Samantha: Good evening everybody and welcome to this evenings Occupational Vaccinations webinar, my name is Samantha and I am your host for this evening.
Before we make a start I would just like to make a quick Acknowledgement 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.
I’d like to introduce our Presenter for this evening; we are joined by Dr Vicky Sheppeard, and our Facilitator Dr Linda Mann.
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 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.
Previously, Vicky managed Health Protection Services in the Nepean Blue Mountains and Western Sydney LHDs from 2008-2013.
Dr Linda Mann, our Facilitator this evening. Linda is a Fellow of the RACGP and is a member of the RACGPs Antenatal and Postnatal Care Network. Linda has both local and international medical experience, especially in genetics and women’s health; she is a GP representative on various national and local government committees and is an experienced medical educator.
Thank you, Linda and Vicky for joining us this evening. I will hand over to Linda now to take us through the learning outcomes for this evening.
Linda: Thanks, Sam.
By the end of this online QI & CPD activity, you should be able to be aware of the occupational vaccination requirements that may apply to your patients. Apply screening, vaccination and documentation requirements to NSW Health employees. Manage hepatitis B vaccine non-responders. Counsel Child care workers seeking vaccination on eligibility for government-funded vaccines, and be aware of occupational risk for Q fever and training opportunities to become a confident vaccinator.
Vicky: Thanks Linda, and good evening everyone, it is good to be here again.
The first slide before we launch into our learning objectives, something which popped us for us all about 10 days ago is the new digital Australian Immunisation Handbook. I recommend you all put a bookmark on your computers for the new handbook, it is important to note that there won’t be any more hardcopy prints of the Australian Immunisation Handbook, and there is now a new format that is online at this new site. I have been starting to use it and find it quite easy to navigate, so please do take a look at it and bookmark it and use that as the most up to date information about immunisations. Sammi will post that link for you all to be able to access it.
Vicky: Before we launch in to the actual learnings tonight, there are a few case studies that we would like to start with and for you to be thinking about as we are going through the presentation.
The first one is about Ishara, an 18-year-old first year nursing student who presents to you with her vaccination record card. Another GP has previously completed most of it except for hepatitis B as she required serology. She has asked that you complete the vaccination record card for her hepatitis B compliance. She brings you the following evidence; Overseas vaccination record of one dose of hepatitis B vaccine at age 14. Ishara tells you that she and her mum are certain that she had another dose six months later while she was living in Sri Lanka, but they are not able to get a written record for this. You have checked the Australian immunisation record and there are no hepatitis B vaccination records there for Ishara. She has also brought you a pathology result from the previous week of hepatitis B surface antibody at 296 IU/mL.
The question for you is, is she now compliant with NSW Health requirements?
The second case is Matthew, a 23-year-old Occupational Therapy student, he presents with the following evidence. He has pathology results from a couple of weeks back; his mumps IgG and measles IgG are detected. Rubella is at 15IU/mL with a comment that between 10 – 30 a booster vaccination should be considered. Varicella IgG not detected, his hepatitis B surface antibody is 12IU/mL. IGRA, which is Interferon Gamma Release Assay or otherwise known as Quantiferon gold test for TB is positive, showing that he has had past exposure to TB. He has also brought you a recent vaccination statement from another practice, which shows that since his serology test, he has had a dose of Measles, Mumps, and Rubella vaccine. He has a past history of Hepatitis B vaccination in 1998 when he was an infant - three doses spaced one month and six months apart, and a Boostrix dose in 2011.
We also need to consider what advice you will be giving Matthew.
The third case study tonight is Scott, a 42-year-old farmer. He has his own cattle farm (who have recently been calving) and he works on other farms assisting with their animals. He had been in two days ago with fever, headache, photophobia, myalgia and arthralgia. He was pretty crook, so you tested him for flu, but also for brucellosis and Q fever, you have the Q fever result back now and it is positive. You see him today to start doxycycline, but he also asks about his wife and 2 children, a daughter, 16 and a son, 8. What should they be doing about Q fever?
I hope we will be answering all these questions during the presentation tonight.
