Shingles vaccination update

PENNY:

Welcome to tonight’s webinar, Introducing Zostavax to the National Immunisation Program. This is the final webinar in the immunisation series for this year. My name is Penny and I am your host for this evening. Tonight I am joined by your facilitator, Dr Tim Senior and presenter Dr Vicky Sheppeard. Those of you who have joined us previously for webinars probably know Tim and Vicky quite well by now. Before we begin I would like to make an acknowledgement to country. We recognise the traditional custodians of the land and sea on which we live and work. A big welcome back and introduction to some people but mostly welcome back to Dr Tim Senior who is our facilitator for this evening. Originally trained in the UK, Tim is a GP working at Tharawal Aboriginal Corporation in southwestern Sydney, in between lecturing at UWS and acting as the medical advisor for the National Faculty of Aboriginal and Torres Strait Islander Health here at the RACGP. Thank you for joining us tonight Tim and welcome back.

TIM SENIOR:

Thank you very much, it’s lovely to be with you all.

PENNY:

And also a big welcome back to Dr Vicky Sheppard. Vicky is a public health physician who has been working for NSW Health since 1999. Her current role is Director of Communicable Diseases Branch Health Protection NSW. This role includes overseeing surveillance of notifiable diseases in NSW, coordinating communicable disease control activities, oversight of immunisation programmes including delivery of the school-based adolescent vaccination programme and representing NSW 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. Welcome to Vicky. Welcome back Vicky.

VICKY SHEPPEARD:

Thank you Penny.

PENNY:

Now I am now going to hand over to Tim and Vicky to take you through the webinar and Tim will talk you through the learning outcomes first of all.

TIM SENIOR:

Yep, so this is, as you’ll be familiar with, this just sets out what it is we are going to cover tonight. So at the end of this event this evening we hope that you will be able to use the new herpes zoster vaccine under the National Immunisation Program Guidelines. We are going to identify who the suitable patients are and we’re going to refer to relevant guides, websites and information so you are able to track down extra information should you need it from reliable sources. We are going to talk about how we report our vaccinations to the Australian Immunisation Register and we are also going to do a quick think about the cold chain and making sure that vaccine storage ensures the vaccines are safe and efficacious.

So this is a slide about shingles, which you will probably be all familiar with. You will recognise it from the picture there. You’d all pick that as being shingles with a localised rash often vesicular in nature following a dermatomal distribution and its reactivation through the nerve root and some special occasions where it affects a particular dermatome, so affecting the ear or in the eye. We also get systemic symptoms and complications are really important from the point of view of the immunisation as well. So these can be locally where the rash is coming out but also immunocompromise can be more disseminated in the body. One of the important complications is post-herpetic neuralgia where you get really nasty neuropathic pain that persists for more than three months, up to 120 days. It is more common in older people and it is a severe pain and severe rash in the acute phase and it impacts quite a bit on people’s quality of life and we’ll see some statistics later on about how that impacts both on patients but also on the health system as well and it can be really difficult to treat.  So just quickly, if you do see patients with post-herpetic neuralgia then in the initial phase of shingles, treatment with antivirals can be useful and simple and more complex analgesia to help, try and help settle down the neuralgia.

VICKY SHEPPEARD:

Now we’ll just go into a bit of the epidemiology of shingles and the main reason for this is that it has informed through the vaccination program funded for and I think there’s some really important information here that you’ll be able to relate to your patients to give the context for the vaccination.

So this slide is taken from a pretty important paper in 2009 and it’s looking at the experience of Australians with shingles and post-herpetic neuralgia and it’s mainly taken from BEACH data, which is of course, general practice data and there is some information here from the Pharmaceutical Benefits Scheme on prescribing of antivirals. So what we can see here is that in all the age groups there’s a fairly close correlation between the data that’s extracted from BEACH and the data from the Pharmaceutical Benefits Scheme so that gives us some confidence that we’re estimating what the epidemiology is reasonably well and of course you’re aware, certainly in New South Wales, it’s not a notifiable condition so we don’t have the same level of information on zoster as we do on other conditions.

So as we expect the incidence increases through the age groups so the dark and the light bars are both estimating incidence of herpes zoster and reaching a peak in the 70 to 79 year old age group, which is similar to the incidence per 1,000 persons in people above 80.

