Adolescent and antenatal vaccinations

SAMANTHA:

Welcome to this evenings Adolescent and Antenatal Vaccinations webinar. We are joined tonight by our presenter Dr Vicky Sheppeard, and our facilitator Dr Tim Senior. This is another instalment in the Twilight Online series, thank you for joining us.

Before we get started, I would like to make a quick acknowledgment of country. We recognise the traditional custodians of the land and sea on which we live and work.

I will now give a bit of an introduction on our presenters for this evening.

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, Health Protection NSW; the 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 the Communicable Disease Network Australia. Previously Vicky managed the health protection services in the Nepean-Blue Mountains and Western Sydney LHD (Local Health District) from 2008 – 2013.

Dr Tim Senior works with us here at the RACGP; he is a GP at the Tharawal Aboriginal Corporation in South Western Sydney and originally trained in the UK. Tim is an RACGP Medical Advisor for the National Faculty of Aboriginal and Torres Strait Islander Health, a senior lecturer in general practice and indigenous health at UWS and a medical educator.

Thank you Tim and Vicky for joining us tonight.

VICKY:

You are welcome, thanks Sammi.

TIM:

Thank you very much; it is lovely to be joining you all.

SAMANTHA:

What I will do now is hand over to Tim to take us through the learning outcomes for this evening and then we will hand over to Vicky to get started on the presentation.

TIM:

The learning outcomes are on the screen and this is what we hope you all get out of this evenings session. As you can see, there is a lot of things we are going to get through.

By the end of this Twilight Online activity, you should be able to

1. Source appropriate records of vaccinations to determine if adolescent patients are fully vaccinated and update the Australian Immunisation Register if required
2. Develop a personalised vaccination catch up schedule and report the vaccine doses on the Australian Immunisation Register
3. Discuss the recommended dosing schedules for both two and three dose HPV vaccinations for different age cohorts, referring to international evidence
4. Explain the additional benefits of the newest nine-valent HPV vaccine
5. List the benefits of adhering to antenatal vaccinations for the flu and pertussis while utilising the pregnancy card to ensure good communication with shared antenatal services.

That is a lot to get through tonight, as we go through feel free to ask us questions as Sammi was saying via the questions box and we will attempt to answer those as we go. If we do not get to them tonight then we will get back to you offline.

Vicky, I think we are going to start off by talking about the NSW School Vaccination Program for 2018.

VICKY:

Thanks very much Tim and good evening everyone.

It is actually very timely that we have this webinar tonight because there is quite a lot of new news about adolescent vaccination, so it will be good to work through that.

Our first slide is the consents that will be going home to year seven students for 2018, some of the parents will get them this year, and others will get them early next year. There is some important changes to the program next year.

From next year, the program will be simpler for year seven students, we will talk about this in more detail in a few slides, but we are now moving nationally to a two-dose HPV program for year seven students. We will also still be offering Boostrix to all year seven students and that remains an important booster against both whooping cough and tetanus. You will note the varicella catch up will no longer be offered to year seven students and that is because the 18-month dose has been on the program long enough that every child who now goes into year seven from next year (2018) should have been offered a dose during infancy.

The other thing to note about our program next year, we will continue to offer the meningococcal ACYW vaccine and in 2018 it will be offered to 10 and 11, this year we offered to years 11 and 12, so we will be covering another two age cohorts of students for meningococcal ACWY next year, and we will look at that in more detail in a minute.

On top of what we are giving in the school program, the commonwealth have now made the adolescent catch up an ongoing program. You will probably recall that in 2016 they had a time limited, two-year catch up period for adolescents and the commonwealth have now agreed to continue that indefinitely. This catch up can be started any time up until a child turns 20, but once they have started their catch up it can be completed at any stage.

These are important vaccines that if an adolescent missed out on in infancy or adolescents they are now able to have the catch up, we also have our catch up for meningococcal ACWY, which is a NSW funded program that is still available this year. Children who were in year 11 or 12 or would have been if they left school and are doing something else, but are of that age group, they are still eligible to go to the GP and get a free meningococcal ACWY vaccine. Next year students who are in years 10-11 or 15-17 years of age if they have left school, will get the free vaccine at school or are eligible to come to their general practice for that vaccine.

