BBC BLOGS - Fergus's Medical Files

Archives for January 2011

Flu on decline in UK but rising elsewhere in Europe

Fergus Walsh | 17:25 UK time, Thursday, 27 January 2011

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When has a flu outbreak peaked? You can only know this retrospectively, but it does seem that the worst of this winter's outbreak is behind us.

Figures from the Health Protection Agency (HPA) show GP consultations fell in England and Northern Ireland over the past week, with only a slight rise in Scotland.

The HPA also said the predominant strain in circulation is now influenza B, which has overtaken influenza H1N1 swine flu. Flu B tends to be milder than H1N1 (although it has caused some fatalities) and mostly affects children.

The number of people reported to have died from flu since October has risen to 338, up by 84 since last week. The HPA said: "The vast majority of the new deaths reported today did not occur in the past week - a substantial number will have occurred over the past six weeks, but due the verification process they have only been confirmed this week."

Of the 306 deaths for which there is information on age, 10 were under five, 14 were aged 5-14, 217 aged 15-64 and 65 were older than 64.

The HPA said where information is available on the fatal cases, 184 out of 252 (73%) were in a clinical 'at risk' group for vaccination. 82 out of 108 (76%) had not received their jab this season.

In the past week, the number of number of GP consultations in England has fallen to 40.7 per 100,000, down from 66.5 per 100,000 the previous week.

Professor John Watson, head of the respiratory diseases department at the HPA, said: "Our latest flu report suggests levels of flu are continuing to decline across the UK and we appear to be over the peak of activity.

"However flu is still circulating and it is important that people remember to practice good cough and hand hygiene such as covering your nose and mouth with a tissue when you cough and sneeze, and then disposing of these as soon as possible to stop it spreading in the community."

But although flu may be on the decline in the UK, rates are rising elsewhere in Europe. The European Centre for Disease Prevention and Control (ECDC) said flu is progressing from west to east across the continent, as in previous years.

Rates are increasing in Austria, Bulgaria, Czech Republic, Germany, Greece and Hungary. Professor Angus Nicoll, a flu expert at the ECDC said: "Countries should be looking at the experience of the UK and prepare for a surge of patients requiring higher level care." The ECDC said immunisation could prevent many fatalities. It has a useful one-stop shop giving information on flu and flu rates.

Melinda Gates and immunisation

Fergus Walsh | 17:44 UK time, Tuesday, 25 January 2011

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I had expected one of the world's richest women to arrive in a convoy, with police outriders, akin to those that transport visiting heads of state. So it was with some surprise that just two vehicles drove into a health clinic in Nairobi that was offering immunisation against pneumonia.

Melinda Gates emerged, smiling, from the back of a nondescript Toyota mini-van, and went straight into meeting nurses and mothers at the Westlands Health Centre.

Mrs Gates's arrival may have been low-key, but her influence is immense. Together with her husband Bill, she set up the Gates Foundation and has so far donated $23bn to fund global healthcare. The Gates have pledged to give away 95% of their personal wealth.

That will still leave them with quite a bit left over , and you could argue that it is wrong that one couple were able to accumulate so much money.

Nonetheless, it is a remarkable piece of philanthropy , and it is hard to argue with the Gates Foundation core statement that "every life has equal value", or its aim of lifting people out of "hunger and extreme poverty".

The Gates Foundation drives research and development of new vaccines for the developing world. That is why Melinda Gates was in Nairobi to witness the roll of the pneumococcal jab. It protects against 10 strains of pneumococcal bacteria, responsible for the majority of pneumonia deaths.

Mrs Gates said: "Vaccines are the single most cost-effective tool we can use to save children's lives. Bill and I think it is the most incredible investment you can make."

But she warned the field of global immunisation faced a funding shortfall of $3.7bn in coming years, and said unless governments committed more money to immunisation then children would continue to die from preventable illnesses.

She said: "I am extremely concerned about the $3.7bn shortfall. The chances of getting pneumonia here in Kenya is very high - around 20,000 children a year die from it. So when I think about that I try to think about a child living because of the vaccine. "

We filmed Mrs Gates on her tour of the health centre. A mother of three school-aged children, she seemed completely at ease surrounded by dozens of mums and infants. In the immunisation room, Mrs Gates held a six week old orphan being given her pneumonia jab and polio drops.

