Transcript: Adult Vaccination

Jennifer: Welcome to this evening's webinar Update on Adult Vaccination and Emerging Diseases. My name is Jennifer, your host for this evening. We are joined by our presenters, Dr Vicky Sheppheard, Ms Keira Glasgow and Dr Valerie Delpech.

And I would just like to make an Acknowledgement of Country. So we recognise the traditional custodians of the land and sea on which we live and work, and we pay our respects to Elders past, present and emerging. I myself am joining from Dharawal land this evening in south western Sydney. I would also like to acknowledge any Aboriginal and Torres Strait Islander colleagues that may be joining us online this evening.

I would like to formally introduce our presenters for this evening. Vicky is the Director of South Eastern Sydney Public Health Unit and she is a member of the TGA's Advisory Committee on Vaccines. She has previously been the Director of the Communicable Diseases Branch at Health Protection New South Wales and from 2017 to 2019, Vicky was also the chair of the Communicable Diseases Network Australia, so welcome Vicky.

Keira is a senior epidemiologist and current Director of the Enterics Zoonoses and Multi-Resistant Organisms branch of Health Protection New South Wales. So welcome Keira.

And last but not least, Valerie is a public health physician and currently Director of the Communicable Disease Branch at New South Wales Health. She was Head of HIV and other STI's at Public Health England from 2005 to 2021. So welcome, Valerie.

Before I hand over to our presenters for this evening, I will just run through the learning objectives. By the end of this online CPD activity, you should be able to summarise the vaccine recommended and funded for elderly individuals, discuss disease patterns for monkeypox and Japanese encephalitis, discuss the vaccination recommendations for monkeypox and Japanese encephalitis, summarise the recommended vaccines for patients planning overseas travel and utilise immunisation resources. So now I am going to hand over to Vicky.
 

Vicky: Thanks very much, Jennifer, and good evening, everyone. So I last did a presentation on vaccines for adults in 2019 and it is quite interesting that the list of vaccines that we are talking about as are being routine for people 70 years and over have changed. At that stage it was people 65 and over was the trigger for new vaccines and on top of that we have brand new vaccines that are recommended for this age group. So it is I think a good time to go through these. So I will talk briefly about COVID vaccine and the need for at least four doses. Just a brief reminder on influenza vaccine. Pneumococcal vaccine recommendations have changed quite considerably since we last looked at it, so I spend a bit of time on that and also on zoster. Keira will address Japanese encephalitis, and I will not spend any time really on diphtheria, tetanus and pertussis, just to remind you that boosters are recommended every 10 years.

 
So this first slide is just to illustrate the disproportionate impact of severe COVID disease on people over 70 years of age and in particular over 80 years of age. So this is Australian data on the age specific rates of COVID cases that are admitted to ICU or died from May 2021 to September 2022. I think it is a really good illustration. The blue line is people 80 years and over, and the reddy-orangey line is people 70 to 79. And there you can see, as each wave comes through, the disproportionate impact on older people winding up in ICU or dying from COVID. So people 70 to 79 are around about 10 times, more five to 10 times more affected than those in the younger age groups. And those in the 80 and above age group are up to 40 to 50 times more affected. So I think this is an important message to give your older patients, because despite current COVID vaccines not being as effective in preventing transmission as we saw initially, they still remain highly effective in preventing ongoing severe impacts of COVID. What we also know is that more than 30%, and that varies a bit by where people live in New South Wales, but over 30% of older adults have not received their 4th dose. So that 4th dose is due three months after their previous dose or their latest infection. And so it is something that I would really encourage you to offer and remind all your older patients that until they have had their 4th dose, they are not optimally protected against these severe effects of COVID. And you can use any Australian registered vaccine as a booster, however, ATAGI prefers either Pfizer or Moderna, one of the mRNA vaccines, and for Pfizer it is the purple top, but the grey bivalent one will be available from the 12th of December and Moderna, either the red or the blue-green preparation are the preferred options for people in this age group.

