Flu vaccination update 2018

Sammi: Good evening everybody and welcome to this evening’s flu vaccination update for 2018. We are joined tonight by our presenter, Dr Vicky Sheppeard and our facilitator, Dr Tim Senior. I will just give you a bit of background. So Vicky is a public health physician who has been working for New South Wales Health since 1999. Vicky’s current role is Director of Communicable Diseases Branch, Health Protection New South Wales. This role includes overseeing surveillance of notifiable diseases in New South Wales, coordinating communicable disease control activities, oversight of immunisation programs including delivery of the school-based adolescent vaccination program and representing New South Wales on Communicable Disease Network Australia. Previously, Vicky managed Health Protection Services in the Nepean Blue Mountains and Western Sydney Local Health Districts from 2008 to 2013. And we are also joined by Dr Tim Senior. Tim is a GP at the Tharawal Aboriginal Corporation in South Western Sydney. He originally trained in the UK. Tim is an RACGP medical advisor at 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. Before we go any further, I would like to make an Acknowledgement of Country. We recognise the traditional custodians of the land and sea on which we live and work. I will hand over to Tim now to take us through the learning outcomes for this evening, and then Vicky will commence the presentation.

Tim: Thank you very much, Sam. Good evening everyone. I hope you enjoy tonight’s webinar. These are the learning outcomes, and so this is educational speak for what we want you to get out of tonight. By the end of this online activity, you should be able to describe the key features of the 2017 influenza season, so last year, explain the rationale for giving influenza vaccines to children who are under five years of age, recognise the content of the 2018 (this year’s) influenza vaccine and which formulations are available for each group – each age group, plan to maximise the uptake of influenza vaccine in eligible groups of people and use resources to obtain current information on influenza activity. And so I will hand over to Vicky who is going to start telling us about some of the flu last year and I will keep an eye open for questions that you want to ask as well.

Vicky: Thanks very much Tim and good evening to everyone. I am glad to be able to speak with you all as we prepare for the coming flu season with vaccines due within a month. So, it is just always good I think to reflect on what we saw in 2017, and I think useful for your patients if they have questions about what we should be doing this year. So as you will have heard many times in the media and through other reporting, 2017 was the biggest influenza year ever recorded in Australia. Now, what contributes to this, partly was increased testing. So we had over 103, 000 notifications in New South Wales and several hundred thousand across the country, and that is about three times what we had the year before. So we know testing did not increase three times. We also had a very high percentage of the testing that was done peaked at about 50% of the tests being positive during the season, so very appropriate testing being done in general practice. So it was a busy season. A lot of people were sick and part of the reason for that was that we had both influenza A and influenza B circulating at the same time.

So the graph that is on the screen at the moment shows influenza A in red and influenza B in blue. The number of positive tests per 100 samples. This is from 2013 through to 2017 and in fact the beginning of 2018. So while the influenza A peak was not as high in 2017, in the positive per 100 samples taken as we saw in 2014, we had on top of that a very high rate of positive influenza B samples. So these two things together contributed to a high burden of disease in 2017.

The next slide looks at the age groups affected by influenza A and B in New South Wales last year, and there are a few things that we can see here. So influenza A is the top graph and influenza B is the lower one. So, children under five years of age which is the first bar in both graphs, they were 12% of the notifications. So they had twice the rate of notification expected for the size of their population. And you can see the very youngest children were particularly hit by influenza A, whereas the five to nine year olds were quite predominant with influenza B, so they have formed the bulk of the notifications of influenza B and caused a lot of morbidity in that age group.

The next graph is from GP surveillance. So we are going to go through here just a few of the different mechanisms we have to look at flu activity and flu burden in the community.

Tim: We have had a few people asking as well, do you want GPs to test more routinely and who do you want them to test? I think the GP surveillance will go towards that question to some extent.

Vicky: Yes. I think that is a really interesting question. So what we do find with more testing happening, we do get a better picture of flu activity in the community, but you know, looking at patient costs and Medicare costs and so forth, once we know that there is a lot of flu around and you are starting to find that 50% of the swabs you are doing are coming back with flu, then there is probably not a lot of utility to continue swabbing. Now, swabbing is probably useful for your high risk patients in whom you might be using Tamiflu. So that may be a reason to continue swabbing once you get a picture of what flu is looking like and who you are diagnosing with flu, but apart from people where you are going to use Tamiflu, there is probably not a good indication to keep on swabbing once you know what flu looks like this year and you know there is a lot patients presenting with it. And because we have these other forms of surveillance, we do not need the notifications to continue to monitor flu activity.

