Flu vaccination update 2019

Sammi: Good evening everybody, and welcome to this evenings ‘Flu Vaccination Update 2019’ webinar. My name is Samantha and I am your host this evening.

Before we jump in I would like to make an Acknowledgment of Country. We recognise the traditional custodians of the land and sea on which we live and work, and we pay our respects to Elders past and present.

Okay, I would like to introduce our presenters for the evening. We are joined by Dr Vicky Sheppeard. Vicky is a Public Health Physician who has been working for NSW Health since 1999. Vicky’s current role is Director, Communicable Diseases Branch for Health Protection NSW. This 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 Communicable Disease Network Australia. We are joined by our Facilitator tonight also, Dr Tim Senior. Tim is GP at Tharawal Aboriginal Corporation in South Western Sydney. Tim is also 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 an RACGP Medical Educator. So, welcome Vicky and Tim and thank you for joining us this evening.

Tim: Thank you very much. Good evening everyone, it is nice to join you on this Wednesday evening. First of all we will go over the learning outcomes, which is educator speak for what we want to accomplish this evening. So, by the end of this activity we should be able to prepare ourselves for the 2019 influenza season, understand the factors contributing to varying influenza impact in NSW in recent years, learn about the impact and outcomes of the 2018 influenza vaccine to children under 5 years of age program, be aware of the formulations of the 2019 influenza vaccine and their optimal use in eligible age groups and utilise the NSW Health Flu Vaccination Tool Kit to optimize vaccine supplies and maximize uptake of influemza vaccine.

So without further ado, I will pass over to Vicky. Good evening.

Vicky: Thanks Tim, and good evening, to everyone. It’s good to be back and once again talking about flu, and I guess, even though we have done this for a few years, the thing about flu is that it changes every year, so there is always something for us to learn and be ready for.

The first graph that we have tonight shows the number of notifications of influenza A and influenza B amongst NSW residents for the past 10 years. So influenza A is the black graph and Influenza B is the yellow line. What we see there is a number of things, in most year’s influenza A is much more common, we had a very big peak in 2017, so the winter before last you will recall was the worst that we have had since the pandemic and then we also had relatively big years in 2016 and 2014. Right over on the right hand side of the graph, you can see the final numbers from 2018, and we had one of the mildest seasons in a long time because as the decade has progressed we are getting a lot more testing in general practice, and so a lot more notifications of flu, and yet despite all that testing last year we had quite a mild season. Now there is probably a number of reasons for that, and we will just look at a few more features of the season and then we can think about why that happened.

Last year, these two graphs here are showing the 2018 experience for influenza A on the top graph and influenza B on the second graph, by age and sex. We can see that children under 10 years of age were most affected as far as the number of notifications go, and then gradually increasing amongst mid-range adults, particularly for influenza A, but quite a lot of sparing of the elderly, and that is a feature of influenza A when we have H1N1, the pandemic virus predominant, which we did last year, that we get relative sparing of the elderly. The pattern of influenza B was a little different, so we do see a bigger blip there in the over 85’s, noting that the relative number of notifications between these two groups, the axis on the A is 10 times that of B, so absolute numbers of influenza B were much less, but a slightly different age distribution.

The next graph is looking at cases reported from sentinel GPs, this is through ASPIRIN. The dotted line is the NSW in Blue and the National rate (in red), from the bad year 2017 and the solid line is our experience last year, so clearly, I hope all your practices experienced a much milder flu season in 2018. It is very hard to even see a peak there in NSW last year.

Then we have also got this graph showing emergency department activity. The solid black line is 2018 and the pink line is 2017. The top graph is about influenza like illness, which is quite a specific category, and the lower graph is emergency department presentations for all respiratory and fever (related illness). So, once again, different numbers of patients on the axis, but we can see again that emergency departments didn’t have a lot of increased activity from flu in 2018, particularly compared to 2017.

The final one we have looking at the 2018 season are from our three sentinel hospitals, so Westmead Hospital, Westmead Children’s Hospital and John Hunter Hospital where we have active surveillance for flu. This shows the spread of the flu season last year amongst patients presenting to those hospitals with confirmed flu, and once again showing that the orange, yellow and red, which is all the influenza A compared to influenza B shows the predominance of influenza A causing severe disease, and while we don’t have comparisons to other years, this is certainly fewer than previous years, though we did get quite a lot of admissions at Children’s Hospital, Westmead from quite sick children.

