It is acknowledged that GP Practices have already spent a great deal of time planning their Flu Clinics. This document aims to further support this work by helping
practices identify any gaps in planning.
HIOW STP have provided Practices with a supporting document for flu delivery this year as uptake of vaccine is expected to be higher with the addition of new
eligible groups due to Sustained Community Transmission of Covid-19. The WHCCG Quality team have provided an additional checklist for the Practices. The purpose
of the document is to help provide further information on specific areas of concern raised by Practices and to help ensure governance around particular issues.
CONTENTS Page
Staff Competency and Training 1
Planning Clinics 1
Call & Recall 2
PGDs/PSDs 2
PPE 2
Cold Chain 3
Waste 3
Record Keeping 4
Patient Safety and Comfort 4
Support to Care/Nursing Homes 5
Home Visits 5
Occupational Health 6
Communication between Providers 6
GP Practice – Flu checklist 2020-2021
APPENDIX Page
A: Who can give the Flu vaccine & Recommended training 7 – 8
B: Competency 9
C: Equipment list 10
D: Validated medical cool box monitoring log 11
E: Cold chain breach flow chart 12
F: Transportation of waste 13
G: Example of a PSD 14
H: Example of Staff flu record 15
I: Example letter from employer of health/social/domiciliary
care staff to GP Practice 16
J: Inoculation Injury Poster 17
References 18
1 Version three; Quality Team WHCCG; NH 09/09/2020
CHECKLIST FOR THE FLU DELIVERY PROGRAMME DURING SUSTAINED COMMUNITY TRANSMISSION OF COVID19 2020-2021
Date _____________________ Completed by __________________________________
CHECKLIST
THINGS TO CONSIDER
Please circle
Staff Training & Competency
Have you identified all staff members delivering the flu programme this year?
Annual Basic Life Support completed
Annual Anaphylaxis Training completed
Annual Online Training for Flu (https://www.e-lfh.org.uk/programmes/flu-immunisation/)
Competencies completed and signed off by a Registered Health Care Practitioner (HCP), who is experienced &
competent in delivering immunisations.
See Appendix A for further information on Training
See Appendix B for Competency tool kit
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Planning clinic
Have you considered/completed the following for your clinics?
Infection Control Measures (to include social distancing, PPE/hand hygiene)
Risk Assessment for your clinic/s (especially if offsite)
Workforce – number of immunisers required and additional support staff e.g. Marshalls
Do you have planned emergency equipment available for the clinics, including emergency equipment for
offsite?
Measures to support the wellbeing of ‘shielding/vulnerable,’ and less mobile patients? E.g. waiting area near
Practice entrance to reduce walking
If required, have you informed CQC? e.g. if carrying out flu clinics in areas other than GP Premises
https://www.cqc.org.uk/guidance-providers/registration/registration-flu-vaccination-arrangements
(See Appendix C equipment list for clinics)
Yes/No
2 Version three; Quality Team WHCCG; NH 09/09/2020
Call & Recall Process
Unlike previous years, recalls are not limited to 3 reminders. Therefore, have you considered the following?
Promoting the flu vaccination via PCNs and social media can be beneficial in improving uptake of the vaccine
Using different forms of call and recall; text, email, phone call, econsult
Flag on individual patient records with every consultation (for opportunistic vaccination)
Do you have a system in place to promote vaccine to vulnerable and ‘hard to reach’ groups e.g. clinical risk
groups, NHS Shielded Patient List, Black, Asian and Minorities Ethnic (BAME) groups?
Yes/No
Patient Group Directive
(PGD)
and
Patient Specific Directive
(PSD)
Do you have the up to date PGD?
Has the PGD been read, understood, signed and dated by the individual Registered health care professional?
Has the PGD been signed with an authorising signature, (by a current employee/employer if the pratice)
Do you have a system in place to ensure that PSDs for patients are checked and completed by a prescriber? E.g. Health
Care Assistants/Nurse Associates and Nursing Home Staff
(Example of a PSD see Appendix G)
Yes/No
Yes/No
Yes/No
Yes/No
PPE in a clinic setting
Do you have enough PPE? Have you considered the following?