So this slide we have here which is GP surveillance shows the same kind of thing that we saw in the notification data. So the 2016 rates are in dotted lines and the 2017 in solid lines, so a very considerable increase in New South Wales and also in Australia over the influenza-like illness rates per 1,000 consultations.

The next slide is New South Wales Emergency Department activity. The top graph is influenza-like illness presentations which are very sensitive, particularly for monitoring the start of the season. The black line is the presentations in 2017 and you can see there the 2009 pandemic. So interesting that obviously the pandemic was earlier in the year than our usual flu season and a very broad and high peak. But apart from the pandemic this year’s influenza-like illness presentations was quite exceptional. But perhaps a lot of that was Emergency Departments’ classification or a greater tendency to classify more people as having influenza-like illness because they have the benefit of rapid testing in Emergency Departments. So an indicator less sensitive to that kind of categorisation error is the second graph, which is all respiratory presentations. And again, in this very broad category, it was a bumpy year, and actually quite similar to the numbers of presentations in 2009 peak, although remembering we have had a big population increase and an increase in utilisation in Emergency Departments since 2009. But still a very substantial burden.

The next slide here is another of our flu severity measures and this is confirmed influenza hospital admissions between April and October 2017, and this is in a group of sentinel hospitals, three hospitals, John Hunter, Westmead and Westmead Children’s. There we have sentinel surveillance and we know who is admitted and then diagnosed with flu. So, peaking at about 90 admissions per week in the three hospitals and quite a lot of activity with both influenza B in green and influenza A in red, orange and yellow depending on the level of typing that was done. So in summary, in the 2017 season, it commenced early. It started in June and peaked in mid-August. It lasted at least a couple of weeks longer than what we typically see. There was record high activity in the community and in Emergency Departments. The severity was similar, so the number of people admitted and according to the number of cases was similar. We think part of the reason for a big year was a poor match with the vaccine and the influenza A/H3N2 strain. But the other three strains were well-matched to the vaccine and we had a record number of outbreaks reported through institutions, 591, and that was predominantly due to the A/H3N2 strain in aged care facilities. So really, the lack of effectiveness of the vaccine in the elderly was a big factor there. And notifications were matched to 654 deaths including two young children and several young adults, but of course, influenza associated deaths was still much larger than that.

Tim, shall we just break before we move on to the 2018 predictions with some of the questions that have come in there?

Tim: Yes, absolutely. Someone is wondering if those two child deaths, terribly sad, were there any particular comorbidities that made that more likely in them?

Vicky: No. Both of those children were previously healthy and Children’s Hospital Westmead had an incredible year. They had a lot of encephalitis and also pneumonia associated with influenza in children, around half of them previously well children.

Tim: So again, that reinforces the message about getting people vaccinated. And someone is asking about just clarifying the peak last year, that it was an earlier peak or a later peak?

Vicky: The season started earlier and it peaked in August. It was a prolonged peak but it was later after the start of the season than usual because of the prolonged season.

Tim: And there are a few people worrying about your statistics if we stop swabbing early, but I imagine you have got other ways than relying purely on the swabbing of clinical patients that we see.

Vicky: That is right.

Tim: So do what you feel is right clinically I think.

Vicky: Yes.

Tim: And the only other one is about people wondering why the H3N2 vaccine was not a particularly good match. Do we know the reasons for that?

Vicky: Yes. As I am sure you are all aware, the flu vaccine is grown up in eggs. So what happens with particularly the H3N2 strain, is that once it starts to grow in eggs it becomes what we call egg-adapted. So it deviates from the virus from which it was taken, and the strain that was used to make the 2017 and the 2016 H3N2 vaccine had quite considerable egg-adaptation. So the antigen that came out of the eggs was quite different to the antigen that had initially gone into the eggs. And that was not able to be rectified in manufacturing. So what the WHO have done for the coming season, they have selected an H3N2 strain which is less subject to egg-adaptation and remains quite well-matched to what is circulating in the Northern Hemisphere. So we are hopeful that we will see a better match and a better effectiveness for the H3N2 this year.