Tim: We have actually had someone asking – Has there been more influenza A in the last two months?

Vicky: Ah, yes, that’s right. So after that very quiet year, 2018 was quiet and there were some really positive things going for us. First, we had a very severe year in 2017, so a lot of people caught flu in 2017, so would have had persistent protective immunity. We also had a season dominated by the H1N1, the pandemic virus, and we know the vaccine is highly effective against that, and on top of that we distributed about 2.3 million vaccine does in NSW, so we had more than 50% higher uptake of vaccine in 2018 than we have ever had before. So we had an immunizing event in 2017 through a severe season, then we had fantastic uptake of vaccine and the vaccine was really well matched to the predominant virus. So that was great for last winter, but then at the end of 2018 and starting about December, we started to see increase influenza A activity up in northern NSW, which we thought was related to the outbreak in the Northern Territory that was going on, then in January (2019) we started to see returning travelers with influenza, mainly A again, both H1N1 and H3N2, and it has been quite remarkable, we see this phenomenon every year in January and February, but this year it is probably double the number of notification we have ever seen, and it has persisted into March. So that has an impact on what we need to do to prepare for the 2019 season, which we will get onto in a minute.

So just finalizing 2018. Despite a mild season, we identified at least 43 deaths, including in one previously healthy young child and there were very few outbreaks in aged care facilitates compared to other years, only 46, where as in 2017 we had over 500.

What do we expect this year?

So in North America has had a similar season to what we saw last year, mainly H1N1, Europe has also had a milder year, but has both types of A circulating. The vaccine has been updated, so the H3N2 component has been updated to a strain to better match what is circulating, and also the B componenet of the 2019 vaccine has been updated. So we expect that the vaccines that are manufactured for us this year will be very effective again against H1N1 and against the B strains, and it is a bit of wait and see about the H3N2 componenet will perform. Also good news, the circulating virus has no resistance to Tamiflu, so it will be effective, but as we started to say, these high levels of Summer flu that aren’t going away, we don’t yet know if that is going to finally start to decrease, or will keep on this level and then start to increase. We will talk a bit later about how we are going to manage the vaccine distribution strategy to deal with that, and because of the strains that are likely to predominate, we expect once again that the elderly and young children to be most affected in 2019.

So, how do you keep up to date with what is happening about flu? We issue monthly reports until May, and from May we issue weekly reports, and they are on this webpage, so if you want to know what’s happening with flu and see all these graphs and information about the various indicators, please use that web page.

So, still staying on 2018, what was the impact of Flu in children under five? They had the highest rates of hospitalization, so similar to those over 65; we observed complications such as pneumonia and encephalitis. Every year we have deaths reported in children from flu, so there has been 20 deaths in 13 years, and we had at least one last year. What we do know about flu in children, is that death is not restricted to children with higher risk medical conditions, it just equally effects previously perfectly well children as we saw last year in NSW, and has already been seen this year in Victoria and Western Australia with previously well children dying from flu already.

So, how did we do with our flu program last year in NSW (the under-five flu)?

We distributed about a quarter of a million doses of FluQuadri Junior to general practice and about half of those had a record in the Australian Immunisation Register, so the data that we are showing now is from vaccines that GP’s in NSW reported to the register for flu last year. On the left we have graphs about Aboriginal children and on the right is non-Aboriginal children, and we are looking at age groups six months to one year in yellow, blue is children one-two years of age, red is children two-three and grey is children three-five. So there is a number of things we can see, infants, six months to one year of age achieved the highest reported vaccination rates in 2018, so 35% of them received at least one dose, which is a great uptake for the first year. About 30% of one year olds received a dose, and then about 24% of children two and over received at least one dose of vaccine. So that’s a very good start to the first year of the program, because GPs and parents were all learning about it, and I think we realized that reporting to the AIR is still not routine for non-National immunization program vaccines, so we don’t know the extent of under reporting and I don’t know Tim if you have any comment, or if you are aware of how routinely these vaccines administered to children, flu vaccines, might have been reported to the AIR?