• How will staff perform good Hand Hygiene (hand washing facilities/ Consumables e.g. paper towels, alcohol
gel, soap, baby wipes)
• FRSM (fluid resistant face mask) & Goggles/ Visor – ‘sessional use’ *
• Uniforms; staff should wear clean clothing for each shift, which should be washed at the highest temperature it
will tolerate and tumble-dried or ironed. (Staff should change out of work clothing prior to going home)
• Do NON clinical staff have the appropriate PPE e.g. FRSM
Wearing correct PPE is essential for ‘Test and Trace.’
(* Sessional use to be determined locally)
Yes/No
Yes/No
3 Version three; Quality Team WHCCG; NH 09/09/2020
To ensure the integrity of the Cold Chain, have you ensured the following?
Vaccines stored in the original packaging at +2°C to +8°C and protected from light
Fridges are stocked with vaccine with a capacity of 66% or below of the internal volume
Vaccines are not stored in the bottom of the fridge or the fridge door
Inside the fridge there is a 4 cm gap at the side and rear of the fridge to allow air to circulate around the vaccine
A system in place to monitor dates and rotate stock as required
There is a fridge temperature monitoring system in place as per Practice Cold Chain Policy (e.g. 2 thermometers,
one supported by the fridges power supply and one separate thermometer e.g. datalog.
Availability of a Validated Medical Cool box for the transportation of vaccine to other premises e.g. home visits/
non GP Practice Premises e.g. village hall/ Nursing & Care Homes (Appendix D)
Processes in place to record and declare Cold Chain Breaches (See Appendix E)
Note – allow the flu vaccine to reach room temperature before aminstering
Yes/No
Waste
Due to the increase in vaccinations this year, there will inevitably be an increase in clinical and non-clinical waste. Have you made considerations for the following?
Appropriate size sharps box for different types of vaccination sessions Separate sharps boxes for clinics off site (they will need to be sealed and locked for transportation purposes &
not to be reused)
Nursing Homes and Care Homes; where they have a system in place to collect sharps, leave the sharps boxes in the homes for them to dispose of.
Separate normal waste (black bin bag) from clinical/healthcare waste (orange waste bag)
Additional storage for clinical and non-clinical waste
System in place to regularly check stock for waste bags/sharps bins and order as appropriate from SRCL
Transportation of waste from a Flu clinic outside the GP Premise (See Appendix F)
Yes/No
4 Version three; Quality Team WHCCG; NH 09/09/2020
Record Keeping
Each clinician is responsible for their own record keeping, all records should be signed and dated or logged under password control/smart card of the named clinician administering the vaccine
Do you have a system in place to incorporate the following?
• Check patient’s name, address and DOB
• State name of immuniser
• Document if vaccine declined or postposed if unable to give on the day due to contraindications
• Date of administration and type of flu vaccine
• Name, Dose & route & anatomical site
• Batch number & expiry date (often templates are created in advance of the Flu Clinic to include this information)
• Was flu given under PGD/PSD
• All records should be clear, legible, contemporaneous and coded accurately
• If given in a clinic, records should be updated as soon as possible after the administration of the vaccine by the administrating clinician.
• Clinicians must ensure that they meet the necessary standards for Record Keeping as outline by their Professional Registering Body e.g. NMC, RCGP, HCPC, GPhC
Yes/No
5 Version three; Quality Team WHCCG; NH 09/09/2020
Patient Safety and Comfort
Have you considered the following?
Is the patient well, and absent of COVID19 symptoms?
Encourage patient own face masks/coverings and have spare masks (which do not need to be FRSM; TYPE I or
II)
Facilities such as seating (for the less mobile), access to a toilet, covers in the event of bad weather
Patient hand hygiene (alcohol gel)
You will need several thermometers, depending on the size of your clinics
ENSURE THAT STAFF ARE TRAINED HOW TO USE A THEMOMETER
Yes/No
Support for Care & Nursing
Homes
Have you ensured that your Patients in Care and Nursing Homes have access to the Flu Vaccination?
Care/Nursing Home staff may also request their Flu vaccination from the Practice. (See appendix I).
Care Homes – If not being delivered by the Practice, ensure you know who is giving Residents their Flu Vaccination this
year?
Nursing Homes – Are Practice Staff or Nurses in Nursing Homes giving the flu vaccination to their Residents this year?
