Video of the Occupational Vaccination webinar is available on RACGP Webinars.

Samantha: Good evening everybody and welcome to this evening's Occupational Vaccinations webinar. My name is Samantha and I am your host for this evening.

Before we make a start 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.

I'd like to introduce our presenters for this evening, so we're joined by Dr. Vicky Sheppeard and our facilitator Dr. Linda Mann.

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 of 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. Previously Vicky managed health protection services in the Nepean Blue Mountains and Western Sydney LHDs from 2008 to 2013.

And Dr. Linda Mann facilitated this evening Linda is a fellow of the RACGP and is a member of the RACCP's antenatal and postnatal care network. Linda has both local and international medical experience especially in genetics and women health. She is a GP representative on various national and local government committees and is an experienced medical educator and so thank you Linda and Vicky for joining us this evening and I'll hand over to Linda now to take us through the learning outcomes for this evening.

Linda: Thanks Sam. By the end of this online QI and CBD activity, you should be able to be aware of occupational vaccination requirements that may apply to your patients, apply screening vaccinations and documentation requirements to NSW Health employees, manage hepatitis B vaccine non-respondents, council child care workers seeking vaccination on eligibility for government-funded vaccines, and be aware of occupational risk Q fever and training opportunities to become a confident vaccinator.

Vicky: Well thanks Linda and good evening everyone, it's good to be here again. The first slide before we launch into our learning objectives something which popped up for us all just about 10 days ago is the new digital Australian Immunisation Handbook so I recommend you will put a bookmark on your computers for the new handbook. it's important to note that there won't be any more hard copy prints of the Australian Immunisation Handbook and there's now a new format that is online at this new site and I've been starting to use it and find it quite easy to navigate so please do take a look at it and bookmark it and use that as the most up-to-date information about immunisation. And Sammy will post that link for you all to be able to access.

So before we launch into the actual learnings tonight, there's a few case studies that we'd like to start with and for you to be thinking about as we're going through the presentation. So the first one is about Ishara, an 18 year old first year nursing student who presents to you with a vaccination record card. Another GP has previously completed most of it, except the hepatitis B as she required serology and she's asked that you complete the vaccination record card for her hepatitis B compliance. So she brings you the following evidence, she's got an overseas vaccination record of one dose of hepatitis B vaccine at age fourteen. Ishara tells you that she and her mum are certain that she had another dose six months later while she was living in Sri Lanka but they're not able to get a written record for this. You've checked the Australian Immunisation Record and there are no hepatitis B vaccination records there for Ishara and she's also brought you a pathology result just from the previous week of hepatitis B service anybody at 296 million international units per mil. So the question for you is she now compliant with NSW Health requirements?

The second case is Matthew a 23 year old occupational therapy student. So he presents with the following evidence, so he's got pathology results from a couple of weeks back so his mumps IgG and measles IgG are detected. The rubella is at 15 international units per mil and with the comment that at between 10 and 30 a booster vaccination should be considered. Varicella IgG not detected. His hepatitis B surface antibody is 12 international units per litre and IGRA which is interferon gamma release assay or otherwise known as QuantiFERON Gold test for TB is positive showing that he's had past exposure to TB. He's also brought you a recent vaccination statement from another practice which shows that since his serology tests, he's had a dose of measles mumps rubella vaccine and he's got a past history of hepatitis B vaccination in 1998, when he was an infant, three doses spaced one month and six months apart, and a Boostrix dose in 2011. So we also need to consider what advice you'll be giving Matthew.

And the third case study tonight is Scott, a 42 year old farmer he has his own cattle farm. He's recently been carving and he works on the farm with on other farms, assisting with their animals. He had been in two days ago with fever, headache, photophobia, headache myalgia, arthralgia. He was pretty crook so you tested him for flu but also for brucellosis and Q fever. You've got the Q fever result back now and it's positive. You see him today to start doxycycline but he also asks about his wife and two children - a daughter sixteen, and a son eight. What should they be doing about Q fever? So I hope we'll be answering all these questions during the presentation tonight.

So a large range of your patients will need consideration of occupational vaccination - so health care workers, child care workers, carers for the elderly or disabled, emergency service workers, laboratory workers, people who work with animals and people exposed to human tissue, body fluids or sewage, are just some of the groups we need to consider.