This table here is a summary of what the commonwealth is offering for free catch up, so anyone who starts the course under 20 years of age. This tells you how many doses an adolescent should have had of these vaccines and the minimum intervals between doses. We will go through this in more details in a minute about how to work out a catch up schedule, and you will note importantly, depending on the age of the adolescent, we can use a two-dose hepatitis B adult course if they are between 11 and 15 years of age. Unfortunately, if they are 10 or over 15, the three-paediatric doses is what is licensed for a full course of hepatitis B.

The important news here is that the HPV catch ups, so this is a relatively new thing that students who did miss out on HPV vaccine when they were in year seven in the school program are now eligible for a free catch up, and that is quite a new, important advantage for young people if they did not take advantage of the school program.

TIM:

I think that information is available from the NSW Health website isn’t it? We will put the link in the chat box so you don’t have to remember these tables. We have got another question coming through asking if the meningococcal vaccine is available in the ACT. As it is federally funded, I would assume that it is available in the ACT as well as NSW?

VICKY:

Meningococcal C vaccine is, but at the moment, the commonwealth are not funding any meningococcal ACWY, those are individual state funded programs and I do not believe the ACT government has made any announcement about free vaccine for the full valent vaccine yet.

TIM:

Lovely, thank you.

VICKY:

This is just a close up of that previous table, and really, catch up is quite a simple thing to calculate, obviously, the first thing you need to know is how many doses the child has received previously, now that is not always as simple as that. The first port of call would be to check on the Australian Immunisation Register and if they do have doses recorded, it is really important not to repeat any doses that have been given before but just to complete the course. While there are minimum intervals between doses there are no maximum interval and for all these vaccine listed here there is no need to repeat previously given doses.

It can be a little harder, and we will go on to this in a minute about checking doses that children might have received in the school program and if the parents don’t have the written record that we give, I’ll tell you how to get the record of school doses. But really if you go into the register and find out that the child has had two doses of poliomyelitis and two doses of diphtheria, tetanus and pertussis they just need one more dose and that can be given, but if they only had one dose they will need to have two more doses and then you have a look at the minimum dosing in between. That should be fairly straightforward. The other thing to note here, and we will go onto this again, in 2018 the catch up schedule for human papillomavirus will change (HPV) in moving to a two dose schedule, so we will look at that a bit more in some of the slides further on.

That is a long list of vaccines that are available free, importantly for families only a certain number of them are required for their commonwealth payments. If families are coming to you looking to get caught up with their vaccines so they can receive their family assistance payments, then only a subset of those vaccines are required, in particular, the HPV course is not required for families to be eligible for their child being fully vaccinated and eligible for family assistance payments.

Sourcing and updating vaccination records. Many of the records of childhood vaccine, given particularly before children were seven years of age will be on the Australian Immunisation Register and you can obtain those in the usual way you would look up any younger child’s vaccination history. With vaccines that parents think might have been given in the school program, if they don’t have the hard copy record then the parent or your office can call the local public health unit, which is 1300 066 055 - it takes you through to the public health unit that is local and they can look up on our school vaccination register any vaccines that might have been given there.

If families are bringing overseas records or perhaps from another provider not already recorded on the register they can be added to the register via the online system that Medicare provides or by filling in an immunisation history form. This can be really important for families because as I said on the earlier slide, they may not be eligible to get their family assistance payments until their children are recorded as fully vaccinated against the range of antigens that are in the list there.

TIM:

We have a question about the meningitis B vaccination and whether that is going to be included.

VICKY:

No, not at the moment. On three occasions the manufacturer have submitted to the Pharmaceutical Benefits Advisory Committee consideration of adding meningococcal B vaccine to the schedule in Australia, and on three occasions it has been considered to be not cost effective and at the moment I don’t believe there are any applications before the PBAC (pharmaceutical Benefits Advisory Committee). So if families wish to vaccinate their children against meningococcal B that remains a private purchase.