The important thing to note here is the light bars, the white bars, and that’s estimating post-herpetic neuralgia based on BEACH data, and you can see that it’s actually a pretty low rate in people under 60. It does increase once you get to 60 to 69 years of age but really jumps up in the over 70s and this is one of the important decisions about bringing in this National Immunisation Program because it’s the post-herpetic neuralgia that is causing a lot of the morbidity and this is the importance of focusing on this age group.

So we also know that people over about 35 about 97% have evidence of prior varicella vaccination, prior varicella infection, beg your pardon, and you know overall we’re getting about 60,000 new cases of herpes zoster annually in Australia, so it’s about 10 per 1,000 people and the cumulative life risk is somewhere between 20% and 30%. So around almost a third of the population will develop shingles at some time in their life and that risk is significantly greater once you’re over 60. About a quarter of patients with zoster develop complications and the post-herpetic neuralgia incidence increases from about 11% in people in their fifties up to about 20% of people who get shingles in their 80s.

The next slide is just a bit more about hospitalisation rates and again I think this really underlines the higher morbidity in the older age groups. So this is national hospitalisation rates and in the younger age groups, which are the blue, red and green bars calling younger people under 70, the hospitalisation rates, the population rates are relatively low but jump up significantly once people reach in the 70s and obviously even much higher for people in their 80s.

Tim mentioned the morbidity of post-herpetic neuralgia. This is data from a Canadian study but I think quite relevant to Australia. There is not a comparable Australian data that we can use but what this is showing here is for people with post-herpetic neuralgia the impact on their activities of daily living, the people who aren’t able to function normally in these different domains that monitor their functionality. So really high rates, particularly of pain and discomfort affecting their ability to function out to 90 days, remaining high out to six months after the onset of post-herpetic neuralgia.

So and you know, what’s the reason that post-herpetic neuralgia is more of a feature in the elderly? It’s thought to be the flagging T cell immunity increasing the risk of herpes zoster and then once herpes zoster manifests then the risk of post-herpetic neuralgia is much higher in these age groups. And then we also know that the available treatments for post-herpetic neuralgia have a lower efficacy and a poor side effect profile particularly as our patients age and have more comorbidities.

So the vaccine that we’re going to be focusing on tonight is Zostavax. It’s the only herpes zoster vaccine that is licenced in Australia or anywhere. So it’s a live attenuated vaccine and it’s the same strain as the vaccine that’s in the varicella vaccine that you’re familiar with that we’ve been using for children and adolescents but it’s very important to note that there’s 14 times more virus in this preparation than there is in the varicella vaccine and the reason for that is the importance of boosting T cell immunity. Most of these patients will have antibodies to varicella if we chose to measure them, which is not recommended routinely but more than 97% of people will have antibodies but in this age group that’s not preventive of developing zoster. The vaccine is licenced for adults 50 years and over at the moment a single dose, and it’s administered subcutaneously in the deltoid region. The contraindications are really important and we’ll go into more detail in later slides but very important to assess patients for significant primary acquired immunodeficiency and also of course anaphylaxis to any component.

Tim I don’t know if you wanted to make any comment about the administration here.

TIM SENIOR:

Yeah, I think it’s worth noting that it’s subcutaneous in the deltoid region. I have just seen someone earlier who had a particular question asked for a 60 year old lady who never had chickenpox, will you give Zostavax or varicella vaccine as a second booster and I think this makes it clear that for a 60 year old person it’s actually highly unlikely that they’ve never had chickenpox. It’s likely that they had had it, even if they didn’t remember, and it’s important we’re wanting to boost older people’s T cell immunity so you would use Zostavax rather than varicella vaccine.

VICKY SHEPPEARD:

So we’re just going to look at some of the evidence in the next few slides behind what Zostavax can do and really focus on particularly the patients over 70 but the studies of Zostavax, which a number of papers arising from these studies, they’re call The Shingles Prevention Study. It was a randomised double-blind placebo-controlled efficacy study of Zostavax and almost 40,000 people ages over 60 years of age were involved, including more than 9,000 cases and controls over 70 years of age. So a very substantial cohort there to test this vaccine.

