Video of the Childhood Immunisation Schedule Update webinar is available on RACGP Webinars.
Samantha: Good evening everybody and welcome to this evening’s twilight online Childhood Immunisation Schedule Update webinar. My name is Samantha and I am your host for this evening. Before we get started, I would just like to make a quick 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. Alrighty, so I will introduce our presents for this evening. So we are joined by Dr Vicky Sheppeard and Dr Tim Senior. Vicky is a public health physician who has been working for New South Wales Health since 1999. Vicky’s current role is Director of the Communicable Diseases Branch for Health Protection New South Wales. This role includes overseeing surveillance of notifiable diseases in New South Wales, coordinating communicable disease control activities. Oversight of immunisation programs including delivery of the school based adolescent vaccination program, and representing New South Wales on Communicable Disease Network Australia. Previously Vicky managed Health Protection Services in the Blue Mountains and Western Sydney Local Health Districts from 2008 to 2013.
And Dr Tim Senior is a GP at the Tharawal Aboriginal Corporation in South Western Sydney. He is an RACGP Medical Advisor for the National Faculty of Aboriginal and Torres Strait Islander Health, a Senior Lecturer in General Practice and Indigenous Health at UWS, and also a Medical Educator. So, thank you Tim and Vicky for joining us tonight.
Vicky: You are welcome.
Tim: Good evening, thanks. It is nice to join you.
Samantha: Fantastic. Well I will hand over to Tim now to take us through the learning outcomes for this evening and then we will hand over to Vicky to take us through the rest of this evening’s presentation.
Tim: Thank you very much Samantha. So this slide shows the learning outcomes which is education-speak for what we want to get out of the session tonight. So by the end of this online activity, you should be able to discuss the recent changes to the childhood vaccination schedule, identify at risk patients that may require additional vaccine doses, explain possible adverse reactions to childhood immunisations and strategies to manage them, review the process for informing the staff of the changes to the vaccination schedule to minimise administration errors and to correctly update the Australian Immunisation Register once vaccinations have been administered. So hopefully that is what we will all have achieved by the end of tonight. So Vicky, how are we going to open?
Vicky: Ah, thanks very much, Tim. So we will start tonight with just an overview of how we are doing with immunisations in New South Wales and basically it is congratulations everyone. So the first graph is showing what shows on the Australian Immunisation Register for children at one year of age, so the primary course of vaccination for 10 years from 2008 to 2017. And overall, both Aboriginal and non-Aboriginal children are achieving over 94% fully vaccinated. And there is a really marked increase in improvement of about 10% amongst Aboriginal children and we have recently published a paper in the MJA that really details how that has changed and some of the programs that have helped that. So, you know, I guess well done to you all because all your hard work with your patients has achieved this really excellent outcome in New South Wales.
The next slide is about coverage at two years of age and that is certainly above 90% and it is a bit disappointing that since the schedule change with the moving of the second dose of measles to 18 months of age and the inclusion of varicella as part of the fully vaccinated algorithm as well as I think inclusion of the Prevenar doses, unfortunately we know that the kids are still getting vaccinated but due to, mainly due to errors in recording of vaccines in the register it is not showing up as well at two years of age, so unfortunately that is looking like it is just above 90%, even though we do know children are better vaccinated than that.
And then, the next slide shows the really excellent result at five years of age, so completion of the childhood schedule, with Aboriginal children achieving 97% of Aboriginal children in New South Wales fully vaccinated and non-Aboriginal children just about 94%, getting close to 90%. So it is really remarkable improvement over the last 10 years in New South Wales and you know, I can only keep on saying well done, everyone.
But as with all immunisation programs and the reason we need to have these webinars, is that the schedule continues to change and so it is really crucial that we all stay on top of it and understand what is happening so we can continue to maintain these excellent rates of immunisation in children. So, what is on the screen is a poster that you have hopefully received from the Commonwealth Government because it is changes to their program that we are implementing. So, that summarises what the changes are. And what we are going to tonight is go through those key diseases that the vaccines are changing for, so that is pneumococcal, meningococcal and Haemophilus influenza, and look at the reasons why the schedule is being changed and look at the new vaccines and how they are going to be implemented.