NSW Health form, there's about a hundred and forty thousand across the state so I'm sure most of you do have patients who are staff of NSW Health, so within NSW we have a policy directive which is a requirement for all staff to comply with it's called occupational assessment screening and vaccination against specified infectious diseases. So there's very specific requirements for new recruits, existing workers and also for any health student who does a placement in a NSW Health facility.

So this policy has just been updated this year and there's now three categories of staff risk, there's Category A, which is any staff member who has direct patient contact. That's divided into two categories: a sub category at Category A - High Risk which is specific about influenza requirements and that's for people working in maternity, paediatric intensive care, transplant, oncology, so with the very highest risk and most vulnerable patients and then Category group B our other employees that have no different exposure to patients than any regular member of the community so they might be gardeners, reception staff at front desks, people who are just doing clerical work within the hospital so don't have any different exposure to patients than any regular member of the community would.

So in this slide these are the diseases that we need to think about as far as our policy directive for NSW Health employees. And the evidence required for each of those diseases differs and is quite specific it's quite important that you sorry it's important that you are familiar with those requirements for each of the diseases.

So diphtheria, tetanus, pertussis, all that's required there is evidence of an adult dose of that vaccine in the last 10 years and for our existing workers we continue to require that booster every ten years.

For measles, mumps and rubella, there are three options to comply: if someone's born before 1966 they're assumed to be immune, so no testing and no vaccination records required. For people born after that date, if they have a written vaccination record of two doses at least one month apart, that satisfies the requirement or alternatively if there's no written vaccination record or if it's a person born after 1966, we require positive immuno-serology tests for measles mumps and rubella.

Linda: Victoria can I just ask a question there?

Vicky: Yes. 

Linda: The positive IgG does that have a titre or?

Vicky: That's according to the laboratory, Linda. So each laboratory will usually have a comment that either it can be detected or as we saw in Matthew's case there was a comment that it was a the rubella was of a titre where they recommended a boost is required, so adhere to the standards of your own laboratory.

Linda: Thanks

Vicky: Different for hepatitis B, here we require both a history of an age appropriate hepatitis B vaccination course and a serology titre to show that the person has mounted an adequate immune response to hepatitis B. Alternately if they have evidence of past hepatitis B infection, so a core antibody then they are obviously not susceptible to hepatitis B infection so that is also adequate evidence.

For varicella we require evidence of two doses of varicella vaccine one month apart or one dose if they were vaccinated in infancy or a positive IgG for varicella. Now in the older population, staff over fifty years of age if they've had a Zostavax, that is also taken as evidence for immunity against varicella.

Influenza, as I mentioned certain staff at the highest risk are now required to have annual influenza vaccination. And TB, people who have a risk of TB there's a screening tool if they're born in a high-risk country or spent more than three months in a high-risk country or have had a contact with a person with TB they're required to have either a IGRA test, a TB blood test or a tuberculin skin test, which can be done in a chest clinic.

So moving on, this again goes through the information we just talked about, but I'd really like to be clear that serology is not accepted at all for diphtheria, tetanus, pertussis. It's only vaccination within the past ten years and it's important that adult diphtheria tetanus vaccines not be used because the whooping cough component is essential for compliance. Now of course for our employees we meet the cost of this and offer the vaccine as a booster in in the local health district but if someone comes to you, if they prefer to get their vaccine on you then that's fine as long as it's recorded on a vaccination card for them.

Measles, mumps rubella we've talked about that and as Linda's question indicated the numeric levels from different laboratories must be followed. If for example someone born before 1966 or that has two documented doses of MMR if they happen to have had serology done and shows they're not immune, then they do need a single booster dose but no further serology is required. If basically we're very much trusting these vaccines that they do give a very good level of immunity.

Hepatitis B, we've talked about that and the new thing with hepatitis B is that we now accept a statutory declaration, because we do recognise that some people had trouble obtaining a written history of vaccination, and a GP is the appropriate witness for a statutory declaration, it doesn't have to go to our justice of the peace and the statutory declaration is in the paperwork for our employees, in the policy directive, so they should be bringing that to you, if they don't have a document history of the three doses of hepatitis B, but are able to give you a sound history that sounds very reasonable as if they most likely were appropriately vaccinated.