Tim: Lovely. Which takes us very nicely on to the 2018 predictions and someone was wondering if the Northern Hemisphere helps us predict what is going to happen in 2018.

Vicky: Well, certainly the Northern Hemisphere have had a tough winter. But they have had a tough winter with the viruses we had last year and the vaccines we had last year.

Tim: That is right, my relatives have all caught the Australian flu.

Vicky: That is right, yes. So as would have been predicted from our season last year, they have had a bad year because their vaccine was not modified in time to give them the additional protection. So, on the basis of two big seasons of H3N2, so a lot of people would have had infection and developed immunity to that virus, on top of an improved 2018 flu vaccine, we are hoping that we will have a quieter season this year. But of course we can never be certain with our predictions. But at this point in time, this is the best we can predict. But that does depend on a really good uptake of vaccination in the community. And I will talk a little bit later about the campaign that we are running this year which is also having a lot more emphasis on measures people can take to stop spreading the flu. So those are the main things to expect, but of course we will particularly need to look at ways to protect the elderly and young children, and the good news is there is no Tamiflu resistance in the strains that are circulating.

So the next slide is just reminding you where you can find flu reports. So a lot of the information I have just presented is in our annual reports and monthly reports are on our website. And once we get to May we start to issue weekly reports. So you can access all those reports there.

So the big news for New South Wales and quite a number of states and territories, so we are now onto the free flu jab for New South Wales kids under five. So we and many other states and territories are funding free flu vaccine for children under five.

So moving onto the next slide which starts to talk about the impact of flu in young children. So they do in Australia, children under five have the highest rates of hospitalisation comparable to that in people 50 years and older. They not uncommonly get pneumonia and encephalitis complicating influenza, and every year we get deaths reported in children under five. And as I said, not restricted to children with known high risk medical conditions.

The vaccine in children under five. So, there has been quite a lot of research done in Western Australia and of course they have had an under five flu program since 2008 there. So Chris Blyth, who was actually an infectious disease trainee in New South Wales and then went to Western Australia, has done a lot of really good work over there, and he has published studies that show very high vaccine effectiveness in previously healthy children, 70% and even higher among children with medical comorbidities. So we get the same kind of performance of flu vaccine in young children as we do in healthy adults. We have got studies from overseas also. We quote here a Japanese study that found that vaccinating 71 children will prevent one flu A hospitalisation and prevent 10 acute febrile respiratory illnesses per 10 children vaccinated. And then the other line of evidence that we look at is the community level protection. Because, as I am sure I do not need to tell you, the way that young children are very excellent at sharing their germs among their peers and also amongst their family, by vaccinating young children, even if we can vaccinate 30-50% of them, we can get a community level benefit, so suppress community level flu transmission. So those are the reasons that we based the decision to do this program.

And then the next slide has some very recent evidence. So this is published in The Lancet this month, and it is quite a ground-breaking study. It is a randomised control trial done over five years and 13 countries, with 6,000 children given quadrivalent inactivated flu vaccine and 6,000 controls. In some years they had considerable mismatch with the circulating strains, but over those five years and 13 countries, they found a 64% vaccine effectiveness against moderate to severe influenza and 50% vaccine effectiveness against all influenza. They found no clinically meaningful safety differences between those vaccinated with the influenza vaccine and the control group. So I think that is really excellent evidence to come in at this time.

So, some of the questions that are coming through, we will be getting to those in the slides, so perhaps if we just leave those for a minute Tim if that is okay.

Tim: Yes, that is fine. I was just thinking exactly that. I was going to let people know that we are coming to some of those questions very shortly.

Vicky: Okay, so the next slide is the ATAGI advice, ATAGI being the Australian Technical Advisory Group on Immunisations, so our national expert group, and that advice is now available on the Department of Health website. So they reiterate previous years’ advice that annual vaccination is the most important measure to prevent flu and its complications. They recommend annual flu vaccination for all people six months in age and older. Now, clarifying some of their advice from last year and I saw Dr Duani’s question earlier on about the duration of protection. So they say that optimal protection occurs in the first three to four months following vaccination. So there is no recommendation for re-vaccination in the same year, but again they do say it is not contraindicated if someone wishes a second vaccination. And ATAGI also say if a flu is circulating, it is never too late to vaccinate.