So moving now on to influenza. So the graph on the left is showing influenza hospitalisations. This is again across Australia at sentinel Hospitals from 2017 to 2022 during the influenza season. And the solid red line is 2022. The very highest peak there in kind of a grey greeny-blue dotted line, that is 2017. So that is the worst influenza season that we have had on record in the past couple of decades. And the yellow line is the five-year mean. So we have certainly had an unusual influenza season in 2022. It was very, very early, so peaking in early May. And the peak in hospitalisations was quite similar to 2019, which was also quite a bad year. So if we look at notifications that would misrepresents the amount of influenza that was around because we know that there is so much more testing now than there was in 2017 and then in 2019 and even more testing in 2022. But by looking at hospitalisations, that is a reasonable way to compare the impact of influenza over those years. So quite a severe season, but very, very early. The graph on the right is another quite reliable source that is the flu tracker. So that is community sourced volunteers weekly reporting incidents of fever and cough and then that is translated to a representation of influenza-like illness. So once again 2022 is in the solid red line and that also we will be picking up in 2022 some of the COVID activity, and you can see there in January there was quite a lot of fever and cough reported that then declined. And then during March, April, May we had really combined influenza and COVID circulating.

And once again similar to the hospitalisation graph, but perhaps a little delayed because the second peak here is probably COVID, that then declined again. So yes, quite a reasonable influenza season this year and no sign of it re-emerging. The numbers are very, very low right now.

So looking forward to 2023, we will have a new formulation of our southern hemisphere vaccine in 2023 in that the influenza A component has been replaced. As usual, we will be expecting our 2023 vaccines in late March and New South Wales Health will be I think doing the pre-ordering confirmation process so that you will be asked to confirm your influenza orders, and the sooner that you do do that, the sooner that they get delivered to you. In 2023, pharmacists will also have access to all NIP influenza vaccines, including the vaccines for older Australians.

Okay. So moving on now to invasive pneumococcal disease. So just looking at the patterns we see of invasive pneumococcal disease in New South Wales in the past 12 months. And this is by five year age groups. So we can see that the number of notifications is highest in the zero to four-year-old age group, and then starting from about 55 years of age onwards, the number of notifications are increased amongst adults. But of course this is not a rate. So while the numbers are in, those are 85 plus are not all that higher than the others, of course the rate will be higher because the population is smaller in those age groups. Another way to look at invasive pneumococcal disease once again in New South Wales and over a 10 year period, is the seasonality of the disease. And I am sure we have looked at this before, but prior to the pandemic we saw peaks of invasive pneumococcal disease every winter and it is thought that there is an interaction between influenza and invasive pneumococcal disease so that it does peak when viruses such as influenza are also circulating. So quite a bad year, in particular in 2017.

The blue line here is the children under five and the black line is people five years and older. During the pandemic, if you recall in 2020, we did not have an influenza season or very much COVID, so there was not very much invasive pneumococcal disease that occurred. And in 2021, we still had no influenza but a little bit of COVID, so that probably prompted a small invasive pneumococcal disease peak that year. But in 2022, invasive pneumococcal disease is back again, quite similar to what we were seeing back before the big outbreak in 2017.

So, before we go into the details of the vaccine recommendations for pneumococcal vaccines, I just like to go through this table to talk about the funded and the recommended groups. So all the conditions on this slide are recommended to have additional pneumococcal vaccines, but only a proportion are funded. So those who are funded to have additional pneumococcal vaccines are those with some types of suppurative lung disease, such as bronchiectasis and cystic fibrosis. Whereas other people with other types of chronic respiratory disease such as chronic bronchitis or asthma are recommended and would be expected to self-fund the additional doses. Other funded conditions are functional or anatomical asplenia, immunocompromising conditions such as haematological malignancy and solid organ transplant and HIV. Whereas those on immunosuppressive therapies or with non-haematological malignancies on chemotherapy or radiotherapy are recommended to receive but not funded. Proven or presumptive CSF leaks including cochlear implants, chronic renal disease with either nephrotic syndrome or EGFR less than 15 mils per minute and prior pneumococcal disease. So this smaller group is funded to receive additional vaccines. The groups of conditions on the right are recommended.