Just to talk about hepatitis B non-responders and this does occur in a small percentage of people and so after a course, an age appropriate course of hepatitis B for health workers it's important that serology is done to confirm that they have seroconverted and that should be done four to eight weeks after their primary course of vaccination or anytime in the future after that, but it must be at least four weeks after. So if someone has had a full course and you do the serology and it's less than ten then the steps are, consider if they may have chronic hepatitis B infection that hasn't been previously diagnosed, so test for surface antigen and core antibody, if they're negative if they don't have evidence of past hepatitis B infection, then the recommendation is to administer a single booster dose and repeat the serology in four weeks. If at that time they're still below ten international units per mil then administer to further doses, one month apart and then check their serology again, no I'm sorry check the serology again. If they're still non-responders, they comply with the policy directive because they've done everything they can to be made immune to hepatitis B, but they need to be informed that they're not protected and they need to take post, action for post exposure prophylaxis if they are exposed to hepatitis potentially exposed to hepatitis B in work so if there's any parenteral, any needle stick injury or a splash of blood into their eye or their mouth then they need to follow the procedures for unprotected people for hepatitis B. Any questions about any of that Linda that we should?

Linda: Yes, a couple of questions have been asked. One question that's been asked is about evidence of shingles or varicella infection is that adequate evidence of exposure to varicella?

Vicky: Yeah, under the previous policy directive we used to accept that, but we no longer do as we were finding that we weren't getting good validated evidence so this is now the serology or a documented vaccination history is required for varicella.

Linda: Okay because there was a couple of questions about that. One of the other questions has been asked it's about people whose vaccination evidence for Hep B has waned, so there was so if a person's been able to demonstrate greater than 10 international units at any time is that adequate?

Vicky: Mm-hmm yes, yes, so if there is documented evidence in the past then that that is adequate, so it shows they've responded, and then if if they do have a inadvertent exposure it's likely that they will respond mount a response, so as long as there is a documented adequate serology taken at least four weeks after the completion of their vaccination course.

Linda: So just thinking about the vaccination itself, in some areas in NSW access to Hepatitis B as the vaccination has been hard to get yes can they use two paediatric doses to make up the right amount and is there any need to vary the dosage according to the body size of the patient?

Vicky: No the only variation in the dosage is with age, so paediatric doses can be used up to the 15 years of age, I believe. We've got because of the ongoing hepatitis B vaccination shortage, particularly in the private market, we have a whole webpage about the options there. so Twinrix, is an option as is double dose of paediatric vaccine so I can give that link to Sammy to post with the meeting notes so that people can find that information.

Linda: That's great, thanks a lot.

Vicky: Okay, alright and then moving on to influenza, I think I've pretty much covered this, this shows that the categories of workers at our health in public health system that now require annual influenza vaccinations. So what I didn't mention before was intensive care units, so they're now required to receive that vaccine by the 1st of June each year, or if not wear a surgical mask and this was the first year we've introduced this and I must say it was implemented with very minimal fuss actually. And of course we make this vaccine available free for our staff and make free clinics available, but it's always their choice to come to the GP if they if they do prefer. But of course if they do come to you, it's essential that that vaccine is documented and we'll get to their record card in a minute, because we you do need documented evidence for our staff.

And TB, as I mentioned, there's an assessment tool that any students or staff have to complete before they commence a clinical placement and that's about their past history of TB exposure, also about any current symptoms, and any student or staff member who is experiencing symptoms of TB must be screened before they commence clinical work and also as I mentioned if they have resided or travelled for 3 months or more in a high incidence country. If you do an IGRA, a QuantiFERON Gold on your patients and it's positive please refer to a TB service so they can be further investigated and there's no cost to them ,if for any investigation that's done at a TB clinic.

Linda: Can I just ask a question about the planning of these catch-up type vaccinations? It sometimes if you have to do testing or you have to send people to a chest clinic the poor person wants to start work can you annotate their form to say that this is in train?