So these slides demonstrate, there’s a group in red who received placebo and a group in blue who received Zostavax and on the left is the cumulative incidence of post-herpetic neuralgia and herpes zoster on the right. So the incidence of zoster and this figure here is for people, the whole cohort, is reduced by about 50% and I think that’s really important information because patients who receive this vaccine will still develop shingles. So it will reduce their risk but reduce their risk by 50% but what’s very substantially reduced is the risk of post-herpetic neuralgia. So it’s reduced down from about a cumulative incidence of 0.7 over five years down to 0.5. So this is the really important information. So it’s about a 66% reduction in post-herpetic neuralgia over this follow-up period.

So this is just summarising the points from that slide. Again, from this cohort, the shingles prevention study, so the herpes zoster incidence reduction was high in the 50 to 59 year olds, 70% reduction and in fact your 70 and over patients can only expect about a 40% reduction in the risk of shingles. So when they’re vaccinated it’s important that they know that they may still develop shingles but the real benefit of the vaccine for them is in this reduction of post-herpetic neuralgia, which is similar for both the 60 year age group and the 70 year age group of 66-67%. I don’t now Tim if you wanted to comment about that efficacy.

TIM SENIOR:

No I think it’s really, I think it’s worth just re-emphasising that what we’re preventing with the vaccine is particularly the complications of post-herpetic neuralgia and the morbidity associated with that. We’re not necessarily preventing the onset of shingles but the real big impact that we can have with this is the prevention of the post-herpetic neuralgia and the morbidity associated with that and so people’s ability to function and ability to stay out of hospital and be more pain-free.

VICKY SHEPPEARD:

So the next question is, you know, how long does the protection from Zostavax last? And this slide combines data from a few studies. So the shingles prevention study but also some other studies that have been done and monitoring efficacy over time. So this is showing us that certainly in the first four years there’s that 66% figure that we talked about, reduction in post-herpetic neuralgia and that’s persisting reasonably well to seven years. The protection against herpes zoster is reduced even in that second time period and then it looks as if there’s again a substantial drop off in protection against both herpes zoster and post-herpetic neuralgia after seven to 10 years. So this is something that we need to keep a close eye on in Australia and we’ll talk a bit more about that later whether subsequent doses might be required.

These study, the shingles prevention study and others have also looked at the safety of Zostavax and in these placebo-controlled studies there was no difference in serious adverse events compared with placebo. There is this phenomenon of a varicella-like rash at the injection site, so little vesicles but that’s a very rare complication but we’ve got another slide about local reactions and we need to talk about those. But importantly high fever is not more common in vaccine recipients but there is about a 6% rate of systemic symptoms such as headache and fatigue. So you would need to alert your patients that that might be something they could experience in the days after vaccination.

And just a reminder here about our New South Wales Immunisation Specialist Service, which is a phone support that we have for suspected adverse events or other complex immunisation questions. So that 1800 number is available throughout New South Wales if you wish to discuss what you suspect might be a serious adverse event or have questions about complex, vaccine complex patients. Of course any reporting of adverse events still goes either to the TGA or through your Public Health Unit.

So this slide that we’re looking at now is looking at the local adverse events, so the injection site adverse events taken from a randomised control trial reported separately, and again we have a placebo group as well as the herpes zoster vaccine group, the Zostavax group. And just wanting to point out the erythema, swelling and pain that is an increased risk particularly of erythema and swelling, so it’s important to alert your patients that they may expect some local reaction but you note that most of those are mild to moderate and any severe effects of local reaction are rare.

So Tim did you want to talk about the SmartVax at all?

TIM SENIOR:

So this is a new app. I’m not sure if this is, so it’s an app that allows SMS and smartphone technology to look at, monitor vaccine safety in real time and links up with practice software and can send SMSs afterwards to the patient to see if they’ve had an adverse reaction. The patient just clicks yes or no on their phone and where there is a reaction that can be flagged in the GP’s software and sometimes I think it can go to the local health authority. So it’s in real time. I haven’t tried this out yet though it sounds very interesting to me and I think Vicky are New South Wales Health promoting this or trialling this as well?

