Transcript - 2023 Influenza Vaccination

​Transcript of 2023 Influenza Vaccination webinar 

Sammi: Good evening, everybody, and welcome to this evening's webinar Influenza Vaccination Update for 2023.

Before we get started, I would like to make an Acknowledgement of Country. We recognise the traditional custodians of the land and sea on which we live and work, and we pay our respects to Elders past and present. I myself am joined from Tharawal Country this evening in South West Sydney.

Okay. I would like to formally introduce our presenter for this evening, Dr Tim Senior. Tim is GP at Tharawal Aboriginal Corporation in South Western Sydney. He is also an RACGP Medical Advisor for the National Faculty of Aboriginal and Torres Strait Islander Health and a Senior Lecturer in General Practise and Indigenous Health at UWS. So thank you and welcome Tim, who is going to jump on and join us now and he is going to take us through our learning outcomes before we jump into the content for this evening. So Tim, welcome and thank you for joining us.

Tim: Thank you very much, Sammi. I am joining you as well from Tharawal Country, southwest of Sydney, and that is the land that I live and work on. And I would also like to say thanks to Dennis Meyer and Joe Sutherland, who are behind the scenes answering some of your questions as well and have been very helpful in putting together tonight's presentation. So these are our learning objectives. This is what we hope to get out of tonight together. So that by the end of this online activity, we should all be able to discuss factors contributing to varying influenza impact in New South Wales in recent years, discuss the impact and outcomes of the 2022 influenza vaccine program, including the uptake in children under five years of age and that is a bit of a spoiler for what is to come. Recount the formulations of the 2023 influenza vaccine and their optimal use in eligible age groups, including children under five and those aged 65 and over, discuss strategies to increase uptake in at-risk groups, especially children aged six months to under five years, pregnant women and Aboriginal and Torres Islander people, and finally utilise the flu vaccination toolkit to optimise our vaccine supplies and maximise uptake of influenza vaccine.

So we are going to start with looking at some of the recent epidemiology just of influenza in the last five to 10 years. And the take home message from this slide is essentially you can see that flat line through 20 to 22 which is obviously the lack of flu transmission and possibly lack of testing that we saw during the COVID pandemic. But then last year, we saw a big spike in flu cases, an early steep onset and that started in late May or June and then rapid offset again. And so that was similar to what was seen in the Northern Hemisphere and is actually an early pattern compared to normal where we normally see the peak later on in the year. So last year was a big flu season and it came earlier than we often see it coming as well.

The next slide shows us the serotypes from last year. And as you can see, the vast majority of, or most of what we know about the flu that came through last year was that it was mainly influenza A and when that got subtyped, it was mostly H3N2. And so that was again similar to what we saw from the Northern Hemisphere. There is quite a lot there that you can see in the cyan colour, not yet determined, but the vast majority was of influenza A. And so that is what we were dealing with last year. And again, what we had seen coming through was the same as we have seen in the Northern Hemisphere.

The next slide shows us, I mean I am sure you remember like I do, lots of people with varying respiratory illnesses. And so this shows the different respiratory viruses that were circulating last year. And certainly I remember seeing a lot of RSV, a lot of rhinovirus, a lot of parainfluenza and there was also metapneumovirus, which I saw some of too. And so we can see that especially the rising RSV, so that is the graph on the left, second up from the bottom, and parainfluenza on the right, just above that. And that roughly tracked influenza peaking in June, July, but also the metapneumovirus and the rhinovirus, both of which peaked later than the influenza. So there was a lot of respiratory illness ebbing and flowing in all our patients last year, and I am sure you remember that we were seeing nonstop respiratory symptoms.

So to summarise that, the last season, influenza season, last year had early onset. If we move on to the next slide, Sam. Thank you. So it was early onset with a rapid peak and actually an unexpected rapid offset. We often see it slightly prolonged and we are wondering about, we always get a question about whether people should have two flu vaccines. Last year, that would not have, the recommendation is not normally to do that because it is an evidence free zone, but last year that would not have had much effect because there was a high early rate of flu that did not last very long. That was similar to the Northern Hemisphere experience in 2022-2023, but we saw plenty of other viruses, especially RSV, human metapneumovirus, rhinovirus all prevalent.

And so there is implications for multiplex testing for respiratory viruses, which is done in some labs and we have seen results come through from that. And also worth noticing, not for this year but in trials, is a combined influenza COVID vaccine. And so that is worth watching this space because I think that is going to be coming not this year, but it could be coming in future years, And I think that will be an important development. And it is worth about the multiplex testing which is testing for multiple respiratory viruses, that can be really useful when pre-test probability is high. So people have a higher risk of exposure, or they have significant symptoms, or the patients at risk of poor outcomes from it, and that is when multiplex testing to work out exactly which respiratory virus people have is useful. 