Vicky: That's right so the only the only one where there's any significant deduct delay is hepatitis B which may require a full course of vaccine so provided they've commenced the course they will be given temporary clearance to start work, provided all the other serology and vaccinations in place and then they undertake to complete the course within six months and then then have to show evidence that that's been completed, so that wouldn't shouldn't delay them more than a couple of days even, for a completely unvaccinated person because all the other vaccines can be given immediately if their serology is negative.

Linda: Thanks.

Vicky: So here is the record that's required, so all healthcare workers and students are given this card to have all the relevant testing and vaccinations completed, so there's a spot there for everything. And on the reverse side of the card is a summary of the information we've discussed about the different requirements for the evidence for the different conditions so I hope that's all clearer for you now. And we'll look at that in more detail when we go through the cases that we're considering.

I'll just move on briefly now to some other occupational groups that who may be your patients, so aged care workers there are recommendations that they have annual influenza and also that they're immune to measles, mumps, rubella and varicella. This year the Australian Government made it a compulsory requirement for all operators of aged care facilities to have an influenza vaccination program for their staff and that can be offered on-site or it can be arranged through local GPs and this followed a survey of aged care facilities around Australia which were was frankly quite disappointing in the achievement of vaccination flu vaccination coverage of aged care facility staff and of course as we've talked about in our other flu webinars, it's essential that the staff of aged care facilities are vaccinated to reduce the risk of them introducing flu vaccine to the facility and also helping reduce the spread of it of flu if it is introduced into the facility.

Linda: Can I just ask a question in general about some of these vaccinations? Some of the staff that we may be seeking to vaccinate maybe people who are taking medications that might affect their immunity for example methotrexate or imurane is there any limitation on vaccinating patients who are fit to work but are taking medications like that?

Vicky: Certainly so that there is the option for temporary medical exemptions, pregnant women for example, immunocompromised people, who aren't able to have live vaccines in particular, so if it's contraindicated for your patient to have a live vaccine at this time, that needs to be documented for them and that evidence can then be assessed by the staff health team at the hospital and then depending on where they're going to be working and the level of risk there, that temporary or permanent medical exemption can be accommodated.

Linda: Thanks.

Vicky: No, thank you, Linda. Great question. Moving on to child care workers are people well people who work with children. So this might be a child care workers, but it might be school teachers, out of our care, child counselling, justice health staff etc a wide range of people who might be working with small children.

So there are some recommended vaccines for this group, like once again annual influenza, measles, mumps, rubella, whooping cough and varicella. And then staff who work in early childhood education and care should also receive hepatitis A vaccine, similarly to staff that work with people with developmental disabilities, who should receive both hepatitis A and hepatitis B.

We've put together some information for child care workers in NSW and there's a fact sheet there on the right that's has been distributed to child care workers through their employers and it describes for them the range of vaccines that are recommended and also what access they might have to free vaccines.

So of course in NSW we make measles, mumps, rubella vaccine available to anyone who doesn't already have two documented doses, that anyone born since 1966, so hopefully most childcare workers will be fit in that group. And then there is some limited availability for whooping cough and flu vaccines, so there's the Commonwealth catch-up, up to 19 years of age so younger childcare workers might be eligible for that, and of course pregnant women are eligible for free pertussis vaccine. Similarly patients who are Aboriginal are eligible to have free influenza vaccine as are any of your patients with underlying health problems. And the varicella catch-up is also available free on the Commonwealth catch-up if they haven't already had chickenpox. So hepatitis A unfortunately is not free on any of the programs in NSW so they may have to to pay for that one, but of course being an occupational vaccination, they may be able to claim it back on tax or they may be able to claim it on private health insurance, so we're just trying to ease the way a bit because we certainly understand that early childhood childcare workers aren't particularly well paid, so I'm trying to ease their way to catch-up their vaccines.

Linda: On the subject of hepatitis A don't say for full vaccination should be two vaccines at least about six months apart from memory

Vicky: Yes.

Linda: How about I only have one does that help is that is that okay?

Vicky: That will give some short-term protection this, yes I guess, counselling them if they do, can afford that second one, then they've got life lifelong protection and so if they're traveling to any Bali, Thailand, anywhere so there's some real benefits of making sure that you are immune to hepatitis A.