Okay, so pneumococcal disease I am sure you all know, it is infection with Streptococcus pneumonia. The infection causes a variety of diseases like pneumonia, otitis media and meningitis, and we measure what is notifiable in New South Wales is invasive pneumococcal disease, so the meningitis, the bacteraemia. So we are not necessarily counting the full spectrum of disease in our data but the vaccine is effective at preventing all forms of pneumococcal disease. So the Prevenar 13 that we have been using since late 2011 protects obviously against 13 types of pneumococcal bacteria and these are the ones that are most prevalent in Australia causing invasive pneumococcal disease.
So this slide shows what has been happening with invasive pneumococcal disease, so the more severe end of the spectrum, with notification rates per hundred thousand in New South Wales children under five years of age and this is from 2002 to 2017. So predating the introduction of the Prevenar in 2005 and including the impact of Prevenar 13. So we have got, looking at the medium blue bars, children under the age of one, the red bars are children aged one year old, green aged two and so on. So, there are a few things that we will notice there. The children in the second year of life from 12 months to two years have been the most impacted by this condition throughout the years. And when that Prevenar was introduced in 2005, there was of course a really marked drop by 80% in the incidence of invasive pneumococcal disease in children and there were benefits across that full under five year old spectrum which improved as time went on. After a few years, we started to see an increase in disease in the under ones and one year olds, and this was due to emergence of some of the types of pneumococcal disease that were not included in the vaccine, particularly 3 and 19A. So, there was a change to that Prevenar 13 in 2011. And that had an impact on disease incidence, but not as great as we saw with the 7 valent vaccine. And then you can see in 2016 and 2017, we are starting to see an increase again in disease in the under ones and the one year olds.
So, onto the next slide and this is a different way of looking at the same information, and it is looking at how the different serotypes of pneumococcal disease have changed over time, so the paler blue bars are the types of pneumococcal that was in Prevenar and the dark blue bars are the types that are in Prevenar 13 and unfortunately with our colours here, we cannot see the non-vaccine types so we will have to fix that up before we send out the slides. So, as expected we saw a marked drop in the 7 valent types with Prevenar, and you can see even more clearly here that the impact of Prevenar 13 has not been as strong as on those additional six serotypes, and starting to rise again. So, this really gives… sorry, Tim? Yes?
Tim: I was just going to say, we have got a question come through, but I think we are going to come to it. Is there a particular reason why there is an increase in disease again in 2016 and 17? And I think you might come on to this as a reason for changing the immunisation schedule, is that right?
Vicky: Yes. That is one of the reasons that we are changing. So there are a couple of reasons behind this. And so the changes are expected to significantly improve both the direct protection, that is in vaccinated children, but also what we saw with Prevenar was community-wide protection and reduction in disease in all age groups. And that has not occurred as much with the Prevenar 13. So what we started to see are some vaccine failures, so children who are fully vaccinated and in the second year of life are getting invasive pneumococcal disease due to one of the 13 serotypes. So, that is counted as a vaccine failure. And so this is something that ATAGI, the Australian Technical Advisory Group on Immunisation has taken a close look at. On top of that, some of the increased disease that we are seeing is due to replacement serotypes. So some are vaccine failures and others are types that are not included in the vaccine but are starting to slowly increase in the population.
So, this is some of the evidence that was looked at of the different types of serotypes of pneumococcal disease that are affecting different age groups. So you can see in the 12 to 24 month group, there is a lot of 19A disease and also 3, type 3 disease, and those are both vaccine serotypes. So not much under 12 months of age, but really affecting children in that second year of life.
And what ATAGI also did is look at the overseas experience. So Australia we have always had what we call a 3+0 schedule, so just a six week, four month and six month vaccines and no follow up. By comparison, in the United States, they have that primary course and then a booster at 12 months. And the United Kingdom has had just a two dose primary course and a booster at 12 months. And both those schedules were getting better protection for children in the second year of life than we were getting with our schedule without a booster.
So, some modelling was done about what we are seeing. So this is a table from the ATAGI public consultation document. The first line there is what we are actually seeing in Australia, so in children under 12 months, one case of severe invasive pneumococcal disease and seven of all types, and then children 12 months and older, 24 cases of severe and 101 of all types. Whereas what is seen in the United Kingdom with a population around three times I understand bigger than Australia, well at least twice as big as Australia, they are seeing a bit more disease relatively in the younger children but much less in the second year of life and the net disease in the UK is less than in Australia. So in the third line there is if we had the UK rate and applied it to the Australian population, how many cases would we see, and we can see there that we are saving almost 80 cases of invasive pneumococcal disease in children under five. So, this is the basis of this recommendation to change the schedule.