I doubt many of the mothers at the clinic recognised Mrs Gates or knew of her pivotal role in securing new vaccines for countries like Kenya. Understandably, they were focussed on the task in hand - getting their children protected from pneumonia. You can view my report on pneumonia vaccines here.

Meanwhile Bill Gates will be raising the issue of immunisation later this week at the World Economic Forum at Davos, Switzerland. Mr Gates will be urging world leaders to commit more foreign aid to immunisation.

There is also a photo gallery with images relating to pneumonia immunisation in Nairobi.

Click below to see my interview with Melinda Gates.

Tackling the 'forgotten killer'

Fergus Walsh | 11:49 UK time, Sunday, 23 January 2011

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Baby Vanessa undergoing treatment for pneumonia

Millions of children, like baby Vanessa, fall victim to pneumonia in the developing world

Vanessa is struggling to breathe. Her lungs are full of fluid, and she is anaemic and malnourished. She is on a drip and receiving a blood transfusion at Mbagathi Hospital in Nairobi. The eight-month-old has bacterial pneumonia.


Her mother and grandmother watch over her in the tiny acute room at the hospital which she shares with four other children - there is barely room to move in the cramped space.

Pneumonia has been called the forgotten killer. It does not get the same attention as HIV/Aids or malaria. Yet it claims the lives of more young children worldwide than both of them combined.

A vaccine against the bacteria responsible for the majority of serious pneumonia is widely used in richer countries. I covered the introduction of the pneumococcal jab into the UK immunisation schedule in 2006. It prevents a good deal of sickness among children in Britain. But the real impact, in terms of saving lives, will be felt in poorer nations.

I'm in the Kenyan capital Nairobi, where I've witnessed the introduction of the pneumococcal vaccine. The jab protects against 10 strains of pneumococcal bacteria which can cause serious pneumonia, meningitis and blood poisoning.

Kenya is one of 19 countries receiving the vaccine from Gavi - the Global Alliance for Vaccines and Immunisation.

The health centre carrying out the immunisation is on the edge of the huge Kibera slum. Disease thrives amid the overcrowded, insanitary and squalid conditions. Many of the children living there suffer malnutrition, which means that they are less able to fight an infection like pneumonia.

It is estimated that a comprehensive roll-out of the pneumonia vaccine among developing countries could prevent more than half a million deaths a year.

In Britain, as in other developed countries, we tend to think that infectious diseases have been conquered by modern medicine. The ancient killers like tuberculosis, measles, pneumonia and diarrhoea have been largely consigned to history, thanks to improved living standards, immunisation and modern health care.

But the deaths of young children and adults from flu this winter demonstrate that viruses and bacteria remain a potent threat. The official death toll from swine flu in Britain runs into the hundreds.

But among poorer nations, deaths from infectious diseases run into the millions. Pneumonia kills around 1.7 million young children each year. Diarrhoeal disease claims another 1.3 million (Black et al, Lancet June 2010). Together they account for about one in three deaths of children under five.

As well as a jab against pneumococcal disease, there is also a vaccine available against rotavirus, the main cause of deaths from diarrhoea.

Gavi and Save the Children estimate the two vaccines could prevent at least one million deaths a year if they were comprehensively rolled out in developing nations. But Gavi says it is facing a funding shortfall for new and existing vaccines, of around £500m a year.

A major meeting on global immunisation is being held in London in June where world leaders will be under pressure to put more money into vaccines. The jabs against pneumonia and diarrhoea are far more costly than other childhood vaccines, but they could have a dramatic impact on mortality.

Other key issues to be addressed are the serious shortage of trained health workers in the developing world and the lack of access to basic healthcare for many - especially around childbirth, when four in 10 of all child deaths occur.

I have reported on the issue of neonatal and maternal mortality in Sierra Leone.

Back in 2000, world leaders set a target of cutting child mortality by two thirds, by 2015 (one of the Millennium Development Goals). There has been substantial progress. Deaths have fallen by a third. But that still means that eight million children a year never make it to their fifth birthday.