Linda: Thank you.

Vicky: Thanks Linda. I will just move on to Q fever and because it's not something we have discussed in webinars before I'll just give a bit of background about the incidence of Q fever in NSW. So we get around about 250 cases a year it's mainly affecting people 40 years and older and more prevalent in men than women and we also have an increased incidence in Aboriginal people and interestingly when we do see it in Aboriginal people, it does tend to be more in the under 20s or 20 to 29, so that's important thing to keep in mind if particularly, if you're in rural general practice.

This is a map that shows the incidence in NSW during 2017 by I think that's SA3 areas or local government areas so across most of our regional areas but particularly concentrated in 2017 in the central west and the southwest but we also get quite a lot of cases on the coast, the mid-north coast and the north coast. It's a large range of occupations that you need to consider at risk of Q fever.

So everyone I think knows about abattoir workers and of course it's compulsory for abattoir workers to be vaccinated to go into the workplace, and we rarely see now cases in abattoir workers. Where we see cases as in farmers, in livestock workers, in people working in stockyards, transporting animals, as I said, shearer's that's particularly affecting young Aboriginal men, but working in wool classing or with hides, people washing clothes of people who work in primary industry, vets are an important group so that's both city and country vet workers and agricultural college staff and students, laboratory workers, wildlife and zoo workers, so even if you're a city GP, there's a chance that you will have some patients who Q fever vaccination should be considered for.

On top of the occupational risks there's also the families of these workers, so bringing home contaminated clothing, boots or equipment, unpaid workers on hobby farms for example, also people living close by high-risk industries, so if the stock yards or abattoirs, particularly the large and the twice that are being developed, so people living nearby and if they're not involved in the industry can be at risk of Q fever, and we've also certainly had cases in people just from mowing either occupational, if there might be council workers mowing in regional areas but also regular residents of rural areas that mow where there's been kangaroos for example can be exposed to Q fever and certainly have developed the infection in NSW in recent years.

I'm just going to briefly touch on tonight the Q fever vaccination process and I will go on to tell you about an online learning module that we have with the Australian College of Regional and Remote Medicine that I will recommend to you, and we make that free for all NSW GPs whether or not you are an ACRA member or an RACGP member.

So I'm just going through the steps of Q fever vaccination. The first step is to check if the person's had previous Q fever infection, if they've got a verbal history of that, or if they've been previously vaccinated. And if there's any indication that they have had previous Q fever vaccination or infection, then they must not be vaccinated. Once you've cleared that on history and checking any available records, then the next step is to do both the blood test and a skin test. And they should be done at the same visit, it's important that the skin test doesn't precede the blood test, because it can invalidate the blood test. So we need to have an antibody test from the serum and also an intradermal hypersensitivity test, which is a small injection of the vaccine. Then exactly one week later, the your patient needs to come back and if both tests are negative and there's no other contraindications then you can proceed to vaccinate.

And then we recommend including the details of Q fever vaccine on the Q fever register if your patient wishes it to be done and this is not mandatory but recommended and unfortunately at the moment this is the only vaccine in Australia that can't be recorded on the Australian Immunisation Register.

So there's some limitations with the Q fever vaccine. So at the moment there's no recommendation under 15 years of age, pregnant and breastfeeding women are also not recommended to be vaccinated as there's no data on safety or efficacy.

We know this is more complex vaccine than others, so it's one that you're very welcome to call the NSW immunisation specialist service. This is a number we've given out in all our webinars, 1800 679 477 if you've got questions about vaccinating patients for Q fever.

Linda: Vicky just while we're talking about Q fever, there are there have been some questions about it and I guess one way of answering many of these questions will be to do that course that you suggested, but just while we have this collection of folk here listening, there have been some questions along the lines of the actual vaccine and the actual skin test. Where do you get stuff to test?

Vicky: So it come and both come from Seqirus, so both the vaccine and the skin tests can be ordered from Seqirus.

Linda: And does it include information on what a positive test looks like, how you assess positivity?