TIM:

Thank you very much

VICKY:

Moving on to other catch up prompts with adolescents, so particularly overseas family holiday, schoolies – at the moment we are really encouraging schoolies to particularly check their measles, mumps, rubella vaccination before they travel overseas. Young people coming with plans to be health care workers or other careers that might involve vaccine preventable diseases, and also older adolescents from vaccine refuser families. It would be really terrific to have prompts in place to check that in any of these kind of circumstances that young people are up to date with their vaccines, in particular MMR (measles, mumps, rubella) because unfortunately we are still seeing quite a lot of measles introduced from young people unknowingly travelling overseas when they have missed one or two doses in infancy.

TIM:

So that is worth going back to our practices and talking to our practice managers and nursing staff to make sure we are aware of those particular prompts for catch up and how we might implement that in our practice.

VICKY:

I hope so Tim, that would be terrific!

Now we are move on to the new nine-valent HPV vaccine. This will be starting next year, so from January 2018 the only HPV vaccine that will be on the National Immunisation Program will cover nine strains of HPV, and on the NIP this will be a two dose schedule and those two doses need to be given at least six months apart. This new vaccine ads five new oncogenic types of HPV so that we are now increasing the protection against cervical cancer to over 90% of the oncogenic strains of HPV, it is also increasing the percentage of male cancers that are given protection.

This will be a complete change over for the school program, and it will also be the only vaccine that we will be supplying to general practice from 2018, it will also apply to those catch up programs.

Along with the new vaccine comes a new two-dose course. There are now many international studies that show that children aged 9 – 14 years, that a two dose course of any HPV vaccine given at least six months apart provides equivalent protection to a three dose course give at zero, two and six months. This evidence has been noted overseas and it has already been adopted in the UK the US, Canada and New Zealand and it is now WHOs (World Health Organisation) recommendation to adopt a two dose HPV schedule. This is the case for any HPV vaccine, clearly different preparations (the two valent, four valent and the nine valent cover a different range of viruses or strains of HPV) but provided any of them are given at least six months apart to children who haven’t yet turned 15, they are considered to have equivalent protection against the strains they [the vaccines] are protecting against. The two dose schedule is going to be applied both to HPV four and HPV two (2-valent HPV and 4-valent HPV) if for example people are purchasing that in the private market, two doses for anyone under 15 will be considered equivalent to the three dose course. This is good news for adolescents that they no longer need to have three doses of HPV because we know it is a painful vaccine. The exceptions to this are people who start the course after they have already turned 15, or the severe immunocompromised.

So as I said, anyone who has already turned 15 still needs to have a three dose course, and that is because there is no evidence about equivalence of effect and the kinds of significant immunocompromised that are applied to still requiring a three dose course are primary or secondary immune deficiencies, significant immunosuppressive therapy, HIV infection, malignancy, organ transplantation and autoimmune disease. We estimate that there will be about 200 year seven students per year that will fit into this criteria, so we will be working with their general practitioners to ensure that they get a three-dose course.

Tim, I can see quite a few questions coming through about the new vaccine – unsurprisingly. A question about do we need to catch up nine-valent HPV for those who have been given four-valent vaccine.

No, this is a newly funded thing, so it is only the cohort from 2018 that is eligible for the 9-valent. If a parent or a young person comes to you and said they have had the 4-valent and want the increased protection - that is certainly a clinically reasonable thing to do, but that is not funded and they would have to have two doses (the full course) to get the benefit of the extra five-strain coverage. Therefore, giving one dose of 9-valent Gardasil to someone who had a course of 4-valent is not really going to give them protection against those five extra strains.

The new schedule will be given in the school program and yes, GPs will still be able to order the vaccine to give to students who missed out at school or if parents choose to have their kids vaccinated at their general practice that is certainly part of their choice.

TIM:

There is a question there about different autoimmune conditions and whether they require an exception to the 2-dose schedule – examples given are crohn’s or even graves’ disease - and whether it’s the condition or the treatments for the autoimmune condition that mean you need to give a three-dose schedule.