A large range of your patients will need consideration of occupational vaccination. Healthcare workers, childcare workers, carers for the elderly or disabled, emergency service workers, laboratory workers, people who work with animals, and people exposed to human tissue, body fluids or sewage are just some of the groups we need to consider.
NSW Health Staff, of who there is about 140,000 across the state, so I am sure most of you do have patients who are staff of NSW Health. Within NSW, we have a policy directive, which is a requirement for all staff to comply with; it is called Occupational Assessment, Screening and Vaccination Against Specified Infectious Diseases. There is very specific requirements for new recruits, existing workers, and also for any health student who does a placement in a NSW Health facility. This policy has just been updated this year and there is now three categories of staff risk. There is Category A, which is any staff member who has direct patient contact - this is divided into two categories - a sub category, category A, High risk, which is specific about influenza requirements and that is for people working in maternity, paediatrics, intensive care, transplant and Oncology – so with the very highest risk and most vulnerable patients. Category B are other employees that have no different exposure to patients than any regular member of the community. They might be gardeners, reception staff at front desks, people who are just doing clerical work within the hospital, so do not have any different exposure to patients than any regular member of the community would.
In this slide, these are the diseases that we need to think about as far as our policy directive for NSW Health employees. The evidence required for each of those diseases differs and is quite specific and it is important that you are familiar with those requirements for each of the diseases.
Diphtheria, Tetanus and Pertussis, all that is required is evidence of an adult dose of that vaccine in the last 10 years, and for existing workers we continue to require that booster every 10 years.
Measles, Mumps and Rubella there are three options to comply. If someone is born before 1966, they are assumed to be immune, so no testing or vaccination records are required. People born after that date (1966), if they have a written vaccination record of two doses, at least one month apart, that satisfies the requirement, alternatively if there is no written vaccination record, or if it is a person born after 1966, we require positive immuno-serology tests for measles, mumps and rubella.
Linda: Vicky, can I just ask a question there?
Linda: The positive IgG, does that have a teeter?
Vicky: That is according to the laboratory Linda, so, each laboratory will have a comment that either it can be detected, or as we saw in Matthew’s case there was a comment that the rubella was of a teeter with a recommended booster required, so adhere to the standards of your own laboratory.
Vicky: It is different for hepatitis B, here we require both a history of an age appropriate hepatitis B vaccination course, and a serology teeter to show that a person has mounted an adequate immune response to hepatitis B. Alternatively, if they have evidence of past hepatitis B infection - so core antibody - then obviously not susceptible to hepatitis B infection, so that is also adequate evidence.
For Varicella, we require evidence of two doses of varicella vaccine one month apart or one dose if they were vaccinated in infancy, or a positive IgG for varicella. In the older population (staff over 50 years of age), if they have had a Zostavax, that is also taken as evidence for immunity against varicella.
Influenza, as I mentioned certain staff at the highest risk are now required to have annual influenza vaccinations. People who have a risk of TB (there is a screening tool) - If they are born in a high risk country, spent more than three months in a high risk county or have had contact with a person with TB, then they are required to have either an IGRA test (TB blood test) or a tuberculosis skin test, which can be done in a chest clinic.
This goes through the information we just talked about, but I would really like to be clear that serology is not accepted at all for diphtheria, tetanus, pertussis, it is only vaccination within the past 10 years, and it is important that adult diphtheria, tetanus vaccine is not used because the whooping cough component is essential for compliance. Of course, for our employees we meet the costs of this and offer the vaccine as a booster in the local health district, but if someone comes to you and would prefer to get their vaccine from you, then that is fine, as long as it is recorded on a vaccination card for them.
Measles, mumps and rubella - we have talked about that, and as Linda’s question indicated, the numeric levels from different laboratories must be followed. If for example, someone born before 1966 or that has two documented doses of MMR, if they happen to have had serology done and shows they are not immune, then they do need a single booster dose, but no further serology is required. We are very much trusting these vaccines that they do give a very good level of immunity.