Immunisation should not be seen as a quick fix. But without wider use of new and existing vaccines, it is hard to see how the goal of cutting child deaths in the developing world can be achieved.


Flu - your questions answered

Fergus Walsh | 18:20 UK time, Friday, 14 January 2011

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Thanks to all of you who sent in questions about flu which I do my best to answer below:

Steve, from Birmingham, writes:

'Where can I get my children vaccinated? They are not in the "at risk" group and the chemists that have been offering vaccinations won't vaccinate under 18's.'

Only those in at-risk groups are eligible for flu jabs from their GP. Pharmacies will give the jab to healthy adults for around £13-15, if they have stocks remaining, but most will not give flu jabs to children as this requires extra training. You could get the vaccine from a private GP or clinic. I have read a report of parents being charged nearly £80 by a clinic for giving a vaccine to a young child.

Hannah, from Skipton, in North Yorkshire, writes:

'My Three-year-old daughter had the swine flu vaccine last year when it was available to all under-fives (she has no underlying health problems). Will last year's vaccine protect her from this season's outbreak?'

No-one knows for certain what level or duration of protection is provided by last year's pandemic H1N1 vaccine. Flu strains undergo minute changes over the years - something known as "antigenic drift" which is why the vaccine is tweaked every season. That's why those in at-risk groups are offered a new jab every autumn.

Having said all that, the H1N1 swine flu virus does not seem to have altered very much since it hit the headlines in Mexico in early 2009. So being vaccinated last year is likely to offer a good level of continuing protection. But it will not guarantee it. The flu vaccine is not 100% effective. Of 34 deaths for which we have information this winter, one person had received the monovalent (single strain) pandemic H1N1 vaccine last year.

Wendy in Burton-Upon-Trent, Staffordshire, writes:

'In our case both my husband, a diabetic, and myself, 20 weeks pregnant are obviously in "at risk" groups. Although I have two prescriptions from my GP for the influenza vaccine I have to source it myself as they have no stocks and haven't since December. During the last fortnight I have tried many, many places to source the vaccine without success - now it has peaked should I just give up?'

This situation should have changed. Yesterday, the head of immunisation at the Department of Health, Professor David Salisbury, said there was no reason why anyone in an at-risk group should be turned away.

This is because the government has now opened its stockpile of H1N1 pandemic vaccine. There are nearly 13 million doses available. As of yesterday, 400 orders had been submitted and nearly 200,000 doses of vaccine dispatched. So it is worth contacting your GP again to check if they have doses available. If they don't, ask them politely to order some - the Department of Health says it is not charging GPs for the jabs.

If you are in an at-risk group, you should not simply hope for the best. We cannot be sure when the outbreak will peak and it is likely to have a long "tail" - flu viruses will continue to circulate for many weeks to come. So it is best to be protected.

Sue, from the Midlands, asks:

'Why are older people, around my age of 62 not becoming infected with swine flu in the same numbers as younger people? Is it because we have immunity from succumbing to earlier flu epidemics and how similar to H1N1 would these earlier strains have to be for you to build up resistance to the current H1N1?'

The H1N1 virus - or swine flu - is similar to a strain that was circulating between 1918-1957. This was replaced by another strain of flu with a different genetic make-up (H2N2) during the pandemic of 1957. So people born before 1957 seem to have developed some level of immunity from the current swine flu strain.

Having said that, it is no guarantee that elderly people won't fall ill. There have been 16 flu-related deaths among the 65+ age group this winter, out of a population of around 10 million. That number will be an underestimate because it will simply include those who have been tested for flu. Some of the deaths are likely to have been due to other strains of flu that are circulating. So annual immunisation for all older people is a wise move.

Andrew, from Newcastle, asks:

'How do this year's flu death figures compare with each of the last five years? Are they steady, increasing or decreasing?'

The first year of H1N1 swine flu- up to April 2010 - saw nearly 500 confirmed deaths throughout the UK. In each case the person who died tested positive for the virus. But there will have been more deaths where the virus will not have been identified. Since October there have been 112 confirmed deaths from flu.