If Nursing Home staff are giving the vaccine they will require;
• Support in Training/ Competency assessment
Adrenaline provision (x 2 Adrenaline ampules)
Provide a PSD for each resident (this can be combined or a single document). Most systems such as Arden’s will
have a PSD template ready to use.
The PSD should have the following; Name, DOB, NHS number, name of vaccine *, route, frequency (one off),
name & signature of prescriber. * Note some residents will be under 65 years of age.
Yes/No
6 Version three; Quality Team WHCCG; NH 09/09/2020
Home Visits
Have you considered the following for housebound, ‘shielding & vulnerable’ patients and their carers?
Who is delivering the vaccine to the housebound patients? E.g. Community Care Teams, GP Practice Staff
PPE (gloves, apron, FRSM and visor (if risk of splash)
Cold chain (validated medical cool box) and cold chain monitoring
Appropriate equipment including Sharps box, Vaccine, Adrenaline, clinical wipes, alcohol gel
(Only take what you need into the home in a wipeable/plastic box to help prevent contamination)
PGD/PSD as required
Map/plan in place of who visiting and when. Have the patients/relatives/carers been informed?
Record Keeping
Maintaining social distancing of 2 metres from the patient/carer until you give the vaccine
Yes/No
Occupational Health
Have you organised the flu vaccination of your staff for the purposes of Occupational Health?
All General Practice staff should be offered a flu vaccination, (aiming for 100% uptake)
It is deemed a ‘private service’ and therefore is not covered under the NHS/DES contract and you cannot claim
back the cost of the vaccine
Staff must NOT register as a INT or TR.
check with your insurance company that you have the indemnity cover to deliver the flu vaccination to your employees.
Ask the staff member to inform their own practice if they have been given the flu jab by their employer
Record all staff you have vaccinated or refused (see appendix H)
Yes/No
7 Version three; Quality Team WHCCG; NH 09/09/2020
GP Can give without PGD/PSD,
Registered Health Care
Professional e.g nurse,
paramedic, pharmacist
Covered under a ‘Written Instruction’
https://www.sps.nhs.uk/articles/written-instruction-for-the-administration-
of-seasonal-flu-vaccination/
HCA HCAs must complete their training and competencies must be signed off
prior to giving the flu vaccination to ones’ peers. Give under a PSD
Ensure that:
• Staff are absent of a temperature, new continuous cough, and/or a reduction in taste and smell
• Staff wellbeing including ensuring hydration and taking frequent breaks (including mask breaks)
Communication between
providers
The flu campaign this year is encouraging as many as possible to have the flu vaccination and is being delivered in a
variety of settings:
GP Practices
Pharmacies (reported on ‘Pharmoutcomes’)
Community Care Teams (District nurses)
Maternity services
In patients/ Out patients
Nursing homes (delivering to their own residents and staff members within specific parameters)
Schools
If the Flu jab is given in one of these settings this will be communicated via ‘MESH,’ discharge summaries etc. Do you
have a system in place to check and update patient records regularly e.g. on a daily basis.
You may be asked to provide the flu vaccination to your Patients who work in Care & Nursing Homes/Domiciliary Care.
Appendix I is an examples of a letter that patients may bring to the Practice to request their flu jab from you.
Yes/No
8 Version three; Quality Team WHCCG; NH 09/09/2020
Appendix A WHO CAN GIVE THE FLU VACCINE?
1. HCAs and Nurse Associates;
Can administer the flu vaccination if they are trained at level 3 QCF (and above) and have at least 2 years’ experience as an HCSW.
They must complete a thorough formal foundation course on flu administration and receive the necessary supervision with support and meet the necessary standards of competency.
Attend annual half day updates (https://www.e-lfh.org.uk/programmes/flu-immunisation/)
Require an identified clinical supervisor who is a Registered Health Care Practitioner, and experienced & competent in delivering immunisations.
A trained clinician must be present on the chosen premises when an HCA/Nurse Associate delivers a flu vaccination
Can deliver the flu vaccine under a PSD which has been authorised by an appropriate prescriber.