The next slide shows us a little bit about the global influenza implications. So the best data we have is from the USA and UK, but that does not capture, that only captures maybe about 50% of all destinations. So it is good data, but it is not complete data. And so in both the UK on the left and the USA on the chart on the right, same influenza A, H3N2, predominated. And the virus travels with travellers. But as I say all the destinations were not UK or USA, so we are getting it coming in from all the countries that people travel from. Now, interestingly, one of the things the US data suggests is that this last influenza season had a very high hospitalisation rate. And so that is worth watching out for this season. Obviously it is going to be unpredictable as to exactly what happens, but that is certainly a possibility. And the other thing is it looks from the UK data that the A and B influenza are both still susceptible to antiviral treatments. So that is a sort of way we have of trying to pick what the 2023 flu season might be like. It is never an exact science.

So if we move on again, the impact of flu in 2022. There were 225,000 plus notifications of laboratory confirmed influenza and 308 influenza associated deaths notified. Interestingly, the highest notification rates were in people aged five to nine years, so children, and then next up in children age six months to five years, so they are the underage group, and then people aged 10 to 14. So the notification rates in children were significantly high. Admission rates, so that is of people in sentinel hospitals, so where they confirm and they are charged with watching out for what is happening in the influenza season, so confirmed influenza admitted to hospital, 56% were children aged younger than 16. 24% were adults aged 16 to 64, and 20% were adults aged 65 years or older. So again, I tend to concentrate on the older populations, I think about them as being particularly susceptible to flu, but there is a large number of children being admitted to hospitals there. And again, as you might expect, there is some geographical variations about the rates of people being impacted by flu.

This is a reminder that flu can be a really nasty illness for some of our patients. So common complications across all ages, as you know, include pneumonia, bronchitis, exacerbations of asthma, cardiac complications, otitis media and acute respiratory distress syndrome. And it is probable that you have seen some examples of that yourself. Again, those people most at risk, babies and young children, pregnant women, importantly, people with underlying medical conditions, which I think we are all familiar with, and older people and particularly residential aged care facility residents.

And so as a reminder, really, we are just quickly going to go through a case study which really is a reminder of really uncommon but particularly serious consequences of flu, just to sort of get our head in this mindset of potential serious consequences of people picking up flu. So this was a three-year-old girl with the past history of failure to thrive and she was up to date with a childhood vaccinations. And she presented to the Royal Children's Hospital Emergency Department with a five day history of fever, coryzal symptoms and lethargy. We had commenced her on oral antibiotics a few days earlier, but she deteriorated in the preceding 24 hours with slurred speech and a fluctuating conscious state. So I think we would all agree there would not be much doubt about what we would be doing in those sort of circumstances. Blood test suggested a viral illness and she had normal inflammatory markers. CT was normal. They did not do a lumbar puncture and she was commenced on intravenous antibiotics and acyclovir. And when she had an MRI that demonstrated extensive focal necrotic and haemorrhagic changes in the deep white matter and spinal cord around C4 to C5 in keeping with acute necrotizing encephalomyelitis or AME. Now that is rare, but it is a potential complication. And so if we continue the case study, nasopharyngeal aspirate was positive for influenza A which got typed and the child commenced a seven day course of antiviral medication after confirmation of the diagnosis and a three day course of IV steroids, pulse methylprednisolone and an oral weaning course of prednisolone. She was in for a while, requiring physiotherapy and ongoing care in rehab. She did have some short term memory deficits and persistent right sided weakness but was able to communicate and mobilise independently by the time of discharge. And so really the take home for us is not that we are likely to be seeing this, I hope we really do not, but that consequences of influenza can be really serious and that children particularly last year were quite badly affected by flu.

And so if we move on now, this is moving on to the strains that we are expecting and are in the vaccines for 2023. So both trivalent and quadrivalent influenza vaccines are available. Only quadrivalent vaccines are funded under the National Immunisation Program. So all the trivalent are private. The recommended components of the 2023 Southern Hemisphere vaccines are: an influenza A Sydney strain, which is a new strain for this year, Darwin strain influenza A, so that is an H1N1 and an H3N2 influenza A viruses, an influenza B Austria strain which is a Victoria lineage, and an influenza B Phuket strain which is a B Yamagata lineage. So again, we are covering all the bases with the quadrivalent strain there. Both egg based and cell based vaccines will be available in Australia, but only egg based vaccines are funded and supplied under the National Immunisation Program and there are no new vaccines being supplied for 2023.

