Video of the Flu Vaccination Update 2019 webinar is available on RACGP Webinars.
Samantha: Good evening everybody and welcome to this evenings flu vaccination update for 2019 webinar. My name is Samantha and I am your host for this evening.
Before we jump in, I would like to make an acknowledgement of country. We recognize 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'd like to introduce our presenters for this evening.
We're joined by Dr. Vicky Sheppeard. Vicky is a public health physician who has been working for NSW Health since 1999 Vicky's current role is Director of the Communicable Diseases Branch at Health Protection NSW. This role includes overseeing surveillance of notifiable diseases in NSW coordinating communicable disease control activities, oversight of immunisation programs including delivery of the school-based adolescent vaccination program and representing NSW on Communicable Disease Network Australia.
And we're joined by our facilitator tonight also, Dr. Tim Senior. Tim is a GP at Tharawal Aboriginal Corporation in South Western Sydney. Tim is also an RACGP medical advisor for the National Faculty of Aboriginal and Torres Strait Islander Health and Senior Lecturer in General Practice and Indigenous Health at UWS and an RACGP medical educator. So welcome Vicky and Tim and thank you for joining us this evening.
Tim: Thank you very much. Good evening everyone, nice to join you on this Wednesday evening.
First of all we'll go over the learning outcomes which is educators speak for what we want to accomplish this evening. So by the end of this activity, we should be able to prepare ourselves for the 2019 influenza season, understand the factors contributing to varying influenza impacts in NSW in recent years, learn about the impact and outcomes of the 2018 influenza vaccine to children under 5 years of age, be aware of the formulations of the 2019 influenza vaccine and their optimal use in eligible age groups and utilise the NSW Health flu vaccination toolkit to optimize vaccine supplies and maximize uptake of influenza vaccine. So without further ado well pass over to Vicky. Good evening.
Vicky: Thanks Tim and good evening to everyone. it's good to be back and once again talking about flu and I guess even though we've done this for a few years, the thing about flu is that it changes every year, so there's always something for us to learn and be ready for.
So the first graph that we have tonight shows the number of notifications of influenza A and influenza B amongst NSW residents for the past 10 years. Influenza A is the black graph and influenza B is the yellow line. So what we see there is a number of things, in most years influenza A is much more common. We had a very big peak in 2017 so that went to before you last, you'll recall was the worst that we'd had since the pandemic. And then we also had relatively big years in 2016 and 2014 and right over on the right-hand side of the graph, you can see the final numbers from 2018 and and we had one of the milder seasons in a long time because as the decade has progressed we're getting a lot more testing in general practice and so a lot more notifications of flu and yet despite all that testing last year we had quite a mild season. Now there's probably a number of reasons for that and we'll just look at a few more features of the season and then we can think about why that happened.
So last year these two graphs here are showing the just the 2018 experience for influenza A on the top graph and influenza B on the second graph by age and sex. So we can see that children under 10 years of age were most affected as far as the number of notifications go and then peak you know gradually increasing amongst mid-range adults particularly for influenza A but quite a lot of sparing of the elderly and that is a feature of influenza A when we have H1N1 the pandemic virus predominant which we did last year that we get relative sparing of the elderly. The pattern of influenza B was a little different so we do see a bigger blip there in the over 85s, noting that the relative number of notifications between these two groups, that the axis on the a is you know 10 times that of B so the absolute numbers of influenza B was much were much less but a slightly different age distribution.
The next graph is looking at cases reported from Sentinel GPs, this is through Aspirin, and the dotted line is the NSW in blue and the national rate in from the bad year 2017 and the solid line is our experience last year, so clearly I hope all your practices experienced a much milder flu season in 2018, it's very hard to even see a peak there in NSW last year.
And then we've also got this graph showing emergency department activity, so the solid black line is 2018 and the pink line is 2017, so the top graph is about influenza-like illness which is quite a specific category and the lower graph is emergency department presentations for all respiratory and fever. So once again different numbers of patients on the axes but we can see again that emergency departments didn't have a lot of increased activity from flu in 2018 particularly compared to 2017
And then the final one we have on looking at the 2018 season are from our three Sentinel hospitals, so Westmead Hospital, Westmead Children's Hospital and John Hunter Hospital, where we have active surveillance for flu. And this shows the types of the spread of the flu season last year amongst patients presenting to those hospitals with confirmed flu and once again showing that the orange and yellow and red which is all the influenza A, compared to influenza B shows the predominance of influenza A causing severe disease. While we don't have comparisons to other years, this is certainly fewer than the previous years though we did get quite a lot of, still get quite a lot of admissions at Children's Hospital Westmead from quite sick children.