2. Nurses and midwives, paramedics, physiotherapists, pharmacists, occupational therapists (All HCPs must be registered with their professional body);
All HCPs delivering the flu vaccination programme should complete an annual update (as per guidance)
Online flu vaccination training can be accessed via; https://www.e-learning fh.org.uk/programmes/flu-immunisation/
Anyone delivering the flu vaccination and the employer should ensure that they are competent and confident at delivering the programme (as HCPs one should not operate outside of their competency)
Those giving the flu vaccination for the first time require supervision and completion of the competency tool kit. This must be signed off by a Registered Health Care Practitioner who is competent and experienced in the delivery of immunisations. Face to face training is recommended for first time immunisers
Ensures that the PGD is read, understood, signed and dated by the individual practitioner and has an authorising signature. • The PGD only relates to NHS staff including those who work in General Practice.
(https://www.cpsc.org.uk/application/files/7415/9005/1524/Flu_comms_2020_-_01.pdf see link for pharmacist training)
3. Working as an appropriate Prescriber
For example, GPs/Advanced Nurse Practitioners/Pharmacist
https://www.e-learning fh.org.uk/programmes/flu-immunisation/
9 Version three; Quality Team WHCCG; NH 09/09/2020
Flu e-learning programme (core knowledge)
Flu e-learning programme; inactivated flu vaccines and/or –live vaccines depending which vaccine they will deliver
Basic life support and anaphylaxis training
Immunisation e-learning programme – vaccination storage
Immunisation e-learning programme – vaccination administration
Immunisation e-learning programme legal aspects
Face to face training which could include webinars, socially distanced classroom type training
Work-based practical training and assessment of competency
Estimated time required 30-60 minutes depending on prior knowledge and experience
30 minutes each session
Approx 2-3 hours face to face
30 minutes 30 minutes 30 minutes Will depend on what is included
Depends on how long it takes until immuniser and assessor agree immuniser is competent and confident
Workforce group
Experienced flu vaccinators (registered HCPs and unregistered HCSWs)
Yes Yes If no BLS training within one year
If not undertaken in the past year
If not undertaken in the past year
If not undertaken in the past year
If available Competency assessment tool can be used by experienced immuniser to self-assess and identify if there are any areas where they need to update or further their knowledge
Registered HCPs new or returning to vaccination after a prolonged period
Yes Yes If not undertaken in the past year
Yes Yes Yes If available Yes
Vaccination support workers (unregistered healthcare workers new to immunisation with a specific role in vaccination administration only)
Yes Yes Yes Yes Yes Yes If available Yes
Admin support No No Depending on role assignment
Yes if responsible for cold chain maintenance/ monitoring
No No No No
https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/906537/Flu_immunisation_training_recommendations_appendix_A.pdf
Recommended training requirements by workforce for flu vaccination
10 Version three; Quality Team WHCCG; NH 09/09/2020
Appendix B
Competency tool kit - Competency tool – areas only need completing for those relevant to the individuals’ roles
https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/906539/Flu_immunisation_training_recommendations_appendix_C.pdf
• review the immuniser’s self-assessment, discussing any areas that are identified as ‘need to improve’ and the relevant action plan
• observe their performance as they provide immunisations/advice to several patients and indicate whether each competency is ‘met’ or ‘needs to improve’ in the supervisor review column
• if improvement is needed, help the immuniser to develop an action plan that will enable them to achieve the required level of competence and plan a further assessment
• when the supervisor and immuniser agree that the immuniser is competent in all the relevant areas, sign off the section at the bottom of the assessment page
• acknowledge if they and/or the immuniser decide that they are not suitable for the role and communicate this to the employer
Keep a copy of the competency tool in the immunisers training record to demonstrate continuing professional development
11 Version three; Quality Team WHCCG; NH 09/09/2020
Appendix C
EQUIPMENT RQUIRED FOR FLU CLINICS;
Clinic Equipment/ Organisation
Tick when completed
Immunisers Equipment
Tick when completed
Crowd Barriers
Furniture (tables, chairs, screens)
Power supply
Computers (desk top or lap tops)
Internet connection
Appropriate PPE
Refreshments
Lighting (if required)
Heating (if required)
Clear signage
Receptionists
Stewards (to direct patients)
Alcohol gel
• Clinical, wipeable, well maintained trolley
• Appropriate PPE • Appropriate flu vaccines
• Sharps box (appropriate size & capacity and 1 per immuniser) • Cotton wool/ plasters
• Clinical waste bin (additional waste bags) • Pen and Paper • Thermometer and covers (several depending on clinic size) • Kidney dish
• Alcohol gel • Clinical wipes for surfaces
• Non detergent wipes for staff such as baby wipes to remove build up pf alcohol gel on our hands
• Emergency equipment e.g. anaphylaxis kit, emergency bag and oxygen
• Validated Cool Box; If you are working off site (e.g. Car park, village hall, home visits) you will require a validated cool box to ensure that a continuous cold chain is maintained
12 Version three; Quality Team WHCCG; NH 09/09/2020
Appendix D
VALIDATED MEDICAL COOL BOX TEMPERATURE MONITORING
Date of flu clinic: / /
Location of flu clinic
Time flu vaccine removed from fridge: :
Fridge temperature at time of removal from fridge: °C
TIME Temperature taken:
Current Temperature in °C
Highest Temperature in °C
Lowest Temperature in °C
Comments;
13 Version three; Quality Team WHCCG; NH 09/09/2020
Appendix E
Cold Chain breach for vaccine storage event identified (lasting more than 20 minutes)
Is there an immediate rectifiable cause? YES NO
Embargo vaccine Fridge
Isolate potentially compromised vaccines. Maintain at +2° to +8° C if possible. If not, consider moving the vaccines to an alternative monitored environment.