So, the decision has been after assessing all of this information that the third dose of Prevenar 13 will move from six months to 12 months of age. So, the first two doses will continue to be given at six weeks and four months, and then the dose at 12 months is considered to be a booster.
So, there are some risks associated with this approach and in particular, we have got to be thinking about children who are at higher risk of invasive pneumococcal disease and we will talk about who they are in a minute. So, they have actually always had a recommendation for additional doses of pneumococcal vaccines, but probably not always been given it. So, those children should continue to receive three dose primary course and then a booster at one year, so a 3+1 course. So, and it is expected that now that all children will get this 12 month dose, we are hoping that that will also have an added benefit that the at risk children will have a higher chance of being remembered to get their full recommended schedule.
So, who are the children who should get additional doses of Prevenar 13? So, here is part of the list of conditions. So asplenia, significant immunocompromising conditions including things like chronic renal failure, organ transplant, any known or presumed CSF leak, cochlear implants, any intracranial shunts and then a further list a group of chronic diseases including diabetes which is obviously rare in very small children, Down syndrome and children who are born at less than 28 weeks gestation. So, all those children should have four doses of Prevenar 13 and then a dose of Pneumovax 23 at four years of age.
So, are there any concerns with this change in schedule? You would have seen on the earlier slides there is a small risk that some children who only receive the six week and four month doses may get some breakthrough disease before they receive their 12 month booster, but that is estimated to be very small. And it is important that at risk children do not miss that third dose of the primary course so that they are fully protected.
Now we have a transition period coming up which we have now started in. So, children who are due for their 12 month vaccination from Sunday are recommended to receive this funded booster dose, so Prevenar 13. Now, some children who were born in the second half of last year, will have already received their, be fully vaccinated with three dose primary course. They are eligible to get the fourth dose as a booster and that is recommended. That is safe. That is the schedule that is used in the United States. It is not going to be funded long term in Australia, but it certainly is fine for children who have already had a three dose primary course to get the booster at 12 months. And as far as being considered fully vaccinated, parents do not have to get that 12 month dose, if the child has had three primary doses in this transition period, they are still considered fully vaccinated.
So I will just break there, that is pneumococcal disease, Tim. Were there any other questions?
Tim: Yes, a few questions have come through. Just got someone, one person wondering if the children of healthcare professionals are at higher risk, just because we tend to be exposed to it and bring it home possibly.
Vicky: Yes, they are not recognised as a higher risk group, and so certainly not funded and you know, pneumococcal carriage is not a straight forward thing. So it is not like viruses that you tend to take home. It is probably unlikely that healthcare workers would acquire carriage and transmit it. It is more likely to be transmitted amongst younger children. But, a bit of a muddy area.
Tim: Yes, and there is someone wondering if parents will opt for, will make decisions based on the number of needles that they are getting, so you get sort of two needles rather than at 12 months or three needles.
Vicky: Yes, so we will go through that a bit later. It does present a challenge. So the six month vaccine point from now on is just the one vaccine, whereas at 12 and 18 months there are three injections required now. That is a challenge and even more so for Aboriginal children who are eligible, you know particularly in other states and territories, where they might be needing to get hepatitis A and other boosters. So, it is difficult but most vaccination experts are happy to give three vaccines at a time, and I think that can be fairly nicely coordinated with a practice nurse so that it can still happen pretty quickly.
Tim: Yes, that is right. And are the injections given at the same time, someone is asking about that.
Vicky: Yes same time.
Tim: How do you feel about that?
Vicky: I mean it is okay to split them, but you know we would discourage that if at all possible because you know that is when we get the risk of kids falling behind and you know the importance of providing the right protection at the right time to be emphasised to parents.
Tim: And what about, so children say 12 to 24 months someone was asking about, who have already received the 12 month vaccination prior to the 1st July, so they are fully vaccinated. They may need, should they have a booster or not?
Vicky: A parent could choose to, but that is not funded. So it is only funded for these children who are just turning 12 months now.
