General Practice Nurses

Transcription

1 General Practice Nurses Annual Immunisation Update 2018 Prepared by Kym Bush Immunisation Coordinator Public Health Unit May 2018

2 Topics to be covered Vaccine preventable diseases update Current schedule Recent changes in 2018

3 Vaccine preventable diseases

4 Measles Measles notifications in NSW residents, by month of disease onset and age group. January 2014 to May 2018.

5 Measles Measles alert from NSW Health March 2018 Two adults and three infants acquired infection whilst travelling in Asia One spent time in Deniliquin town centre Adults born after 1966 should have 2 doses MMR (free) prior to travel Parents of children <12 months and planning travel to Asia should discuss vaccination after 9 months of age

6 Pertussis Pertussis notifications in NSW residents, by month of disease onset and age group. January 2014 to May 2018.

7 Pertussis control strategies Timely primary vaccination 2, 4 and 6 months DTPa; Two booster doses of DTPa at 18 months and 4 years; dtpa in Year 7; dtpa vaccine is recommended during the third trimester of each pregnancy; People in contact with infants: dtpa every ten years; dtpa recommended every ten years for HCWs.

8 Rotavirus Rotavirus notifications in NSW residents, by month of disease onset and age group. January 2014 to May 2018.

9 Rotavirus Large increase in 2017 likely due to an emerging strain that is not well matched to the vaccine. New evidence of slight increase to 14 cases of intussusception per 100, 000 infants vaccinated per year in Australia however the benefits of rotavirus vaccination far outweigh the risks associated with it Further information: nise-rotavirus E66B537AED07CA257D4D0081E4AE/$File/rotovirus-sept13.pdf

10 Valid consent Valid consent can be defined as the voluntary agreement by an individual to a proposed procedure, given after sufficient, appropriate and reliable information about the procedure, including the potential risks and benefits, has been conveyed to that individual The table inside the back cover of the Handbook, Comparison of the effects of diseases and side effects of NIP vaccines, can be used to advise the risks and benefits of each vaccine

11 Invasive meningococcal disease IMD notifications in NSW residents, by month of disease onset and age group. January 2014 to May 2018.

12 Meningococcal Serogroup B naturally declining and serogroup C now very rare (vaccination). Serogroup W is now the main serogroup causing IMD MenCCV: Menitorix combination Hib and MenCCV NeisVacC monovalent MenCCV MenBV: Bexsero, Trumenba 4vMenCV: Menactra, Menveo and Nimenrix

13 Meningococcal B Bexsero (4CMenB vaccine) has been registered for use in Australia for people 2 months of age (but may be given to infants from 6 weeks of age) There are recommendations for use in the online Handbook ATAGI recommends prophylactic paracetamol 30 minutes prior to vaccination or as soon as practicable after each dose to reduce risk and severity of fever GSK advised that there is an interruption to the supply on the Australian private market Full Clinical Advice 85A C02B4DCA257B640002F38E/$File/ATAGI-advice-bexsero.pdf

14 Recommended schedule of Bexsero by age group Age at commencement of vaccine course 2 months* Primary immunisation Interval between primary doses 3 doses, delivered at ~2*, 4 and 6 months of age; (intervals ~2 months, at least 1 month) Age for booster dose 12 months 3 to 5 months 3 doses 1 2 months 12 months 6 to 11 months 2 doses 2 months 12 months to 10 years 12 months, or 2 months after previous dose, whichever is later 2 doses 2 months No booster required 11 years and above 2 doses 1 2 months No booster required

15 Recommended brands and doses 4vMenCV by age group for healthy individuals and travellers Age at commencement of vaccine course Recommended brand Primary immunisation Recommended interval between primary doses 2 6 months Menveo 3 doses 8 weeks 7-11 months Menveo 2 doses 8 weeks months Either Menveo Or Nimenrix > 2 years Menactra, Menveo or Nimenrix 2 doses 8 weeks 1 dose Not applicable 1 dose Not applicable

16 MenACWY onto the NIP The Hon. Greg Hunt MP

17 MenACWY and the schedule NIP is going to be tricky.. replacing 12 month menitorix but still need to have Hib booster..no monovalent Hib in Australia.likely to change in July 2018 NSW MenW Response Program is offering a single dose of menactra to older adolescents as part of the SVP ATAGI is currently reviewing the use of meningococcal vaccines and will be updating the meningococcal chapter of the Handbook In the interim:

