Why do the majority of NHS staff not get the flu vaccine?
All NHS staff in Scotland are offered a flu vaccination but less than half have had it. Why?
The number of people going to see the doctor with influenza-like illness is higher than any year since 2010-11 but the rate is still considered "moderate" by health experts.
In order to halt the spread of the virus, the government recommends that people who qualify for the vaccination take it up.
Those eligible include young children, people over 65, pregnant women and those working in the health service.
Of these groups, it seems that NHS workers have the lowest rate of take-up, with just over 40% of staff - including those who have contact with patients and those who don't - having had the jab.
Flu vaccination rates
Earlier this week, Sir Bruce Keogh, national medical director of NHS England, called for a "serious debate" over whether NHS staff should be forced to have the vaccination.
He said thousands of healthcare workers were unwittingly "putting patients and their own families at risk" by not having the flu jab.
In the Scottish Parliament on Tuesday, Health Secretary Shona Robison told MSPs the take-up among NHS staff was "lower than we would want".
Ms Robison said "ultimately" it was a decision for each individual to take but urged those eligible to get the flu vaccination.
The NHS recommends that anyone in health and social care who works directly with patients should get the vaccine.
It also offers it to anyone working in:
- GP practices
- children's wards
- cancer centres
- intensive care
- dental surgeries
- care homes
Are NHS staff selfish for not having the vaccination?
England's top doctor said flu was a "double whammy" for the NHS, increasing the number of patients and putting staff out of action.
He said a third of people with the virus do not know they are carrying it so staff may not be aware they are putting patients, colleagues and their own families at risk.
In 2011, the then chief medical officer in England, Dame Sally Davies, criticised those who did not get the jab, describing them as "selfish".
BBC Scotland spoke to a number of doctors and nurses who said many believe the flu vaccine was "ineffective".
One GP, who wished to remain anonymous, said: "When flu changes to a new strain, the old vaccine no longer works.
"The evidence is conflicted on the benefits. The current epidemic still happened despite the vaccination programme."
Carl Heneghan, professor of evidence-based medicine at the University of Oxford, agrees that take up is low because the evidence of its effectiveness is "uncertain".
Prof Heneghan, who is also an out-of-hours GP, told BBC Scotland there was little good evidence on the benefits of giving the vaccination to healthy individuals in the NHS.
He said: "When the evidence is strong and makes a difference to patient care, health workers can be counted on to do the right thing."
However, the professor said not all vaccines were equal and others such as the measles jab had clear evidence of their effectiveness.
He said the same evidence could not be claimed for the flu vaccination.
A study into the vaccination of healthcare workers, published in 2016, pulled together trials looking at its effectiveness.
It found such programmes "probably have a small effect on lower respiratory tract infection but they may have little or no effect on admission to hospital".
Prof Heneghan said: "The best way to reduce flu is scrupulous hand-washing between every patient.
"Barrier methods such as face masks and quarantine give reductions in the spread of all acute respiratory infections, not just flu."
Sinead McLean, a nurse at the Queen Elizabeth University Hospital in Glasgow, said she had the flu jab because she has asthma.
She backs the vaccination programme and says it has been heavily promoted within the hospital.
However, Ms McLean says that some colleagues have been too busy to get the jab, while others think it does not really help protect people from the flu.
Scotland's chief medical officer, Dr Catherine Calderwood, said: "This year's flu vaccine is a good match for the current predominant strain of virus in Scotland and has an excellent safety record.
"Staff can protect themselves and their families and, importantly, reduce the spread of flu by being vaccinated."
Dr Calderwood said the 40% figure for all healthcare staff in Scotland was "lower than I would like" but she agreed it was not something that should be mandatory and the decision remained with each individual.
She said: "I have had my flu vaccine as it is very important for me to protect the pregnant women I see in my antenatal clinic and flu can be particularly harmful for pregnant women and their babies."
And while many medical staff avoid taking the vaccine, their leaders maintain its importance.
BMA Scotland chairman Dr Peter Bennie said: "NHS staff come into contact with patients suffering from flu on a day-to-day basis at work, and the virus contributes to our heavy workload at winter.
"Ironically, we often feel so busy that we don't think we can make the time to get vaccinated ourselves, but it is important to do so."
Theresa Fyffe, director of the Royal College of Nursing Scotland, said all nursing and other frontline staff should be vaccinated to protect both themselves and their patients.
She said: "While most cases of flu are mild, it can lead to complications for patients with health problems.
"Nursing teams and other staff are working extremely hard to ensure that they can provide quality patient care during this challenging winter period and we urge all frontline staff to get the vaccine as soon as possible."