So we will go over the exact vaccines available in a minute, but this is a summary of the four quadrivalent vaccines through the government programs. So for all children six months to under five years, Vaxigrip Tetra and Fluarix Tetra are usable in that age group. But at risk groups aged five to 64, Vaxigrip Tetra again, Fluarix Tetra again and Afluria Quad, are the vaccines available to those age groups. And for people aged 65 years and older, the vaccine you need to use is Fluad Quad, which is the adjuvant vaccine which promotes a stronger immune response. And we will go over, we will look at the packaging for all of those and just summarise those in a minute for you.

Again, a reminder that all the vaccines are 0.5 mil doses, no half vaccines for children. So here we have a nice picture of Fluarix Tetra. And so this is licenced for use from six months of age. And again, it states that on the box quite clearly. And certainly I am in a habit of checking and re-checking and re-checking the ages that they are eligible for because it never sticks in my mind. We need to have systems for that in our practice. So Fluarix Tetra, universal six months to less than five years influenza vaccine program. Also funded for all Aboriginal people aged 5 to 64. It is funded for pregnant women and it is funded for people with medical risk factors, again, five years to 64. If it is a child's first vaccine, so under nine or greater than six months, if this is their first flu vaccine, then give two doses one month apart. Again, that is the same as previous years.

Next up is Vaxigrip Tetra. And there you can see a picture of the box there. And again usually clearly marked the ages, six months and older. So this is licenced for use from six months of age and it is funded under the National Immunisation Program for everyone six months to less than five years. For all Aboriginal and Torres Strait Islander people five years to 64 years, for all pregnant women, for all people with medical risk factors who are between five years and 64 years of age. And same again for children aged six months to nine years, if this is the first time they are getting flu vaccine give two doses one month apart. So again, that is similar to previous years as well.

Next up is Afluria Quad. And this is the adult one, well, children five years and over, and adults that is licenced for, so do not use this in children under five years. This is funded for all Aboriginal people five years to 64 on the National Immunisation Program, funded for pregnant women, funded for all people with medical risk factors, five years to 64 years of age, and same again for children aged five to nine, if it is their first year of receiving flu vaccine, then they get two doses one month apart. I cannot say it often enough, do not use this for children less than five years of age. It is very easy for that to go wrong and each year there are some examples of where that has been given and so we need to make sure in our practices that there are we have ways of avoiding giving the wrong vaccine to the wrong age group.

And the final National Immunisation Program flu vaccine available for 2023 is Fluad Quad. So this is licenced for use in people aged 65 years and over only, so do not use it in any other people under 65. It is funded under the National Immunisation Program for all people aged 65 and over. Again it is a quadrivalent vaccine like the others. And this has an adjuvant in it which makes it different to the other vaccines. So it increases immunogenicity in older people who tend to have a reduced immune system, and so studies indicate if you use Fluad Quad compared to the other vaccines available, you get about a 25% reduction in influenza infection and hospitalisation compared to the standard vaccines. That enhanced immune response though from the adjuvant, can result in more marked local reactions to the vaccine. And also worth noticing, again as in previous years, you will be familiar, the appearance is of milky white suspension. So unlike the other vaccines, it is not clear, it is milky white. So that is the normal appearance of this vaccine.

We have got a question come through. Does it need to be the same vaccine if it is for the first time for children? So do we need to give the same brand? My understanding is no you can give a different brand as long as it is licenced in that age group again and on the National Immunisation Program. Because all the vaccines, they have different manufacturers, they all do have the same strains of vaccine. I will be corrected if that is incorrect.

And I hope none of you mind, my cat has just joined us to join in the webinar as well. Always helping.

Sammi: The more the merrier.

Tim: My cat will get CPD points too and the practice of being a cat.

So the vaccine distribution is the similar system to last year. Our first flu vaccine shipment will be pre-allocated to us and we need to accept that allocation before we can order any more. So the pre-allocation calculation is based on our 2022 usage and discarded expired vaccines from the practice and also dependent a bit on the delivery schedule into the New South Wales Vaccine Centre, so the logistics of that can be organised. As I said, the first shipment allocation must be acknowledged on the New South Wales vaccine website, so that order can be reduced, but it cannot be increased. That is the first one. As soon as the vaccines have arrived at the practice, you can put a second order in. So that is, as soon as the vaccines have arrived and you have confirmed receipt of the vaccines on the New South Wales vaccine website, then you can submit a second order for vaccines if you need more. And I think that is similar to last year's new system.

We have got a question that I think Dennis or Joe might be able to answer, I do not think. My manager tells me we cannot order yet. Should we be able to by now? I have a feeling that the information about the vaccines has just been sent out today, but I do not think the pre-allocations have gone out yet. But we will get confirmation of that for you.