Tim: Yes. And just to clarify about being Aboriginal and high risk for invasive pneumococcal disease.
Vicky: There are some new recommendations for Aboriginal children and we are going to come to meningococcal disease and I saw another question there about is the handbook being updated, and yes the online version will be updated if it has not already and I am sorry I did not check with all this new information and there is going to be a new recommendation that all Aboriginal children up to 19 should be vaccinated for meningococcal B and ACWY. Of course that is not all funded, so there are recommendations that are funded and unfunded.
Tim: Excellent. I think we should move on to talk about the next.
Vicky: See how we go. There is a lot to cover, so we will move on to meningococcal disease and we can always come back to questions if we have time.
So, this is looking at the epidemiology of meningococcal disease in Australia this time and it is going back to 2002. And I have shown a similar graph in the meningococcal presentation we did last year. So this is now updated to the end of March and so what we see here is a dramatic drop in green, in the meningococcal C disease with the introduction of the National program in 2003. We see meningococcal B disease being predominant through both these two decades, but it was actually declining in incidence prior to 2014. But since 2014, we have seen an increase in meningococcal B, but most markedly an increase in meningococcal W, the purple, and an increase in meningococcal Y, the orange. So, as I am sure everyone is aware, we have had, just about every state and territory has had meningococcal W adolescent programs in place.
Just to look a bit more closely at the New South Wales situation, so moving from Australia to New South Wales, and this is just since 2010, we see a similar pattern but with meningococcal B declining but then increasing just in the past couple of years, increasing meningococcal W in green and then we do not know if it is coincidental with the adolescent program, but we definitely got a drop in New South Wales in 2017, and also a flattening of the increase in meningococcal Y.
And then this is again in New South Wales and looking at the age groups that are affected by meningococcal W and Y, so in relation to our new program, and so those two types of serotypes are most prevalent in New South Wales in people over 25 and then children and adolescents, young adults are similar incidence and has remained low in children five to 14 years. Again, that line shows where we introduced our vaccination program.
So, meningococcal vaccine. We have obviously talked about this before, so children until last weekend were offered a combination meningococcal C, Haemophilus influenza B vaccine at 12 months of age, Menitorix. So from Sunday, this vaccine is replaced by Nimenrix and Nimenrix is a conjugate meningococcal vaccine that protects against four serogroups, ACWY meningococcal disease. And we will talk in a bit more detail later, the Haemophilus influenza component of Menitorix is moving to 18 months of age.
So, just a little bit more detail about Nimenrix. It is you know, very similar to Menactra which we have all been using for a year or so now, so it is containing the antigen for serogroup A, C, W and Y. A remains a very rare serogroup in Australia, but it is in the vaccine. As we have discussed, C was common 15 years ago, but has been very well controlled by the meningococcal C vaccine and we have discussed that serogroup W and serogroup Y were very rare in the past but have both increased in New South Wales and Australia in the past few years. So because of this emergence of meningococcal W and Y, that is the reason for the replacement of Menitorix with Nimenrix. So all children who are turning 12 months old from Sunday are eligible for this new vaccine. Now there is no catch up program, so children who have already received Menitorix are not eligible for a free dose. But if children have not yet had their 12 months vaccinations and present now, they are eligible to receive Nimenrix.
And some considerations who are at risk children for meningococcal disease. So, both 4 valent conjugant meningococcal vaccine and meningococcal B vaccine, are recommended for people with asplenia, HIV infection, haematopoietic stem cell transplant, any complement deficiencies and current or considered treatment with ecul – ah there is that word that got me again – eculizumab. And I did mention already that it is also recommended for all Aboriginal people under 19. So, it is only funded for these specific groups on the National Immunisation Program, for children at 12 months of age, and of course in New South Wales we are funding an adolescent program. There is no government funding of meningococcal B, but I am sure you are all aware that it is available on the private market.
So, if parents are not eligible for Nimenrix, for example, their child has already received Menitorix at 12 months of age and they wanted their child to have broader coverage against meningococcal serogroups, they would need to purchase it from the private market. If parents do choose to get an additional dose, you will get the best boosting if you wait eight weeks after the Menitorix or any other dose of conjugate meningococcal vaccine. If parents want to have meningococcal B vaccine and there are now two options, Bexsero and Trumenba, you can give it at the same time as the ACWY vaccine, but remember that in children under 12 the Bexsero can cause a high fever so it is, Panadol is recommended at the same time.