Hepatitis B –we have talked about that – and the new thing with hepatitis B is that we now accept a statutory declaration, as we do recognise that some people have trouble obtaining a written history of vaccination. A GP is the appropriate witness for a statutory declaration; it does not have to go to a Justice of the Peace. The statutory declaration is in the paperwork for our employees in the policy directive, so they should be bringing that to you if they do not have a documented history of the three doses for hepatitis B but are able to give you a sound history that sounds very reasonable as if they were most likely appropriately vaccinated.
I just want to talk about hepatitis B non-responders, and this does occur in a small percentage of people. After an age appropriate course of hepatitis B for health workers, it is important that serology be done to confirm that they have sero-converted, and that should be done 4-8 weeks after their primary course of vaccination, or anytime in the future after that, but it must be at least 4 weeks after. If someone has had a full course, you do the serology, and it is less than 10, then the steps are; consider if they may have chronic hepatitis B infection that hasn’t been previously diagnosed, so test for surface antigen and core antibody. If they are negative, if they don’t have evidence of past hepatitis B infection, then the recommendation is to administer a single booster dose and repeat the serology in 4 weeks. If at that time there is still below 10 IU/mL, then administer 2 further doses 1 month apart check their serology again.
If they are still non-responders, they comply with the policy directive because they have done everything they can to be made immune to hepatitis B, but they need to be informed that they are not protected, and they need to take action for post exposure prophylaxis if they are potentially exposed to hepatitis B in work. So, if there is any needle stick injury or a splash of blood into the eye or mouth, then they need to follow the procedures for unprotected people from hepatitis B.
Any questions about any of that Linda?
Linda: Yes, a couple of questions have been asked.
One question that has been asked is about evidence of shingles or varicella infection, is that adequate evidence of exposure to varicella?
Vicky: Under the previous policy directive, we use to accept that, but we no longer do as we were finding we were not getting good validated evidence, so now the serology or documented vaccination history is required for Varicella.
Linda: Ok, because there was a couple of questions about that. Once of the other questions that has been asked, is about people whose vaccination evidence for hepatitis B has waned. So, if a person has been able to demonstrate greater that 10 IU/mL at any time, is that adequate?
Vicky: Yes. If there is documented evidence in the past then that is adequate as it shows they have responded and then if they do have an inadvertent exposure it is likely they will surmount a good response. As long as there is a documented adequate serology taken at least 4 weeks after the completion of the vaccination course.
Linda: Just thinking about the vaccination itself, in some areas of NSW access to adult hepatitis B vaccination has been hard to get. Can they use two paediatric doses to make up the right amount?
Linda: Is there any need to vary the dosage according to the body size of the patient?
Vicky: No. The only variation in the dosage is with age, paediatric doses can be used up to 15 years of age I believe. Because of the ongoing hepatitis B vaccination shortage, particularly in the private market, we have a whole webpage about the options available. Twinrex is an option as is a double dose of paediatric vaccine, I can give that link to Sammi to post with the presentation notes so that people can find that information.
Linda: That is great, thanks a lot.
Vicky: Moving on to influenza, I think I have pretty much covered this. This shows the categories of workers in the public health system that now require annual influenza vaccination. What I did not mention before was intensive care units, they are now required to receive that vaccine by the 1st June each year, or if not they must wear a surgical mask. This was the first year we introduced this, and I must say it was implemented with minimal fuss, and of course we make this vaccine available for free for staff and make free clinics available, but it is always their choice to come to the GP if they do prefer. Of course, if they do come to you it is essential that the vaccine is documented and we will get to their record card in a minute because we do need documented evidence for our staff.
TB, as I mentioned there is an assessment tool that any students or staff have to complete before they commence a clinical placement, and that is about their past history of TB exposure, also about any current symptoms. Any student or staff member who is experiencing symptoms of TB must be screened before they commence clinical work and also as I mentioned, if they have resided or travelled for 3 months or more in a high incidence country.
If you do an IGRA (a Quantaferon gold) on your patients and it is positive, please refer to a TB service so they can be further investigated and there is no cost to them for any investigation that is done at a TB clinic.