We will go through some of the resources available to you. I think some of these will be mailed out to you and to practices and are also available from the New South Wales Immunisation website pages. So the toolkit for us will include a checklist and timeline and a vaccination decision aid to help discussions with our patients. The toolkit will be available be available soon. I am not sure if that is up on the website yet. And also, a reminder, the New South Wales Immunisation Specialist Service is available for advice as well.

The next page shows. So these are vaccine posters, so that we have readily available near the fridge. There are pictures of the packets, of the boxes of containing vaccines for different ages and the vaccine basket stickers so that we can clearly reach for the right vaccines in our vaccine fridges. You will notice the deliberate mistake, just to check that you are all looking, that that says 2021 influenza vaccine. Obviously yours will actually say 2023. Unless they are using old stickers, but I doubt that. But again, just so that we can reach into the fridge. And this is about having the systems that will allow us to give the right vaccine to the right people without making errors.

 

Sammi: And just to confirm what you said, Tim, we have had confirmation in the chat box for anyone that missed it, that that is correct that you cannot order just yet. But we did have someone following up saying that they received their order form today. So there you go.

 

Tim: We have got a question as well from Phillip. Previous studies have shown that vaccine effectiveness vanishes after 90 days. Would you recommend vulnerable patients receive a second vaccine after three months? It is a really good question. It comes up every year. And essentially if you do, that is not funded on the National Immunisation Program. So the second one will be a privately funded vaccine. It is pretty much an evidence-free zone as to whether that provides extra protection over and above the initial vaccination. I know some people that do that and do offer it to their patients or even do it themselves, but it is not the universal recommendation and it is not funded on the Immunisation Program. So that is not the recommendation at the moment.

Do the posters and stickers go automatically with the first order? I think they come separately to the first order. I think they are probably being sent out very shortly. They normally arrive separately in the mail is my understanding of those when I have seen them before.

If we move on to the next slide. So every year there is a campaign for patients to increase their vaccine uptake, influenza vaccine. I think it has been the same over a few years but after last year, and there is multiple respiratory viruses running around, from the 1st of May to 31st of August, the winter respiratory campaign will include influenza, COVID-19 and RSV, so targeting some of the most common and most serious respiratory viral illnesses. So they are aiming to re-engage the community around the risks of respiratory illness across the winter months. I think we all, certainly many of my patients have that sort of vaccine fatigue, because there was so much effort put into the COVID vaccination and again then into the flu vaccination and also pneumococcal as well, that people are sort of struggling a little bit about doing that. And so it is an attempt to re-engage the community. There is three main pillars of the campaign, influenza vaccination, COVID-19 vaccination and antivirals and hygienic behaviour, which is useful for all the respiratory viruses. So for flu vaccination, which is what we are concentrating on tonight, the priority audiences are children at age six months to five years, pregnant women, Aboriginal and Torres Strait Islander people, and people from culturally and linguistically diverse communities. So, often migrants and refugee communities.

Just draw your attention to the asterisk there, data shows that young children had the highest rate of admission to hospital from emergency departments for influenza like illness in 2022. And since 2019, vaccine coverage in children under five has fallen. So we sort of probably need a big push on children having flu vaccines. There will be targeted communications aimed at parents and carers to increase vaccination rates in young children, so hopefully when we are giving that message, they will already have heard some of the information about that.

Next slide show is the practice checklist that we will get. And so this is the steps that we need to go through. I would imagine that usually most of us on the webinar are GPs but I think this is good. Vaccination is actually a team sport, and so we will need to go back and talk to our practice staff, our receptionists, nurses, our practice manager and our colleagues about doing this systematically through the practice. So we need to calculate our vaccine requirements for the practice. So based on the populations that we have talked about, confirm that we have got cold chain measures in place and prepare a fridge to receive vaccines. That is likely to be already going because of having a fridge for childhood vaccinations, but it is a good opportunity to confirm that. To do an in-service and make sure all staff are up to date on the new vaccine types and the indications and age groups, make sure our practice software is updated and that ensures uploading to the Australian Immunisation Register, and ensuring that information about vaccines and recommendations is up to date as well. When the allocation reviews open, we confirm our pre-allocation order with the New South Wales Vaccine Centre. Then, when we have got vaccines, we offer influenza vaccine for our patients and so those that we identify as being eligible under the National Immunisation Program, we offer them those vaccines and those where we would recommend it but not be funded under the NIP, then we can use private vaccine stock.

We are advised only to reorder what can be used in a maximum four week period so that we have the turnover going and it means that the available amount of vaccine and the stock can get distributed widely across all our practices. And then we can think in each of our practices how we are going to maximise uptake among children from six months to 59 months, among pregnant patients, among Aboriginal and Torres Strait Islander people of all ages greater than six months, among those people with chronic conditions that put them at risk of severe complications of flu, and among people aged 65 and over, which is particularly the NIP ones but I will draw your attention to children as well, because I think that is going to be an important one.