VICKY:

I am sorry, this is the depth of information I have on this, so that is something I am very happy to take offline and confirm with the National centre. (Directly below you will find the follow up from this question)

*Dear GPs. Following participant questions during the webinar about autoimmune disease being an indication to use a three-dose HPV schedule in children aged 9 – 14 years, the National Centre for Immunisation Research and Surveillance has clarified that this is only if the child is also on significant immunosuppressive therapy.*

TIM:

Excellent, thank you very much!

VICKY:

Always great questions.

TIM:

Yeah, and there is so many questions, some of them we won’t get to tonight, for example I’m not sure that we will be able to explain why Australia is the last country to adopt this schedule. We will be too short on time for a debate such as that I think.

VICKY:

And some of them we will be getting on to as we look at catch up, so I might move on.

This is a table that is on our website, it is just to clarify how many doses children need according to how many doses they have already had, and their age, I won’t go through this in details. It talks about different timings and different starting ages, but really it means if you have started the course before your turn 15 and have your doses at six months apart then you are fully vaccinated, if your doses are given at a shorter interval you will need a third one and if you start over 15 you will need a three doses. The minimum timings between a second and third dose is 12 weeks, and the minimum timing between a first and either second or third dose is six months, but it can be longer and there is no maximum time that is set.

TIM:

Again, that table is available on the NSW Health immunisation website.

VICKY:

Yep, that is right Tim.

So, what does this mean?

The current students who are in year seven, in the 2017 cohort, they have had two doses of four-valent Gardasil six months apart because as you may recall from an earlier webinar (Meningococcal W Update webinar), in order for us to roll out the meningococcal ACWY vaccine to years 11 and 12 we have vaccinated year seven either side of that this year. So these students who are in year seven this year, provided they have had those two doses at least six months apart are considered fully vaccinated against four strains of HPV, so a third dose is not necessary. We have returned to parents, sent information to GPs, written to schools to say that these year seven students don’t need a third dose, but they are certainly eligible to have it, so if parents do still wish their child to receive a third dose, they can get it but they must leave at least 12 weeks after the second dose is given for that to be fully effective.

TIM:

I’m just looking at some of the questions coming through are about those specific questions about those timing issues and I think its worthwhile people going back to that table on your website and working through that for patients with particular timings and immunisations that have been given.

VICKY:

That is right, and ill push on then Tim.

Catch up HPV vaccines, so this is the commonwealth program. As we have said in the earlier slides, you can offer a free course of HPV vaccine to adolescents provided they have not turned 20. In this year [2017], this is using HPV Gardasil 4, and you can do it as a two-dose course, provided they meet the age restriction or a three-dose course for those who have already turned 15 or those who have significant immunocompromise.

In 2018 with the change in the national schedule you can only offer two doses of free Gardasil, it will be Gardasil 9, but that will mean that adolescents who start the course after their 15^th birthday would have to pay for their third dose because from next year the commonwealth is only funding two doses of vaccine. So that is a little bit complicated in this transition period and so clearly it is advantageous for adolescents to start the course before they turn 15 so that two doses would be considered fully vaccinated. Just a note there, we also strongly encourage GPs to notify all doses of HPV vaccine to their national register and that is really important for program evaluation and for young people knowing whether or not they are fully vaccinated.

TIM:

Do we know what the cost of a private dose of Gardasil 9 will be?

VICKY:

No, I don’t Tim, but I am happy to try to find that out as well, I imagine it is going to be more expensive than Gardasil and I think part of the economics that has gone into the two-dose course is that that evens out the cost for the commonwealth. However, I am not privy to those discussions so I cannot say for sure, but can certainly try to find out the cost will be on the private market.

TIM:

Someone is quoting the cost of (and thank you for knowing this) $145 to $150 for the current Gardasil, so Gardasil 9 will likely be more expensive.

VICKY:

Yeah, but that will obviously be up to the manufacturer.

TIM:

That’s right, thank you.

VICKY:

We have a slide here that is just where to find more information, so we have a lot of these information and Q&As about the new dosing schedules and the changes in the program on our website, so as Tim already said we refer you to there, including the international evidence of why we are now adopting this new two dose schedule.