Tim: Im not sure, Im thinking about our own service, and I think you’re right, it would have been less routine than the childhood vaccination program because the systems would be these are probably more likely to be reported than adult vaccines, so I suspect it is a reasonable representation.

We do have a question as well, just wondering if the fortunately small number of deaths in children, did they occur in non-immunised children?

Vicky: That’s right, so going back to that graph for example where I showed the admissions at Children Hospital, Westmead and John Hunter. Most of those were children and only one of those had received the vaccine, and that was a child that was medically indicated I think with lymphoma or some condition that made them highly susceptible, so that was the only child that was admitted that had had a flu vaccine. So the vaccine is obviously not going to provide 100% protection, the vaccine effectiveness that was calculated was about 75% for children, so that’s three quarters reduced risk of being hospitalized with flu if they were vaccinated last year.

Tim: When pharmacists give immuisations, do they go up to the immunisation register? Im not sure they have access to it, do they?

Vicky: They do. Pharmacists are actually in NSW for a pharmacist to be allowed to vaccinate we require them to report to the register, pharmacists are not allowed to vaccinate children, so only people 16 years and older can be vaccinated by a pharmacist.

Tim: Excellent, thank you.

Vicky: I guess the other really pleasing thing about these graphs is that the coverage in Aboriginal children is actually higher than non- Aboriginal children, and prior to this year, ever though prior to 2018 even though flu vaccine was free for Aboriginal children, we were only getting less than 5% vaccinated, so having a program that is available for all children has greatly improved the coverage for aboriginal children as well, so that is another positive we see from 2018.

That is about all I was going to say about 2018, are there any other questions about that, Tim that we should touch on?

Tim:  So, someone was asking what strain was responsible for the summer outbreak?

Vicky: The summer outbreak is A and it is about 50/50 H1N1 and the other arc is the H3N2.

Tim: Lovely, thank you. The other questions we have we will cover later on in the presentation.

Vicky: Ok, we will go on to this year then, to 2019. Alright, so the Chief Medical Officer has issued advice, and think you have received a letter all from him, or you should have. So continuing to advise that annual vaccination is the most important measure to prevent flu and its complications. Annual Flu vaccination recommended for all people six months of age and over. We have very important new funding information that all Aboriginal people six months and older are eligible for free flu vaccine, so before there was a gap, Aboriginal children from five-14 were not funded, now that has been changed and the Australian Government is funding vaccine for all Aboriginal people six months and older. And then similar to last year, the optimal protection against flu occurs in the first three to four months following vaccination, and that I guess is most important for the elderly, which is why we are recommending vaccination in April or May. The full statement is on the department’s website, and we anticipate that the annual statement from ATAGI, the Australian Technical Advisory Group on Immunisation will be published very shortly to help support vaccination practice this year.

All right, so I mentioned this already, the vaccine in 2019, the four-valent vaccines cover two A strains and two B strains, and the trivalent vaccine, which is Fluad, will cover two A strains and the Yamagata B lineage, which is the Colorado strain, so there is two new parts of the vaccine.

So, the vaccines available I think are a little less confusing than last year, but still requires some concentration. So under government funded programs we’ve purchase FluQuadri Junior for children six months up to three years of age, so that is the same vaccine that was used last year, and is a quarter of a ML. There is also three other four valent vaccines, there is FluQuadri and FluarixTetra, now they are on the National program for people three years and over, but important to note that the registration of FluarixTetra has changed. It is now licensed for six months and older, so that gives a bit more flexibility and we will talk about that a bit later. Also the Afluria Quad, the Australian manufactured vaccine, has a change in its age indication. Before last year it was only for people 18 years and older, but now it is licensed and on the NIP for people five years and older. So im sorry about all those changes, but it probably does give a bit more flexibility with the vaccines that are available, and it’s good to know that the Afluria Quad was like the old flu vaccination that CSL manufactured, and you will recall we had the problems in 2010 with febrile reactions with children and for a number of years and well since then haven’t used it in anyone under 10. There is now a lot of data from the United States in particular where this vaccine has been used in thousands of children and it’s really quite safe, so that’s why it is now licensed down to five years of age in Australia.

