The Immunisation Service s at the Royal Children s Hospital Sonja Elia Nurse Practitioner and Manager Immunisation
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
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
Service activity 10000 9000 8000 7000 6000 5000 4000 3000 2000 1000 Immunisation Service Activity 0 2005-06 2006-07 2007-08 2008-09 2009-10 2010-11 2011-12 2012-13 2013-14 2014-15 2015-16 Overall no. of patients
Telephone advice line 11000 10000 9000 8000 7000 6000 5000 4000 3000 2000 1000 Immunisation Telephone Advice 0 2004-05 2005-06 2006-07 2007-08 2008-09 2009-10 2010-11 2011-12 2012-13 2013-14 2014-15 2015-16 Number of calls
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
Advice calls by type Advice Travel Appt Catchup Influenza Adverse event Varicella Pertussis Egg allergy Rotavirus Error MMR autism HPV
Weekly outpatient clinic Previously single weekly Immunisation clinic Combined Immunisation / Adverse Event clinic (New medical appointments 1-4 clinics per week) Telehealth delivery
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
Inpatient Immunisations 160 0.8 140 0.7 120 0.6 100 80 60 0.5 0.4 Patients identified as due/overdue Those who received vaccines Percentage 40 0.3 20 0.2 0 0.1
Inpatient Immunisations 70 60 50 40 30 RCH GP Council Other 20 10 0 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17
BCG immunisation Weekly outpatient clinic at RCH for infants less than 12 months of age Older infants, 12 months to 5 years = www.rch.org.au/immunisation
BCG immunisation 1100 1000 900 800 700 600 500 400 300 200 100 0 2012 2013 2014 2015 2016
Research Buzzy and Coolsense Vaccines under sedation Refugee immunisations recorded on AIR Impact of No Jab legislations Ausvax safety influenza, DTPa
Frequently asked questions Who can use the service? Hours of service? Opportunities for visiting staff? Nurse Practitioner off schedule vaccines
Surveillance of Adverse Events Following Vaccination
Topics for discussion Common and uncommon Adverse events Surveillance of Adverse Events Following Vaccination In the Community (SAEFVIC) Management of adverse events
Topics for discussion Reporting AEFI Fainting Anaphylaxis Urticaria Hypotonic, hyporesponsive episode (HHE)
Vaccine side effects Low-grade fever Pain or redness at injection site Crying/irritability in infants Page 19
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
Example presentation title Page 21
SAEFVIC Objectives 1 Improve AEFI reporting Provide AEFI signal detection Maintain consumer confidence in immunisation
Evaluation of SAEFVIC
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
Proportion of reporting 2 25
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
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
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): 16-18.
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
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
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
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
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
Adrenaline dose: 1 in one thousand (1:1000)
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
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)
Acknowledgements SAEFVIC Dr Nigel Crawford, Dr Jim Buttery Dept of Health, Immunisation Section
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): 483-95. 2. 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): 3726-30 3. Clothier H J, Crawford N W, Kempe A & Buttery J P (2011). Communicable Diseases Intelligence, 35(4). p. 294-298. 4. 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).