Linda: Can I just ask a question about the planning of these catch up type vaccinations. Sometimes if you have to do testing or you have to send to a test clinic, the poor person wants to start work. Can you annotate their forms to say that this is in train?
Vicky: That’s right, so the only one where there is any significant delay is hepatitis B, which may require a full course of vaccine. Provided they have commenced the course they will be given temporary clearance to start work, provided all the other serology and vaccinations are in place and then they undertake to complete the course within 6 months and then show evidence that it has been completed. It should not delay them more than a couple of days, even for a completely unvaccinated person because all the other vaccines can be given immediately if their serology is negative.
Vicky: Here is the record that is required. All health care workers and students are given this card to have all the relevant testing and vaccinations completed. There is a spot there for everything, and on the reverse side of the card is a summary of the information we have discussed about the different evidence for the different conditions, so I hope that is all clearer for you now. We will look at that in more detail when we go through the cases we are considering.
I will just move on briefly now to some other occupational groups who may be your patients. For aged care workers there are recommendations that they have annual influenza and also that they are immune to measles, mumps, rubella and varicella. This year the Australian government made it a compulsory requirement for all operators of aged care facilities to have an influenza vaccination program for their staff, and that can be offered on site or it can be arranged through local GPs. This followed a survey of aged care facilities around Australia, which was frankly quite disappointing in the achievement of flu vaccination coverage of aged care facility staff. As we have talked about in our other flu webinars, it is essential that the staff of aged care facilities are vaccinated to reduce the risk of them introducing influenza to the facility, and also helping reduce the spread if it is introduced to the facility.
Linda: Can I just ask a question in general about some of these vaccinations. Some of the staff we may be seeking to vaccinate may be people who are taking medication that may affect their immunity, for example methotrexate or Imuran, is there any limitation on vaccinating patients who are fit to work, but are taking medications like that?
Vicky: Certainly, so there is the option for temporary medical exemption, pregnant women for example, or immunocompromised people who are unable to have live vaccines in particular. If it is contraindicated for your patient to have a live vaccine at this time, that needs to be documented for them, that evidence can then be assessed by the staff health team at the hospital. Depending on where they are going to be working and the level or risk, temporary or permanent medical exemption can be accommodated.
Vicky: No, thank you Linda, great question!
Moving on to childcare workers or people who work with children. This could be childcare workers, it could be school teachers, out of our care, child counselling, justice health staff etc. a wide range of people who might be working with small children. There are some recommended vaccines for this group, once again annual influenza, measles, mumps, rubella, whooping cough and varicella.
Staff who work in early childhood education and care should also receive hepatitis A vaccine, similarly to staff that work with people with developmental disabilities, who should receive both hepatitis A and hepatitis B.
We have put together some information for childcare workers in NSW; there is a FAQ sheet there on the right that has been distributed to childcare workers through their employers. It describes for them, the range of vaccines that are recommended and what access they might have to free vaccines, in NSW we make measles, mumps, and rubella vaccine available to anyone who doesn’t already have two documented doses, so anyone born during or since 1966 – hopefully most childcare workers will fit in that group.
There is some limited availability for whooping cough and flu vaccines. There is the commonwealth catch up, up to 19 years of age, so younger childcare workers might be eligible for that, and of course pregnant women are eligible for free pertussis vaccine, similarly patients who are aboriginal are eligible to have a free influenza vaccine, as are any of your patients with under lying health problems.
Varicella catch up is also available free on the commonwealth catch up if they have not already had chicken pox. Hepatitis A unfortunately is not free on any of the programs in NSW, so they may have to pay for that one, but of course, being an occupational vaccination, they may be able to claim it back on tax, or they may be able to claim it on private health insurance. We are just trying to ease the way a bit, because we certainly understand that early childhood care workers aren’t particularly well paid, so we are trying to ease their way to catch up their vaccines.
Linda: On the subject of hepatitis A, you should be able to say that full vaccination should be two vaccines at least six months apart from memory.
Linda: How about if they only have one, does that help, is that ok?