Tim: We have actually had someone asking has there been more influenza A in the last two months?
Vicky: Yes. So that's right, so after that very quiet year and so last year 2018 was quiet and you know there was some really positive things going for us. First we had a very severe year in 2017, so a lot of people caught flu in 2017, so would have had persistent protective immunity. We also had a season dominated by the H1N1 the pandemic virus and we know the vaccines highly effective against that, and on top of that we distributed about 2.3 million vaccine doses in NSW - so we had more than 50% higher uptake of vaccine in 2018 than we had ever had before. So we'd had an immunising event in 2017 through a severe season, then we had fantastic uptake of vaccine and the vaccine was really well matched to the predominant virus. So that was great for last winter but then at the end of 2018 and starting about December we started to see increased influenza A activity up in Northern NSW which we've thought was related to the outbreak in the Northern Territory that was going on but and then in January we started to see returning travellers with influenza mainly A again both H1N1 and H3N2 and it's been quite remarkable. We've see this phenomenon every year in January and February, but this year it's probably double the number of notifications we've ever seen and it has persisted into March. So that has an impact on what we need to do to prepare for the 2019 season, which we'll get on to in a minute.
So just finalizing 2018, you know despite a mild season we identified at least 43 deaths including in one previously healthy young child and there were very few outbreaks in aged care facilities compared to other years, only 46, whereas in 2017 we had over 500.
So what do we expect this year? So in North America has had a similar season to what we saw last year mainly H1N1. Europe has also had a milder year but has both types of A circulating. The vaccines been updated so the H3N2 component has been updated to a strain to better match what's circulating and also the B component of the 2019 vaccines been updated. So we expect that the vaccines that are manufactured for us this year will be very effective again against h1n1 and against the B strains and it's a bit of wait-and-see about how the h3n2 component will perform. Also good news the circulating virus is has no resistance to Tamiflu so it will be effective but as we started to say these high levels of summer flu that aren't going away, we don't yet know if that's going to finally start to decrease or we'll keep on at this level and then start to increase. And we'll talk a bit later about how we're going to manage the vaccine distribution strategy - to deal with that and because of the strains that are likely to predominate we expect once again the elderly and young children to be most affected in 2019.
So how do you keep up-to-date with what's happening about flu? We issue monthly reports until May, and from May we issue weekly reports and they're on this web page so if you want to know what's happening with flu and see all these graphs about and information about the various indicators, please use that webpage.
So still staying on 2018, what was the impact of flu and children under five? So they had the highest rates of hospitalisations, so similar to those over 65. We observed complications, such as pneumonia and encephalitis. Every year we have deaths reported in children from flu, so there's been 20 deaths in 13 years and we had at least one last year. And what we do know about flu in children is that death is not restricted to children with high-risk medical conditions, it just equally affects who previously perfectly well children as we saw last year in NSW and has already been seen this year in Victoria and Western Australia with previously well children dying from flu already.
So how did we do with our flu program last year in NSW - the under five flu? So we distributed about a quarter of a million doses of FluQuadri Junior to general practice and about half of those had a record in the Australian Immunisation Register so the data that we're showing now is from vaccines that GPs in NSW reported to the register for flu last year. So on the left we have graphs about Aboriginal children, on the right is non-Aboriginal children and we're looking at age groups six months to one year in yellow, blue is children one to two years of age, red is children two to three and grey is children three to five. So there's a number of things we can see, so children, infants six months to one year of age had achieved the highest vaccination reported vaccination rates in 2018, so 35 percent of them received at least one dose which is very you know it's a great uptake for the first year. About 30 percent of one year olds received a dose and then about twenty four percent of children two and over received a dose of at least one dose of vaccine. So that's you know I think a very good start to the first year of the program because GPs and parents were all learning about it and I think we realized that reporting to the AIR is still not kind of routine for non national immunisation program vaccines, so we don't know the extent of under-reporting and I don't know Tim if you have any comment, if you are aware of how routinely these vaccines administered to children flu vaccines might have been reported to the AIR?