2009 was the first year that flu deaths were collected in such a precise manner. In previous years the Office for National Statistics worked out the excess of deaths over the winter period during a flu outbreak and compared them to similar periods where there was no flu about. This resulted in a rough estimate of 8,000 flu-related deaths each winter, with 20,000 or more deaths during epidemics. In 1989-90 there are estimates that flu was responsible for 25,000 deaths. But we can't directly compare this winter's figures with years gone by.

Most of the deaths prior to April 2009 were among the frail elderly. The difference, since the advent of swine flu, is that the virus mostly affects those under 65 with people in middle age accounting for the biggest proportion of serious illness. But other flu stains are circulating - H3N2 and Flu B - and these can also cause serious illness especially among the elderly.

What are your chances of dying of flu?

Fergus Walsh | 19:25 UK time, Thursday, 13 January 2011

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What are your chances of dying of flu this winter? It's a pertinent question given the apparent doubling of the confirmed deaths since October. Figures from the Health Protection Agency reveal that, across the UK, flu-related deaths rose from 50 to 112.

So are the chances of dying one in 10,000 or 1 in 100,000? Neither is remotely close.

Here's why: We've been told the ages of 101 of those who died.

Six were 0-4 years old; nine were 5-14; 34 were aged 15-44; 36 were 45-64 and 16 were 65 and over.

Now if we look at the number of deaths per head of population, the highest is among those in middle age. One in 440,000 people aged 45-64 have died. Among the under-fives it is one in 630,000 - the same rate as those 65 and over.

I hope that reassures people who have been alarmed by swine flu stories in the media.

So does this mean we do not need to be concerned about flu? No it does not. If you have a chronic respiratory problem and are pregnant, then your risks from - especially swine flu - will be a lot higher than those listed above. That is why anyone in an at-risk group should be immunised.

In any case, statistics are a dangerous thing, so I would urge caution. The real death rate will be higher because it doesn't include age data on 11 people AND because the HPA admit that their figures will underestimate the number of deaths. This is because some people who die of other causes will probably have had flu and this will have played a part in their deaths but will not have been tested for.

Nonetheless if you are an otherwise healthy person then your chances of dying from flu are very small indeed. There have been deaths among those without previous conditions, such as the case of Lana Ameen. But these are rare.

I thought it worth giving you that context because in the wake of the Lana Ameen case, there will be a lot of concerned parents with healthy children desperate to get their children immunised. Her parents appealed yesterday for all healthy children to be allowed a flu jab but the Department of Health said that it was best to focus on those most vulnerable to the virus.

So when will the worst be over?

Cases of influenza-like illness have risen sharply in Northern Ireland, and slightly in England and Wales. But there are other indicators which suggest that outbreak will peak soon.

The number of people in critical care in England has fallen to 661 from 783 last week. The number of flu-related calls to NHS Direct has also fallen.

The Department of Health has distributed 200,000 doses of the pandemic H1N1 vaccine to GPs in England and Wales and have said that no-one who is eligible for the jab should be refused it.

Vaccinate all children says mother of girl killed by swine flu

Fergus Walsh | 21:25 UK time, Wednesday, 12 January 2011

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The heart-rending story of three-year-old Lana Ameen has once again raised the issue of whether flu jabs should be available for healthy under-fives.

She fell ill with swine flu on Christmas Eve and died of multiple organ failure in Alder Hey Hospital, Liverpool, on Boxing Day. She had no previous health issues.

Her parents, a doctor and a nurse, released photos of her in intensive care, just hours before her death, in a bid to persuade ministers to change the policy on vaccination to allow all children to be immunised.

Her mother Gemma, who is 12 weeks pregnant, said: "I don't know how they can say my child wasn't worth having a few pounds worth of vaccine which could have saved her life. Not everybody who is healthy has been able to fight it off."

It is certainly true that some healthy people have died from flu this winter. About one in three deaths since October have been among those who did not fall into the official at-risk groups.