Vicky: That will give some short term protections, but I guess counselling them if they can afford that second one, then they have lifelong protection, so if they are travelling to Bali, Thailand, anywhere - so there is some real benefits to making sure you are immune to hepatitis A.
Linda: Thank you.
Vicky: Thanks, Linda.
We will just move on to Q fever, and because it is not something we have discussed in webinars before, I will just give a bit of background about our experience with Q fever in NSW. We get around 250 cases a year, it is mainly affecting people 40 years and older, and more prevalent in men than women. We also have an increased incidence in Aboriginal people, interestingly when we do see it in Aboriginal people, it does tend to be more in the under 20’s or the 20-29 age group, so that is an important thing to keep in mind, particularly if you are in rural general practice.
This map shows the incidence in NSW during 2017 through three areas, or local government areas, across most of our regional areas, but particularly concentrated in 2017 in the central west and south west, but we also get quite a lot of cases on the mid north coast and the north coast. There is a large range of occupations that you need to consider at risk of Q fever, everyone I think knows about abattoir workers, and of course, it is compulsory for abattoir workers to be vaccinated to go into the workplace.
We now rarely see cases in abattoir workers, however we do see cases is in farmers, livestock workers, people working in stockyards, transporting animals, in shearers - as I said it is particularly affecting young Aboriginal men. Those who work in wool classing or with hides, people washing clothes of people working in the primary industry. Vets are an important group, that is both city and country vet workers, and agricultural college staff and students, laboratory workers, wildlife and zoo workers, so even if you are a city GP, there is a chance that you will have some patients who Q fever vaccination should be considered for.
On top of the occupational risk, there is also the families of these workers - bringing home contaminated clothing, boots or equipment, unpaid workers on hobby farms for example, also people living close by high-risk industries. So if there is stockyards or abattoirs, particularly the large abattoirs that are being developed. Those living nearby, even if they are not involved in the industry can be at risk of Q fever. We have also certainly had cases in people just from mowing; this might be council workers mowing in regional areas, but also regular residents of regional areas that mow where there has been kangaroos for example can be exposed to Q fever and certainly have developed the infection in NSW in recent years.
Im going to briefly touch on the Q fever vaccination process, we will go on to tell you about an online learning module that we have with the Australian College of Regional and Remote Medicine that I will recommend to you, and we make that free for all NSW GPs whether you are an ACRRM member or an RACGP member. Just going through the steps of Q fever vaccination. The first step is to check if the person has had previous Q fever infection, if they have a verbal history of that, or if they have been previously vaccinated. If there is any indication that they have had previous Q fever vaccination or infection then they must not be vaccinated. Once you have cleared that on history and checking any available records, the next step is to do both a blood test and a skin test, and they should be done at the same visit. It is important that the skin test does not precede the blood test because it can invalidate the blood test; we need to have an antibody test from the serum, and an intradermal hypersensitivity test, which is a small injection of the vaccine. Exactly one week later, your patient needs to come back, and if both tests are negative, and there is no other contraindications, then you can proceed to vaccinate, and then we recommend including the details of Q fever vaccine on the Q fever register if your patient wishes it to be done, this is not mandatory but recommended. Unfortunately, at the moment this is the only vaccine in Australia that can’t be recorded on the Australian Immunisation Register.
There is some limitations with the Q fever vaccine, at the moment there is no recommendation under 15 years of age, pregnant and breast feeding women are also not recommended to be vaccinated as there is no data on safety or efficacy. We know this is a more complex vaccine than others are, it is one that you are very welcome to call the NSW Immunisation Specialist Service, this is a number we have given out in all our webinars - 1800 679 477 - If you have tricky questions about vaccinating patients for Q fever.
Linda: Vicky, just while we are talking about Q fever, there have been some questions about it, and one way of answering many of these questions would be to do that course that you suggested. However, while we have this collection of folk here listening, there have been some questions along the lines of the skin test and where you get stuff to test?
Vicky: It comes from Seqirus, so both the vaccine and the skin test can be ordered from Seqirus.
Linda: Does it include information on what a positive test looks like and how you assess positivity?