Again, monitoring flu vaccine safety. This is important every year. So the AusVaxSafety survey monitoring for last year included reports of vaccine adverse events following immunisations in people over 60 who received an adjuvanted vaccine. And so in the Fluad Quad or the Fluzone high dose quadrivalent last year, 16% reported at least one adverse event.  But, only fewer than 1% reported seeking care, so there may well be quite a lot of mild, not severe, vaccine adverse events happening out there. But not everyone is seeking care for that. 2% of people reported that it limited their routine duties, and mostly that was lethargy, headache and joint pain. And so we can expect similar sorts of things. And again, those are the reports on the Fluad Quad and Fluzone high dose quadrivalent which is not on the NIP. We would expect probably slightly less reactions but not zero in in the non-adjuvanted vaccines.

So moving on. This is how we can report adverse events following immunisations and vaccine adverse events. So anything that is uncommon, serious or unexpected to you, or if in your opinion it is felt to be a significant event following immunisation, then report those. And you can use these using that reporting form from the TGA, the Therapeutic Goods Administration, and then provide any relevant medical reports and investigations, and report it via the local public health unit using that form. And I have reported vaccine on that form myself, and we all hate forms, but this was not the worst form I have filled out by a long shot. And it is important just in being able to identify if there are adverse events happening that are new to us or we have not been aware of.

And again on the next slide, if you want, you can participate in the Smart Vax which is that SMS system where patients receive a text message after being given a vaccine. And they get to report adverse events. They are just asked if there were any adverse events and they can reply with a yes or no. And so it is a really effective way of collecting some basic data about the rate of adverse events following vaccination. So you can participate in that if you need to or if you want to.
 

Sammi: There is just a couple of questions that I thought maybe we could address before we move on to the case studies, Tim, if that is okay? And we may need Joe or Dennis to jump in for some of these. But the first one is, with the new recombinant influenza vaccine, is there anyone in particular that would be recommended specifically for this year and do we have any idea of the prices for non-funded vaccines?

 

Tim: Yes. Now to be honest, I do not know the prices because I work in an Aboriginal medical service and so almost all of my patients are eligible for the National Immunisation Program. But I am sure that people online will know that the prices and I do not know about the new recombinant influenza vaccine. I would imagine that there is not so much of a clinical advantage in which vaccine and I think the important thing is that vaccines get into people, and what is available and what is easy, gets into them. We saw last year, well over the last few years with COVID vaccines, about people getting very determined to know which brand of vaccine that we are getting. And the AstraZeneca one, which was an effective vaccine, sort of collapsed in popularity and people were saying they were waiting for Novavax. It would be interesting to see if that has opened up any people's knowledge about different types of influenza vaccine or brands of influenza vaccine. It does not seem to have done yet, but my impression would be that people should get whichever vaccine is going to be the easiest to get into them. There may be a few people who we are concerned about, say, egg allergy or something, which is not actually a contraindication.

 

Sammi: Thank you. And what is the current take on pneumococcal and influenza vaccines given on the same day at the same time, especially in over 65s?

 

Tim: Do it. We do it all the time. And you may get a slightly higher rate of complications but I would much rather get vaccine into people on the day I offer it. So when I spot it I offer it there and then take them to the nurse, give them both. So if it is convenient and the patient agrees, you can definitely do that. And again if the patient does not want it, that is fine, it can be given on separate days if they are worried about it. But certainly there is no particular reason not to do that.

 

Sammi: Fantastic.

 

Tim: We have someone commenting that the Fluzone vaccine will be around $58. So that is probably going to be a reasonably popular option for quite a few people, I would imagine.

 

Sammi: Wonderful. Well, let us move on to our case studies.

 

Tim: I think there was one other question that someone asked as well, which I think got accidentally marked as being answered, which was around giving flu vaccines when someone turns from 64 to 65.

 

Sammi: Yes. So Joe gave an indication to that one. So the answer to that was give the dose at the usual time, do not wait for the August birthday. And a better response is likely from the adjuvanted vaccine.

 

Tim: Yes, that is true. But it is not licenced in those under 65, so you would be going off-label if you give them an adjuvanted vaccine before they are 65. So do be wary of that.

 

Sammi: Yes.