I am going to move on to antenatal immunisation now if that is ok. The key points here are that influenza and pertussis vaccination should be a part of standard antenatal care, and the important things are that they are protecting pregnant women but also important protection to infants in the early months of life. So we will go through those factors for each of the vaccines.

First off, pertussis, and I am sure we have talked about this before, but infants bare the greatest burden of pertussis and between 2009 and 2014, we had four deaths in NSW in infants from whooping cough. Fortunately, we have had no deaths in infants since we started the antenatal pertussis vaccination program in 2015, and importantly behind everything we do about whooping cough is that neither vaccination nor naturally acquired infection provides long-term immunity, so vaccination and awareness remain key parts to preventing pertussis morbidity and mortality.

So just to recap our antenatal pertussis vaccination program has been offered at 28 weeks since March 2015 and in public hospitals there is opportunistic post-natal vaccination available for women who missed out on vaccination in the third trimester. Of course, we supply a lot of vaccine to general practice and for shared care patients or for patient under GPs care who are pregnant and we encourage that vaccine to be given at 28 weeks, particularly if the public hospital is not doing so.

This is just a recap of whooping cough epidemiology in NSW for the last 12 years; you can see that there are peaks and troughs in notifications. We know with whooping cough in developed countries that vaccinate that we will get epidemics of pertussis every three to four years. The dotted lines there are the notifications in children under five, and you can see while it is at a different rate to the overall notifications the epidemiology in young children follows pretty closely that in all age spectrums. We point out here the beginning of the last outbreak, which started to take off in mid-2014 and when we introduce free antenatal vaccine on the 1^st April 2015.

The next slide is just a little bit of interesting ecological data over the same time period. Here the solid line is the notifications in all the children under five and the dotted line is notifications in infants under six months. There could be many factors behind this but you will see in the earlier outbreaks prior to the most recent ones, the under six months were relatively always higher than the remainder of the under five years old. Whereas in this most recent outbreak, only for a really brief period have the relative notifications in those under six months exceeded those of other children. This is some of the information that we have that perhaps our antenatal pertussis vaccination program might be having a population wide impact on the disease in the very youngest children.

We have some evidence that we will just run through that is important for pregnant women. They want to know about safety of vaccines that they receive, and I think we can be very reassuring that there has been extensive vaccine trials including randomised control trials that haven’t seen any increase in adverse events or adverse pregnancy outcomes with whooping cough vaccination.

We know that there is really good placental transfer of pertussis antibodies, and in fact we will see later that there is an enhanced antibody transfer to infants with recent maternal vaccination.

These are some studies from Europe, the solid bars are women who have been vaccinated during pregnancy and the hatched bars are the controlled group of women. You can see at one-month post vaccination, only the vaccinated women were tested and they had a very strong antibody response, there are two types, the FHA and the Prn antibodies to pertussis, a very strong response is shown in the pregnant women, that was maintained in the pregnant women at delivery and in the cord blood. The infants then started to get measured on their antibody responses and they had significantly higher levels of antibodies against pertussis before they were vaccinated compared to those infants whose mothers who were not. The other interesting thing is whether there is any blunting of the infant program in infants whose mothers had been vaccinated, and there is no significant difference once they get to 18 months of age between the antibodies in the group of infants whose mother were vaccinated and those in the control group. The important message here is that there is very good evidence of transfer of antibodies to infants of vaccinated mothers giving them important protection until their own vaccine course can kick in and they make their own antibodies.

Looking at effectiveness and how it works in the real world as far as preventing disease. There is good evidence from the UK of preventing whooping cough in infants under three months of age, they found 91% vaccine effectiveness in infants of mothers who had been vaccinated in the third trimester, and the UK found a very significant reduction in whooping cough deaths once they implemented the program.