Vicky: Seqirus have a lot of good information on their website, including a video, and in our online learning module, we also have information about interpreting the skin test. We all rely very heavily on Dr Steven Graves who is our National expert on Q fever and Q vaccination and testing, so we have incorporated in our module Steven Graves talking about interpreting the skin tests and that is also straight on the Seqirus website.
Linda: Just while we are talking about the disease, those win the city may have little familiarity with, if you are treated for Q fever, does that mean you don’t get all the long term effects?
Vicky: Certainly being treated is important at preventing it, but there is still the chance of chronic Q fever, particularly in people with pre-existing bowel disease. It is important that despite having appropriate treatment that they are still assessed and monitored for the risk of chronic Q fever.
Linda: Thank you.
Vicky: You are very welcome.
Just so that you are all aware, there is no approved provider scheme for Q fever vaccination in Australia, and there is no requirement to register with the Q fever registry as a vaccinator, so any doctor is able to undertake Q fever screening and vaccination.
We mentioned that NSW Health has developed an online module that is hosted on the ACRRM site. It takes about two hours to complete and covers both diagnosis of Q fever, management of patients and also screening and vaccination. Of course, it is available to ACRRM members, however in NSW Health we make that available free to all NSW GPs, you just need to put in the code, which is NSWGP18 and Sammi will send that code out with the meeting notes. You put that code in and you can access the module free, otherwise it costs $95, so we encourage you all to do that.
Just a reminder, all the occupational groups and the recommendations that we have gone through tonight are in the new Australian Immunisation Handbook – that link on the screen will take you to all the recommendations for your patients.
To summarise the availability of occupationally recommended vaccines, many of your patients may be eligible for free MMR and free hepatitis B, as there is a range of eligibility for both those vaccines. Then of course, the commonwealth are making available additional catch up vaccines up to 19 years of age, so do explore if your patients are eligible for those and then your patients with at risk medical conditions, aboriginal people, pregnant women and older people will also have eligibility for free occupational vaccines.
The next thing I would like to emphasise is ensuring you do record the vaccines for NSW Health workers on that record card, but also it is very helpful to your patients if you are able to record them on the Australian Immunisation Register. This is important because vaccines do not need to be repeated, if someone has had hepatitis B, even if doses are 10 years apart, then they are still fully vaccinated if they have had three doses. Similarly, any two life time doses of measles, mumps, rubella or varicella also mean that they are fully vaccinated. Now that we can record vaccines of any age group on the register, I really encourage you to do that to help your patients meet their occupational requirements and any other vaccination requirements that they need.
The data on the register is used to monitor vaccination coverage across Australia. We can use it to monitor effectiveness of vaccines. We can look and see where people might be at risk of being under vaccinated in outbreaks. It is also used, as I am sure you are all aware, for eligibility for family tax benefits and childcare subsidies for infants and young children. We use it for policy and research, it is used as evidence for entry to childcare and school, and it can be used for proof of vaccination for employment.
The Australian Immunisation Register is a very busy place, this is some information they have given to us, and we thank the register for this. They receive over 130,000 records each day, most of it automatically through practice management software, some of it through the AIR site, and still about 900 a day on manual forms. They do need to look in to some of these to verify them, those are pended transmissions. They are processing 1000 forms a day from manual encounters and immunisation history forms reporting overseas vaccinations. It is a very busy place that operates around the clock also receiving emails, phone calls and outgoing emails and phone calls. It is a big organisation and you possibly all have some frustrations with it, but they are actually gearing up and doing a really terrific job now in receiving vaccines for all ages across Australia. So, in making sure your patient’s data gets there, it is important that your software is up to date so that it will function properly for Medicare and PBS. My understanding, and Linda can certainly pop in and correct me here, is that you record the vaccines in real time, then your practice will send them in batches to the AIR, but if you use the AIR site then those are recorded in real time in the register. You are also able to print out for your patients if they need it, an immunisation history statement by going to the ‘Identify Individual’ menu.