Tim: And I think the other side of that coin, is it ever worth delaying vaccination until a little bit late to get optimum protection towards the peak?

Vicky: Well, now that ATAGI are quite clear that you have got optimal protection for the first three to four months, by vaccinating in April/May, then that should cover any flu season. We do not want to leave it too late because we can get flu seasons, well we started in June last year, that have started as early as May and it does take two weeks to develop optimal protection after being vaccinated. So I would not advise trying to leave it any later than May.

Tim: And is there any evidence around the second vaccination? Does that prolong protection or do we know anything about that?

Vicky: There is no evidence Tim. No, it is an evidence free area and ATAGI also caution that the use of multiple types of vaccines, for example trivalent and adjuvant it with a standard quadrivalent has not been studied, so some of the potential combinations are evidence free zones I am afraid.

Tim: Yes.

Vicky: If we move on to – I just saw a question is there a second vaccine later in the flu season prior to Northern Hemisphere travel. Look that might be a good idea in a particularly vulnerable person, so if they are vaccinated in April and they are travelling in December, then that is probably a good idea to do that, but I must say that is not actually funded, but I guess if there is left over vaccine in the fridge, no harm done.

This slide now is about Australians and the 2018 vaccine. Now, we have got two types of vaccines this year, so the quadrivalent which is for children and people under 64 has the same contents as last year, except that as we have already talked about the H3N2 component has changed and so that is a Singapore strain and that is the one we are expecting will be a better match for what is circulating. But the other components are the same as last year. And as we will come on to talk about the vaccine for the elderly is trivalent, so this has two A strains, the same two as in the quadrivalent and the B strain, the Yamagata strain, or otherwise known as the Phuket strain of influenza B. So, the question is, is there any difference between the flu vaccine from the Northern Hemisphere and Southern. So, our Southern Hemisphere vaccine in 2018 is updated from the Northern Hemisphere, the difference being that new H3N2 strain. Otherwise they are the same.

So as I have alluded, so the flu vaccines will have and this is one reason why it is really important that we pay attention to this, there are six flu vaccines for four different age groups in 2018. So it is really important that we all get our heads around that. So there are four quadrivalent vaccines. There is FluQuadri Junior, FluQuadri, Fluarix Tetra and Afluria Quad. And then our two new higher immunogenicity vaccines, the trivalent ones for people 65 and older, Fluzone High-Dose and Fluad. So we will go through all of these one by one.

 

So this slide here is just a little checklist that is taken from the ATAGI statement and indicating which vaccines can be used for which age groups. And again, we will go through each of these. But as you can see, you and your nurses are going to have to keep your wits about you to ensure that the right vaccine is given to the right aged person.

So, looking at the vaccine for children less than three years of age, we have got FluQuadri Junior. So this is both on the national immunisation program for Aboriginal children and medically at risk children, but for all New South Wales resident children, this is the vaccine that we have purchased as well. So this is up to 35 months of age from six months. As has always been the case, if it is the first time the child has received any flu vaccine, then you should give two doses, one month apart. And it is important if you are giving it at the six month age point that there is an increased risk of febrile reaction if given with pneumococcal vaccines so it is important to talk to parents about managing fever. So for the children under three you cannot use a half dose of the straight FluQuadri or Fluarix Tetra, so this is the vaccine to use for children under three years of age.

The next slide is the two vaccines that are available for the children from three years for everyone up to 64, so that is FluQuadri and Fluarix Tetra. You will be familiar with these. These are the vaccines that we had last year. So they are free for all children up to five through the state funded program, for any Aboriginal person who is 15 years or older, or pregnant women and that should be given as early in pregnancy once the vaccine is available, and then it is free for all people with medical risk factors from five to 64 years of age, and again if you are seeing a child under nine who has not had a flu vaccine before, they should have two doses one month apart.

Tim: And just to clarify that the two doses one month apart for children, is it the first dose that is funded on the free program.

Vicky: That is correct. Yes. Thanks, Tim. Up to five or with medical contraindications. Though if they have had one dose in 2016 or 2017, they just need the one dose in 2018. So it is they are completely flu vaccine naïve that they need the second dose.