So that is meningococcal disease. I will break there.
Tim: So, yes we have got a few questions coming through about the different brands of different types of meningococcal vaccines and how interchangeable they are and whether you can give one as a booster if people have already had a different brand?
Vicky: Yes, you can. So Menveo, Nimenrix and Menactra are all the same vaccine from different manufacturers. They are considered interchangeable. In the new version of the handbook there is a preference for Nimenrix and Menveo because they have better immunogenicity, but all three of the vaccines are considered you know, good protection against meningococcal ACWY disease.
Tim: Yes. And some people just wanted clarification on that eight weeks interval, because I think it used to be four weeks, and whether you would have an eight week interval between meningococcal B vaccines if it was not given at the same time as ACWY.
Vicky: No, it is just eight weeks if you want to get maximum boosting of menACWY. So if you have Menitorix and then the parent wants to have Nimenrix, then it, or Menveo, then the optimal thing is to wait eight weeks. Bexsero is completely separate it can be given at any time in relation to Nimenrix.
Tim: So, just looking at the other questions again. If a child is between 12 and 17 months now, and already had Hib at 12 months, can they have it again on the new schedule at 18 months now? I think we are coming up towards Hib. We might answer that one later.
I am just looking through the questions. I think we have covered all the questions. The only other thing is, do you know what the costs are of the vaccines available on the private market?
Vicky: Someone always asks that and I should have looked it up. Sorry. Look, the Nimenrix will be in the range of 60 to 80 I expect and the Bexsero we already know is usually over 100 per dose depending on where it is purchased and I am afraid I have never heard a price for Trumenba but I am happy to provide, you know, look send that back with the questions after the session. Sorry.
Alright we might move to Hib disease Haemophilus influenza type B. We are going back even further in time to look at Hib epidemiology both nationally and New South Wales because it has been notifiable for quite a long time. We have got data back to 1991. So these are the numbers of notifications in that, this nearly 30 year period. And the blue is the national numbers and the red is New South Wales. And you can see that there was a relatively high burden of disease, and some of you will remember epiglottitis and meningitis from Hib, it was a dreadful disease and with the introduction of the vaccine in 1993, there was a really rapid drop in incidents and we continue to have very low incidence of Hib disease in Australia. There is very, very little breakthrough of that disease or vaccine failures.
This is the New South Wales data by age group in the same period. So, the blue is children under one, the red is children under four years who had the highest incidence of disease pre-vaccine and the green is children over five. So, in all age groups we continue to have very low incidence in New South Wales. We did have an unfortunate case in a 10 year old last year who was fully vaccinated. But those vaccine failures remain very rare.
So, this is our new vaccine, Act-HIB. So as we have discussed, the fourth, the booster dose of Hib vaccine was given with meningococcal C as a Menitorix. From last Sunday, that Hib component is now separated out and it is being given as a stand-alone vaccine, well a monovalent vaccine at 18 months of age. And you know, it is mainly to balance out the numbers of vaccines rather than giving four at 12 months and two at 18 months. But again, this has been very closely, the evidence has been closely looked at and ATAGI have recommended that moving the fourth dose to 18 months will be safe and effective. So what ATAGI did is obviously reviewed our Australian epidemiology and found only 17 cases of Hib disease had occurred in partially vaccinated children under two and most cases of Hib disease were in children who had not completed their primary course. The US has moved their Hib booster to 18 months and that did not result in any increase in vaccine failures there. So, we do not expect that moving that booster dose will result in any additional cases of Hib. But obviously we will keep a very close eye on it.
So, this transition period, so children born in the first half of 2017 will have had Menitorix do not have to have the additional dose at 18 months. So they will have received the primary course and a booster already if they have been on schedule at 12 months. So when they are 18 months of age, you do not have to give them a second booster. So they will be considered fully vaccinated. They will be eligible for their benefits. But, if parents wish to receive a second booster, so five doses or they are inadvertently given the second booster, that is fine. ATAGI have said that is quite safe. So, you know, you can make a decision with parents either way in this transition period and we have obviously already started distributing these vaccines but if you choose to use Menitorix at 18 months instead of Act-Hib, then that is also perfectly acceptable in this transition period.