Linda: I would suspect that most practices use their practice management software because it is usually the practice nurses, if there are practice nurses, who actually carry out these processes. In terms of producing an AIR print out, that is the kind of thing that people generally use for official things, for example childhood schools access, otherwise if they have a full record in their own software you don’t need that.
Vicky: Great, thanks Linda!
We really encourage you also to use the register to check, particularly for adults, if they have had vaccines recorded before, as I said there is no need to repeat previously given vaccines, provided they are given at the right interval.
Now this is a slide I would like to thank Penny Burns for, she gave me some screen shots because obviously I do not work with this software every day, it is just emphasising how to record vaccines on your software so that they are effectively transmitted to the register. What we found while monitoring the register for all ages during the flu season trying to look for uptake, and while we certainly saw adult vaccines recorded there, it did not meet our expectations as far as the number of vaccines that were distributed. I think the register showed somewhere around 50% of the over 65’s had been recorded on the register as receiving a flu vaccine, whereas as we are aware from the vaccines that were distributed, and the great interest in flu vaccine, particularly with the over 65s, we expected that coverage would have been much higher than that. We would really like to make sure that everyone’s vaccines are recorded correctly on the register, and Penny has helped me by taking some screen shots from Best Practice. The first thing on the drop down menu is to make sure you have picked the right vaccine, and I agree with the flu it is a bit daunting with may names that are very similar, but if you record the wrong one for the wrong age group the Public Health Unit will be asking you why you have given Fluad to a baby, so make sure you select the right vaccine. Indicate which site you have given the vaccine and indicate the route that you have given it, and I think the rest of the data in that field is automatically populated, including the batch number.
Linda: No, certainly in many practices, like mine, we have anything up to six batches going at once, depending on where there vaccine has been sent to (I’ve got more than one site), so we actually have a drop down of the collection of vaccines and unfortunately the software keeps them all, so even ones that we have used up, we cannot delete.
I was going to ask you a question about this, I do confess, sometimes when I am in a bit of a hurry, and it is me that is recording this and not the nurse, I do not always right the site. If I do not put the site in, is that a reason why it would not go up to AIR properly?
Vicky: I don’t think that prevents it going up, but we certainly encourage it just in case an adverse event should occur, but Im not sure Linda, I will have to find out.
Penny has emphasised to fill in all of these, then to obviously save it, and the magic happens and it goes to the register. What we are finding is a lot of practice doctors are recording them in the notes, and if it is just in your practice notes, that’s not going to go anywhere.
Linda: In fact, we have a comment from someone that they also identify that if you are not identifying the correct number for the vaccine, that can interfere with its upload so if I’m quoting a vaccine number that is out of date, or that was distributed six weeks ago, then according to someone here online, that is an issue.
Vicky: I think what the register is trying to do is get a better communication back to practices that if there has been a fault in uploading then you will be notified. I think at the moment that is not happening, but they recognise that it is important to have that feedback loop so that it can be corrected and the records go in.
Vicky: Is there anything else about that before we move on to the case studies?
Linda: I think we should go back to the case studies, because in the case study responses will be the answers to many of the questions I have sitting in front of me.
Alright, so Ishara, who is a nurse and needs to show both an age appropriate course of vaccination and a surface antibody level more than 10ml/mL. So, first up, as we said, she commenced her vaccination course when she was 14, so all she is required to do under the age of 15 is to have a two dose course of hepatitis B, appropriately spaced at six months - that was the verbal history she gave. She does not have the second dose documented, but her and her mum are very convincing and they are very reliable patients, so you believe it is very plausible that she did have a second dose. You witness the statutory declaration that comes in our policy directive because it does not need a Justice of the Peace, it needs an authorised assessor, so a GP or a nurse immuniser. You you help her by signing that statutory declaration and then fill in her completed vaccination card, stamp and date it with the serology result and she is now ready to comply with the whole process, so you have solved Ishara’s problems.
Linda: Just on the subject of hepatitis B, we have a question here asking whether you can explain why there needs to be evidence both of vaccination and hepatitis surface antibody above 10. Why do we need both and not just serology?