So just trying to keep things as simple as possible, this helps me. So, important to remember that the age for the first dose of pneumococcal vaccine which is now Prevnar 13 is at 70 years of age, and people at 70 years of age who do not have those conditions on the prior slide do not need any other doses of pneumococcal vaccine. Aboriginal people 50 years or over, or people 12 months or over with the risk conditions on the previous slide, should have an initial dose of Prevnar 13 and 12 months later have a dose of Pneumovax 23, and then five years after that a second dose of Pneumovax 23 and that is the most doses that anyone is recommended to receive.

So now I am moving on to shingles vaccine for people 70 to 79 years. So we have two options here, we have Zostavax which as you know is live attenuated, a single dose. Recommended for adults aged 60 years and over and recommended and funded at 70 years with a funded catch up program for people up to 79 years for just under another 12 months, until 31st of October 2023. We now also have Shingrix registered and available in Australia, but not on the national immunisation program. It is recombinant and it is a non-live vaccine. It is a two dose course, two to six months apart, available only on private prescription, but it is preferred for those with significant immunosuppression.

So we just have a quick quiz about Zostvax that Jenny's going to help me with. So if you could move through that.

 

Jennifer: We actually had a question come through that I think relates to this. So if a patient has been vaccinated with the zoster vaccination, what are the pros and cons of also getting vaccinated with the Shingrix vaccination?

  

Vicky: Well, yes. So a person who has received the zoster vaccine is considered fully vaccinated and there is no recommendation for any additional doses. So they would not be recommended to have Shingrix. Now people might have individual circumstances and very particular concerns in regards to shingles, and we do know that Zostavax effectiveness wanes over five to seven years. So I think that would be a question that I would take the individual patients circumstances and discuss it with NSWISS, but generally once the person has had Zostavax, they would not be recommended to have Shingrix.

So first question, that is true. Eligible people can receive the zoster vaccine with their influenza or pneumococcal vaccine. Zoster vaccine is live, but it is fine to administer it with the inactivated vaccines that are influenza and pneumococcal.

Immunocompromised people should not receive the zoster vaccine. Well, yes, that is true. They should not. Now there is some nuance in that question, but the initial response is that immunocompromised people should not receive the zoster vaccine.

The zoster vaccine is not recommended for people aged under 50 years. That is correct. It is recommended for people aged 50 and older, whereas the Shingrix has no particular age recommendation on it. So it could be used for younger immunocompromised people as well.

The zoster vaccine is recommended but not funded for people 60 to 69 years. That is true. And the zoster vaccine is recommended but not funded for people aged over 79 years. And that is also true. It is recommended for all adults 60 years and over and funded for people 70 to 79 years. So it is still recommended for an 80 year old person who has not received it, but not funded. And the main reason it is not funded is that the effectiveness really drops off a great deal. But if a person aged 80 years or over came in and was seeking a vaccine against zoster then you could offer them Zostavax, or depending on their other conditions also discussed Shingrix as well.

Good. Okay, whoops, we are going the wrong way now. That is better. So interestingly, your responses were very similar. There was a national poll that is in the RACGP magazine, I think, I have lost the reference on this one. And this was a poll of over 400 GPs, and your results are very similar to what was found in that national poll.

So I would really just like to spend a minute. And I will probably need to finish up very soon. Zostavax precautions. We are still seeing and saw just last month, cases of disseminated varicella infection following inappropriate administration of Zostavax. So Zostavax is contraindicated in people with current or recent severe immunocompromising conditions and that includes high dose systemic immunosuppression, people on biologic or targeted synthetic disease modifying ARDs, lymphoma or leukaemia or symptomatic HIV. So I think if we have a key message tonight it is that if you are unsure if your patient's immune compromise will be a problem, do not give Zostavax. You can call NSWISS or speak to your patient's specialist, but this is one vaccine where we would really prefer not to give it if there is any doubt whatsoever if it is going to be safe.