 

Tim:  Thank you. So, if we get look at some case studies, this will allow us just to again practise some of the clinical reasoning that we will be doing with patients. So think about Padmini. She is 30 weeks pregnant with her third pregnancy after two normal, uncomplicated term births in India. She is an overseas student, who has been in Australia for three months, and this is her first antenatal visit. Her partner is an Australian resident. She is on a student visa. She is not currently covered by Medicare but has private health insurance, the Overseas Student Health Cover. She mentions that she has heard some stories about babies who have died from a bad cough, and she wants to know what she can do to prevent this. Padmini has had some immunisations before, but she is not sure what. She remembers she has had two COVID-19 vaccines in the last 12 months, most recent was ten months ago. Excuse me. And she had a mild COVID-19 infection just before she arrived in Australia four months ago. So I think we launch a poll, Sammi.

 

Sammi: We certainly do. So the first poll is up now and there is two questions for this poll. The first one is, what vaccines would you recommend Padmini have today? And you have got four options there to select from. And once you have selected, your next question is, are any of these vaccines funded for Padmini? So we will give people kind of another 30 seconds to answer those, Tim, and then we will move on to the responses and what our audience said.

 

Tim: Excellent. I love seeing that. You cannot see this, but I can see the little bar charts going up and down as you vote.

 

Sammi: And once we end the poll, we will share those and you will be able to see what percentage of the audience voted for which response. And please note that it is anonymous.

 

Tim: We are going straight into the second question after this one.

 

Sammi: Yes, they are in the same one, so people will answer the two of them.

 

Tim: Yes, there we go.

 

Sammi: I can see that 62% of people have participated in the poll. Let us see if we can get that up to 70% in the next.

 

Tim: No one could see your answers.

 

Sammi: It is all anonymous.

 

Tim: It is all anonymous. We cannot see it. It does not get sent to the College or anything.

 

Sammi: All we see is the percentage.

 

Tim: All we see is the percentage. So it is always much more fun to take a punt. And right or even horribly wrong, does not matter.

 

Sammi: We have still got a few more responses trickling in. I will give you five more seconds and then we will. All right. Let us end that one there. Now, up on the screen now is the responses, the correct responses. And I have just shared the results up as well so you can see the correct responses and also what the audience has said. 

Tim: So this is interesting. The vast majority of you recognise that the vaccines recommended for Padmini would be COVID-19, influenza and whooping cough, and we will go through the reasoning for that in a minute. And interestingly, are any of these vaccines funded for Padmini? And by funding we went through the National Immunisation Program, and the answer to that is actually no. The National Immunisation Program only funds people with a Medicare card or eligible for Medicare, which may be true for Padmini's partner, but it is not true for Padmini. So I suspect that some of the insurance companies may well fund the vaccine, so I am not sure, that may depend on the insurance company, and I know that some of those do fund whatever is available on Medicare, but it would not be through the National Immunisation Program, it would probably be a reimbursement for a private vaccine.

So if we go on to the next slide, then this just discusses the rationale for the answers that we just saw. So Padmini should receive a third COVID vaccine booster like you all said, as it is over three months since the recent infection and she has already had two doses.

Both influenza and whooping cough vaccines are covered by the National Immunisation Program during pregnancy, but she is not eligible for the National Immunisation Program because she does not have Medicare and is not eligible for Medicare. Babies under six months are too young have the influenza vaccine, so the best way to protect her newborn baby is to have the influenza vaccination during pregnancy, and vaccinating other children in the family is also recommended, though maybe not funded. The whooping cough vaccine is recommended between 20 and 32 weeks of every pregnancy, although it can be given up to the time of delivery and it is the best way to protect a newborn baby against whooping cough.

 So whilst most vaccines can be co-administered with other vaccines at the same schedule point, separate injection sites should be used to ensure adequate immune response is induced and to reduce adverse events. There may be an increase in minor side effects if more than one vaccine is given at one session. The other reason also I think for giving separate sites is that if there is a local reaction, you know which one it was.

And so Padmini has no Medicare card and her insurance is unlikely to cover her for pregnancy as she was pregnant at the time of purchase. The COVID-19 vaccine will be free through participating community pharmacies. I forgot that bit. And she will likely need to pay for the consultation as well as private influenza and whooping cough vaccines, and it is debatable, it will depend on the insurance company as to exactly what she has covered.

So something that is often seen as simple by outsiders can become a little bit complicated. But certainly you all did well on recommending the vaccine, but actually it is not on the National Immunisation Program.

Let us move on to the next case study. We will do the same thing. So this is Nick. He comes to our clinic for a COVID booster and he mentions that he also wants to get the flu vaccine. He explains that he is concerned about his wife Stella, who has some mild asthma. He and Stella care for their three-year-old granddaughter Zahara. Nick understands neither of them can have the flu vaccine, but he wants to help protect them. You explore with Nick his understanding of why his wife and granddaughter cannot have the flu vaccine. Nick explains that he understands that as his wife had influenza late last year after trip to Italy, she should not receive the vaccine, and Zahara has never been able to have the vaccine as she has eczema and an egg allergy. So Nick is 57, he has type 2 diabetes and he is obese, BMI of 32. Stella she is aged 45, has mild asthma and smokes 30 cigarettes a day. And Zahara is three and does develop a rash after the consumption of egg. So we are going to put up a poll and I think you can probably guess what the question will be.