I will take a pause before we move onto the other extra vaccine requirements to see if there are questions about Hib?
Tim: Yes, so one or two. Is there a preferred site of administration for the three vaccines? I think that is more than just Hib, but are there any particular recommendations about sites for vaccinations?
Vicky: Yes, per the handbook, so according to age, anterolateral thigh, but then if infants and you can remind me about this Tim, that is anterolateral thigh up to 12 months.
Tim: Yes, that sounds right.
Vicky: Yes, and then the third dose can go in the arm or if they are older, then both arms and one in the thigh.
Tim: And I will send around a link to the immunisation handbook to everyone so that they have all got that. There we go, so that you can all have a look at that after the webinar. So if patients have already received a non-funded Nimenrix after 12 months, is it still safe to receive the Menitorix at 18 months? And I think we covered that, that it is safe to use that with no increase in risk of side effects. Someone was asking out of curiosity why the notifications have showed a fall prior to the introduction of vaccines in the National Immunisation Program.
Vicky: Yes, I was wondering that myself and it is something I should have looked at carefully. It might be, sometimes when notifications first start, there is a bit of a back log in them and it is there was not a longer time period prior to the vaccine introduction. So, yes, they can be counted in more than one year, for more than one year can be counted.
Tim: Ah, lovely. And a few people have been putting through the costs of the Nimenrix and Bexsero. So it is $75 for Nimenrix and about $130 for Bexsero, Trumenba $110 on the Chemist Warehouse website. The question about multiple vaccines, the person who asked is just clarifying that they would have received three meningococcal vaccinations in that case, but that is still safe.
Vicky: Ah, yes. So if they have had the course under 12 months of age, there is detail on that, that the booster is still needed at 12 months.
Tim: And it is not recommended for people to have ACWY earlier than 12 months without a private script.
Vicky: Well, if parents, you know there are recommendations, there is information in the handbook of course for children under 12 months and we did go through that in the previous webinar on, well not the very previous one, but on the one on meningococcal disease, so if parents are seeking earlier protection that is available and then the 12 month booster is still going to be needed for those children because if you are vaccinated under 12 months of age you will usually need three doses and then a booster at 12 months.
Tim: Yes. And someone is just clarifying the varicella recommendations are still the same at 18 months.
Vicky: Yes. Yes and we will go through that in a minute as well, the new schedule.
Tim: Lovely. Excellent. So let us move on. I think it was the additional hepatitis B requirements coming up.
Vicky: Yes, that is right. So just for completion, looking at which children need additional doses, so hepatitis B, there are children born to hepatitis B surface antigen positive mothers, should receive the primary course, obviously the birth dose, the primary course and then serology three to 12 months after the completion of the primary course. And then if their surface antibody is less than 10, it is important to check if they have got infection, so check for surface antigen and these children need to be referred to a hepatology specialist service preferably at one of the children’s hospitals for investigation and management. So that is hepatitis B. And then just reinforcing the additional requirements for influenza which we talked about in the influenza webinar. So remember there is a group of chronic diseases that are recommended and funded to have free influenza vaccine, including pre-term children – infants, and at the moment we have our free funded vaccine for all children aged from six months up to five years. So those are the additional vaccines that you need to think about for at risk children. So, some need meningococcal, some need pneumococcal, some hepatitis B and some influenza.
So, I was going to just briefly talk about adverse events now, is that okay, Tim?
Tim: Just myself, yes. Let us do that.
Vicky: Okay. So, I am sure we are all familiar with adverse events, or AEFIs. So it is defined as any untoward medical occurrence that follows immunisation. And it does not necessarily have a causal relationship with the vaccine. So, obviously common AEFIs are minor like a low grade fever or pain and redness at the injection site. There are rare but serious AEFIs including anaphylaxis. The common ones are as I said mild and will go away within a few days and normally no medical treatment or assessment is necessary. And we have talked in other webinars about AusVaxSafety and that is a good method to monitor your patients and contribute to national monitoring of vaccine safety.
There is a common, this looks a very nasty reaction, it is a very what we call a significant local vaccine reaction, and this is a problem for general practice if a child presents back looking like this, because of course the first thing you think of is cellulitis. But in fact, this is not cellulitis and it does not require antibiotics for management. So, severe extensive limb swelling reactions and redness can be treated symptomatically with paracetamol and cold packs and you know, these are the kinds of reactions that the specialist service would be very happy to you know, look at a photo and help you manage and provide reassurance that antibiotics are not needed.