Okay, so I think I am just about to go over time. But we have done presentations on travel vaccines before. So just a reminder of the three Rs of travel vaccine. There is routine, recommended and required vaccines. Routine vaccines, so if a patient comes to you for travel, make sure they are up to date with all routine vaccines, especially influenza, COVID-19, that may be also required depending on their destination. Two doses of measles, big outbreaks in many parts of the world at the moment, we do not want people bringing back measles. And also diphtheria, pertussis and tetanus. Just last month we had diphtheria imported from Bali. So really important to make sure routine travel vaccines are up to date in your patients.

Influenza. It is the most common vaccine preventable disease caught by travellers. Well, that was before 2020. Maybe now it is COVID, I am not sure. ATAGI have a recommendation that people who receive the current southern hemisphere vaccine and are travelling to the northern hemisphere during their influenza season, so that is starting now, may receive a second dose of influenza vaccine. And many of our seasonal vaccines have an expiry date of February 2023. So if you have influenza vaccine in your fridge and the person has not had a dose of influenza vaccine, you are quite at liberty to use any leftover flu vaccine to give them another dose before they travel. Recommended, I do not have time, I am sorry to focus on this, and we did do it in some depth last time when we had a webinar on travel. So it does depend on where people are travelling and I would refer you to useful websites such as the US CDC, Travel Health Pro, or Fit for Travel about the local vaccines recommended on your patient's destination. And then required vaccines, yellow fever. To be a yellow fever provider you need to undertake the Commonwealth online training and apply to the local public health unit to become a provider. And important to note that now there is only one lifetime dose recommended.

And the other required vaccines on top of course COVID for some countries are people travelling to Hajj and Umrah, where the meningococcal ACWY conjugate vaccine has to be given within the past five years. So those are the three Rs of travel and I am sorry I had to rush through that, but right now I think I need to hand over to Keira.
 

Keira: Thanks, Vicky. I was going to say I could probably be a little bit faster if I if I needed to be. But that is okay. We can always make time at the end if needed. So thank you everyone for coming, and for those who have joined since we started, what I would like to do, to take the liberty this evening is to talk about what we know about Japanese encephalitis virus in New South Wales. This is the first time we have had a chance to really talk about the vaccine as it applies to locally acquired JE virus and how those vaccine recommendations have come about.

Until this time it, and I guess it flows nicely from Vicky's presentation or the last few slides on travel vaccination, that it was previously recommended as a travel vaccine only. But of course earlier this year, February 27 at 5:36 p.m. on a Friday night, we got the phone call to say that some pigs had tested positive for Japanese encephalitis. And over the course of a few weeks there was Japanese encephalitis virus confirmed in people and pigs, other animals including horses and alpacas, and also mosquitoes across the four states, New South Wales, Queensland, Victoria and South Australia. So all up, over a period of about six to eight weeks, there were a total of 42 humans notified in Australia, 32 of those were confirmed, meaning that we were able to definitively demonstrate a rise in titre, of which 13 of those occurred in New South Wales, and also a series of probable cases for which I do not think will ever be able to confirm those infections.

Now, I am sure some of you were keeping quite up-to-date with the news. Seven of those people died, of which two were in New South Wales. And overall 30 of the infected piggeries were in New South Wales of about 70 total across the east coast of Australia. Now we conducted a serosurvey soon after this outbreak as we were unsure about what it actually meant, this finding in New South Wales, especially because less than 1% of people do show signs and symptoms and we were unsure about whether those 13 people represented the tip of the iceberg. So we visited five towns where we believed that people had acquired the illness based on the public health interview that had been conducted after they were confirmed with the infection, and that serosurvey found that about one in 11 people actually demonstrated positive antibodies to Japanese encephalitis virus. And most notably that was after excluding those people who could have acquired the infection through travel or previous vaccination. So this really does show that their risk is actually quite high and elevated especially in parts of New South Wales.