 

Sammi: And the first one is, is Nick eligible for funded influenza vaccine? There are five questions as a part of this poll. And they are all available to you now. So number one is Nick eligible for funded influenza vaccine? Number two, should Nick be offered the flu vaccine today? Is Stella eligible for funded influenza vaccine? Should Zahara receive a flu vaccine despite her history of egg allergy? And finally, is Zahara eligible for funded influenza vaccine? And the details of Nick, Stella and Zahara are still up on your screen underneath the poll if you want to refer back to them as well.

We have hot 56% of our audience has voted, 58%, 59% will give you a minute.
 

Tim: It will be a bit slow because there is more questions.

 

Sammi: Correct.

Tim: Again, watching the answers come through.

 

Sammi: 67%, 69, we have still got that number going up, so we will give you a little bit longer to respond to those questions. Slowing down now. We will give you a couple more seconds before we close that off to submit your responses. Alrighty, I am going close that one off there. I want to put up the responses to those on the screen and share the results from our audience as well.

 

Tim: Fantastic. So if we go through the questions in order. Is Nick eligible for funded influenza vaccine? Yes, he is and the vast majority of you said yes, he was. Should Nick be offered a flu vaccine today? Yes. And again, virtually all of you said yes, he should. Is Stella eligible for funded influenza vaccine? A really interesting split 52/48 on this? And actually the answer is no. She has mild asthma, which does not make her eligible for the National Immunisation Program. If it was more severe asthma, and similarly smoking does not make you eligible for the National Immunisation Program either. If it was more severe asthma then she might be, but mild, does not. And thanks to Dr McCrory as well who points out correctly that if Stella was Aboriginal or Torres Strait Islander, then she would be eligible for funded influenza vaccine. And that is an important thing to note because of course we will be identifying whether our patients or Aboriginal or Torres Strait Islander or not. And moving on to Zahara, should Zahara receive a flu vaccine despite her history of egg allergy? And again the overwhelming majority of you correctly said yes. And is Zahara eligible for funded influenza vaccine? And again, the overwhelming majority of you correctly said yes.

On the next slide, we will go through the rationale for those answers. I think the one about how severe your asthma has to be to be eligible for National Immunisation Program is always a tricky question for everyone. So, Nick is eligible for funded vaccine because he has type 2 diabetes. The obesity on its own would not mean that it was funded on the National Immunisation Program, even though it would be a recommended vaccine. And we can give COVID-19 boosters and flu vaccines on the same day.

Stella is ineligible for funded vaccine as mild asthma and smoking do not classify her as medically at risk even though they are problematic, as the word says on the slide. The vaccine is recommended but not funded due to both her mild asthma because she is a smoker, so she should be encouraged to purchase a private market influenza vaccine. A recent infection in the Northern Hemisphere does not preclude this season's vaccine in Australia.

Zahara is eligible for funded vaccine because she is less than five years old and greater than six months. Allergy to egg is a non-anaphylaxis allergy, therefore she can safely receive the vaccine. There is no evidence that having egg allergy increases the risk of having an allergic reaction to the currently available influenza vaccines. As with all vaccines really, it is recommended that we are able to recognise and treat suspected anaphylaxis, including administration of adrenaline and observing for 15 to 20 minutes after vaccination, which we all become very familiar with COVID. If we were really concerned about egg allergy for her, then I think the Immunisation Dervice that we mentioned earlier are able to provide advice and I think there is even an immunisation clinic at Westmead that can help with those vaccines where we are really concerned about anaphylaxis with vaccine administration.

If Zahara has not had a flu vaccine in the past, then she will need a second dose four weeks later. So, anyone less than nine for whom this is their first vaccine has two doses four weeks apart and both doses are funded in those aged less than five. So Zahara's second dose would be funded. But for children between five and nine, even though the second dose is recommended, the second dose might not be funded. And so that is the NCIRS factsheet, which is a really good source of vaccine information.

So we have got a question there about the recent infection in the Northern Hemisphere. If that had been COVID, we should wait for at least three months before another COVID vaccine. That is right, yes. So as per the current ATAGI guidance. And ATAGI said today, just keep in the practice for 30 minutes with the egg concern. I think that is right. If it is going to be anaphylaxis, it is going to happen pretty quickly. Yes, that is a good point, that Westmead is 10 hours drive away, not useful for most of New South Wales. That is absolutely correct. And so management of anaphylaxis is more important than Westmead Hospital.

