Green Book also specifically mentions clinical judgement for people with cerebral palsy, severe/profound and multiple learning disabilities, Down’s syndrome, MS, dementia, Parkinson’s disease, MND and similar conditions. [1]
• Diabetes and adrenal insufficiency
  Any diabetes, including diet-controlled diabetes; Addison’s disease and secondary/tertiary adrenal insufficiency requiring steroid replacement. [1]
• Immunosuppression
  Due to disease or treatment, including chemotherapy, radical radiotherapy, solid organ or stem cell transplant, HIV at all stages, haematological malignancy, biologics, protein kinase inhibitors/PARP inhibitors, cyclophosphamide/mycophenolate, and prolonged systemic steroids. [1]
• Asplenia / splenic dysfunction
  Including sickle cell disease, hereditary spherocytosis, thalassaemia major, and coeliac disease causing splenic dysfunction. [1]
• Class III obesity
  Adults with BMI ≥40 kg/m². [1]

3) Other eligible groups

• Pregnant women at any stage of pregnancy. [1]
• Household contacts of people with immunosuppression. [1]
• Carers
  Those on carer’s allowance, or the sole/primary carer of an elderly or disabled person. [1]
• People experiencing homelessness. [1]
• Residents in long-stay residential or other long-stay care facilities. [1]

How I’d prioritise clinical risk groups this winter

There is no formal sub-ranking within the Green Book clinical risk groups; it explicitly says the list is not exhaustive and clinicians should use clinical judgement. [1]

Practical prioritisation for a GP practice

If you need a working order because of capacity, I would prioritise:

Tier 1 – highest risk / highest consequence

• Severe immunosuppression: transplant, haematological malignancy, active chemotherapy/radiotherapy, profound immune deficiency, prolonged high-dose steroids, biologics/JAK-type agents as relevant. [1]
• Residents in long-stay care settings. [1]
• Pregnant women: vaccinate as soon as vaccine is available in season. [1]
• Severe chronic respiratory disease / poorly controlled asthma / COPD / bronchiectasis. [1]

Tier 2 – substantial medical risk

• Chronic heart disease / heart failure / vascular disease. [1]
• CKD stage 3–5 / dialysis / transplant. [1]
• Chronic liver disease. [1]
• Significant neurological disease / severe neuro-disability. [1]

Tier 3 – still eligible and should not be missed

• Diabetes. [1]
• Asplenia / splenic dysfunction. [1]
• BMI ≥40. [1]
• Household contacts of immunosuppressed people, carers, and people experiencing homelessness. [1]

Operational points for this season

• NICE advises using every opportunity to identify eligible patients throughout the season, including new pregnancy, new diagnoses, BMI ≥40, outpatient/antenatal contacts, hospital patients, and home visits. [2]
• The Green Book advises pregnant women should be vaccinated once vaccines are available in September, while most adults should start from October to align with peak circulation. [1]
• For children aged 2 to <18 years, LAIV is generally preferred unless contraindicated; if unsuitable, use IIV. [1]