Now I will say as well that so far we are in a new season, a new mosquito season, the mosquito season has started. It is still too early to know definitively whether we will get more infections in people, but we do know that the virus has been able to overwinter. We have confirmation of one PCR positive pig down in the same region where Japanese encephalitis virus was found last season along the Murray River. So for those of you who are practicing down south and west, please bear that in mind. These vaccine recommendations really do apply to people that live in that area.

The clinical presentation of Japanese encephalitis virus. It is estimated that that less than one in 250 people will experience clinical disease. And those that do, do tend to have quite variable presentations, very similar to Murray Valley encephalitis that is been in the same area for a very long period of time. So fever, anorexia, headache, vomiting, nausea, diarrhoea, muscle aches, dizziness, and then of course you get the much rarer severe symptoms with the photophobia, lethargy, irritability. I will not go through them all here because we will not have a lot of time. But the most important thing is of course this case fatality rate, and all those people that do develop severe infections, between 20 to 30% of people will die, and those who survive, do have ongoing significant neurological, cognitive or psychiatric sequelae. I am thinking in particular one of the cases from the last season who spent six weeks in hospital relearning how to walk, and so we want to really prevent those sorts of infections from happening if we can now through vaccination.

It is believed that if you have a symptomatic patient showing severe disease that it is best if they are referred to the local hospital for investigation and management, and there is no antiviral treatment for infection.

There is really three key tools to disease prevention and fortunately for Japanese encephalitis virus, there is actually a vaccine, which is why we are talking today. But we have to remember that there are also other viruses that mosquitoes carry, particularly in New South Wales. Now the vaccine for Japanese encephalitis   virus, it is safe and it is effective and it is available for people aged two months and older. But it is in short supply, because the situation in Australia emerged so quickly and at such a broad geographic scale that it has been difficult to source vaccine supply enough for the whole country, and especially for New South Wales. We do however have some recommendations for that, that we hope really addresses the most at risk people. Mosquito bite prevention is one of the cornerstones of course of mosquito borne disease, whether it is wearing long sleeved clothing and light and loose fitted clothing and regular repellent use. And we have got a new mosquito bite prevention campaign that is just launched last week. So those of you in regional New South Wales may have seen that, and there will also be some more going on in more urban areas as well. And then of course the messaging about vector control on site, so emptying out, you know, water holding vehicles and making sure that they are putting fly screens on windows. And I would like to hope that those last two pieces of advice can really be advice to patients in addition to any discussion about vaccination.

So there are two vaccines available in New South Wales. Imojev is the one that we have larger quantities of. So for that reason, it is preferred for those people who are eligible. It is a live attenuated vaccine given by subcutaneous injection, and the primary course is one dose. And this is registered for healthy people who are aged nine months and older. There is also an inactivated JE vaccine called JEspect in Australia. For those of you who have been on their state vaccine centre ordering portal, you might have also seen it is called Ixiaro, that is just a different countries labelling and it is related to trying to source enough vaccine supply for New South Wales. Exactly the same vaccine. So it is inactivated, and it is given by intramuscular injection, and the primary course is two doses given 28 days apart. Now this is available for use in infants and children, two months and older, immunocompromised people and pregnant women.

Now, we know that immunocompromise can mean lots of different things to lots of people, and would really like to encourage people to refer back to the handbook on what that means, given that we are in such short supply of JEspect, in particular. So there is information there on how to order for those who have not so far.  Now I have put a note down there to say that supply really is constrained. I do not think I can emphasise enough how constrained the global supply situation is. Every vaccine that we take to provide locally in New South Wales does come from an endemic country, so we need to be very, very careful. We have ordered the manufacture of 100,000 doses, but this will arrive sometime next year, so we have only got a limited supply for now and we need to make sure that this goes to the highest risk people in New South Wales.

