The Immunisation Service s at the Royal Children s Hospital. Sonja Elia Nurse Practitioner and Manager Immunisation

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1 The Immunisation Service s at the Royal Children s Hospital Sonja Elia Nurse Practitioner and Manager Immunisation

2 The Immunisation Service Three core services Drop-in centre Telephone advice line Weekly outpatient clinic Additional BCG, inpatient s Funding through partnership with the Vict. DHHS Immunisation

3 RCH Immunisation Team NURSING STAFF Sonja Elia (NP) Phillippa Van der Linden Rebecca Feore Narelle Jenkins Nadine Henare Lucy Lam Lynne Clutterbuck MEDICAL STAFF Nigel Crawford (Medical Lead) Teresa Lazzaro Kirsten Perrett Margie Danchin Daniel Golshevsky ADMIN Jessica Elia Jo Gleeson

4 Service activity Immunisation Service Activity Overall no. of patients

5 Telephone advice line Immunisation Telephone Advice Number of calls

6 Telephone advice calls by caller (2014/16) Telephone advice - caller type 6% 8% 2% 3% 3% Parents GP / Practice nurse RCH paed 19% 59% RCH RN MCHN Other internal Other external

7 Advice calls by type Advice Travel Appt Catchup Influenza Adverse event Varicella Pertussis Egg allergy Rotavirus Error MMR autism HPV

8 Weekly outpatient clinic Previously single weekly Immunisation clinic Combined Immunisation / Adverse Event clinic (New medical appointments 1-4 clinics per week) Telehealth delivery

9 Inpatient Immunisations Immunisation status of inpatients <7 years reviewed by immunisation centre nursing staff Details of due/ overdue children (according to ACIR) sent to the hospital Care Managers To provide catch-up immunisations or a catch-up plan or update ACIR

10 Inpatient Immunisations Patients identified as due/overdue Those who received vaccines Percentage

11 Inpatient Immunisations RCH GP Council Other Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17

12 BCG immunisation Weekly outpatient clinic at RCH for infants less than 12 months of age Older infants, 12 months to 5 years =

13 BCG immunisation

14 Research Buzzy and Coolsense Vaccines under sedation Refugee immunisations recorded on AIR Impact of No Jab legislations Ausvax safety influenza, DTPa

15 Frequently asked questions Who can use the service? Hours of service? Opportunities for visiting staff? Nurse Practitioner off schedule vaccines

16 Surveillance of Adverse Events Following Vaccination

17 Topics for discussion Common and uncommon Adverse events Surveillance of Adverse Events Following Vaccination In the Community (SAEFVIC) Management of adverse events

18 Topics for discussion Reporting AEFI Fainting Anaphylaxis Urticaria Hypotonic, hyporesponsive episode (HHE)

19 Vaccine side effects Low-grade fever Pain or redness at injection site Crying/irritability in infants Page 19

20 SAEFVIC Dept of Health and Human Services (DHHS) funded initiative Enhanced passive reporting system Established to help immunisation providers manage patients who have had an AEFI It is for all children and adults

21 Example presentation title Page 21

22 SAEFVIC Objectives 1 Improve AEFI reporting Provide AEFI signal detection Maintain consumer confidence in immunisation

23 Evaluation of SAEFVIC

24 Evaluation of SAEFVIC AEFI reporting for Victoria improved from a low rank of 7 (out of 8 jurisdictions) to rank third Top state judging by reports per 100,000 population Number of reports tripled since 2007

25 Proportion of reporting 2 25

26 Consumer reporting More likely to describe AEFI in a child than providers but less likely to describe adults More likely to report a serious AEFI than providers (22% c/w 17%) 26

27 Management of an immediate AEFI In adults and older children, the most common immediate adverse event is a vasovagal episode (fainting) Most faints usually occur within 5 30 minutes, therefore warn of the risk of driving or operating machinery for 30 mins after vaccination

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29 Minimise the risk If patient has a history of fainting Should be lying down five minutes prior to vaccination Remain in a lying position for twenty minutes post the vaccination Crawford N W, Clothier H J, Elia S, Lazzaro T, Royle J and Buttery J P. Syncope and seizures following human papillomavirus vaccination: a retrospective case series. Medical Journal of Australia 2011; 194(1):

30 Management of an immediate AEFI Vaccine recipients should remain under observation in the vaccination centre for at least 15 minutes Severe anaphylactic reactions usually occur within 10 minutes of vaccination

31 Uncommon and rare AEFI Anaphylaxis is very rare, but can be fatal All immunisation providers must be able to distinguish between anaphylaxis, convulsions and fainting

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33 Anaphylaxis Anaphylaxis is a severe adverse event of rapid onset Characterised by sudden respiratory compromise and / or Circulatory collapse Early signs include involvement of skin and/or Gastrointestinal tract

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35 Management of Anaphylaxis Rapid Intramuscular administration of adrenaline Protocol for management adrenaline and 1 ml syringes must always be immediately at hand whenever vaccines are given

36 Management of Anaphylaxis If patient is unconscious, lie him/her on left side and position to keep airway clear If patient is conscious, lie supine in head down and feet up position Give adrenaline by IM injection for any signs of anaphylaxis with respiratory and / or cardiovascular symptoms or signs

37 Adrenaline dose: 1 in one thousand (1:1000)

38 Adrenaline dose The recommended dose of 1:1000 is 0.01 ml/kg body weight up to a maximum of 0.5 ml. Given by deep IM injection (not the deltoid) Adrenaline 1:1000 must not be administered intravenously Repeat dose every 5 min as necessary until clinical improvement

39 Administration of adrenaline Absorption is faster after intramuscular injection than after subcutaneous injection Absorption is faster when given IM in the vastus lateralis than after injection in the deltoid region (Simons, et al. J Allergy Clin Immunol 2004;113:837-44)

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41 Acknowledgements SAEFVIC Dr Nigel Crawford, Dr Jim Buttery Dept of Health, Immunisation Section

42 References 1. Clothier HJ, Crawford NW, Russell M, Kelly H & Buttery JP (2017). Evaluation of SAEFVIC, A Pharmacovigilance Surveillance Scheme for the Spontaneous Reporting of Adverse Events Following Immunisation in Victoria, Australia. Drug Safety. 40(6): Clothier HJ, Selvaraj G, Easton ML, Lewis G, Crawford NW & Buttery J (2014). Consumer reporting of adverse events following immunisation. Human Vaccines and Immunotherapeutics. 10(12): Clothier H J, Crawford N W, Kempe A & Buttery J P (2011). Communicable Diseases Intelligence, 35(4). p Elia S, Perrett K & Newall F (2017). Providing opportunistic immunisations for at-risk inpatients in a tertiary paediatric hospital. Journal for Specialists in Pediatric Nursing 22(1).