Tim: I'm not sure I'm thinking about our own service and I think I think you're right I think it would have been less routine than the childhood vaccination program because their systems would be these are probably more likely to report as an adult vaccines, so I suspect it's a reasonable representation. We do have a question as well just wondering if the fortunately small number of deaths and children they did they occur in non immunised children?
Vicky: That's right. So going back to that so the graph for example where I showed the admissions at Children's Hospital and Westmead and John Hunter, out of and the most of those were children, only one had received the vaccine and that was a child that was medically indicated, I think lymphoma or some condition that made them highly susceptible. So that was the only child that was admitted that had received a flu vaccine. So the vaccines obviously not going to provide 100% protection. The vaccine effectiveness that was calculated with about 75% for children, so that's you know three-quarters reduced risk of being hospitalised with flu if if they were vaccinated last year.
Tim: When pharmacists give immunisations do they go up to the immunisation register? I'm not sure they have access to it do they?
Vicky: They do. Pharmacists are actually, in NSW for a pharmacist to be allowed to vaccinate we require them to report to the register. Pharmacists are not allowed to vaccinate children though, only people 16 years and over can be vaccinated by pharmacists.
I guess the other really pleasing thing about the these graphs is that what the coverage in Aboriginal children is actually higher than non-Aboriginal children and prior to this year, even though, prior to 2018, even though flu vaccine was free for Aboriginal children we were only getting less than 5% vaccinated, so having a program that's available for all children, has you know greatly improved the coverage for Aboriginal children as well. So that's another positive we see from 2018. So that's that's about all I was going to say about 2018. Are there any other questions about that we should touch on?
Tim: So someone asking what strain was responsible for the summer outbreak?
Vicky: Yeah the summer break is A and it's about 50/50 H1N1 and the other half is the H3N2.
Tim: Lovely thank you. The other questions we've got we'll cover later on in the presentation.
Vicky: Okay well I'll go on to this year then to 2019. Alright so the Chief Medical Officer has issued advice and I think you've received a letter from him or should have. So continuing to advise that annual vaccination is the most important measure to prevent flu and its complications. Annual flu vaccinations recommended for all people six months of age and over.
We have very important new funding information that all Aboriginal people six months and older are eligible for free flu vaccine, so before there was a gap Aboriginal children from five to fourteen weren't funded, now that's been changed and the Australian government is funding vaccine for all Aboriginal people six months and older.
And then similar to last year the optimal protection against flu occurs in the first three to four months following vaccination and that's I guess most important for the elderly, which is why we're recommending vaccination in April or May. And the full statement's on the department's website and we anticipate that the annual statement from ATAGI the Australian Technical Advisory Group on Immunisation will be published very shortly to help support vaccination practice this year.
Alright, so mentioned this already so the vaccine in 2019, the four valent vaccines covered two A strains and two B strains and the trivalent vaccine which is Fluad will cover two A strains and the Yamagata B strain which is the Colorado lineage Yamagata lineage and the Colorado strain so there's two new parts of the vaccine. So the vaccines available I think are a little less confusing than last year but still requires some concentration. So under Government funded programs we've purchased FluQuadri Junior for children six months up to three years of age, so that's the same vaccine that was used last year and it's a quarter of mL. There's also three other 4-valent vaccine so this FluQuadri and Fluarix Tetra. Now they're on the national program for people three years and older but important to note that the registration of Fluarix Tetra has changed, so it's now licensed for six months and older. So that gives a bit more flexibility and we'll talk about that a bit later. Also the Afluria Quad, the Australian manufactured vaccine, has a change in its age indication before last year it was only for people 18 years and older but now it's licensed and on the NIP for people five years and older. So I'm sorry about all those changes but it probably does give a bit more flexibility with the vaccines that are available and it's good to know, so the Afluria Quad was like the old Fluvax that CSL manufactured and you'll recall that we had the problems in 2010 with their bowel reactions with children and for a number of years well since then haven't used it in anyone under ten there's now a lot of data from the United States in particular where this vaccine is being used in thousands of children and it's really quite safe, so that's why it's now licensed down to five years of age in Australia.