18 Influenza notifications Jan 2014 to May 2018 Influenza notifications in NSW residents, by month of disease onset and age group. January 2014 to May 2018

19 Unflattering New York Times appraisal of Australia s response to 2017 flu season Under 10% of children get the vaccine in Australia The figure for children in US is 4 times higher Australian attitude to influenza do not take time off work Ineffective messaging focuses on very young and elderly US opts for universal vaccination Misinformation and confusion about vaccine

20 Statement from Chief Medical Officer Sept 2017 Only 70% of eligible people take up the free vaccine Characterised by high levels of influenza A (H3N2) affecting elderly (SNSWLHD had 40 outbreaks reported in ACFs and hospitals) The quadrivalent vaccines were a relatively good match for the circulating strains however the effectiveness of the vaccines has been less than usual this year especially for the elderly protecting against flu A(H3N2) Other international vaccines, specifically a high dose formulation for the elderly, is not registered in Australia

21 Composition of 2018 flu vaccine A (H1N1): an A/Michigan/45/2015 (H1N1)pdm09-like virus A (H3N2): an A/Singapore/INFIMH /2016 (H3N2)- like virus* B: a B/Phuket/3073/2013-like virus. B: a B/Brisbane/60/2008-like virus. *Different A(H3) candidate vaccine virus to 2017 vaccine

22 Seasonal influenza vaccines in 2018, by age

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24 Programs

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26 Childhood vaccinations

27 Free flu vaccine for under fives Only use FluQuadri Junior for children aged from 6 months to 35 months FluQuadri for children aged from three years DO NOT ADMINISTER A HALF DOSE of FluQuadri to children aged 6-35 months as this vaccine is not licensed for this use All vaccine doses are to be reported to AIR

28 Adolescent vaccinations

29 HPV changes Gardasil (4vHPV) has been given on a three dose schedule over 6 months since Protected against two high-risk HPV types (types 16 and 18) and two low risk types (types 6 and 11) From 2018 Gardasil9 (9vHPV) providing protection from more high risk types that cause over 90% of cervical cancers International evidence with HPV vaccine given to persons under 15 years in a two dose schedule at least 6 months apart is as efficacious as a three dose schedule

30 HPV changes (cont.) A small number of students are still recommended to have three doses of HPV vaccine to be protected i.e. significantly immunocompromised (1 o or 2 o immune-deficiencies). Refer student to GP for vaccination Year 7 students from 2017 (who were given 4vHPV vaccine as dose 1) can be safely caught up in Year 8 using 9vHPV vaccine as dose 2 (must be given at least 6 months apart) Free 4vHPV vaccination for MSM and transgender clients aged years until 31 December Three dose course at 0, 2 and 6 months

31 NSW Meningococcal W Response Program During 2017 NSW Health offered MenACWY to adolescents in Year 11 and 12 through the SVP in response to an increase in cases of the hypervirulent MenW and the emergence of MenY in Australia NSW SVP 2018 to offer single dose of MenACWY to students in Year 10 and 11

32 Adult vaccinations

33 Pneumovax 23 ATAGI made the following recommendations about Pneumovax 23: a dose of Pneumovax 23 should be given to all adults aged 65 years a second dose continues to be recommended for those with any predisposing conditions as listed in the Handbook recommendations for Aboriginal and Torres Strait Islander people aged <65 years of age are unchanged from the Handbook No more than three 23vPPV doses are recommended during a person s life

34 Zostavax Live attenuated vaccine containing the Oka VZV strain 14 times more virus than in chickenpox vaccine to give T cell boost Licensed for use in adults 50 years Single dose currently funded for all adults aged 70 years A single catch up dose for adults years until October 2021 Efficacious against PHN

35 Zostavax (cont.) Can be given at the same time as flu and pneumococcal and is usually well tolerated. Rash at injection site and generalised rashes are rare Be careful contraindicated in immunocompromised patients 69 year old Qbn man on methotrexate developed rash 4 weeks post vax. Swab of rash Oka strain identified. Secondary bacterial infection and overwhelming sepsis. ICU 3 days antivirals and antibiotics. Survived. Risk of disseminated VZV replication 1 death in UK and also a death in Sydney in January last year