And further, over 65’s – This year there is only one vaccine available on the NIP, that is Fluad, we had this one last year. That is the vaccine that has an adjuvant in it, so that’s only licensed for people 65 and older, and that the preferred vaccine over 65 on the NIP. The other one that we had last year, Fluzone High-Dose is not on the NIP anymore, but it will be available via prescription via pharmacies, but obviously, patients would have to pay for that. The ATAGI recommends that these two vaccines, there are no preference between them, but they are both preferred to the Quadravalent vaccine for people over 65, so the strong recommendation is to use the Fluad for people over 65.

You have probably seen this; it is part of the commonwealth materials that summarises that. The varying age groups and eligibility of the five vaccines that are on the National Immunisation Program, noting that the FluarixTetra, while it is currently not on the NIP for anyone under three years, it can actually be used for children from six months of age.

Okay, I see some questions there about the trivalent vaccine, but maybe we will talk about those as we go through each of them.

Tim: Yeah, that’s what I was thinking.

Vicky: So this is the pack shot of the under three vaccine, the FluQuadri Junior. So, because of NSW funding, any child aged from six-35 months is eligible for this vaccine free, if it is their first year of being vaccinated, they should have two doses, one month apart, and we do know there is an increased risk of febrile reaction if given with pneumococcal vaccine, which is of course due at 12 months of age, so parents would need to be warned about that, and perhaps using Panadol respectively or separating the doses if a 12 month old presents for flu vaccination.

So this is Fluarix Tetra.

Tim: Sorry, just one question about the previous one. Someone is just asking, can you use half of FluQuadri for FluQuadri Junior?

Vicky: No, you can’t, but you can use Fluarix Tetra and the dose for Fluarix Tetra, irrespective of age is half a ML, so there is no half doses, so I guess that is a simple message that we can remember – there is no half doses, you either use FluQuadri Junior or if you are using Fluarix Tetra in a child under three, you still give the full half ML, but just remembering in the NSW program for children eligible, we haven’t funded the vaccine, so we should be using the FluQuadri Junior that we have purchased for those children, even though, as far as registration goes this Fluarix Tetra could be used in children under three.

So it is only free for children six-59 months of ages if they are eligible on the NIP. It is free for all aboriginal people five years and older, pregnant women, people with medical risk factors from five-64 years of age, and once again if you are vaccination children from three-nine years of age, the first year they receive the vaccine they should have two doses a month apart and both doses are funded.

FluQuadri is free for all children in NSW from 36-59 months of age, all Aboriginal people five years and older, pregnant women, people with medical risk factors, and once again, two doses a month apart in the first year and don’t give a half dose, it is not licensed for that.

Tim: Just on those two doses. Someone is asking if someone has just one dose and misses the second, do they get two doses the next year, or do they just carry on with single doses?

Vicky: That’s right Tim, If they don’t get the second dose the first year, the next year they just get one, so they will have had less than optimal protection the first year they were vaccinated, but from then on they will get optimal protection from one dose.

Here is the Afluria Quad, noting it is available five years to 64 years on the NIP, so for Aboriginal people, pregnant women, medical risk factors and then children five to nine who might be eligible because they have medical risk factors, they would need two doses, and please don’t use it under five, it is not licensed for young, small children.

Here is the Fluad, so this is licensed only for people 65 years and older, just three strains of vaccine, 3 strains of flu in there and it has the adjuvant. So, there is a couple of questions in there about why we would use this instead of the Quadravalent. The advice from our experts from ATAGI is that this is preferred because of the enhanced immune response that is created by this vaccine, the B strain that is in there is the one that was circulating last year and still seems to be circulating, so it should be providing the best protection for people over 65. We will of course be monitoring closely the strains that are circulating, and if there are any concerns that we are having a predominance of the Victoria strain we will of course provide any updated advice from ATAGI, but at this point in time, this is the recommendation for the over 65’s.

Okay, so I think I have pretty much covered the material in this slide. You could tell your patients that this vaccine provides around a 25% better protection than the standard flu vaccines, so a number of very large studies have shown that, so that is why it is preferred. No flu vaccine is obviously anywhere near 100% effective, so we are looking at relative performance. Fluad recipients might get a more marked local reaction than people having a Quadravalent vaccine, but that is because of the enhance Immunogenicity and as I said before, the Fluzone High-Dose, which is quadruple the strength rather than have an adjuvant is only on the private market this year.