So who are those highest risk people? We have got effectively two groups, and these two groups are guided by expert panel advice and some nationally consistent Communicable Diseases Network of Australia recommendations. So in New South Wales and in Victoria, our Victorian colleagues collaborated on this, the free JE virus vaccine is available for people who live in any of those 41 coloured local government areas of New South Wales. They also have to spend a significant amount of time outdoors per day for unavoidable work or recreational, educational or any other activity. Or living in temporary or flood damaged accommodation that might put them at increased risk of exposure to mosquito bites, or are engaged in the prolonged outdoor recovery efforts of stagnant waters following floods. And we know that flooding has been a big topic of conversation and it is a particular concern for people living in western New South Wales. The advice that we have from expert entomologists is that for this particular mosquito species that likes to transmit Japanese encephalitis virus, that was most effective at transmitting the virus, is that it will not come immediately at the time of floodwaters that they will tend to wash away at the time. But what we are concerned about is people who are outdoors over a number of days and in the weeks following floods and engaging in that clean-up, because that is when those particular Culex species will come, and so it is those people we want to protect through this program.

The CDNA recommendations are nationally applied and these are for people who live near or visiting piggeries. And that includes people who might just be there as contract workers, such as pig transportation or vets or others involved in the care of the pigs, and also pork abattoirs and pork rendering plants. And the reason for that criteria is because pigs are a known amplifier of the virus for a short window of time. I think it is about five or six days, the pigs produce sufficient viremia to enable more mosquitoes to become infected and therefore lead to outbreaks in workplaces. There is also criteria for people who work with mosquitoes through their surveillance and also all diagnostic research laboratory workers. Now these are all people who are recommended to receive the vaccine because of local risks. The Australian Immunisation Handbook does also include a group of people who are travelling overseas. That is for people who are, it is recommended, not required, for people who are travelling overseas to Asia and Papua New Guinea for at least a month or more, or for people who live and work in the Torres Strait Islands. But this is not under the funded program. Those people would have to buy the vaccine from the private market and we do understand that the vaccine manufacturers have been working to ensure that there is sufficient supply for those people who will be travelling.

So this gives you a very short summary of how quickly we have been trying to get vaccine out based on when we received vaccine in and there is been a large number of clinics that have been held in western and southern New South Wales. And as you can see in the last two weeks pharmacies also came out online. So pharmacists can also now provide JE vaccine, but again they need to undertake specific training to ensure that they administer the vaccine appropriately. So it is great to see GPs really leading the forefront there of delivering vaccine to the community.

And then this is the communications campaign I referred to. So I am not going to go into it too much, but there is a range of new fact sheets and a new website and other materials available to assist those communications with patients. So I would really encourage everyone to check it out if you are interested. And I think we have also got a few links there to click on later. So given the time, 10 past, I am hoping that 10 minutes is enough for Valerie. So over to you, Valerie.
 

Valerie: Thank you, Keira. That is great. And thanks Vicky. I hope you can hear me and, yes, fantastic. Okay. So, I am going to discuss monkeypox. I have got a lot of slides for you I will not go through in great detail. But basically, it is another new and unexpected infection that we have seen globally and that has started to have an impact on Australia and New South Wales in particular. Really, a little bit about the outbreak. We know that monkeypox, which in fact I should start from today because WHO from today have renamed monkeypox to mpox, so I will try and say mpox as much as possible, but I am sure my slides are already quite out of date. And really, I just do not know if I can, yes, I can swap over. Yes. Fantastic. I was just doing that. Okay, sorry about that. So really the outbreak, the current outbreak, began in May this year and it is been focused on populations of gay and bisexual men and it started mostly identified in Europe as many of you will know. But monkeypox, mpox, is not new and in fact it was identified back in the 1970s and it is been largely in African countries and associated with transmission from animal reservoirs. So it is really been a very unusual situation and certainly we think some of that outbreak has been associated with people coming out of COVID, a lot of summer parties and the introduction of unfortunately this virus into a population that was very active over the summer. And I think you can see from this graph that really illustrates here that the global outbreak is now very much on the decline and that has been the success of really behavioural modifications by far, with people having fewer sexual partners, but also the vaccination program. So that is been huge. It is largely self-limiting, and worldwide we are now over 80,000 cases but we are down to about 600, only notified across the world only last week.