VICKY SHEPPEARD:

Well yes we’ve, it’s been developed by a GP in Western Australia and quite a lot of practices in Western Australia are using it and it sounds a very positive initiative so we have started discussions about making it available in New South Wales. So I thought it might be worthwhile just introducing the idea tonight but public health units may be in touch with GPs about getting this installed on their software and it seems to be a good additional service to offer patients but it’s also part of a national initiative to have real time innovation and pick up any safety signals in relation to vaccines.

TIM SENIOR:

Yeah and certainly that would be a really interesting way of gathering systematic information rather than just ad hoc. So that’s definitely watch this space and see if you can get involved in that if you’re interested.

VICKY SHEPPEARD:             
Mmm. Yep. So, you know, other questions your patients might have is what, so we’ve got these randomised control trials, which show that the vaccine is safe and effective but, you know, what’s been the real world use of Zostavax and particularly in this older age cohort?  So in the USA there’s been over 25 million doses distributed in the past decade. We understand that the uptake is so because of course it’s not a funded vaccine there but they have observed in practice similar vaccine effectiveness as what was observed in the randomised control trials. And the UK is a little bit similar to Australia in that it’s funding a program for 70 to 79 year olds. It’s structured a little bit differently than our program in Australia. They’re not doing the whole cohort at the one time but nevertheless that’s the eligibility and that’s been going for a few years now. They’re getting reasonable uptake but we don’t have any data back yet on any effectiveness but once again there have been no concerns about vaccine safety with the exception of one person who was improperly vaccinated and we might talk about that a little bit later on.

TIM SENIOR:

And just on vaccine safety a question comes through about SmartVax. If it’s flagged in the medical software who is responsible for the reaction, would the GP be responsible to contact the patient to manage the reaction? So I think not all reactions would need to be managed. The difficulty is I suppose that we’re going out seeking whether patients have had a reaction, whereas if it wasn’t for the SMS message they may not actually seek help if it wasn’t so bad but I suspect either a GP or one of the practice nurses or a system would have to be developed in the practice to follow those up and see if any management was needed or if there was any reporting that was required that. So I think it would have to be in practice systems for following that, they couldn’t just be ignored. I think that’s a good point.

VICKY SHEPPEARD:

Yeah, that’s right. It’s meant to be part of patient management of the practice so that’s right Tim.

VICKY SHEPPEARD:

So very important now to be talking about the precautions for Zostavax. So, as we’re said, it’s a live vaccine. So there are some administration factors to consider there. So you can give it with other live vaccines, which obviously are rarely used in this age group and we’ve got yellow fever there as an example but of course there are also strong precautions against the use of yellow fever in this age group as well. So I guess other live vaccines are unlikely but as with any live vaccine they can be given on the same but if not then there needs to be a 28 day interval between live vaccines.   But the other vaccines that you are using commonly in this age group are influenza vaccine and pneumococcal vaccine and Zostavax can be given any time in relation to those vaccines and can be given on the same day and in fact all three vaccines could be given on the same occasion, so that might be a useful way to program it and we’ll talk more about that later. So that does differ a little bit from the production information but ATAG, the Australian Technical Advisory Group, on immunisation has given this advice that it’s okay to co-administer with flu and pneumococcal vaccine, and it’s fine to give to people with mild to moderate immunocompromise but it’s really important to note, very important take home message that the vaccine is contraindicated in those with severe immunocompromise and we’ll go on to talk a little bit about what we’re meaning by that.

Okay, so and I must say all this information is in the immunisation handbook and please use the online version because that has been updated I think in August and so the online version of the Australian Immunisation Handbook has the latest information here and there’s also a very useful fact sheet that’s published by the National Centre for Immunisation Research that goes into some more detail and we’ve got a table from that fact sheet in a minute.

So, what is severe immunocompromise? So high dose systemic immunosuppressive therapy. So whether that’s chemotherapy, radiation therapy, oral steroids or disease modifying antirheumatics, and we’ll go on and look at some of the dosages there to give a bit of a rule of thumb. People with current malignant conditions particularly lymphomas, leukaemias, Hodgkin’s, people with AIDs or symptomatic HIV infection, recent solid organ or bone marrow transplant recipients or any recipients who are still on immunosuppressive drugs and any other person with a similar immunocompromise due to a disease or treatment.

So the vaccine must not be given to these people and there was one person in the UK who was administered Zostavax and they had leukaemia and so then there is a risk of disseminated herpes zoster.