Tim: Someone was just asking about the incidence of anaphylaxis after vaccination?
Vicky: It’s one in 100,000. It remains very rare, but you know, because we do give a lot of vaccines, there are definite cases every year in New South Wales so it is crucial that every practice has an anaphylaxis response kit, adrenaline ready, and yes.
So, this is about anticipating AEFI’s and many of you will have your own system to do this. But some basic things that can be done is you know, being aware of patients that are known to have severe allergies, have had severe reaction to previous vaccination, a past history of Guillain-Barre or a bleeding disorder, so these patients need careful assessment before vaccination and again the New South Wales immunisation specialist service can help with these patients and in fact if you are very concerned, patients can be vaccinated under medical supervision at the Children’s Hospital Westmead if they are particularly at risk of severe adverse events. And of course, always a discussion ahead of time about the likely adverse events that can occur can help the parent manage and less likely to cause concern and additional calls if they know what to expect and there is former gping New South Wales or PHN resources that can help with showing parents what to expect and how to manage common mild AEFIs. And of course to keep our vaccine system safe it is really important that AEFI’s are reported and this can be done straight to the TGA or to your local public health unit, and any AEFI can be reported, even if it is milder than expected. But importantly if it is more serious or an unexpected event.
Tim: Where can people find out about the specialist clinic service for anaphylaxis?
Vicky: Yes, so I know that Samantha has sent that to us.
Samantha: Correct. I have the link and that will go out to all of you tomorrow in the follow up when I will send you a copy of the slides as well. So you will receive that link tomorrow.
Vicky: So that is a clinic at Westmead Hospital. The phone is manned business hours five days a week, so they will take phone consultations. They can do video remote medicine consultations or have patients to their clinics which I think are Friday mornings. So they are there for advice but also to you know, they will vaccinate children with behavioural problems under anaesthetic and things like that. So they have got a really good website with their services.
Alright, so then I think we will just move on then if it is okay, to preparing your practice for the new changes. So, as we saw with at least the data, with children of two years of age, it does take time once the schedule changes for everyone to get used to it. So we are keen to have that happen as soon as possible. So, front desk staff, nursing staff, make sure that they are all aware of the new schedule. The image on the top right corner has some stickers that we have printed up and posted to all practices, so please have a look out and those are designed to go on the baskets in your fridge, so that it helps your staff identify which vaccines are for which children and there is a poster that correlates with those colours and we will look at that in a minute. And we have also mailed out a new A4 schedule which we will look at in a minute. And on top of that, we have sent a fax to you all. We have got frequently asked questions on our website and Samantha also has that link which will be sent out. And also the Commonwealth Government has sent out and made available a range of resources.
So that is the knowledge aspect of it, but you know updating your practice software is also really important so that the vaccines that you are giving are recorded properly. So you need the latest software to have the new vaccine brands available on the drop down list, and make sure in this transition period that you are selecting the right vaccine that you are giving to the child. And that is really important for us to be able to monitor, particularly as we are trying to look very closely for any unexpected vaccine failures and things. It is really important that the correct vaccines are recorded. And of course, continue your usual practices about running reports on your practice software, looking at getting overdue children in to get them caught up.
So this is an image of the new New South Wales Schedule which has been posted to all practices. And so I hope it clearly, it gives you, there is also some other new vaccines on there. So there are some of the age points there is Tripacel I think is a new vaccine that is equivalent to Infanrix and Adacel is also available instead and equivalent to Boostrix. So, hopefully you have received that schedule.
And the next image is a poster that we have also posted out to you, and we are hoping it might go on the fridge. And the colours down the side correlate to, correspond to the colours of the new stickers that we sent you. So we hope those resources are helpful to easing the transition to the new vaccines.
So this is just looking at the new vaccines again, so while Prevenar 13 is not new, you are very familiar with it and the thing to remember there is finding your at risk children and making sure they still get the three dose primary course.
This is what Nimenrix looks like. So this is the vaccine that you give to children at 12 months of age.
And this is Act-HIB which is the new monovalent haemophilus influenza B vaccine at 18 months of age.