Tim: And is there any danger if that is accidently given to someone under 65 years if age?

Vicky: Well there is no studies to know, which is why it is not licensed under 65’s at the moment, Tim. We do get a lot of inquires about immunocompromised under 65 and could they have it. Im afraid that at the moment it is an evidence free zone, so we can only recommend what it is licensed for and what studies show, so we really don’t have any information on that. Im aware that there are studies underway on younger immunocompromised and otherwise susceptible people, and once that data comes in, then we can make recommendations.

Other changes in 2019, as you have already highlighted, appropriately trained pharmacists can provide influenza vaccination persons 16 years and older, but we have already talked about how pharmacists are required to report all vaccines given to the Australian Immunisation Register, and they are also required to advise patients if they are eligible for a free vaccine via their GP, so I hope that’s all in place.

So, I was just going to go on and talk a bit now about planning for the vaccination program this year and we have had very good feedback last year from RACGP and AMA, they helped us with the debrief, and we also got feedback from public health units, it was quite a staggering year, as I said 2.3 million vaccines distributed. We have made some changes to how we are doing things this year, and I hope it assists practices in preparing and managing the flu vaccine program. So, we have produced a flu vaccine provider toolkit, which is on our website, it has a check list there that is meant to help you prepare your practice, about what you should be doing and when to get ready, including when to place orders and so forth. There is a decision aid in the toolkit about assessing adult patients for flu vaccination, and we have also provided a work book, which there is a link you can download the spreadsheet from our website, because some of the feedback we got last year, people didn’t know how many vaccines to order, they were running out before we could re supply. So, basically with the number of practice in NSW, it takes three weeks to get vaccines out to all those practices. So the worksheet helps you estimate the number of patients in your practice that need to be vaccinated, how many you can vaccinate per day, how many to order in your first order, and then how many to order in your subsequent orders so that you can maintain enough stock to meet the expected demand. We hope that is helpful and something we would really appreciate feedback on, and we will obviously be talking to RACGP and AMA again at the end of the season to get feedback on the whether this helped us all cope better with this very busy time of the year. With that said, we always have to be a little bit flexible with flu, what we have flagged in this toolkit is that we are going to start distributing mid-April, but because of the level of influenza that is still circulating, particularly affecting age care facilities, we have already got our supplies of Fluad in, so we are actually going to start distributing to aged care facilities tomorrow, and we should enough Afluria Quad in by next week, so we anticipate starting to deliver to general practice next week.

Tim: Someone is asking – apparently, pharmacies already have their supplies in, Is that right?

Vicky: Yeah, well pharmacies purchase from Seqirus, and Seqirus, because they are an Australian manufacturer, they are the first ones with flu vaccine available, so we’ve just received our Fluad today, and we anticipate having a good supply of Afluria Quad by next week, so it’s very likely that pharmacies are also getting those vaccines, although they won’t have the Fluad, but they will have Afluria Quad any maybe Influvac, which is another vaccine that is not on the NIP. So yes, pharmacies will have vaccines now. We will be sending a fax out to all GP’s, fax and email, probably tomorrow to keep you updated about when to expect your deliveries, but I guess the strong message is, don’t actually book in any clinics until the vaccine is in your fridge. Prioritise the elderly and pregnant women once you receive appropriate vaccines for those ages. We are probably going to have to wait a couple more weeks before have vaccine for children, but as soon as you do get that, we really  do encourage you to be vaccinating children as well, as we really are seeing a lot of impact on children and the elderly at the moment.

Also to help managing the program, we are producing similar resources to what we produced last year, and we will send these out with vaccine deliveries. There is a poster that illustrates the vaccines and the indications, which you will receive, and also the stickers to go on the baskets for your fridge to help you more readily find the vaccines that you need to use. Obviously, we might have to amend these a little bit because of the changed for Fluarix Tetra.