There is a danger that tragic and rare cases like that of Lana Ameen could create a fear factor among parents - greatly exaggerating the risks from swine flu which has already infected millions of children. The vast majority who have been infected recover completely. But Lana's parents say her death shows that all children should be protected.

It would take several weeks to gear up GPs to offer the jab to healthy children and then about two weeks for the vaccine to take effect. So it is too late for a change of policy on immunisation this winter.

There is an apparent contradiction in government policy on flu immunisation. Last year, all children between six months and five years were offered the pandemic H1N1 swine flu jab - more than three million children.

This year swine flu remains the dominant strain and has caused nine out of 10 deaths, yet healthy children are not being offered the vaccine. But to be fair the government is following the advice of experts (opens pdf) on the Joint Committee on Vaccination and Immunisation (JCVI).

So any contradiction - if there is one at all - is not with ministers, but with the committee that recommends policy on immunisation. The JCVI's advice is in contrast to that from the US where the Advisory Committee on Immunization Practices (ACIP), has recommended (opens pdf) that people of all ages, healthy and otherwise, should be immunised.

We interviewed the head of Immunisation at the Department of Health, Professor David Salisbury, and he stressed that the JCVI was constantly reviewing the data on flu risks.

He said: "The first thing we must use our health resources for is to get at the people where the greatest gain will come, and the greatest gain will come from people with risk factors. If we suddenly said, without evidence, we should include all children under 18, that is up to 12 million people. It would divert doctors and nurses from saving lives. In 2011 we will be reviewing all our vaccine policy for influenza and we will look very carefully at the issue of age groups, risk factors and so on."

It is clear the issue of who gets offered the jab will be reconsidered in future, as it is each year. If the policy does change then GPs will need to be told quickly, as they will be putting their orders in soon for next winter's flu jabs.

There is also the question about how many parents would take up the offer of a jab. Just 23% of healthy children under five were immunised last year.

We don't know for sure whether having the H1N1 jab last year guarantees protection from the virus this winter - those studies are being done.

Just one in two of those under 65 who are in at-risk groups and so are most vulnerable to flu get protected each year. If immunisation is extended, then how many parents would get their healthy children protected year after year?

Should healthy people be allowed a flu jab?

Fergus Walsh | 12:10 UK time, Tuesday, 11 January 2011

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Finally it seems there is someone to blame for the shortage of seasonal flu vaccine. It is the worried well.

The new chair of the Royal College of GPs, Dr Clare Gerada, believes healthy people are compounding the flu vaccine shortage among some doctors in England, by buying it privately from pharmacies and supermarkets. In an article in the Daily Telegraph she is quoted as saying there should be a study to find out how many healthy people had had the jab privately, to gauge "whether there should be a law that they are not allowed to have it."

So the Telegraph had its headline: "Worried well should be banned from having flu jab says leading GP". The story was the lead on the Today programme on Radio 4 at 7am.

Then Dr Gerada was interviewed on Today - you can listen to it here - and her first words were:

"I am not necessarily suggesting it should be banned". Did that mean she was POSSIBLY suggesting it? I was confused. She continued: "We should be targeting those most at need and those who aren't in the risk groups should wait until those who are get what they require to prevent them becoming seriously ill."

Dr Gerada explained that when GPs start to run low of flu vaccine they write prescriptions which patients take to the pharmacy. But this year some pharmacies had run out, in part because healthy people had asked for the jab in response to a lot of reports about flu in the media.

I spoke to Dr Gerada and asked about her apparently far stronger comments to the Telegraph. She said: "I have no recollection of saying that people who are not in risk groups should be banned. Nor would I pass an opinion on whether there should be a law. I don't think people should be banned from buying it".

I also spoke to Stephen Adams, Medical Correspondent of the Telegraph, who co-wrote the story and he is sticking by his quotes.

But let's leave all that to one side.

It's worth reminding ourselves how we got here. GPs in England have received all the doses of flu vaccine that they ordered. It is their responsibility to order enough vaccine for their patients and has been for years. Usually they send many doses back to the manufacturers. Next winter, Dr Gerada has said they will need to factor in greater demand. Those orders need to be made before the end of March, because it takes several months to make the vaccine.