Tim: And just to make sure, there are a few people asking about vaccines for pregnant women, and either of these are the vaccines to use in pregnant women. So just making sure everyone sees that.

Vicky: And also the next one that we are going to talk about, Afluria Quad which we had last year as well. So it is equivalent to Fluarix Tetra and FluQuadri, but it is only licenced for people from 18 to 64 years. Now you probably did not see a lot of it in general practice last year because we preferentially distributed it to aged care facilities because it is licenced for people over 65 as well. So to reduce confusion we did not send a lot of it to general practice, because there is a special vaccine for over 65’s this year, we are going to have to distribute this to general practice so it is just important to remember it cannot be given to people under 18, but it is excellent for pregnant women, Aboriginal people and people with medical risk factors.

So our two new vaccines, people 65 and older. So they are different vaccines. Now as I have said, they just have three strains of flu covered, two As and a B. One of them, Fluad, has an adjuvant in it. The adjuvant is called MF59 and it is an immune stimulant that basically attracts T cells to the site of the injection and enhances the immune reaction of the vaccine. So because of this adjuvant, this vaccine you will have to alert your patients that they may expect more of a local reaction if they receive Fluad. The second new vaccine that is available is Fluzone High-Dose and this is the one you have probably heard a lot more about which has four times the antigen load in it, so 60 mcg of flu A/H1N1, flu A/H3N2 and flu B/Yamagata strains in it compared to the standard 15 mcg. So, because of the increased antigen in this Fluzone High-Dose, it is associated with a higher level of systemic reaction, so as you all know, some people do get a bit “fluy” a day or two after usual quadrivalent flu vaccination, a little bit of low grade fever, a little bit myalgia and a little bit of headache. So with this Fluzone High-Dose, there is an increased risk of these mild vaccine reactions, but neither of them have any increase in severe adverse effects compared to standard vaccination.

So just moving on to the next slide, which is just a little bit more information about Fluzone High-Dose and Fluad. So, important to remember these are only licenced for persons 65 years and older, so of course there will be questions around younger people with HIV and other immune problems. Research is being done on these vaccines in those groups, but there is insufficient information on them at the moment for them to be licenced for younger people.

It is really good to see that the improved immunogenicity even extends to the frail elderly. So we should get a really good response, good improved protection in the elderly from these vaccines. You know, they still remain imperfect flu vaccine, so the benefit we are getting from them is about a 25% improvement in protection. So it is if normally we are getting 30% or 40% protection from our standard vaccine, we can expect to see maybe up to 50% protection from these vaccines. So, I think it is important to make sure people have the right expectations about these vaccines and still elderly people are going to be at risk of flu, but this is just giving a marginal improvement in the protection they will receive.

Tim: We have had quite a few questions coming in about the increased immunogenicity. Some people asking why there is only three strains in that one compared to the four strains in the other one?

Vicky: Well that Tim, my understanding is that is a manufacturing decision. They are in North America starting to develop these high dose and adjuventinated vaccines with quadrivalent vaccine but they are not able to supply that into the Australian market yet. But ATAGI’s recommendation is that these are preferentially used in the elderly because of the better protection and you know, it is good to see that the strain that is in these vaccines, the Yamagata strain is the one that is predominant in North America and Europe and we expect that that will be the dominant strain. So it is good that that will match up well with this trivalent vaccine.

Tim: Yes, we cannot go past that reduction in hospitalisation and influenza infection compared to the standard influenza vaccine as there is evidence that it works. Do people get a choice? People can still use the normal quadrivalent vaccines in elderly people as well?

Vicky: Yes it is still licenced. If there is a reason that an elderly person wished to have protection against the four strains and you felt that they were still quite robust with their immune response, then that would be a good choice.

Tim: And is there any reason for choosing between the adjuvant and the increased dose, the high dose trivalent vaccines?

Vicky: ATAGI has stated that they are equivalent, so, but I think it is more about counselling your patient about the kind of side effects that they should be looking for and how to manage those between the two different kinds.

Tim: And do we have to be careful with people on immunosuppressants?

Vicky: No. No, and there is some good evidence that these work well in immunosuppressed people.

Tim: Lovely. And just to clarify again, some of the information we have given earlier, but you do not use both the trivalent and the quadrivalent in the same person as there is no evidence around this at all. That is not the recommended usage is it?