Vicky: Seqirus have a lot of good information on their website including they have a video and on our you know online learning module we also have information about interpreting the skin test and we all rely very heavily there on Dr Stephen Graves who is I guess our national expert on Q fever and Q fever vaccination and testing, so we have incorporated in our module, Stephen Graves talking about interpreting the skin test, but that's actually also straight on the Seqirus website.

Linda: And just while we're talking about a disease that, those of us in the city may have very little familiarity with, if you are treated for Q fever does that mean you don't get all the long-term effects?

Vicky: Certainly being treated is important at preventing it, but there is still the chance of chronic Q fever and particularly people with for example pre-existing bowel disease, it's important that despite having appropriate treatment, that they're still assessed and monitored for the risk of chronic Q fever.

Linda: Thank you.

Vicky: You're very welcome. So just so that you're all aware, there is no approved provider scheme for Q fever vaccination in Australia and there's no requirement to register with the Q fever registry as a vaccinator, so any doctor is able to undertake Q fever screening and vaccination.

So as we mentioned NSW Health has developed an online module that is hosted on the ACRRM site and it takes about two hours to complete. And it covers both diagnosis of Q fever management of patients and also vaccination screening and vaccination. So of course it's available to ACRRM members but in NSW Health we make that available free to all NSW GPs so you just need to put in the code which is capital letters NSW GP18 and Sammy will send that out with the meeting notes and you put that in and you can access it for free, otherwise I think it costs $95 but we'd encourage you to do that.

So just a reminder that all the occupational groups and the recommendations that we've gone through tonight are on the in the new Australian Immunisation Handbook so that link there will take you to all that of the recommendations for your patients.

And just to summarise the availability of occupationally recommended vaccines so many of your patients may be eligible for free MMR and free hepatitis B because there's a range of eligibility for both those vaccines and then of course the Commonwealth are making available additional catch-up vaccines up to 19 years of age so do explore if your patients are eligible for those. And then of course your patients with at risk medical conditions, Aboriginal people, pregnant people and older people will also have eligibility for free vaccines, free occupational vaccines, so please consider that.

The next thing I'd just like to emphasise is ensuring that you do record the vaccines for NSW Health workers on that record card but also it's very helpful to your patients if you're able to record them on the Australian Immunisation Register and this is important because vaccines don't need to be repeated if someone's had hepatitis B, even if the doses are 10 years apart, is then they're still fully vaccinated if they've had three doses.

Similarly any two lifetime doses of measles, mumps rubella or varicella also mean that they're fully vaccinated. So now that we can record vaccines of any age group on the register, I really encourage you to do that to help your patients meet their occupational requirements and any other vaccination requirements that they need.

So the data on the register is used to monitor vaccination coverage across Australia, we can use it to monitor effectiveness of vaccines, we can look and see where people might be at risk of being under vaccinated and outbreaks. It's all also used as I'm sure you're aware for eligibility for tax family tax benefits and childcare subsidies for young infants and young children, we'll use it for policy and research, it's used as evidence for entry to child care in school, and it can also be used for proof of vaccination for employment.

The Australian Immunisation Register is a very busy place, this is some information they've given to us and thank the register for this. So they receive over a hundred and thirty thousand records each day, most of it automatically through practice management software, some of it through the AIR site and still about nine hundred a day on manual forms. They do need to look into some of these, to verify them, so those are pendant transmissions and they're processing you know a thousand forms a day from manual encounters and immunisation history forms reporting overseas vaccinations so it's a very busy place that operates around the clock, also receiving emails, phone calls and outgoing emails and phone calls. So it's a big organisation and I you possibly all have some frustrations with it but they're actually I think gearing up and doing a really terrific job now receiving vaccines for all ages across Australia.

So making sure that your patients data gets there, it's important that your software is up-to-date, and so that it will function properly for the AIR, Medicare and PBS. My understanding and Linda can certainly pop in and correct me here is that you record the vaccines in real time but then your practice will send them in batches to the AIR but if you use the AIR site then there is a recorded real time in the register and then you're also able to print out for your patients if they needed a immunisation history statement through going to the identify individual menu.

Linda: I would suspect that most practices use their practice management software actually because it's usually the practice nurses if there are practice nurses who actually order down these processes and they and in terms of producing an AIR printout that's the kind of thing that people generally use for official things for example childhood, schools access otherwise we would if we've got a full record in their own software we don't need it.