For the over 65s, this year there's only one vaccine available on the NIP that's Fluad so we had that one last year that's the vaccine that has an adjuvant in it and so that's only licensed for people 65 and older and that's the preferred vaccine for people over 65 and over on the NIP. The other one that we had last year Fluzone High-Dose is not on the NIP anymore but it will be available by prescription by pharmacies, but obviously patients would have to pay for that so the ATARGI recommends that these two vaccines, there's no preference between them and but they're both preferred to the quadrivalent vaccines for people over 65, so the strong recommendation is to use Fluad for people 65 and over.
So you've probably seen this, it's a part of the Commonwealth materials that summarises that, the slightly, the varying age groups and eligibility of the five vaccines that are on the National Immunisation Program. Noting that the Fluarix Tetra, while it's currently not on the NIP for anyone under three years, it can actually be used for children from six months of age. Okay, I see some questions there about the trivalent vaccine but maybe we'll talk about those as we get go through each of them.
Tim: Yeah, that's what I was thinking.
Vicky: Yeah so this is the pack shot of the under three vaccine in the FluQuadri Junior. So because of NSW funding, any child aged from six to 35 months is eligible for this vaccine free. If it's their first year of being vaccinated they should have two doses, one month apart. And we do know there's an increased risk of febrile reaction if it's given with the pneumococcal vaccine, which is of course due at 12 months of age, so it would be parents would need to be warned about that and perhaps using panadol prospectively or separating the doses if a 12 month old presents for flu vaccination. So this is FluarixTetra.
Tim: So can i just interrupt?
Vicky: Yeah.
Tim: Just one question about the previous one, someone just confirming asking can you use half of FluQuadri for FluQuadri Junior?
Vicky: No you can't but you can use Fluarix Tetra and dose for Fluarix Tetra, irrespective of age is half a mil so there's no half doses. So I guess that's a simple message, that we can remember. There's no half doses. You can either use the FluQuadri Junior or if you are using Fluarix Tetra in a child under three, you still give the full half a mil. But just remembering, I'm you know in the NSW program children eligible, we haven't funded vaccines, so we should be using the FluQuadri Junior that we've purchased for those children, even though as far as registration goes, this Fluarix Tetra could be used under three. Well it's only free for children 6 to not 59 months of age if they're eligible on the NIP. It's free for all Aboriginal people five years and over, pregnant women, people with medical risk factors from five to sixty four years of age and once again, if you're vaccinating children from 3 to 9 years of age, the first year they receive a vaccine they should have two doses a month apart and both doses are funded. FluQuadri, it's free for all children in NSW from 36 to 59 months of age, all Aboriginal people 5 years and older, pregnant women, people with medical risk factors and once again, two doses a month apart in the first year and and don't give a half dose. It's not licensed for that.
Tim: So just on those two doses someone's asking if someone has just one dose and misses the second, do they need do they get two doses next year or just carry on single doses?
Vicky: That's right Tim, if they don't get the second dose the first year, the next few they just get one so they will have had less than optimal protection the first year they were vaccinated, but from then on they'll get optimal protection from one dose.
And here's the Afluria Quad so noting it's available five years to sixty four years on the NIP, so for Aboriginal people pregnant women, medical risk factors, and then children five to nine who might be eligible because they've got medical risk factors, they would need two doses and you know, please don't use it under five, it's not licensed for people for young small children.
And here's the Fluad so this is licensed only for people 65 years and older, just three strains of vaccine flu in there and it has the adjuvant. So you know there's a couple of questions in there about why would why to use this instead of the quadrivalent, and as like the advice from our experts from ATAGI is that this is preferred because of the enhanced immune response that's created by this vaccine. The B strain that that is in there is the one that was circulating last year and you know still seems to be circulating, so it should be providing the best protection for people over 65. We'll of course be monitoring closely the strains that are circulating and you know if there's any concerns that we're having a predominance of the victorious strain we'll of course provide any updated advice from ATAGI but at this point in time this is the recommendation for the over 65s.