Vicky: It is not a recommended usage, no.

Tim: I think that is all the questions, or there are still some questions coming through. I am wondering if we might move on and I will have a quick scout through those.

Vicky: Okay. So other changes that I would like you to know about in 2018, again there has been a little bit of publicity about this. So just the week before last, we launched a new policy directive for all New South Wales Health healthcare workers. It is our old policy directive that required mandatory measles, mumps, rubella, whooping cough and TB vaccination, and we are now introducing mandatory annual flu vaccination for a subset of healthcare workers that work with highest risk clinical groups. So this is antenatal, perinatal, postnatal, neonatal, paediatric intensive care, intensive care, transplant and oncology wards. So some of your patients will be working in these areas and may be asking you about the mandatory flu vaccination. Now of course we do provide free flu vaccine for all our health care workers and those programs will be made very accessible in hospitals this year, but of course health care workers are always welcome to go to their GP for their vaccination if they wish and so if they are asking you about the reason for the mandatory vaccination for a subset of workers, I think it is recommendation of a number of august bodies that flu vaccination is the best thing that health care workers can do to protect their patients, but also to protect themselves and their families to prevent them from introducing flu into their home. So I hope that measure meets support from you and your patients. And of course we are having a new flu campaign this year and the Minister launched it only yesterday. So it is about the theme of not spreading the flu, it’s in your hands. So it is up to individuals to get a flu shot, to sneeze into the elbow to stop spreading germs, to clean their hands and to stay at home when they have flu to stop spreading the germs. So we will be having posters and brochures and other promotions of these messages that we will make available to you. What is going to happen Tim with every vaccine order, there will be a one page card that comes with it that shows the different vaccines and the different age groups that they are eligible for, so the same information that has been in the earlier slides, and on the reverse of that there will be ways to order our resources which are the posters and the pregnancy brochures et cetera. So get your staff to look out for those as they come in once the flu vaccine orders start arriving.

Tim: Lovely. That is good.

Vicky: And then this next one is just a shot of some of the promotions that we will be doing. So we are quite actively going out in the community spreading these messages about not spreading flu.

Tim: And there are a few questions coming through about the healthcare workers and the funding for that, whether the mandatory vaccines are funded or whether they will have to pay for it, especially if they get it through the GPs.

Vicky: Well, certainly we pay for them to get them at the workplace. Unfortunately the vaccines that GPs have are mainly national immunisation program vaccine, so they are not actually funded for healthcare workers. So if they do make the choice to have it at the GP, really the free vaccine should not be used unfortunately.

I see an egg allergy question there which is always a good one.

Tim: Why is it a good one?

Vicky: So egg allergy is no longer contraindication to flu vaccination and that is covered in the ATAGI statement. So ATAGI now state that someone with egg allergy, even anaphylaxis can be vaccinated in any medical practice and there is no half dose et cetera, but of course it is crucial that there is an anaphylaxis kit and an adrenaline kit ready as should be the case with all medical intervention should there be a reaction. But it is safe to vaccinate egg allergic people in general practice.

And of course if you are worried about particularly children that are egg allergic, there is always referral to our specialist immunisation service at the Children’s Hospital. They will vaccinate them there, give them first vaccines under medical supervision if you prefer, or they are always on the phone for you to ask those questions. And I will make sure we circulate the 1800 number for the specialist immunisation service with the presentation as well, in case you do wish to contact them about any of your allergic or any other patients.

Tim: Are there any other contraindications to the flu vaccine?

Vicky: Just anaphylaxis to the vaccine itself or to any of its components.

Tim: Okay, good.

Vicky: So underlying illness is fine. It is actually recommended to vaccinate with underlying conditions. Patients who had Guillain-Barre associated with previous flu vaccine, then that is something that again I would recommend consulting with our specialist immunisation service for.

Tim: And someone has heard from an oncologist that Nivolumab reacts with flu vaccine. Do you know anything about that? I do not know. I would need to look that up specifically. Have you come across that before?

Vicky: I have never heard of Nivolumab before.

Tim: It is part of a new biologic agent I think.

Vicky: Obviously, I think. No, I am happy to take that on notice and get back on that. But again, the New South Wales Immunisation Specialist Service can also answer your questions. Because the patients that are on these medications are the ones that most need protection from flu vaccine.