Vicky: Yeah, okay, great, thanks Linda. Okay so we really encourage you also to use the register to check but particularly for adults if they have had vaccines recorded before and as I said there's no need to repeat previously given vaccines provided they're given at the right interval.

And now this is a slide I just like to thank Penny Burns for, she gave me some screenshots because I obviously don't work with this software every day, but just emphasizing how to record on your software vaccines so that they're effectively transmitted to the register. What we found, we were monitoring the register for all ages during the flu season trying to look for uptake, and while we certainly saw adult vaccines recorded there, it didn't meet our expectation as far as the number of vaccines that were distributed. So that I think the register showed somewhere between around 50% of the over 65s had been recorded on the register as receiving flu vaccine, whereas we're aware from the vaccines that were distributed and their great interest in flu vaccine particularly with the over 65 we expect the coverage would have been much higher than that, so we'd really like to make sure that you know everyone's vaccines are recorded correctly on the register and Penny's helped me by taking some screenshots from best practice so I guess the first thing on the drop-down is to make sure that you've picked the right vaccine and I agree with flu that's a bit daunting with many names that are very similar but if you record the wrong one for the wrong age group the Public Health Unit will be asking you why you've given Fluad to a baby so select the right vaccine, indicate which site that you've given the vaccine and indicate the route that you've given it and I think the rest of the data in that field is automatically populated and including the batch number.

Linda: No, certainly many practices like mine have anything up to six batch numbers going once depending on whether we're the vaccine has been sent to I've got more than one site so we actually have a drop-down of occasion two vaccines and unfortunately the software keeps them all, even ones that we've used up, we can't delete. So I was going to ask you a question about this, I do confess sometimes when I'm a bit of a hurry and it's me that's recording this and not the nurse I don't always write the site because you know I don't kind of care really truly, if I don't put the site on is that a reason why I wouldn't go up to AIR properly?

Vicky: I mean I don't I don't think that prevents it going up, we'd certainly encourage it, just in case it's an adverse event.

Linda: Surely I can understand that.

Vicky: I don't know Linda, I'll have to find out. So Penny's emphasised to fill in all this and then to obviously save it and then magic happens and it goes to the register. And well I think my finding is a lot of practice doctors recording it in the notes and if it's just in your practice notes, that's not going to go anywhere.

Linda: In fact we've got a comment from someone that they also identify that if you're if you know I'm not identifying the correct number for the vaccine that can interfere with its upload so if I'm quoting a vaccine number that's out of date or was distributed you know six weeks ago then that's according to one of the questioners here that's.

Vicky: Yeah and I think what the registers trying to do is get a better communication back to practices that if there has been a fault in uploading, then you're notified. I think at the moment that's not happening but they recognise that it's important to have that feedback loop so that it can be corrected in that and the records go in.

Linda: Excellent.

Vicky: Hmm. Is there anything else about that before we can move on to the case studies? Linda: I think we should move on to the case studies because in the case study responses will be the answer to many of the questions that are sitting in front of me.

Vicky: Alright, so Ishara who is a nurse and she needs to show both an age appropriate course of vaccination and a surface antibody level more than ten mLs. So first up as we said she commenced her vaccination course when she was 14 so all she's required to do under the age of 15 is to have a two dose course of hepatitis B, appropriately spaced at six months. So that was the verbal history she gave. She doesn't have the second dose documented but her and her mum give a very convincing, and they're very reliable patients, so you believe that it's very plausible she did have a second dose. So you witness the statutory declaration that comes in our policy directive because it doesn't need a justice of the peace, it needs an authorised assessor, so a GP or a nurse immuniser, so you help her by signing that statutory declaration and then fill in her completed vaccination card and stamp and date it with the serology result and she's now ready to comply with the whole process. So you've solved Ishara's problems.

Linda: Just on the subject of hepatitis B, we have a question here asking whether you can explain why age appropriate there needs to be evidence both vaccinations and hepatitis antibody above ten, why do we both are not just serology?