In an ideal world, everyone in an at-risk group should have been immunised in October or November. There is no point in playing Russian roulette with flu. Get immunised early. Having said that, there have been comments on this blog from people in the priority groups for the vaccine who said they tried to get an appointment without success and others have told me they were never called for a jab by their GP.

An effective early immunisation round in October-November would also mean that any shortage of flu vaccine could be remedied more easily. European manufacturers still have stock which is unlabelled and unpackaged in November which could have been assigned to the UK market. By January all the doses are in vials and it is a major task to re-label, by hand, flu doses with, say, a German or Italian label and patient leaflet.

Another point is that pharmacies, supermarkets and private companies order their stocks of flu vaccine completely separately from the NHS. They do that, largely to supply a demand from healthy people who would rather not get the flu. This has happened for years.

Dr Gerada made that point that supermarkets have not been in the flu jab market for long and she knew of one which had announced the availability of vaccine over the in-store public address system - I wonder if there was a Buy One Get One Free Deal?

The system in Scotland, where there is no shortage of flu vaccine, is different. My understanding is that pharmacies order the jab centrally rather than individual GP practices. Perhaps there are lessons here for England.

Finally, I watched a brief Commons debate on flu yesterday. The Secretary of State for Health in England, Andrew Lansley was asked whether he had had the jab. He replied that since a stroke in 1992, he now falls into the priorty groups for vaccination and has been immunised. Nice to see Mr Lansley leading by example.

 

Pandemic flu jabs to plug vaccine shortages

Fergus Walsh | 23:03 UK time, Thursday, 6 January 2011

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What do you do with 12.7 million doses of pandemic flu vaccine which will pass its expiry date later this year?

The answer came today when David Cameron ordered it to be made available to any doctors who have run out of seasonal flu vaccine.

In theory, there are enough stocks of seasonal flu jabs to go round. The Department of Health said today that 14.8 million doses of trivalent vaccine were produced for the UK, protecting against H1N1 swine flu, another flu A strain, H3N2 and flu B. That is a similar amount as previous years.

But there has been a late surge in demand for the vaccine and some GPs in England are out of stock.

Swine flu has been responsible for 90% of the deaths so far this winter, with flu B claiming the rest.

So anyone getting the pandemic vaccine can be reassured that they will be protected against the dominant flu strain. The head of immunisation at the Department of Health, Professor David Salisbury said: "People will not be getting a second class vaccine. The pandemic jab is effective and safe. Indeed it is probably better at protecting people against the H1N1 virus than the seasonal flu jab".

He said this was because the pandemic vaccine contained an adjuvant (booster chemical) which gave very strong immunity. That may well be so, but I doubt very many people going to their GP will ask for last year's vaccine, if this year's is available.

There were lots of statistics released today by the Health Protection Agency. Many of you like the detail, so I will pick out some.

In England this morning there were 783 people critically ill with flu complications, the vast majority with swine flu. Of these, 640 were aged 16-64.

Fifty people have died since October with flu, up 11 from last week. Of those who died this is the age breakdown:

Under-five: five deaths

Five to 14: eight deaths

Sixteen to 64: 33 deaths

Sixty-five and over: four deaths

Most had underlying health problems and very few had been immunised. They include Sarah Applin, from Suffolk. who was just 32 when she died from swine flu earlier this week. She gave birth to a healthy baby boy just before Christmas. Her family said she simply didn't get round to having the flu jab and they urged others to get immunised.

The number of people going to their GP with flu-like illnesses in England and Wales was 98.4 per 100,00 down from 124.4 the previous week.

In Scotland it was 52 per 100,000, down from 55.8.

The only increase was in Northern Ireland where it was 179.5 per 100,00, up from 99.4.

But all these levels are far below flu rates in years gone by. In 1989-90 the consultation rate in England and Wales reached more than 600 per 100,000 and research (Curwen et al "Hidden influenza deaths: 1989-90" Population Trends 61 (1990), 31-33) suggests 25,000 people died as a result of flu complications.

The big difference is that seasonal winter flu used to mostly kill the frail elderly - but swine flu mostly hits the under-65s.