Vicky: The trick is, if you take the serology, someone could have one dose of hepatitis B and you do their serology two weeks later, they may well have a positive IgG but that will not be long lasting. We need to be sure that they have had a full age appropriate dose, and that the serology has been taken to show that they have responded appropriately so we can be confident they have long term protection.
Vicky: You’re welcome.
On to Matthew. We saw earlier that Matthew has had a booster dose of Boostrix, he had evidence of that in 2011, so that is fine, he meets that criteria as that is within 10 years. We also saw that Matthew had an age appropriate dose of hepatitis B; he had an infant course at 0, 1 month and 6 months, so he meets that criterion. He also presented you with quite a good teeter of hepatitis B surface antibody, I believe it was in the hundreds, so he meets the criteria for hepatitis B. He was IgG positive for measles and mumps, but for rubella he had an interim level (between 10-30) so the lab suggested he had a booster dose, which had already been given before he came to you, so he is now compliant with that. His IgG for Varicella was not detected, he does not have a history of vaccination, so he is going to need 2 doses, 4 weeks apart. Unfortunately, he is 23 so he is going to have to pay for that, as there is no free Varicella vaccine available for him. However, it is better than catching chickenpox, which I did when I was a medical student.
Matthew had appositive IGRA and he had travelled overseas, so he needs to be referred to a chest clinic for further assessment, but so long as he has made that appointment, it won’t stop him from going into his clinical placement as long as he is asymptomatic for TB.
Please make sure you report the Varicella vaccines to the register as well as filling in his card.
Moving on to Scott - Scott’s family live on a farm, so as we discussed they are at risk of Q fever. They also help on the farm; his wife kindly launders his clothes, so they are at risk of Q fever.
Scott cannot be vaccinated as you have already established that he has Q fever, so there is nothing further that can be done for him apart from assessing if he is at risk of chronic Q fever. His son is only 8, so he is too young to be vaccinated.
You can download our FAQ sheet about Q fever and farms and there is personal protective measures that can be taken such as hand washing, changing clothes, potentially wearing a mask in high-risk activities that you can give to the family to help protect he son who can’t be vaccinated.
You arrange skin testing and serology for his wife and his 15-year-old daughter.
Linda: On the subject of this, it seems to me that there would a very large percentage of any given rural environment that may be at risk.
Linda: Should the doctors in rural places be testing everybody for Q fever?
Vicky: Yes, rural GPs should be thinking Q fever for all their patients, and discussing with them what risk they may be at and discussing if they would like to be assessed for vaccination. If not, we can give them advice about hygiene measures, but yes, I would be encouraging all rural people to consider it as a risk.
Linda: Thank you.
Vicky: You test Scott’s wife and his daughter. His wife’s skin test is positive, and his daughter is negative on both skin testing and serology. His wife has been exposed to Q fever in the past, so she cannot be vaccinated, but the daughter can be as both her testings were negative, so you can arrange for her to be vaccinated, and that should be done as soon as possible – 7 days from when the skin test was read – it should be done straight away before she is further exposed to Q fever.
To go over the resources that we have looked at tonight – The new online Australian Immunisation Handbook, our online learning module for Q fever, the full Occupational Assessment, Screening and Vaccination policy directive, and also our NSW Q fever awareness tool kit where we have a bunch of FAQ sheets about Q fever that you could use with you patients.
That is all I am going to cover tonight, Linda.
Linda: I think that is really impressive and I have learned something about the fact that I am not protected against hepatitis B, I am a chronic non-responder. I used to think that mean I was ok, but now I know I’m not, so there you go, you learn something new every day!
Sammi: Perfect, so up on your screen at the moment is just a review of the learning outcomes that Linda took you over at the beginning of the session. We hope that we have covered all of that for you, and in saying that I would like to thank Vicky and Linda very much for joining us tonight, and everybody online.
Just a reminder, this is a CPD activity, to receive your points please do complete the evaluation survey that follows the webinar.
That brings us to the end of the session, again thank you Vicky and Linda for joining us tonight!
Vicky: Thank you, Sammi.
Sammi: Fantastic, good night everybody.