So the monkeypox response has been very prompt in New South Wales. I have to admit it has been a fantastic effort of many, many people involved in this. It was scheduled and became a medical condition, scheduled medical condition, in May and there has been a range of activities as you can see there. The clinical presentation has been described because this is, you know, fairly new, a lot was not known particularly in this new outbreak, and certainly there has now been a number of good publications showing both cases from multi-country but single countries, and it has very, very much been focused in gay men. Some of them are HIV positive, a lot of them have multiple partners.

And really the rash is the most prominent symptom and uncharacteristic compared to some of the previously historical outbreaks, the rash has been mostly anogenital lesions that have been picked up and when I say rash, it can be one or two lesions. But there have been other symptoms including lymphadenopathy that has been described in the past and not seen in some of the other conditions to distinguish it. And the lesions can have the highest positivity rate and viral loads, but it can also be identified through oropharyngeal and anal swabs.

There has been some discussions around whether there is asymptomatic disease or in fact mild disease that might not be picked up, particularly oral sex for instance, where lesions might be in the mouth et cetera. So the jury is still out on how much there may be asymptomatic disease and there has even been some studies looking at residual historical swabs and for other STIs and where they have picked up a very small number of asymptomatic disease. So it is present, but how much it contributes is still out on the jury.

Treatment. It is largely self-limiting, and there is an antiviral available, Tecovirimat. It is been used in one patient here in New South Wales, but basically it really is rare that people have very severe disease, although people have described quite a lot of pain and proctitis in particular. In New South Wales, so the response has been about getting samples to Westmead and SCiLS have been at the primary laboratories doing most of the testing, and you can see the number of samples in blue there over time and the positivity rate. And essentially, you know, we peaked in samples at around 120 back in August and it is reduced, but we have tested now over 600 samples across those labs.

The epidemiology in New South Wales. We are up to 56 cases because there was one on Friday, all men have had sex with other men, three and now four, have a New South Wales likely acquisition because they did not travel, and the ones that probably acquired their infection within New South Wales had other partners, had casual partners. So we do think the sexual transmission has been the most prominent transmission, and we have not really been able to trace cases beyond that because most of those were casual partners.

And just to say we have hospitalised five people mostly for pain management and assessment of some of the side effects. So overall, there has also been a lot of activity with public health units involved, in particular with contact tracing, and that is the numbers of high risk and medium risk there for you. And 15 people have received post-exposure prophylaxis as a result of contact tracing, most of them were sexual partners or household contacts. So there is been a fair bit of communication through alerts through to general practitioners such as yourselves and also a lot of ongoing activities particularly with these sexual health services and networks.

There is a SHIL as you will be aware hotline, which provides and has been really instructive and instrumental in providing a lot of advice to gay men but also clinicians on this. And what has been really, really key are very close communication with our key partners, NGO partners, particularly ACON have been doing a lot of messaging to gay bisexual men in particular.

So the vaccine, the JYNNEOS vaccine is a third generation vaccine which was a third generation vaccine against smallpox, which works against monkeypox, although to be honest there is a lot of data still needed. There is a number of research studies to look at efficacy as we go along, but there is been very promising already data from the US showing that a single dose is likely to protect in this outbreak, men who have sex with men up to 14 times after a single dose. So it is a two dose stage. We think that it should be at least given 28 days apart, but it could be up to six weeks or even longer at this stage, and the program here in New South Wales has been obviously tailored around the issue of accessibility of the vaccine, which of course there has been a very large global shortage.

