Scottish Immunisation Programme Childhood Flu Programme 2014/15
Guidance on review of consent forms to support assessment of suitability of
primary school children for Fluenz Tetra® as a result of severe asthma
Purpose
The purpose of this paper is to support an initial assessment of the suitability of
children for vaccination with Fluenz Tetra® based on information provided on
consent forms returned by the person with parental responsibility for the child.
Background
The live attenuated influenza vaccine (Fluenz Tetra®) is not recommended1 for
children with severe asthma or active wheezing, defined as;



A history of active wheezing at the time of vaccination (until at least 7 days after
wheezing has stopped) or
Those who are currently taking or have been prescribed oral steroids in the last
14 days or
Those who are currently taking a high dose inhaled steroid – budesonide at a
dose greater than 800 microgram per day or equivalent.
In children aged 5-12 years, the definition of severe asthma corresponds to the
British Thoracic Society (BTS) and Scottish Intercollegiate Guideline Network (SIGN)
step 5. This step recommends the use of daily steroid tablet in lowest dose providing
adequate control; maintaining the use of inhaled steroids up to 800microgram per
day of budesonide/beclometasone dipropionate or equivalent; and refer to
respiratory paediatrician2. See appendix for BTS/SIGN steps in 5-12 years.
There are three inhaled steroids licensed for use for asthma in children aged 5-12
years. Beclometasone dipropionate (BDP) and budesonide are considered as
approximately equivalent in clinical practice and a 1:1 dose ratio is assumed2.
Fluticasone provides equal clinical activity to BDP and budesonide at half the
dosage2.
The three inhaled steroids licensed for children aged 5-12 years are available in a
variety of presentations and strengths. The table below shows the dose equivalents
for inhaled steroids in children aged 5-12 years above which would constitute a
dose that would mean Fluenz Tetra® is not suitable.
Inhaled steroid
Beclometasone dipropionate
Budesonide
Fluticasone
Dose above which Fluenz Tetra® unsuitable
800 microgram per day
800 microgram per day
400 microgram per day
Therefore children aged 5-12 years taking daily steroid tablets for asthma or inhaled
budesonide at a dose greater than 800 microgram per day or equivalent are not
suitable for vaccination with Fluenz Tetra® but should be considered for inactivated
vaccine.
For example a child who is prescribed Seretide 125 inhaler 2 puffs twice daily is
receiving a daily dose of 500 micrograms of fluticasone and is therefore on a dose
which means Fluenz Tetra® should not be offered. Whereas a child who is
prescribed Seretide100 accuhaler 2 puffs twice daily is taking a daily dose of 400
micrograms of fluticasone and is therefore suitable for Fluenz Tetra®.
Checklist for staff reviewing consent forms
Step 1
Check consent form to determine if the patient is taking oral steroids for asthma.


If yes they are unsuitable for Fluenz Tetra® and after discussion with the person
with parental responsibility consideration should be given to use an inactivated flu
vaccine.
If no then consider the dose of steroid inhaler (step 2)
Step 2
Check consent form to determine which steroid inhaler and the number of puffs per
day the patient is reportedly taking.
Compare this to the number in the table above and check if the patient is taking
more than the number of puffs per day included the table.


If the number of puffs is greater than in the table then they are unsuitable for
Fluenz Tetra® and after discussion with the person with parental responsibility
consideration should be given to use an inactivated flu vaccine.
If the number of puffs is at or lower than in the table the patient may be
considered suitable for Fluenz Tetra®
If there is uncertainty then the person with parental responsibility for the child should
be contacted for more information to enable a decision on suitability for Fluenz
Tetra® to be taken.
The table below shows the number of puffs per day for each inhaler above which the
patient has reached a dose equivalent to the BTS/SIGN step 5 inhaled steroid dose.
Name of Inhaler
Strength
Manufacturer
Number
of Puffs
per day
8
Flixotide Evohaler (Fluticasone
Inhaler)
Flixotide (Fluticasone) Accuhaler
50 microgram per dose
Flixotide(Fluticasone) Accuhaler
100 microgram per dose
Pulmicort (budesonide) turbohaler
100 microgram per dose
Allen & Hanbury
Ltd
Allen & Hanbury
Ltd
Allen & Hanbury
Ltd
Astra Zeneca
Pulmicort (budesonide) turbohaler
200 microgram per dose
Astra Zeneca
4
Pulmicort (budesonide) turbohaler
400 microgram per dose
Astra Zeneca
2
Budelin (budesonide) novoliser
100 microgram per dose
8
Budesonide easyhaler
100 microgram per dose
Budesonide easyhaler
200 microgram per dose
Budesonide easyhaler
400 microgram per dose
Beclometasone easyhaler
100 microgram per dose
Beclometasone easyhaler
200 microgram per dose
Beclometasone easyhaler
400 microgram per dose
Asmabec
(Beclometasone)Clickhaler
Asmabec (Beclometasone)
Clickhaler
Clenil Modulite (Beclometasone)
100 microgram per dose
Meda
Pharmaceuticals
Orion Pharma
UK
Orion Pharma
UK
Orion Pharma
UK
Orion Pharma
UK
Orion Pharma
UK
Orion Pharma
UK
RPH
100 microgram per dose
RPH
8
50 microgram per dose
Chiesi
16
Clenil Modulite (Beclometasone
100 microgram per dose
Chiesi
8
Pulvinal Beclometasone
100 microgram per dose
Chiesi
8
Pulvinal Beclometasone
200 microgram per dose
Chiesi
4
Pulvinal Beclometasone
400 microgram per dose
Chiesi
2
Seretide Evohaler
50 microgram per dose
8
Seretide Accuhaler
50 microgram per dose
Seretide Accuhaler
100 microgram per dose
Symicort 100/6 turbohaler
100 microgram per dose
Allen & Hanbury
Ltd
Allen & Hanbury
Ltd
Allen & Hanbury
Ltd
Astra Zeneca
50 microgram per dose
8
4
8
8
4
2
8
4
2
8
8
4
8
References
1
Chaper 19 (influenza) Immunisation against infectious disease. Available at
https://www.gov.uk/government/publications/influenza-the-green-book-chapter-19
Accessed 04/08/14
2 BTS/SIGN Guideline on the management of asthma. Available at https://www.britthoracic.org.uk/guidelines-and-quality-standards/asthma-guideline/ Accessed
26/06/14
Appendix: BTS/SIGN steps for children aged 5-12 years