We are running a similar campaign to what we ran last year, so using the same kind of idea about preventing flu is in your hands, getting vaccinated, keeping your hand clean and staying at home. So again, those posters will come with your vaccine delivery, but one of the lessons from last year is that we won’t be strongly promoting vaccination until May because we want to make sure all the vaccine is available in general practice before we are pushing people to get vaccinated, but as I said, once you receive vaccines, we would like you to be vaccinating your older patients, your pregnant women and children once you get the vaccine that is available.

So a practice checklist, so certainly if you haven’t already ordered your flu vaccines, make sure that you do that now, be checking your cold chain measures and making sure that the fridge has space for the vaccines that you are ordering. We have in the toolkit, we’ve got dimensions of the various packaging of the vaccines to help you estimate how much space they are going to take up. I think it is giving this information to all your staff, particularly your vaccinating nurses so that they are familiar with the different age indications for the different vaccines. Upgrading your practice software is important, as that is how you are then able to automatically choose the vaccine you are giving to then automatically report to the register. Don’t forget to vaccinate your practice staff so that they are protected, and plan to maximize uptake, particularly in children and pregnant women, but all the priority groups – Aboriginal people, people with chronic conditions and the elderly.

If your patients have questions about flu vaccine safety, the AusVaxSafety system is now reaching a lot of practices across Australia, for example, last year there was 16,000 children who participated in the Flu vaccine safety reports, so this is when the practice software automatically sends an SMS to the parent a few days after vaccination asking if there has been adverse event. So of the 16,000 children who were part of that surveillance, almost 94%, the parents said no, nothing happened, of the 6% that did report some kind of an event, it was mainly the expected things, swelling at the injection site, 2% had a fever, and less than 1% sought medical attention for the adverse event that happened after vaccination, which may of course not even be related to vaccination, but they had seen a doctor. So I think that is reassuring to parents, and the SmartVax system is still available if your practice wishes to participate in it, and we have talked about that before Tim, I don’t know if we need to.

Tim: That’s right we have, and we have had quite a few questions come through some of them we might cover during the case studies but I think there are some themes, if it’s alright we will just take a moment to answer some of those if that’s ok?

Vicky: Yep!

Tim: One is about contraindications to vaccines, if there are any new contraindication or particular contraindication that we need to be aware of?

Vicky: So the only contraindication to flu vaccination is prior anaphylaxis to flu vaccine or any of its components. There are precautions, so if you previously had Guillain Barre, then I would seek specialist advice before vaccinating, and of course severe anaphylaxis to egg is a precaution, but people with egg anaphylaxis or egg allergy can be vaccinated under medical supervision, so as long as you’ve got an adrenaline kit and observe them for half an hour afterwards, or you could refer them to the specialist immunization service at Westmead Children’s Hospital where egg allergic children can be vaccinated in the specialist clinic.

Tim: Thanks. We have got a few questions about the timing of flu vaccine with other vaccines, for example pneumococcal vaccine at different age groups or special populations like patients who have had a splenectomy. What is the advice on the timing of influenza vaccine with pneumococcal and with childhood immunisation vaccines?

Vicky: Pneumococcal (Prevenar) is the only vaccine where there is a precaution about increased risk of fever, so all the other childhood and adult vaccines, flu can be given at the same time and there is no indication of any increased risk. For people who have had for example hematopoietic stem cell transplant, they should have two vaccines in the first year that they are vaccinated against flu after their transplant, but otherwise, immunocompromised people just require one dose of flu vax, of course they may not get the same response to others, but only one dose is recommended except for those people that have had their immune system wiped out.

Tim: Yep, lovely, and quite a few people are asking a questions that is asked every year I think, about any recommendation for giving two flu vaccines several months apart to cover the later part of the winter flu season, or a summer flu season?

Vicky: Not for winter flu, but I believe when the ATAGI statement comes out there is consideration if someone is travelling to the northern hemisphere then a second for our summer, then a consideration of a second dose, either of left over southern hemisphere vaccine, or the new northern hemisphere vaccine if available could be considered.

Tim: But it is not a routine recommendation to do that even if the coverage tails off towards the last few months?

Vicky: No, not at the moment, but once again, we need to be closely monitoring what is happening and additional advice could be issued at a later stage.

Tim: My understanding is that is an evidence free zone as well, some people are recommending it where there is no real evidence either way, is there?