Vicky: Well the trick is if you take the serology, someone could have one dose of hepatitis B you do their serology two weeks later, they may well have a positive IgG but that won't be long lasting so we need to be sure that they've had a full age appropriate dose and that the serology has been taken to show that they've responded appropriately so that we can be confident they've got long term protection.

Linda: Thanks.

Vicky: You're welcome. On to Matthew. So Matthew's already, we saw earlier that Matthew has had a booster dose of Boostrix. He's had evidence of that in 2011, so that's fine he meets that criteria. That's within 10 years. We also saw that Matthew had an age appropriate dose of Hepatitis B, so he had an infant course at zero, one month and six months, so he meets that criterion and he also presented you with quite a good titre of hepatitis B surface antibody. I believe it was in the hundreds, so he meets the criteria for hepatitis B. He was IgG positive for measles, for mumps but for rubella he had a interim level between 10 and 30 so the lab suggested he have a booster dose, which would had already been given before he came to you so he's now compliant with that. Varicella, he needs so his IgG was not detected, he doesn't have a history of vaccination, so he's going to need two doses, four weeks apart and unfortunately, he's 23 so he's going to have to pay for that, there's no free there's no free varicella vaccine for him, but it's better than catching chicken pox which I did when I was a medical student That was a long time ago. Matthew had a positive IGRA and he had travelled overseas so he needs to be referred to a chest clinic for further assessment but as long as he's made that appointment it doesn't stop him from going into his clinical placement as long as he's asymptomatic for TB. And then, and please make sure you report the varicella vaccines to the register, as well as filling in his card.

And then moving on very quickly, we're running out of time, to Scott. So Scott's family live on a farm so as we discussed they are at risk of Q fever and they also help on the farm, his wife kindly launders his clothes, so they are at risk of Q fever. Scott can't be vaccinated because you've already established he's got Q fever, so there's nothing further that can be done for him apart from assessing if he's at risk of chronic Q fever. His son is only eight, so too young to be vaccinated but you can download our fact sheet about Q fever in farms and there is personal protective measures that can be taken such as hand-washing, changing clothes potentially wearing a mask in high-risk activities, that you can give to the family to help protect the son who can't be vaccinated. And you arrange skin testing and serology for his wife and his 15 year old daughter.

Linda: Just on the subject of this it seems to me that there would be a very large percentage of any given rural environment that may be at risk.

Vicky: Yes.

Linda: Should the doctors in rural places be testing everybody for Q fever?

Vicky: I think yes, rural GP should be thinking Q fever for all their patients and discussing with them if they would like to be, what risk they may be at, discussing with them they like to be assessed for vaccination. If not, we can give them advice about hygiene measures but yeah I would be encouraging all rural people to consider it as a risk.

Linda: Thank you.

Vicky: So you test Scott's wife and his daughter. His wife's skin test is positive and his daughter is negative on both skin testing and serology. So his wife has been exposed to Q fever in the past so she can't be vaccinated, but the daughter can be both her testing is negative, so you can arrange for her to be vaccinated and that should be done as soon as possible. Seven days on from when the skin test is read should be done straightaway before she's further exposed to Q fever.

So just to go over the resources that we've looked at tonight so the Australian the new online Australian Immunisation Handbook, our online learning module for Q fever, the full occupational assessment screening of vaccination policy directive and also our NSW Q fever awareness toolkits, where we've got a bunch of fact sheets and about Q fever that you could use with your patients. So that's what I was going to cover tonight Linda.

Linda: I think that's really impressive and I've learned something about the fact that I'm not protected against Hepatitis B, I'm a chronic non-responder. I used to think that means I was okay but now I know I'm not. You learn something new every day.

Samantha: Perfect so up on your screen at the moment is just a review of the learning outcomes that Linda took you over at the beginning of this session, so we hope that we have covered all of that for you and saying that I'd like to thank Vicky and Linda very much for joining us tonight and also for everybody online. Just a reminder this is a CBD activity, so to receive your points please do complete the evaluation survey that follows the webinar. That brings us to the end of the session. Again, thank you Vicky and Linda for joining us tonight.

Linda and Vicky: Thank you Sammy. Samantha: Awesome. Fantastic. So good night everybody.

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Current as at: Wednesday 24 April 2019
Contact page owner: Immunisation