Okay, so I think I've pretty much covered the material in this slide, so you could tell your patients that this vaccine provides around a 25% better protection than the standard flu vaccine. So a number of very large studies have shown that, so that's why it it's preferred. No flu vaccine is you know obviously anywhere near 100% effective so we're looking at at relative performance. Fluad recipients might get a more marked local reaction than people having a quadrivalent vaccine but that's because of the enhanced immunogenicity, and as I said before the Fluzone High Dose which is quadruple the strength rather than having an adjuvant is only on the private market this year.
Tim: And is there any danger if that's accidentally given to someone under 65 years of age?
Vicky: Well there's no studies to know and that's why it's not licensed under 65 at the moment Tim, so you know we do get a lot of inquiries about you know immuno-compromised patients under 65 and could they have it? I'm afraid it's a it's at the moment an evidence free zone, so that's your, we can only recommend what it's licensed for and what studies shows, so there's we really don't have any information on that. I'm aware that there are studies underway on younger immunocompromised and other otherwise susceptible people and once that data comes in then we can make recommendations.
So other changes in 2019, as you've already highlighted, appropriately trained pharmacists can provide flu vaccine to persons sixteen years and older, but we've already talked about how their, how pharmacists are required to report all vaccines given to the Australian Immunisation Register and they're also required to advise patients if they're eligible for a free vaccine via their GP. So I hope that's all in place.
So I was just going to go on and talk a bit now about planning for the vaccination program this year and we've had very good feedback last year from RACGP and AMA, they helped us with a debrief and we also got feedback from public health units. It was quite staggering year as I said with 2.3 million vaccines distributed so we've made some changes to how we're doing things this year and I hope it assists practices in preparing and managing the flu vaccine program.
So we've produced a flu vaccine provided toolkit which is on our website. It has a checklist there that is meant to help you prepare your practice about what you should be doing when, to get ready and including when to place orders and so forth. There's a decision aid in the toolkit about assessing patients, adult patients for flu vaccination and we've also provided a workbook which, there's a link you can download the spreadsheet from our website and because some of the feedback we got last year was people didn't know how many vaccines to order, they were running out before we could resupply.
So basically with the a number of practices in NSW it takes us three weeks to get vaccine out to all those practices, so the worksheet helps you estimate the number of patients in your practice that need to be vaccinated, how many you can vaccinate per day, how many to order in your first order, and then how many are order in your subsequent orders so that you can maintain enough stock to meet the expected demand.
So we hope that's helpful and we you know something we'd really appreciate feedback on and we'll obviously be talking to RACGP and AMA again at the end of the season to get feedback as to whether this helped us all cope better with this very busy time of the year. But that said we always have to be a little bit flexible with flu and we had it we would normally have in what we flagged in this toolkit is that we are going to start distributing mid-April but because of the level of influenza that's still circulating, particularly affecting aged care facilities, we've already got our supplies of Fluad in, so we're actually going to start distributing to aged care facilities tomorrow and we should have enough Afluria Quad in by next week so we anticipate starting to deliver to general practice next week. So we will be done.
Tim: Someone's asking, apparently pharmacists already have their supplies in, is that right?
Vicky: Yeah well, pharmacies purchase from Seqirus and Seqirus because they're an Australian manufacturer, they're the first ones with flu vaccine available, so we've got just received our Fluad today and we anticipate having a good supply of AfluriaQuad by next week so it's very likely that pharmacies are also getting those vaccines, well they won't have the Fluad but they'll have Afluria Quad and maybe Influvac, which is another vaccine that's not on the NIP, so yes pharmacies will have vaccines now.
So we will be sending a fax out to all GPs, fax and email probably tomorrow, to keep you updated about when to expect your deliveries, but I guess the strong message is that don't actually book in any clinics until the vaccines in your fridge, prioritise the elderly and pregnant women once you receive appropriate vaccines for those ages. We're probably going to have to wait a couple more weeks before we've got vaccine for children, but as soon as you do get that, really encourage you to be vaccinating children as well because we're seeing a lot of you know impact on children and the elderly at the moment.
So also to help managing the program we're producing similar resources to what we produce last year and we'll send these out with vaccine deliveries. So there's a poster that illustrates the vaccines and the indications, that you'll receive and also the stickers to go on the baskets for your fridge to help you more readily find the vaccines that you need to use. Well obviously might have to amend these a little bit because of the changes for FluarixTetra.