36 Zostavax (cont.) Do not administer Zostavax to patients with immunocompromised or on immunosuppressive therapy If in doubt about whether or not to vaccinate ring the PHU and I will tell you to ring NSWISS If a patient is inadvertently given Zostavax urgently contact the treating specialist or infectious disease specialist for advice on antivirals

37 Shingrix Approved for use in US in adults > 50 years Has an adjuvant system intended to induce a strong and sustained immune response to overcome the age-related decline in immunity Vaccine efficacy of >90% against shingles across all age groups as well as sustained efficacy over a 4 year follow up Can be given to those who have received Zostavax

38 At risk groups

39 Free catch-up vaccines From 1 July 2017 all individuals < 20 years of age are eligible for free catch-up vaccines through the National Immunisation Program on an ongoing basis

40 Catch up for refugees From 1 July 2017 refugees and other humanitarian entrants aged 20 years and over are eligible for free catch-up vaccines on an ongoing basis (excluding HPV)

41 Administration

42 Pre vaccination: addressing parent concerns Direct parents to reputable resources and websites for further information e.g. The Science of Immunisation: Questions and Answers at

43 Pre vaccination screening Table 2.1.1: Pre-vaccination screening checklist in Handbook Table 2.1.2: Responses to relevant conditions or circumstances identified through the pre-vaccination screening checklist

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45 Critical elements of safe vaccine administration The following elements of safe vaccine administration must be followed: Any contraindications? Right patient Right vaccine Right dose Right route Right minimal dosing interval

46 Vaccination

47 Recommended injection site <12 months The anterolateral thigh is the recommended site for IM administration of vaccines in infants < 12 months of age

48 Recommended injection site > 12 months The deltoid is the recommended site for IM administration of vaccines in those > 12 months of age and adults

49 Post vaccination

50 Managing AEFIs Table 2.3.2: Doses of intramuscular 1:1000 (one in one thousand) adrenaline for anaphylaxis* Approximate age and weight Adrenaline dose <1 year (approx kg) ml 1 2 years (approx. 10 kg) 0.1 ml 2 3 years (approx. 15 kg) 0.15 ml 4 6 years (approx. 20 kg) 0.2 ml 7 10 years (approx. 30 kg) 0.3 ml years (approx. 40 kg) 0.4 ml >12 years and adult (over 50 kg) 0.5 ml

51 Reporting AEFIs au/immunisation/pages/aefi.aspx Fax completed forms to the PHU on

52 Other issues

53 ATSI Medicare enrolment and amendment form AIHW identified that young parents were having difficulty enrolling in Medicare Specific ATSI form can be completed with assistance of a referee AIHW can also assist new parents to complete the form

54 Changes to the Public Health Act 2010 From 1 January 2018: It is an offence to enrol children who are unimmunised (with a penalty of 50 penalty units) due to their parent s conscientious objection; The 12 week temporary exemption for children evacuated during a state of emergency and those in emergency out of home care is extended to all children in out of home care and Aboriginal and Torres Strait Islander children It is an offence (with a penalty of 50 penalty units) for a person to forge or falsify an approved immunisation form which is provided to an early childhood service to enable enrolment of a child

55 Changes to the Public Health Act 2010 (cont.) Early childhood services must: Record the child s immunisation status on an immunisation register (using a template) at enrolment Check that an updated approved immunisation form has been provided for each child after each immunisation milestone and record the details on the immunisation register Implications: conscientious objectors can no longer enrol their children in child care and will need to make alternative arrangements

56 Changes to the Public Health Act 2010 (cont.) From 1 April 2018, the immunisation requirements in primary school were extended to secondary schools so that all school principals are required to: Request an immunisation certificate at enrolment Record each child s immunisation status in a register and retain copies of approved immunisation certificates for a period of 3 years after the child has ceased to attend the school Provide a copy of a child s immunisation certificate to another school that the child has transferred to (upon request) Notify the PHU if an enrolled child has a VPD or if they reasonable believe that an unimmunised enrolled child has come into contact with someone who has a VPD Exclude unimmunised children at risk of contracting a VPD from attending school on the direction of a PHO

57 Medical exemptions Natural immunity clinical/serology Only GPs can complete and submit this form Anaphylaxis or severe allergic reaction to previous vaccine Adverse Event clinic at Westmead can provide vaccinations administered under close supervision NSWISS

58 Immunisation History You can complete this form and submit if you view record from overseas vaccinations Department of Social Services has a free translating service Health Care Interpreter Service (HCIS) available for SNSWLHD staff If you start a patient on a catch up schedule this form can be lodged and families can access their payments before the catch up is finished