Clearly label vaccines ‘NOT IN USE’
Fridge should remain switched on, thermometers and temperature probes not disturbed.
Communicate with colleagues and staff within the organisation to ensure vaccines and fridge are not used until further notice
• Keeps vaccine in the fridge • Rectify cause • Notify colleagues that vaccines should not be used until risk assessment is concluded
Confirm and document the current temperature of the fridge
Reset the thermometer
Read and record temperatures at 15 intervals for up to an hour
Fridge temperature returned to +2° to +8° C
NO
YES Complete cold chain incident checklist Inventory all exposed vaccinations
Report incident to local screening & immunisation team
Investigate the incident
Request refrigerator engineer to inspect fridge and thermometers (unless the cause of the breach was not related to appliance performance vaccine
Confirm current fridge temperatures and temperature patterns using data logger for 48-72 hours
Check fridge service history
Check refrigerator temperature records and clarify cold chain practice prior to event
Carry out Informed Risk Assessment
Using available stability data, identify whether vaccine potency is likely to be affected by the cold chain breach/ storage conditions identified
Consider seeking further advice from manufacturers, SIT, HPT or PHE national immunisation team
Vaccine compromised
Dispose of vaccines as per local wastage policy
Complete stock incident capture form on inform
Compromised vaccine given to patients
Report on Datix & NHSE
This include all errors occurred in
Nursing Homes
Report incident to NHSE and identify lessons learned/training needs
Vaccine Satisfactory for use
Label as ‘involved in incident & use first)
14 Version three; Quality Team WHCCG; NH 09/09/2020
Appendix F; TRANSPORTATION OF WASTE BACK TO THE GP PREMISES (e.g. following a flu clinic in a community hall)
‘The healthcare worker producing the waste can transport the infectious or offensive waste from the home environment back to base where waste collection and disposal arrangements are in place. Where healthcare workers are transporting waste in their own vehicles, they should ensure that they are transporting the waste in suitable UN-approved rigid packaging, for example containers or drums’ (DOH, safe management of healthcare waste; 2013) Where vaccinations are given outside of the GP Practice transportation of healthcare waste must be considered.
WASTE CHECKLIST
Checklist for transportation of healthcare waste
Yes/No
Name/signed
Comments
Waste segregated into clinical/non clinical waste
Sharps bin closed & sealed, dated and signed for disposal
Healthcare waste transported directly to GP Premises in appropriate container in agreed staff member’s car (e.g. sharps boxes put in a sturdy lidded box to prevent spillage or exposure to healthcare waste)
Waste labelled with time, date, GP Practice (and identify which waste has been used for the flu clinics outside of the premises/ home visits)
Healthcare waste disposed of directly to secured waste areas within the GP Practice.