Vicky: That’s right.

Tim: There are a few questions about how well the vaccine works in breast feeding mothers, and if there is any special or particular flu vaccine we should be recommending and how effective it is in breast feeding mothers?

Vicky: Yes, there is not a lot of studies, but the expectation is that is just as effective as a breast-feeding person as it is in other people. Of course, it is not funded but it would be recommended and would contribute to protecting the infant, sorry what was the other part of that question?

Tim: It was how well it covers?

Vicky: It would be highly effective and would contribute to protecting if the infant is too young to be vaccinated, vaccinating postpartum, a breastfeeding woman would be recommended, but that’s not funded.

Tim: Let’s move on to the cases, im just aware of time, there is some specific questions coming through that may be covered in the case studies as well.

Vicky: All right, I just see that there is a frequent question about asthma and eligibility.  I think that has been tidied up in the handbook a bit now. So what the handbook says is if someone is under regular medical care or on regular medications, then they’re eligible. So someone who is on a regular preventer, or if they have been hospitalized for asthma, would be eligible for influenza vaccine. So not someone who just has a puffer in the side draw that they might use once a year, but if you have regularly got them on a preventer, then they would be eligible.

All right, we will go to the case studies. So here we are in April 2019, Linda, a 31-year-old woman recently moved to Australia from the UK and she is 36 weeks pregnant. She received the flu vaccine in January before the left the UK and Linda’s daughter who is two years old is with her, and she has a non-anaphylactic egg allergy. So there is a few issues there, so what would we do?

Well we would recommend offering her the 2019 flu vaccine, because the northern hemisphere vaccine she received in January isn’t attuned to the same strains that we are going to have here, and that is free for her, so you could use FluQuadri, Fluarix Tetra, or Afluria Quad – and please check her Pertussis vaccination status, she can receive that anytime in her second or third trimester, but she is 36 weeks so it is last chance for her. Her daughter being 2 years old and in NSW is eligible for free FluQuadri Junior, and that a great idea to vaccinate her, because by vaccinating her you reduce the risk of bring flu into the home when there is the new baby. So she is non anaphylactic allergy to eggs, so that’s quite straight forward receiving the vaccine, just make sure you have an adrenalin kit prepared in the practice and observe her for a half hour afterwards, and this is the first years she is receiving flu vaccine, book her in for a second dose four weeks later and If there is a dad on the scene, it would be good to vaccinate him as well to contribute to protecting the infant when they are born.

So is that ok Tim, any questions about that?

Tim: Not much about that, there are a few questions about access to northern hemisphere vaccines and how different that is to southern hemisphere vaccines?

Vicky: Yeah, so that’s for the travelers. It’s probably rarely available in Australia, there may  be some travel clinics that import it, but for example, people often go away for a few months and if they are travelling in November, they could get vaccinated when they arrive in the northern Hemisphere. They would have to pay for it, but that would be a way to optimize their protection while they are travelling next summer.

Tim: Yeah.

Vicky: All right, second case study! Im running out of time now. So 12^th June 2019, Owen, he is a two and a half year old child. He had a Hematopoietic stem cell transplant about eight months ago and is going back to childcare in four weeks and his mum is very anxious. So, he is at home with his mum, dad, his four year old sister, who attends preschool, and a brother who is in primary school. Now he was vaccinated in 2017 and received two doses then when he was just six months old, so what are we going to do for Owen?

Owen should be offered free FluQuadri Junior, he is two and a half, and because he has had the hematopoietic stem cell transplant since he was previously vaccinated, he needs two doses again, so he’s got to start again from scratch, so book him in for a second dose in four weeks.

Advise mum that she is not eligible for free vaccine, but she would help protect Owen if she does get vaccinated and suggest that dad and the primary school brother also get vaccinated to assist in protecting Owen, and of course his four year old sister is eligible for a free vaccine, so she should come in and get that. Is that straightforward? Any questions?

Ok, I just saw a question there for a pregnant patient who had flu vaccine in 2018, should they be vaccinated again in 2019 when it becomes available? Yes, and please vaccinate them as a priority as soon as you get the AfluriaQuad.