Tim: Yes, that is right. Someone was asking, back on the trivalent strain, if there was a reason they chose the Yamagata strain of the B, was that particularly prevalent, or it is just a manufacturing decision?

Vicky: It is has been the more prevalent circulating strain.

Tim: Good. Okay, let’s move on.

Vicky: Okay. This again is some very late breaking data, a couple of graphs here. So every year we ask on the population survey which covers about 17,000 people a year whether or not they have been vaccinated for flu. So we have just got the 2017 data in and it is quite pleasing. So this first graph is the people over 65, so the dark blue line is all people over 65 and you know, we are seeing a slight increase in that over time, but a very pleasing increase in Aboriginal people reporting being vaccinated, older Aboriginal people, and really good rates in older people with medical indications, particularly diabetes and asthma.

But the next slide is people under 65 and this is really pleasing. It was actually the subject of our webinar last year, was about the medically at risk and pregnant women. And we are seeing really good, steady year on year improvement in the uptake of flu vaccine in these people who are under 65. So you can see there the pregnant women which is the orange line has just been steadily increasing each year and also really good uptake in people with asthma and diabetes. But that said, we are still only reaching 50%, so all these people are eligible for free annual vaccines, so I guess we would like to see that to continue to increase again this year.

And then the final slide, and Tim you might want to comment on this one which is just a bit of a checklist for practices getting ready for flu season.

Tim: Yes, so I think this is helpful. So just to be clear, the state vaccine centre allows you to pre-order vaccines and keep your stock up to date, and I think the most important thing is having systems. Someone commented earlier about how complicated it is having all of these different vaccines available to different groups of people and we are just relying on our own memory for all of these things, then it is almost guaranteed to fail. It is the systems in practice that allow us to know whatever our vaccine stock is and an estimate of how much we need, that confirm our cold chain measures are in place and that the fridge is able to store vaccines and the way we store them in the fridge. I do not know how it is in your practice but it may be worth talking to the practice manager about how it is. We have little baskets with different sets of vaccines in there. I can imagine we can have different sets with a label for each one saying this is for this age group, this is for this age group, and that we talk to all the staff involved about the vaccine types and who they are used in. But also, how we are going to offer as many patients as possible the flu vaccine and possibly combine it with other vaccines that they might be eligible for too, such as if they have not had pneumococcal vaccine or if they are due a shingles vaccine. Practice software is going to be important to make sure that is up to date with the latest recommendations. Worth vaccinating all practice staff. That rumour that all doctors are immune to flu, I suspect is not true and we have just heard that we need to take a day off or time off work not to spread flu, so it is worth us all having flu vaccines. And then there is a list there about people that we can target using our practice software to identify them and recall them and to know who they are in our waiting rooms so that we are able to offer them the vaccine at each appropriate opportunity and then record that it is done in the practice. All of our practices are different, so I think there is no one measure that will work for all of us and I think it is up to all of us to go back and talk to our practice staff, our colleagues, practice managers and practice nurses and Aboriginal health workers to say right, what is going to work for us to protect our patients, because we all work in different practices. Anything that you would add?

Vicky: Yes. So just picking up on that point of the baskets in the fridge. So we are printing up some brightly coloured stickers which have the different age groups on it, so they will also be distributed with the vaccines, so I hope that will help. And the reason I suggested upgrading practice software, is that it is really important that the vaccines that are given are transmitted to the Australian Immunisation Register. Because of these new vaccines, you need to have the most recent version of your software to be able to have those new vaccines on the drop-down, so really it would be fantastic if we could get really accurate reporting of what vaccines are given recorded to the register.

Tim: Yes, so that is important. Now that the immunisation register covers all people, it is not just childhood.

Vicky: That is right.

Tim: Someone is pointing out that GP staff are not covered by free vaccine. That is right and it can be up to you whether you wear that cost, if you are happy to pay or if some of them were actually eligible or not. I guess it is also the cost of our staff having multiple sick days and the impost that that puts on our practices as well. Some people may view that that is a pretty good investment in their staff.