15 Version three; Quality Team WHCCG; NH 09/09/2020
Appendix G
Example of a PSD
Name of Patient Date of birth Address NHS Number
Mrs Ruth May 29/02/1953 Happy Retirement Nursing Home 423 324 452 4644
Name of Vaccination (Strength/ Dose, if appropriate)
Trivalent Influenza Vaccine
Route of administration Intramuscular injection into the deltoid
Frequency One off injection
Start/ Finish date From September 2020 until March 2021
Name of Prescriber Dr Boris Johnson
Signature & date of Prescriber
Name of Immuniser RN David Cameron
Signature of Immuniser
Date of Immunisation 29/10/2020
Injection details
batch number RN1234567 expiry date 31 /03/2021 Anatomical site (L or R deltoid) Right deltoid
Recorded in electronic record by immuniser (if appropriate)
YES / NO
To be completed prior to administration of Vaccination
Your clinical system will also have a template for PSDs
16 Version three; Quality Team WHCCG; NH 09/09/2020
Appendix H
Practice Staff Flu Record
Staff Member
Position/Post
Date Flu given and name of immuniser (state if given by another provider)
Vaccine refusal
17 Version three; Quality Team WHCCG; NH 09/09/2020
Appendix I; Letter to GP/ Vaccine Provider
Name of home
Address 1 Address 2 Address 3
County Postcode
Phone number Date of letter
Dear, To Whom It May Concern,
I am writing to ask you to arrange for the vaccination of name of staff member in line with NHS England and Public Health England’s national flu immunisation
programme offering free influenza vaccinations to Social Care workers during the 2020/21 season.
The national flu immunisation programme states that health and social care workers will be able to attend their registered GP practice or pharmacy to have a flu
vaccination. These individuals may be required to provide some evidence of eligibility, such as an ID badge, a recent pay slip or letter from an employer.
I can confirm that name of staff member is employed as a Health and Social Care Worker employed by name of provider which is a registered residential care/nursing
home/homecare provider (delete as appropriate), this position requires them to be directly involved in the care of vulnerable patients/clients who are at increased risk
from exposure to influenza.
Yours sincerely
Name of home manager
Job title
Name of home
18 Version three; Quality Team WHCCG; NH 09/09/2020
Go to your nearest
Emergency Department.
Or contact
Heales Medical sharps
injury hotline:
03333449006
Mon-Fri 9am-5pm
19 Version three; Quality Team WHCCG; NH 09/09/2020
Flu & Immunisation Training and Competence;
https://www.gov.uk/government/publications/immunisation-training-guidance-during-the-covid-19-pandemic/guidance-on-immunisation-training-during-the-covid-19-pandemic
https://www.gov.uk/government/publications/national-minimum-standards-and-core-curriculum-for-immunisation-training-for-registered-healthcare-practitioners
https://www.gov.uk/government/publications/flu-immunisation-training-recommendations/flu-immunisation-training-recommendations-for-2020-to-2021
https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/679824/Training_standards_and_core_curriculum_immunisation.pdf
https://www.gov.uk/government/publications/flu-immunisation-training-recommendations
Mass Vaccination clinics
https://www.rcn.org.uk/clinical-topics/public-health/immunisation/immunisation-services-and-large-scale-vaccination-delivery-during-covid-19#medicinesmanagement
https://www.rcgp.org.uk/-/media/Files/Policy/A-Z-policy/2020/covid19/RCGP-guidance/RCGP-Mass-Vaccination-at-a-time-of-COVID-
V15.ashx?la=en&hash=1C080B9039F459CE60DCA52459E31FE0
Nurses Code of Professional Conduct (2020);
https://www.nmc.org.uk/globalassets/sitedocuments/nmc-publications/nmc-code.pdf
Directives to give the Flu Vaccination;
https://www.rcn.org.uk/clinical-topics/medicines-management/patient-specific-directions-and-patient-group-directions
https://www.gov.uk/government/publications/influenza-vaccine-fluenz-tetra-patient-group-direction-pgd-template
https://www.gov.uk/government/publications/intramuscular-inactivated-influenza-vaccine-patient-group-direction-pgd-template
https://www.sps.nhs.uk/articles/written-instruction-for-the-administration-of-seasonal-flu-vaccination/
Vaccination Guidance
https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/859773/PHE_vaccine_incident_guidance_January_2020.pdf
https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/796886/GreenBook_Chapter_19_Influenza_April_2019.pdf
https://www.gov.uk/government/publications/national-flu-immunisation-programme-plan
Waste management;
References
20 Version three; Quality Team WHCCG; NH 09/09/2020
https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/167976/HTM_07-01_Final.pdf