So initially the vaccine was restricted to a number of groups, and this is the ATAGI priority groups, which basically focused on gay and bisexual men with high risk, sex workers and any other particularly lab workers or clinicians directly caring for people with monkeypox. We have now opened up that eligibility a little bit more now that we have more vaccine available. The rollout here has been that we have received over 23,000 vials from the Commonwealth in New South Wales, and expect a lot more particularly in preparation for world pride as you know, which will be early next year in New South Wales. And we are expecting up to 50,000 overseas guests and up to half a million overall participants. And the rollout began as subcutaneous and has now phased into an intradermal vaccination, which commenced back in September, and that is to optimise up to five doses per vial. The vaccine rollout has been focused in vaccination hubs in particular, but also offered throughout sexual health services. And now there are some dedicated vaccine clinics opening up which have opened up right across New South Wales, as more vaccine has been available. So eligibility criteria now has expanded for all gay and bisexual men, cis and trans, and anyone who has sex with these men, including women, cis and trans as well as sex workers.

So there is now plenty of vaccine, and people who want to access the vaccine can book directly on a VAM booking system at one of 23 sites. Over 10,000 people have used the system already. And this is, I am just showing you the uptake of vaccines over 20,000 doses over the last time and you can see that people are starting to come in for their second doses, in red here as well, which is important. We are wanting to get people to come in for second doses.

Adverse events are obviously also being tracked. This is a new vaccine and the Aus Vaxtracker has at the moment not reported any signals of significance, which is important. And certainly it is really important to keep these data throughout this time.

This slide is just showing the you the CDC's unvaccinated versus vaccinated after even a single dose, showing 14 times higher protection. So in conclusion, this global epidemic has been concentrated in gay and bisexual men.  The limited transmission to other groups really shows that aerosol spread is rare, even on a crowded dance floor. That is going to be a very significant question over pride. The epidemic has now peaked right across the world, particularly in northern Europe and that is been due to behavioural change and vaccination. The rollout continues to be very, very key and certainly something we are very keen to continue communicating to particularly gay and bisexual men. Certainly WHO have not said that this should be a massive action vaccination rollout, it should still remain focused on those groups most at risk. I think we are in a good place, but we need to be very ready for world pride. Thank you very much.

 

Jennifer: Thank you, Valerie.

So I have just popped the learning objectives up. We do have a couple of questions that have come through. So Vicky, I do not know if you wanted to answer this one live. Can patients with non-Hodgkin's lymphoma in remission receive live vaccines? Sorry, Vicky, you are just on mute.

Vicky: That was the one I was madly typing away at, so definitely not Zostavax. Anyone who has had any haematological malignancy should not receive Zostavax. Shingrix is an option for them.

As far as Imojev, it is not as risky as Zostavax, so people with immunosuppression should not receive Imojev. So depending on the person's immune function, you might need to check with the haematologist whether they thought that live vaccine was fine, or you know, obviously quite safe to get the inactive vaccine.
 

Jennifer:  We have had some more questions come through. Would you like to answer those while we still have a few minutes?

Vicky: Yes, someone has asked for vaccine resources, so I think we will put those in to the chat at the end. So, the most important, vaccine resources, the Australian Immunisation Handbook and all the answers to the questions tonight are in there. And then of course we will give you the links to the New South Wales website and also to those, I think the overseas travel websites give much better vaccination information than Smart Traveller, speaking frankly.

How soon can the patient receive Imojev after JYNNEOS? Yes, so JYNNEOS is not strictly a live vaccine. Did you want to speak to that, Valerie?

Valerie: Yes, I am trying to remember. It is live, but it is not live. You do not treat it as a live vaccine.

 

Vicky: So advice is that JYNNEOS does not need to be managed as a live vaccine as far as other vaccinations go, so you could give a live vaccine at anytime after someone had JYNNEOS.

 

Jennifer: Perfect. Thank you for all answering those questions. Thank you again, Vicky, Keira and Valerie for presenting this evening, but I also wanted to thank everyone for joining us online. We do hope that you enjoyed the session and you also enjoy the rest of your evening.