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