Okay we're running a similar campaign to what we ran last year, so using the same kind of idea about preventing flu is in your hands, getting vaccinated, keeping your hands clean and staying at home. So again those posters will come to your with your vaccine delivery but one of the lessons from last year is that we won't be strongly promoting vaccinations until May, because we want to make sure that all the vaccine is available in general practice before we're pushing people to get vaccinated. But as I said, once you receive vaccine we'd like you to be vaccinating your older patients, your pregnant women and children once you get the vaccine that's available.
So a practice checklist. So certainly if you haven't already ordered your flu vaccines make sure that you do that now. Be checking your cold-chain measures and making sure that the fridge has space for the vaccines that you're ordering. We have in the tool kit, we've got dimensions of the various packaging of the vaccines to help you estimate how much space they're going to take up. I think it's you know giving this information to all your staff, particularly your vaccinating nurses so that they're familiar with the different age indications for the different vaccines, upgrading your practice software is important because that's how you are able to then automatically choose the vaccines that you're giving to then automatically report to the register. Don't forget to vaccinate your practice staff so that they're protected, and plan to maximise uptake particularly in children and pregnant women. But all those all the priority groups, Aboriginal people, people with chronic conditions and the elderly.
If your patients have questions about flu vaccine safety the AusVaxSafety system is now very reaching a lot of practices across Australia, so for example last year there was 16,000 children who participated in the flu vaccine safety reports, so this is when the practice software automatically sends an SMS to the parents a few days after vaccination asking them if there's been any adverse event. So of the 16,000 children who were part of that surveillance last year almost 94% the parents said no, nothing happened. Of the 6% that did report some kind of an event, it's mainly the expected things with a swelling at the injection site, 2% had a fever and less than 1% sought medical attention for the adverse event that happened after vaccination and which may of course not even be related to vaccination, that they had seen a doctor. So that's I think reassuring to parents and this SmartVaxSystem is still available if your practice wishes to participate in it. And we've talked about that before Tim I don't know if we need to.
Tim: We have, that's right. We've got quite a few questions come through so it might just some of them we might cover during the case studies but I think can't there's some theme so if it's all right I'll just start, we'll just take a moment to enter some of those if that's okay?
Tim: One is about contraindications to vaccines, if there's any new contraindications or particular contraindications that we need to be aware of?
Vicky: Yeah, so the only contraindication to flu vaccination is prior anaphylaxis to flu vaccine or any of its components. There are precautions, so prior if you previously had Guillain-Barre then would seek specialist advice before vaccinating. But and of course severe egg allergy is also severe anaphylaxis to egg is a precaution and but if they people with egg anaphylaxis or egg allergy can be vaccinated under medical supervision so as long as you've got an adrenaline kit and observe them for half an hour afterwards or you could refer them to the specialist immunisation service at Westmead Children's Hospital, where they can, egg allergic children can be vaccinated in their specialist clinic.
Tim: We've got a few questions coming about the timing of flu vaccine with other vaccines for example pneumococcal vaccine at different age groups or special populations like patients is that a splenectomy, as a what what's the advice on the timing of influenza vaccine with pneumococcal vaccines and with childhood immunisation vaccines?
Vicky: Yeah so pneumococcal is the only, the Prevenar is the only vaccine there is a precaution about increased risk of fever so all the other childhood and adult vaccines flu can be given at the same time and there's no indication of any increased risk. For people who've had for example hematopoietic tem cell transplant they should have two vaccines in the first year that they're vaccinated against flu after their transplant, but otherwise immunocompromised people don't require it, just require one dose of flu vaccine, of course they may not get the same response to others, but only one doses is recommended, except for those people who have had basically yeah their immune system wiped out.
Tim: Yeah lovely and quite a few people are asking a question that's asked every year I think about there any recommendation for giving two flu vaccines several months apart to cover the later part of the flu season or a winter or a summer flu season?
Vicky: Not for winter flu but I believe when the ATAGI statement comes out there is consideration if someone's travelling to the northern hemisphere then the second for our summer, then consideration of a second dose either of leftover southern hemisphere vaccine or the new northern hemisphere vaccine if available could be considered.
Tim: Yep but it's not a routine recommendation to do that even if it's even if the coverage tails off towards the last few months?