Elderly, vulnerable patients who die at home with pneumonia following a dose of flu do not grab the headlines like pregnant women or teenagers who succumb after battling the virus in intensive care.

Furthermore, 15 of the deaths so far this winter have been among people not in any at-risk group for flu. Last year I recall about one in five deaths were among healthy people, but given the comparatively small number of fatalities, that proportion will vary each year.

Every death from flu is a tragedy for the families. The hope must be that, from now on, pregnant women, and others who are most vulnerable to swine flu, will get a seasonal flu jab. A full list of those eligible is available on the NHS choices website.

Around 70% of the over-65s get the flu jab, but fewer than half of under-65s at risk get protected.

I know I keep saying this, but it is worth keeping a sense of proportion about this. One of tomorrow's headlines - the Daily Express - describes the current outbreak as a "flu plague".

Millions - probably tens of millions - of people in the UK have now been infected with H1N1 swine flu. The vast majority either had no symptoms at all or a mild but unpleasant illness from which they recovered after a few days in bed. That is hardly a plague.

I will leave you with one statistic which should shame the NHS: just 20% of front-line health care workers have been immunised against flu this winter. That really is pathetic.

Immunisation protects them, protects their patients, and ensures that vital healthcare staff can continue to work during an outbreak. How can the NHS encourage the public to get the jab when its own staff don't bother?

The NHS Chief Executive Sir David Nicholson described the uptake figure as "disappointing" but said he would not consider making flu jabs mandatory for frontline staff.

Is there a flu vaccine shortage?

Fergus Walsh | 16:12 UK time, Wednesday, 5 January 2011

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Whether or not there is a flu vaccine shortage seems to depend on who you ask. Dr Rosemary Leonard, a regular on BBC Breakfast, believes there is.

Dr Leonard, who has a practice in Dulwich, south London said: "There's been a rush on the vaccine and my surgery ran out yesterday. We have 40 people waiting to be immunised who are eligible for the vaccine. They didn't come forward when we invited them a few months ago but they want it now."

Dr Leonard said several other GPs in London have reported similar problems.

But according to a spokesperson for the English Department of Health: "There is no national shortage of seasonal flu vaccine. PCTs are working with their GPs to ensure that local supply issues are resolved locally where possible. "

And a spokesman for NHS London said: "Most GPs in London have a good supply of the flu vaccine. However, some are experiencing increased demand with more people than expected wanting the jab. Where stocks run low, GPs are able to share supplies with neighbouring practices.

It would seem that, overall, GPs still have doses, but there are localised problems with individual surgeries which have run out. The Royal College of GPs told me they were not aware of any major national shortage.

To understand how local problems could occur, it is worth setting out how the system works. GPs order their vaccine direct from the five manufacturers who supply the UK or from wholesalers. It is not the responsibility of the various devolved Departments of Health around the UK.

Doctors are encouraged to place orders by the end of March, because it takes several months to create the flu jab. The only way GPs can anticipate demand is to base their order on previous years, taking into account any changes in the recommendations for who should receive the jab. They don't want to run out, but they also don't want to be left with hundreds of unused jabs. There is an element of guesswork involved.

Vaccine uptake this season has been down on previous years, but there has been a sudden surge in demand since the week before Christmas, when the flu story began to grab the headlines.

Usually GPs get their flu vaccine clinics over and done in October and November, so this is very late in the season to be organising them.

So whose fault is it if a surgery runs out? You could simply blame the GPs for lack of foresight if they ordered fewer doses than previous years. But one can hardly expect them to anticipate a late surge.

What about the vaccine manufacturers? Surely they should have made more - just in case they were needed? Nice idea, but they are, after all, running a business, and it does not make economic sense to throw millions of doses away.

Figures from the UK Vaccine Industry Group (UVIG) show that their companies will have delivered 14.7 million flu doses in the UK this season - similar to the two previous years. Most of these were delivered in October, with 98% delivered by the end of November. So they have fulfilled all their orders.

Richard Stubbins, managing director of Sanofi Pasteur MSD, one of biggest vaccine suppliers, said his company had had more calls yesterday from GPs asking for doses, than they would expect in a week.