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60 Shortage of adult hepatitis B vaccine There is a continuing international shortage of adult formulation HBV vaccine now affecting supply under the NIP The following groups are eligible for free HBV vaccine: Aboriginal people - Clients of SHS Immunsuppressed people - Injecting drug users People with HIV or HCV - Persons years Refugees - Sex workers Household contacts of HBV+ve cases MSM Order adult formulation HBV from PHU:

61 Shortage of adult hepatitis B vaccine (cont.) ATAGI vaccination options: <20 years can receive 3 doses of paediatric hepatitis B vaccines 20 years can receive Twinrix vaccine, or A double dose of HBVaxII (paediatric), Engerix (paediatric) or Twinrix Junior is also considered a valid adult dose, or Complete the vaccine course with the same vaccine brand if available or use the alternative brand (HBVaxII or Engerix, whichever is available) to complete the course

62 Latex allergy There is a natural rubber latex present in the sheath covering the needle of the Fluad influenza vaccine Before administering any vaccine, confirm with patients that they do not have a latex allergy Patients aged >65 years with a severe allergy can be still safely vaccinated with Fluzone High-Dose

63 Australian Bat Lyssavirus 8 year old Queensland boy died following exposure to ABLV in All bats, including flying foxes and micro bats, are considered potential sources of infection. Recent wounds should be washed thoroughly with soap and running water for at least 5 minutes followed by the application of an antiseptic containing povidine-iodine or alcohol Contact your local Public Health Unit on for advice and to obtain free post exposure treatment Administer a tetanus booster if needed

64 Q Fever: New e-learning module 2 hour course accredited with Australian College of Rural and Remote Medicine (ACRRM) Worth 2 CPD points and is free for ACRRM members and RRMEO subscribers. Limited funded places are available for NSW-based RACGP members.cost for non-funded places is $95 The module is available at onlinelearning/details?id=11347&title=q-fever+- +Early+Diagnosis+and+Vaccination

65 Vaccine storage and management

66 Online module - Vaccine storage and cold chain management

67 Vaccine storage Vaccine cold chain management power point presentations available at 1. Ordering vaccines 2. Receiving a vaccine delivery 3. Cold chain management 4. Cold chain breaches

68 Fridges Purpose built vaccine fridges are best practice and are recommended There must be a battery powered min/max thermometer available for monitoring fridge temperature in a power outage Each fridge must be continuously monitored by either an inbuilt or external data logger Min/max temperatures to be recorded twice daily

69 Min/Max thermometers Suppliers ACTROL Replace the thermometer every 3 years and record the date of purchase on the back Battery change and ice slurry test must be done every 12 months and recorded on the back of the thermometer Probe should be placed in an empty vaccine box

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71 If the ice slurry test does not record +/-1 o C then needs to be recalibrated by the manufacturer Data loggers TinyTag, HOBO, Enlake, Logtag Must be downloaded weekly and checked Battery changed every 12 months followed by an ice slurry test

72 How to Pack an Esky Step 1 If time permits chill the inside of the cooler prior to use by placing ice/gel packs inside for a few hours and then remove. Place conditioned ice/gel packs on bottom if needed.

73 How to Pack an Esky Step 2 Place polystyrene chips or other suitable insulating material at the bottom of the cooler, this eliminates hot & cold spots (Polystyrene chips are preferred as it promotes air circulation). If using bubble-wrap, avoid wrapping vaccines tightly.

74 How to Pack an Esky Step 3 Place vaccines in esky with a Min/Max thermometer probe in the centre of the vaccine stock.

75 How to Pack an Esky Step 4 Surround the vaccines with packaging material (eg. polystyrene chips) to allow cold air to circulate. Step 5 Place the conditioned ice/gel pack(s) on top, close and seal the lid of the cooler. If using a larger cooler, place conditioned ice/gel packs around the sides of the cooler as well as on top.

76 How to Pack an Esky Step 6 Secure Min/Max thermometer on outside of esky & monitor the temperature before leaving for the session, upon arrival, prior to administrating vaccines and hourly throughout the immunisation session or power outage on appropriate document.

77 Online resources Australian Immunisation Handbook nsf/content/handbook10-home National Centre for Immunisation NSW Vaccine Centre Online Ordering System The Science of Immunisation