Vicky: No, not at the moment but it you know once again we need to be closely monitoring what's happening and yeah additional advice could be issued at a later stage.
Tim: Yeah because my understanding is that's an evidence free zone as well, some people are recommending it but there's no real evidence either way is there?
Vicky: That's right.
Tim: Just looking see as a few questions about the how well the vaccine works in breastfeeding mothers and if there's any special or particular flu vaccine we should be recommending or and how effective it is in breastfeeding mothers?
Vicky: Yes it has not a lot of studies but the expectation is it's just as effective in a breastfeeding person as it is in other people. Of course it's not funded it but it would be recommended, it would contribute to protecting the infant, sorry, what was the other part of that question?
Tim: Oh it was um yeah was how well how well it covers?
Vicky: Yeah it'll be highly effective and would contribute to protecting the if the infant's too young to be vaccinated, vaccinating a pregnant woman, would be a post-partum, a breastfeeding woman would be recommended but that's not funded.
Tim: Let's move on to the caseloads, I'm just aware of time there's some specific questions coming through that may be covered in the case studies as well.
Vicky: Alright that I just see that there's the frequent question about asthma and eligibility and yes I think that's been tidied up in the handbook a bit now, so what the handbook says is if someone's under regular medical care or on regular medications then they're with then they're eligible, so someone who's on a regular preventer or if they've been hospitalised for asthma would be eligible for influenza vaccine. So not someone who just has a puffer in the side drawer that you know they might use once a year but if you've regularly got them on a preventer then they would be eligible.
Alright we'll go to the case studies, so here we are in April 2019, so Linda a 31 year old woman recently moved to Australia from the UK and she's 36 weeks pregnant. Now she received the flu vaccine in January before she left the UK and she's also, Linda's daughter whose two-year-old is with her and she's got a non-anaphylactic egg allergy. So there's a few issues there. So what would we do? Well we'd recommend offering her the 2019 flu vaccine because the northern hemisphere vaccine she received in January won't be isn't attuned to the same strains that were going to have here and that's free for her. So you could use FluQuadri, Fluarix Tetra or Afluria Quad. And please check her Pertussis vaccination status, so she can receive that any time in her second or third trimester. That she's 36 weeks so it's last chance for her.
And her daughter being two years old and in NSW is eligible for free Flu Quadra Junior and that's a great idea to vaccinate her because by vaccinating her you reduce the risk of bringing flu into the home when there's the new baby. So she's not anaphylactic allergy you egg so that's quite straightforward receiving the vaccine just make sure you've got an adrenaline kit prepared in the practice and observe for a half hour afterwards. And if this is the first year she's receiving flu vaccine book her in for a second dose four weeks later, and if there's a dad on the scene then be good to vaccinate him as well to contribute to protecting the infant when they're born.
So is that ok? Tim any questions about that?
Tim: Not so much about that there's a few questions about access to northern hemisphere vaccines and how different that is to the southern hemisphere vaccine?
Vicky: Yeah so that's the travellers? Well it's probably rarely available in Australia, there may be some travel clinics that do import it, but for example you know people often go away for several months and if they're travelling in November they could get vaccinated when they arrive in the northern hemisphere they'd have to pay for it but that would be a way to optimize their protection they're travelling next summer.
Tim: Yeah
Vicky: Alright second case study I'm running out of time now. So 12th of June 2019, Owen he's a two and a half year old child he's had a hematopoietic stem cell transplant about six eight months ago and he's going back to child care in four weeks and his mum is very anxious. So he's at home with his mum, dad, his four-year-old sister who attends preschool and a brother who's in primary school. Now he was vaccinated in 2017 and received two doses then when he was just six months old. So what are we going to do for Owen?
So Owen should have the offered free FluQuadri Junior. He's two and a half and because he's had the hemopoietic stem-cell transplant since he's previously vaccinated, he needs two doses again, so he's got to start again from scratch, so book him in for a second dose in four weeks. Advise mum that she's not eligible for free vaccine but she would help protect Owen if she does get vaccinated and suggest that dad and the primary school brother also get vaccinated to assist in protecting Owen, and of course his four-year-old sister is eligible for a free vaccine, so she should come in and get that. That's straightforward. Any questions?