And just finally a note about pertussis vaccination for pregnant women. Until 1st July the New South Government was funding it. That has now shifted to Commonwealth funding, but it is still recommended for all pregnant women in the third trimester, ideally at 28 weeks. The change there is that we have only previously supplied Boostrix, but now Adacel will also be supplied, so either of those vaccines are fine for pregnant women.
So, we have five minutes left, Tim.
Tim: Excellent. That is good, we have covered a lot of information. We have still got some questions coming in. A couple of people are asking about whether paracetamol is recommended routinely before or with childhood vaccinations, or whether there is any side effects from doing that?
Vicky: It is not recommended at all, except with Bexsero. So, the recommendation is that it is not given for all vaccines and used if a fever develops, but with Bexsero it is recommended prophylactically because of the high incidence of fever in children under two.
Tim: Yes. Someone is asking if vaccines can be given early, for example if someone is overseas at the due time, what variation of the schedule?
Vicky: Well, there are some, there are two things to consider. One is what age the vaccines are licenced for and how early you are giving it and what the risk is. So that is one consideration. That is a clinical consideration. And there is another consideration which is you know, the register and the schedule and what age that the register will accept a valid dose. And those are two different questions. So the first is you know, in consultation with the parents and the handbook to look at you know, what might be reasonable and needed for that child. The second thing, and I am afraid I do not have time to go into detail with do over rules but there is a risk that if a vaccine is given too early that the register will not accept it and the parent then will not be eligible for childcare or benefits when they come back and might have to repeat the dose. So.
Tim: That is right. I have seen that problem happen.
Vicky: So it is not an easy answer but it is something that can be worked through, but needs to be worked through on a one by one basis I am afraid.
Tim: Yes. A few people with just some clarification questions. If someone has a fever of 38° C, should they be given vaccine?
Vicky: Yes, look 38 I think is getting high. Under 38, then it is usually fine, but at 38 you would be wanting to defer the vaccination.
Tim: Yes. Some clarifications around pertussis. So just to clarify, it is recommended for women in each pregnancy. So if she is pregnant in 2016 and 2018, she gets pertussis in both of those years for each pregnancy.
Vicky: That is correct.
Tim: And what, is the same true about her husband or partner?
Vicky: No. The recommendations for other adults remains every 10 years and of course it is not funded. And the reason we vaccinate women every pregnancy is the really important role of placental transfer of antibodies, so that is the reason to give the frequent vaccination to women.
Tim: Someone was asking another vaccination question which was another webinar we did a while ago. That was zoster vaccine. Is that available after 80 years funded and my memory of that webinar is that it is not after 80 years.
Vicky: That is right. It would be a private script because the efficacy of over 80 is low and not judged to be cost effective.
Tim: Yes. Does it, can Adacel be used in pregnancy instead of Boostrix?
Vicky: Yes, definitely. It is interchangeable.
Tim: Yes. And for pre-term children, should vaccines be given at the age according to the birth or the calculated age according to gestation.
Vicky: Certainly the schedule that we are talking about now is their age according to birth, yes.
Tim: Yes, okay. Someone is asking - I have got twins and I would never have thought of this question – should women with twins be given double doses of pertussis? I suspect not.
Vicky: No. No, the mother just gets the one dose and that will, they will get equal transfer of good levels of antibodies from the mother. They will be shared beautifully.
Tim: Ah, excellent. Just looking through. Those are the main questions. Someone is asking what to do with expired vaccines.
Vicky: They, if they have expired they just need to be wasted and then with re-ordering that reported on the request for resupply.
Tim: On your screen, those are the learning outcomes that we had, that we announced at the beginning and so we hope that we have covered each of those and that now we have reached the end of this online activity that you are now able to do all of those things.
I would just like to thank Samantha for running the presentation and all the technology so smoothly. I think that has been very good and thank Vicky for another really useful webinar on the immunisation changes. So thank you very much indeed.
Samantha: Thanks everyone.
Tim: Any final words?
Samantha: I do not think so. And also thank you Tim as well for fielding and answering questions this evening as well.
Tim: Pleasure. And good evening to you all and I hope this was useful. Have a lovely evening. Thank you very much.
Vicky: Thanks Tim.
Samantha: Good night everybody.