There has been cost effectiveness studies in the US and finds that whooping cough vaccination in pregnancy averts more infants cases and deaths at a lower cost than cocooning strategies. We have also gone ahead and gathered our own evidence on this and this is not yet published but it has been submitted for publication. We did a state wide study estimate the effectiveness of the third trimester vaccination in infants under six months of age and we used all notified cases of whooping cough over a one year period and recruited age match controls and collected data on maternal vaccination status and potential risk factors and confounders.

We recruited 117 cases and controls across the state, most of them in the South West and Western Sydney. Just over half the mothers had received vaccination during pregnancy and only 31% of the whooping cough cases were hospitalised, which is interesting. What we found was that antenatal vaccination was highly protective against being hospitalised with whooping cough (94%) and protective against whooping cough infection in the first three months of life (almost 70% effective). We think this is good evidence for the effectiveness of this program and really important to communicate to parents what the vaccine can do, the infant may still catch whooping cough but have a vastly reduced risk of getting a severe case of whooping cough.

Just to summarise, we recommend pertussis-containing vaccination, a single dose in the third trimester of every pregnancy and that is provided free in NSW and in most states and territories in Australia, but it is not commonwealth funded. Vaccination during pregnancy is more effective in reducing the risk of whooping cough in young infants than vaccinating the mother after birth; this is because of the direct passive protection of the trans placental transfer of pertussis antibodies. There is also indirect protecting by preventing the mother catching whooping cough and reducing the risk that she would pass that on to the infant.

TIM:

Just as we are on the summary slide, we have had quite a few questions come through during that so I am just going to check that we have covered those. There is a few questions about the cocooning strategies, and I think the evidence showed that the antenatal vaccination is actually more effective than cocooning. Does that mean you are not recommending vaccinating family members and close contacts now, or that is still the case?

VICKY:

Yeah Tim, it is still recommended but it is not funded and I know this is an issue for some families, and I know sometimes we get very distraught grandparents coming to us because they aren’t allowed near the infant unless they are vaccinated. I think these are really important risk communication issues, so what we emphasise to new parents is not to have people who have a cough near their infant, certainly the mother should be vaccinated, other children in the household should be up to date with their vaccines, and it’s ideal for other adults that will be in contact with the infant to have had a pertussis booster within in the last 10 years. I would really discourage banning contact from grandparent if they are not willing or not financially able to be vaccinated. It is just a matter of sensitively handling that risk discussion.

TIM:

Yep, and then women who have had a pertussis immunisation prior to pregnancy, should they still be immunised at 28 weeks?

VICKY:

If it is immediately prior to pregnancy I would leave it another month or so during the pregnancy to reduce the risk of getting a local reaction, but certainly, even if a woman is pregnant every year, she is still recommended to be vaccinated in every pregnancy.

TIM:

There is also a question about if there is any studies comparing New South Wales and Victoria pertussis vaccination, because in Victoria apparently they get free vaccination while New South Wales only give to the mum. I guess that might be an interesting study to do.

VICKY:

No, we have not done that but as in the US, they found that it was really the mum’s vaccination at 28 weeks that is the most cost effective measure.

TIM:

And here is an interesting question. Do you need to double a [vaccination] dose for twins?

VICKY:

That is a good question! No, the woman will be developing that big boost in antibodies as we saw in the graphs and those antibodies will be transferred via the placenta to both the twins, so no she does not need a double dose. That is one thing poor old twin pregnancies do not need to have.

TIM:

Excellent. I think that covers all the questions that have been coming through on that, thank you very much.

VICKY:

This here is just a reminder of some of the resources we’ve got on our website, what we have is an evidence review, which is focused particularly for GPs or other health professionals who might want to delve into the evidence, I’ve gone across some of it tonight, but there is more details there. We have posters and other resources that you can order for your practice.

We have also developed resources that are specifically targeted at Aboriginal patients as well.

TIM:

Excellent, that is good to see!