Okay I just saw a question there for patient, pregnant patient flu vaccine in 2018 should they be vaccinated again in 2019 when it becomes available? Yes and please vaccinate them as a priority as soon as you get them Afluria Quad.
Case study 3, so we have a family here and so there's a father, who identifies as Aboriginal, a mother non-Aboriginal and a non-Aboriginal grandmother and a non-Aboriginal adolescent and two Aboriginal children three and a half and seven years of age and they all turn up. So um, how are we going to approach that?
So Dad is Aboriginal you know so he's eligible for free flu vaccine, he's a smoker but he's eligible anyway. So you could give him FluQuadri, Fluarix Tetra or Afluria Quad. Grandma's not Aboriginal but she's over 65 so she's eligible for funded vaccine and she you should give her Fluad. Mum's not Aboriginal, she's has a history of breast cancer but she's not medically at risk so she's not eligible for free vaccine but would be recommended to have privately funded FluQuadri Flurix Tetra, AfluriaQuad or Influvac Tetra. The daughter, 15, non-Aboriginal, no medical indications so once again not funded, but everyone is recommended to be vaccinated. The two children, both Aboriginal, so the three and a half year old is eligible for funded vaccine could you could use either FluQuadri or Fluarix Tetra and the seven month old infant is eligible for free vaccine and you'd use FluQuadri Junior or you could use Fluarix Tetra, a full dose.
So that's the three case studies, Tim, sorry I'm cutting it fine with time.
Tim: No that's excellent. You've done brilliantly with time. We've just for a few questions just clarifying about the two doses for children it's only if it's their first flu vaccine that they have two doses a month apart otherwise it's just one for the year is that right?
Vicky: That's correct.
Tim: A scenario here what if a pregnant mum had the vaccine in say November and delivered in April should they have vaccine to cover baby while breastfeeding?
Vicky: Yeah it's not eligible I would try and vaccinate them before they delivered but after that yeah certainly it would be advisable but unfortunately once they're not they're not eligible for free vaccine.
Tim: Yeah we have had a few questions about treatment just about the use of antiviral treatment and whether people should take swabs?
Vicky: That partly depends on the stage of the flu season. If there's a lot of flu around and people are presenting with a very clear clinical picture then it's not necessary to confirm. At this stage of year there's actually more RSV circulating then flu so unless the picture was very clearly flu, so the myalgia or the headache or then being overseas or they contacted with a case you might need to do the swab to you know make your clinical decision about whether it was flu or something else but if your clinical acumen thinks flu's most likely then certainly Tamiflu would be worth trying.
Tim: So the question if Linda in that first case doesn't have Medicare, yes is she still eligible for the NSW vaccine program for the free vaccines on that?
Vicky: Yes in NSW anybody who is in NSW can receive the free flu free vaccines under our programs because when contributing to herd immunity as well as protecting individuals.
Tim: Yep, a few more questions about dosing, of giving different doses a few months of parts or a month apart or a second dose a few months later which I think we covered earlier, again pregnant women can be vaccinated at any stage of pregnancy can't they?
Vicky: Yes they can and they should be vaccinated as soon as possible in pregnancy.
Tim: Yeah and it's we've hit 8:30 we're still getting so many questions coming through I think if people feel that we haven't covered that question then it's worthwhile emailing them through and we'll see what we can do to answer those. I'm keen that we do finish on time.
This the slide up at the moment is the learning outcomes, so hopefully looking at those we've achieved this tonight, feeling a bit more prepared for the 2019 influenza season and those resources will certainly help with that we've understood the factors contributing to varying influence or impact in NSW over recent years we've learned about the impact and outcomes of last year's vaccine to children are in the under five years of age program, aware of this year's formulations of vaccine and their optimal use in eligible age groups and we'll be looking forward to receiving our NSW Health flu vaccination toolkit so we can optimise our vaccine supplies maximise our uptake of influenza vaccine.
Vicky thank you very much, that was a marvellous presentation, I think they've all then heaps. Sammy, thank you very much for running the system and making all run very smoothly underneath. Hope everyone has a good evening and don't forget to fill out your evaluations.
Vicky: Okay thanks Tim, thanks everyone and yeah the presentation will be available online.
Samantha: Great, thanks Tim and Vicky again for joining us this evening and also to everybody online. We do hope you enjoy the rest of your evening.