Case Study three. So, we have a family here, there is a father who identifies as Aboriginal, a mother, non-Aboriginal, a non-Aboriginal grandmother, a non-aboriginal adolescent and two Aboriginal children, three and a half and seven years of age, and they all turn up (to your practice). So, how are we going to approach that?

Dad is Aboriginal, so he is eligible for free flu vaccine, he is a smoker but he is eligible anyway. So you could give him the FluQuadri, Fluarix Tetra or AfluriaQuad. Grandma is not aboriginal, but she is over 65, so she is eligible for funded vaccine and you should give her Fluad. Mum is not aboriginal, she has a history of breast cancer, but she is not medically at risk, so she is not eligible for free vaccine, but would be recommended to have privately funded FluQuadri, Fluarix Tetra, AfluriaQuad or Influvac Tetra. The daughter, 15 Non-Aboriginal, no medical indications, so once again, not funded, but is recommended to be vaccinated. The two children both aboriginal, so the three and a half year is eligible for funded vaccine, you could use either FluQuadri or Fluarix Tetra, and the seven-month-old infant is eligible for vaccine, and you would use FluQuadri Junior, or you could use Fluarix Tetra, a full dose.

So, that’s the three case studies. Tim, I’m sorry I’m cutting it fine with time.

Tim: No that is excellent; you have done brilliantly with time. A few questions just clarifying about the two doses for children. It only if it is their first flu vaccine that they have two doses a month apart, otherwise it is just one for the year, is that right?

Vicky: That is correct.

Tim: And a scenario here. What if a pregnant mum had their vaccine in say November and delivered in April, should they have vaccine to cover the baby while breastfeeding?

Vicky: Yeah, it’s not eligible, I’d try and vaccinate them before they delivered, but after that, certainly it would be advisable, but unfortunately once they are not pregnant, they are not eligible for free vaccine.

Tim: Yeah. We have had a few questions about treatment, just about the use of antiviral treatment and whether people should take swabs?

Vicky: That partly depends on the stage of the flu season. If there is a lot of flu around and people are presenting with a very clear clinical picture, then it is not necessary to confirm. At this stage of year there is actually more RSV circulating than flu, so unless the picture was very clearly flu, SO myalgia, headache, if they have been overseas or in contact with a case, you might need to do the swab to make your clinical decision about whether it was flu or something else. If your clinical acumen thinks flu is most likely then certainly Tamiflu would be worth trying.

Tim: Someone has asked a good question. If Linda in that first case doesn’t have Medicare yet, is she eligible for the NSW vaccine program for free vaccine on that?

Vicky: Yes. In NSW, anybody who is in NSW can receive the free flu vaccine under our programs because we are contributing to heard immunity as well as protecting individuals.

Tim: Yeah. There are a few more questions about giving different doses a few month apart, or a month apart or a second dose a few months later, which I think we covered earlier. Again, pregnant women can be vaccinated at any stage of pregnancy, cant they?

Vicky: Yes they can, and they should be vaccinated as soon as possible in pregnancy.

Tim: Yep, and we have hit 8.30 and we still have so many questions coming through. I think if people feel we haven’t covered their question then it is worthwhile emailing them through and we will see what we can do to answer those, I’m keen that we do finish on time.

The slide up at the moment is the learning outcomes, so hopefully looking at those we have achieved this tonight, that we are feeling a bit more preparer for the 2019 influenza season and those resources will certainly help with that. We have understood the factors contributing to influenza impact in NSW over recent years. We have learnt about the impacts and outcomes of last year’s vaccine to children under 5 years of age program. We are aware of this year’s formulations of vaccine and their optimal use in eligible age groups, and we will be looking forward to receiving our NSW Health Flu Vaccination Tool Kit, so we can optimize of our vaccine supplies, and maximize uptake of influenza vaccine.

Vicky, thank you very much, that was a marvelous presentation; I think we have all learnt heaps.

Sammi, thank you very much for running the system, and making it all run very smoothly underneath. I hope everyone has a good evening, and don’t forget to fill out your evaluations.

Vicky: Okay, thanks Tim, thanks everyone, and the presentation will be available online.

Sammi: Great, thanks Tim and Vicky again for joining us this evening and also to everybody online, we do hope you enjoy the rest of your evening.