VICKY:

Now we move onto influenza vaccination during pregnancy and again we have a website that covers off many of these aspects of influenza vaccination in pregnancy. The key things to remember about influenza and risks in pregnancy is because of the immunological and physiological changes of pregnancy the woman herself is at risk of more severe influenza. There is a relative suppression of immune function during pregnancy to allow tolerance to the foetus, there is also, as pregnancy progresses, a decrease in lung capacity as a pure anatomical restriction measure as the pregnancy grows, and there is an increased oxygen requirement of pregnancy because of having to also supply to foetus and placenta. The flu is more severe and pregnant women are at greater risk of severe influenza, the risk of hospitalisation from flu increases to fivefold compared to other healthy adult women by the third trimester, and it increases even further if the woman has other co-morbidities like obesity or diabetes.

We know from studies that woman hospitalised with flu have a longer hospital stay and a higher risk of pre term delivery foetal distress and C-section. Some of these things are hard to measure in normal flu seasons, but during pandemics we can get more detailed information and during that time we have detected higher rates of spontaneous abortion, more rapid progression to pneumonia or adult respiratory distress syndrome, venous thromboembolic events and renal failure in women with influenza.

In the pandemic, it was observed in the US that 5% of the deaths were in pregnant women compared to them making up 1% of the population, so they had a five-time increased risk of death. In Australia, the highest excess intensive care unit admission rate during the pandemic was first in Aboriginal people but then the next biggest group at risk of ICU admission was pregnant women, there was observed a doubling almost of the risk of foetal death and an increased risk of low birth weight and small for gestational age for women with influenza infection. There is also high risks for infants in the first six months of life as they are highly susceptible for flu, in the US (we don’t have good data on this in Australia) the hospitalisation is estimated to be somewhere between 240-720 per 100,000 infants under six months of age, this is exponentially higher than even the elderly. The US estimates that each flu season around 100 infants under six die from influenza, so it is a very serious condition for both pregnant women and infants.

We know that there is very good evidence of safety of influenza vaccine in pregnancy, particularly in Australia where we are only offering inactivated flu vaccine it is very safe in pregnancy. Similarly, to whooping cough we can reassure pregnant women that there are studies with tens of thousands of women that show that flu vaccine is safe in pregnancy. I have here a couple of reviews of the evidence and that would be something that if women were asking more questions I would refer you there to look at the detail, and really, the only contraindications are previous anaphylaxis to flu vaccine or to eggs, and if that is the case we would need to use the specialised immunisation service to vaccinate a pregnant woman.

Similarly to whooping cough there is good evidence in the literature about efficacy of flu vaccine in pregnant women so we get a very similar immunological response to non-pregnant women. We see in studies about a third reduction in general febrile respiratory illness, and a 50-70% reduction in confirmed influenza in vaccinated women including from randomised control trial evidence.

I have just listed here a number of studies that show the evidence for efficacy both in the women and in the infants; there is different estimates depending on where the studies have been conducted and depending on the flu season, but there is consistent evidence in that flu vaccine protects women and the infants against flu.

This is a very recent study from South Africa that was a double blind placebo control trial of 3-valent flu vaccine with more than 2000 participants vaccinated in the second or third trimester. It is showing the effect here of the antibody levels in infants of vaccinated women compared to unvaccinated women over the first six months of life. You can see very significant increased levels of antibodies in the infants of the vaccinated women, particularly in the first four months - that difference tends to disappear by six months of age.

This study looked at incidence of flu in infants over the first months of life, and we can see very significant incident rate reductions of influenza and very high levels of vaccine efficacy, particularly in the first eight weeks of life when the infants are most vulnerable to severe flu.

In summary, (we don’t have time to look at all the evidence in detail) but there is very good evidence internationally that influenza vaccine is safe and effective for pregnant women and their infants. There is an estimate that between 6 – 20 mothers need to vaccinated to prevent 1 influenza-associated infant hospitalisation and between 6 – 10 mothers need to be vaccinated to prevent a small for gestational age neonate - Perhaps not as relevant in the Australian setting but that is certainly important in the developing world.

It remains a recommendation of RANZCOG that influenza vaccine is recommended for all pregnant women regardless of gestation and also in women planning pregnancy. Despite this information being available for a number of years in the way we have been able to assess uptake in pregnant women, we think only about a third of pregnant women in NSW take advantage of free flu vaccine compared to our older cohorts. I think we have got some work to do here to improve influenza vaccination in pregnant women.