Vicky: I think so. And it is a relatively cheap vaccine as well. So some of the questions I see and some of it is clarification of things that we have already spoken of. So, for the free state-funded vaccine, it is kids under five, so that is who are between six months and still four years eleven months is the free group, and those that are five to 64 and are eligible for the free vaccine are pregnant women, people with chronic conditions such as cardiac disease, severe asthma, diabetes, obesity with a BMI over 35, neurological conditions, immunosuppression. There is a range of most people with chronic illnesses under medical care are eligible for free vaccine, but not simple hypertension for example does not qualify for a free vaccine.

Tim: I have an interesting question here. Someone has a patient in their forties with no comorbidities. He has had flu last year and is adamant he wants the high dose trivalent vaccine. Should he have it and is it available privately? Actually it is not licenced to people under 65, so that would be off label use I would imagine.

Vicky: It is off label use and they are not available on the private market this year. I guess it is a special arrangement to bring them in for the elderly so there will not be any private vaccine available. And the reason Afluria Quad cannot be used in less than 18 is that it is not licenced and it is good to remember that this is a vaccine that is similar to the old Fluvax and with the old Fluvax they have got a different manufacturing process so we had the high fevers in children and it lost its registration for anyone under 10, so I think the manufacturer has not yet done the studies to show its safety in people under 18.

Tim: And someone is asking how much the risk of contracting influenza is reduced in a fit and healthy person. There is still quite high rates in fit people and the vaccine is very effective in people without other comorbidities as well, isn’t it?

Vicky: That is right, yes. So it is certainly something I have every year. While it is not perfect, depending on the year, you will have a 50% to 70% reduction in your risk of catching flu, so that is very worthwhile when we see the enormous numbers of people that do get the infection every year.

Tim: And feel really grotty with it, too.

Vicky: Yes.

Tim: Just looking through some of the other questions. I am not sure if you covered it. Obesity BMI greater than 35 without other comorbidities, that is eligible for the vaccine or not?

Vicky: Yes, it is. Yes. There is no contraindication in immunocompromised for the vaccines. So it is strongly recommended in immunocompromised persons.

Tim: 65-year-olds without Medicare cards. Can they have the flu vaccine or are they ineligible and need private… that is interesting because if they have not got a Medicare card you would not be able to bill for seeing them either, which may be a bigger problem than whether you can get free vaccine for them.

Vicky: So in New South Wales we always encourage people of eligible age groups, whether they are children or the elderly to get the free vaccines, because that is really contributing to the population health effects.

Tim: Someone is asking if there is any data on long term risks of influenza vaccine?

Vicky: Look, there are some people who have looked at the question of whether getting a flu vaccine each is year interacts with the vaccine effectiveness. That might be where that question is coming from. One study group did show that having multiple flu vaccines could reduce its effectiveness. That has not been replicated in a number of other studies, so ATAGI’s recommendation remains that annual flu vaccination is recommended.

Tim: There are a lot of questions coming through about particular instances of complex chronic diseases and whether they are eligible or not and I think rather than go through each one, it is probably worth referring people to the ATAGI statement and immunisation handbook to check that for any patients that they have where they are not certain.

Vicky: For the vast majority of those that are being asked about, yes they will be eligible.

So just moving on to the last slide and again just reminding you about Smart Vax which is an adverse event monitoring system that was developed by a GP and endorsed by RACGP and it is part of our national adverse event monitoring system, and if any of your practices are interested in participating we would like to sign you up and it is wired into your practice software, so that whenever a vaccination is given it automatically sends an SMS to your patient three days later just checking on whether they have had any adverse events and you know, we think it works for the practice and the patients and it also helps ensure that the vaccines that we are using in Australia are safe and are not having any unexpected adverse events.

So those are the slides.

Sammi: So that brings us to the end of this evening’s flu vaccination update webinar, so the learning outcomes that are currently on the screen are the same as the ones we displayed at the beginning. So this is what we hope we have covered for you tonight. And I just want to say a big thank you also to Vicky and Tim for joining us tonight.

Vicky: That is alright. I just see one question, Sammi. When is the vaccine going to be available? We are expecting they are going to be available in about the second week of April to your practices, but please put in your orders and they will be delivered as soon as we receive them in the warehouse.

Sammi: Fantastic. So thank you again Tim and Vicky. So thank you everyone for joining us and enjoy the rest of your night.

Vicky: Good night everyone.

Tim: Thank you very much. Good night everyone.