So we have got another eight minutes. So if there are any questions that people want to put through or if we want to reiterate any of the answers to the previous questions that have come through, then we do have some time for that. The learning objectives are up on the screen again, which if you go through these, then than we have covered those. Someone is pointing out we are not checking for COVID anymore, so a lot gets missed. A lot will certainly get missed, which puts it really in the same sort of bracket, I mean it is a more severe infection than flu, the consequences can be worse. And same for the other respiratory illnesses. But as GPs we will be seeing people with upper respiratory tract viral illness infections of varying severity and to some extent our knowledge of the local epidemiology and the timing through winter will be important, but many times, we can either do multiplex if we think it might help, we can request PCR, the rat tests are not perfect, and I think again, we will be going back to probably what we are used to knowing about managing a lot of this on clinical severity as opposed to laboratory confirmation.

Which vaccines will chemists be doing? I do not know that. Perhaps New South Wales Health will?

So we have got some comments about COVID and chemist and flu vaccines. So remember last year, partly because of those high rates, they expanded the criteria and chemists I think were paid for joining in with doing flu vaccines as well. As I understand it, that is not the case this year at the moment, but it is a fluid situation, so I am not really going to give a definitive answer.

Are masks still mandatory in medical centres and hospitals? Only to the extent that you make them mandatory. So I do not think there is a public health order on it, but I think you can require patients to wear masks if you want. Certainly we are still doing that. And I think in a flu season, it is a good way of preventing flu transmission as well as COVID transmission and RSV transmission.

So just looking at some of the other questions coming through. So, is the influenza vaccine booster dose funded for healthy kids greater than six months to under five years? Yes. So that is, I assume by vaccine booster dose you mean the second dose for children who it is their first year of immunisation? Yes, up to five years.

Can a seven month old with newly diagnosed stage four neuroblastoma not on treatment, be given flu vaccine? I would be confirming with their specialist, but seven months old I would imagine yes, it would be recommended.

What would be the recommendations of vaccinating patients with regular methotrexate therapy on a weekly basis? I assume methotrexate weekly with folate in between times. I will be recommending flu vaccine for them, yes.

Just looking through the other questions. Yes, questions about mask wearing. Sure, I can give a sensible answer to a question about encouraging staff to wear masks.

Do medical staff get a private dose or could we use government vaccine? So you can use the government vaccine if you meet one of the National Immunisation Program criteria. So if you or your staff have a chronic condition, if you or your staff are Aboriginal or Torres Strait Islander, if you or your staff are working beyond retirement age then you can certainly get National Immunisation Program. Otherwise it would be private. Many organisations including services will actually just buy the private vaccine for their staff because it prevents them being off sick and they view the cost of the vaccines as being a good investment in terms of staff sick pay and short staffing.

So I am just still looking at the questions coming through, we have got three minutes there. Is the influenza vaccine likely to be free for new south wales residents like last year? It is a really good question and I do not know the answer. I suspect that decisions about that sort of thing are still being made and will depend on what this year's flu season looks like. I think if it looks a bit like last year, then that may well be.

Sammi: Joe and Dennis may be able to provide further insights, but there was a COVID update webinar with Kerry on Monday last week. And at that point, it was indicated that to their knowledge that was not yet on the radar of potentially happening. So I do not know if Dennis or Joe have any further updates to that at the moment. But that question was asked and the answer was not at not at this stage, we do not believe.

Joe/Dennis: Yes, you are correct. That is the latest advice we have.

 

Sammi: Wonderful.

 

Tim: Thank you. Watch this space there, but that is the situation at the moment. Excellent. Right. Well, we are at 8:28. Thank you very much for all the questions coming through and the commentary and the engagement and the enjoyment of cats. They always make a webinar better, as do those of you who have dogs, I would imagine.

Let us finish. We will let you go, all thinking of the perfect answer to this question that comes up every year from patients who say the flu vaccine gave them the flu this year. And certainly that is a common thing. I do not have a really good answer to that. People do get mild illness, but the flu can be a horrible illness, and I would rather have the vaccine than the actual flu. So thank you very much for spending your time this evening.

Thank you to Dennis and thank you to Joe for behind the scenes and thank you to Sammi very much for making the tech run so smoothly, certainly from my end, very much appreciated and the all the polling. And I think there will be an evaluation when we close the webinar.

Sammi: There certainly will. Thanks, Tim. And I just want to mirror my thanks to our presenter, Dr Tim Senior, and also to Dennis and Joe who have been there in the background from New South Wales Health as well, but also to everybody that joined us online. We do hope you enjoy the rest of your evening.