As for pertussis, we have an evidence review on our website, posters and brochures for pregnant women to help you encourage them to be vaccinated, and this year the commonwealth did a series of videos, again are trying to encourage pregnant women to be vaccinated.

So, some of the questions coming through are about timing and recording of antenatal vaccines. As we have discussed, pertussis vaccination is optimally given at 28 weeks gestation in each pregnancy. The flu vaccine, because it is protecting the pregnancy as well as protecting the infant, should be given at the first opportunity each pregnancy. Even at the first antenatal visit, we would recommend if flu vaccine is available at that time that it be given, but if it is for example in the early part of the year when flu vaccine is not available, then it should be given as soon as the flu vaccine becomes available.

TIM:

If someone has been vaccinated even earlier in the year, and then falls pregnant, should they be vaccinated again in pregnancy?

VICKY:

That’s a good question, Tim.

I think, this would then be later in the year, and they already had one earlier in the year. I guess if they were still going to be pregnant when the 2018 vaccine became available then it might be a good idea to wait until the 2018 vaccine is available and give it to them. If there was going to be any chance of them delivering before the 2018 vaccine is available, then we are not recommending repeating a seasonal flu vaccine. Therefore, a 2017 flu vaccine would only be given one in 2017.

TIM:

There are a few question about egg allergy as well and safety with egg allergy and anaphylaxis.

VICKY:

Flu vaccine can be given to people who have egg allergy, and there is information in the handbook about the process there. The contraindication is anaphylaxis and if a woman does have a history of egg anaphylaxis, I would recommend referring them to the New South Wales Immunisation Specialist Service (NSWISS).

TIM:

Thank you.

VICKY:

Just talking about recording the vaccines, if a woman is attending a public hospital she may have been vaccinated there, so we would just look at the antenatal record, and if you could also please record any vaccines you give to a pregnant woman on their antenatal vaccination record.

This is the card for New South Wales for public hospital antenatal care. There is a spot on the card were both dTpa and flu vaccine can be recorded, we would hope that the hospital does that to inform you, and similarly if you could record there to inform the hospital that the vaccination has been given.

Are there are any other question that we can try to go through now, Tim?

TIM:

There is a comment, we always come across these where people say they got sick after a flu vaccination, and also some comments about the 2017 flu vaccine, which apparently didn’t provide as long lasting immunity and the controversy about whether to recommend extra vaccinations. I think the official recommendation is still not to do that, though some people were giving an extra one later in the year as well.

VICKY:

Yeah, there is a lot of fantastic questions there about flu vaccine and what happened this year and what we are doing next year. I was already planning that we would have our next webinar on flu vaccination because there will be a lot of new things in 2018, including, potentially a super strong vaccine for the elderly and there is also really important questions about why it wasn’t as effective this year, and what we tell patients, so maybe we can hold these questions until that webinar.

TIM:

Yes, I think that is reasonable.

There are a couple of questions just wanting to confirm that flu vaccine was not responsible for a higher miscarriage rate when given in pregnancy.

VICKY:

Yes, that is correct. There is very good evidence that there is no association between flu vaccination and miscarriage, and in fact, failing to vaccinate and catching the flu would increase the risk of miscarriage.

TIM:

That’s a really useful thing for parents and families to know. We will send around the contact details for the specialist allergy/immunology vaccination clinic that people have been asking about. I think that is all the questions that we have got coming through, they have all been covered.

You can see in front of you the learning outcomes, which we went over earlier, and we do hope that over the course of the evening that we have covered all of those learning outcomes, and thank you very much for your questions as well because they have been really helpful, really good questions.

Thank you very much, Vicky. I found that really informative, and I hope our audience did too and thank you very much Sammi for organising us and keeping us to time and keeping us on track with presentation and all the technical discussions in the background.

Look out for the next Twilight Online webinar because there will be more important information coming your way.

SAMANTHA:

Thank you Tim and Vicky, so much for joining us tonight, it has been a great webinar, it has been interactive, so thank you so much.