Mr Stubbins, also the chairman of UVIG, said: "Most companies keep a bit of extra stock for top-ups when GPs run short, but the demand at this time of the year is very unusual. We have perhaps just 8,000 doses left in the UK - and they are going fast."

The five companies that supply flu vaccine to the UK are: Pfizer, GSK, Novartis, Abbott (formerly Solvay) and Sanofi Pasteur MSD.

UVIG said it would be surprised if other manufacturers had stock remaining.

What about blaming the Department of Health? Last year, the DH took over purchasing and distribution of the pandemic swine flu vaccine. They also do this with most childhood vaccines. But flu, adult, pneumococcal and travel vaccines are left to GPs to order direct.

Some might argue that central purchasing would work better. At present, there seem to be enough flu doses around, but some are lying unused in GP fridges - while other surgeries are crying out for them.

The Department of Health has asked vaccine manufacturers how many UK licensed doses are available that are not yet in the UK. This effectively means vaccine with the packaging and leaflet written in English and another language - dual-labelled.

Richard Stubbins said: "My company is looking for dual-labelled doses from Spain and Italy. But altogether there could be less than 100,000 doses spread among all the companies."

That will be a help, but it represents less than 1% of the 14.7 million doses produced this year.

Another option would be to bring in doses which are not labelled in English. But this raises regulatory issues because the vaccines may be packaged differently and the doses will not be licensed for UK use. It would need the Medicines and Healthcare products Regulatory Agency (MHRA) to approve this, which would take some time. By then the flu outbreak may have peaked.

Regarding blame, we could also try pointing the finger at the private sector for buying doses which will largely go to the worried well. About 700,000 doses - 5% of the total - are sold by the manufacturers to the commercial sector - chemists, supermarkets and private companies - who offer the jab to staff.

But this happens every year. And since the manufacturers have supplied all the doses the NHS has asked for, it is hard to see how one can blame the private sector for using doses that it ordered.

I would prefer not to blame anyone, but rather hope that people who need the vaccine get it. Then perhaps some thought could be given to improving the system for supplying flu jabs in the future.

Tomorrow we will get the latest flu figures which might indicate whether the outbreak is getting bigger or easing off. I hope for the latter but suspect the former.

update 18:15

There seems to be some confusion about what the Department of Health has asked the vaccine manufacturers to do.

A DH spokesperson gave my colleague Nick Triggle this quote earlier today: "We have urged the vaccine suppliers in the UK to be in contact with their factories in Europe to see if more UK licensed vaccine can be brought into the UK as soon as possible."

That seems crystal clear. But Richard Stubbins, of UVIG expressed surprise:

"It is not UVIG nor my understanding that we have been asked by the DoH to bring in any available UK licensed flu vaccines.

They have asked 'what doses there are', that is:
The number of available doses in the UK
The number of UK licensed doses which could be brought into the UK
The number of other (non-UK labelled) doses we have around Europe, which could be brought in (regulatory issues notwithstanding).

They had this information on Monday/Tuesday."

So there you have it. Do the DH want extra doses brought in or not? I will let you know when the situation has been clarified.

update 19:30

I am grateful to Kate Pike the Chief Press Officer at the Department of Health who has clarified the situation. She emailed me this: "It appears that what has happened is that the press officer who was speaking to Nick, gave him a statement before we'd checked it with the experts. The "urgently" and "as soon as possible" bits were taken out, as they weren't true.

So my apologies for that. Completely our fault."

I think it is rather nice when people hold their hands up when there is a mistake. The correct line from the DH is this:

"Vaccine suppliers in the UK are in contact with their factories in Europe to see if more UK licensed vaccine can be brought into the UK. "

So they have not asked them to bring in more stocks yet, but I guess they might do in the near future.

update 21:35

If there are local difficulties regarding vaccine supply, they do not, it appears, apply to Scotland. The Scottish govenrment said in a statement: "There are no supply issues with the seasonal flu vaccine here in Scotland.

Over a million doses of seasonal flu vaccine have already been distributed to GP surgeries and pharmacies, with an additional stockpile available should it be required."

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