So this table is from the National Centre for Immunisation Research Q&A on Zostavax and I think Penny will put up the link to that fact sheet. So this is giving a bit more meat around the bones of some the different immunosuppressive medications and what might be considered a dose where you could proceed to vaccinate and dosages above which it shouldn’t happen and, of course, advice to seek specialist advice if there’s any concern about whether a patient’s immunocompromise is significant enough that they shouldn’t be vaccinated.

On this table there’s also some advice about timing of vaccines so there may be patients who are known to be starting these medications or have recently ceased them so that you could consider immunisation a month before anticipated severe immunocompromise due to some of these immunosuppressive medications or various withholding periods of vaccination following ceasing of those different agents. So, and the handbook really emphasises that you be considering specialist advice for patients on lower dose steroids to disease modifying anti-rheumatics. Below those cut-offs, people with asymptomatic HIV infection, so that’s one of the few patients that we would recommend doing serology and so do serology, seek specialist advice and patients anticipating severe immunocompromise. So really I think it’s important to confer with the managing specialist in those cases and then if a patient is inadvertently immunised/vaccinated and you suspect they may have severe immunocompromise then get immediate specialist advice both from the managing specialist but also from the New South Wales Specialist Immunisation Service.

TIM SENIOR:

And so the thought of doing that fills me with terror really and so I wonder, it makes me think about the systems we need in practice to be able to identify these patients and not give them any Zostavax and so whether we need to put an alert on patients with relevant conditions or on relevant medications or if we’re doing a recall of that particular patient population whether we need to go through that manually and I think that’s where thinking about it in our practices how we make sure that we don’t inadvertently give Zostavax to immunocompromised patients.

VICKY SHEPPEARD:

That’s right Tim and so there’s a question about what dose of Prednisone is a high dose, a contraindication. So Prednisone higher than 20 mg per day for more than 14 days is considered a high dose and similarly with Methotrexate higher than 0.4 mg/kg would be considered a high dose. So if your patients are above any of these cut-off doses then vaccination should not be considered while they’re on these immunosuppressants. If they’re below these doses, so less than 20 mg/kg for Prednisone for example then probably a good idea to consult with the specialist about the timing of vaccination.

PENY:

And this is another question from Dr McMullan, would you like to address that as well?

VICKY SHEPPEARD:

So for the first few categories, low-dose steroids would advice be from their treating specialist or the phone line? Yeah, look I think the treating specialist is the first port of call. In the mail-out of information the Commonwealth has sent information both to general practitioners and also to all registered specialists and I think the specialist is the one most familiar with the patient’s level of immunocompromise but if after that discussion there is still a question about the advisability of vaccinating then the information line would be the next place to go.

TIM SENIOR:

Consulting with a specialist also means that if there is a problem the specialist has been forewarned and knows the advice that was given regarding it and knows that we’re considering Zostavax or not.

VICKY SHEPPEARD:

Yeah, and you know, I guess we’re really emphasising this point and it’s important to be aware of it but, you know, noting in the UK this program has been run out with just the one incident so far so yeah, mainly it’s very safe and I certainly don’t want to put you off offering this vaccine to your patients.

So this is, as we’ve said, it’s a national vaccination program. It was announced in the budget last year, so from November 2016 there is this national program. It’s an ongoing program for 70 year olds and then there’s a five year period when we can offer the vaccine to 71 to 79 year olds, so others who will benefit from it. So the Commonwealth released vaccine supplies to us a couple of weeks ago now so they’ve been in the State Vaccine Centre and they have been available to order and we have started distribution. At the moment the supplies are limited so we’re delivering to practices what we have and we’ll be able to anticipate in the coming weeks that the supplies will become more stable and we’ll be able to get more vaccine out to you and you’re able to start vaccinating any time even though the program officially starts on 1 November if you have the vaccine and seeing patients that are appropriate then it’s fine to start vaccinating.

So this slide just summarises some of the recommendations you might like to think about for the different age groups. So we’ve discussed the 79 year olds, the vaccine’s free and it should be considered for all patients and you know particularly for those that are at risk of the complications or the complications of zoster impacting on them more than others. So, splenectomy, diabetes, inflammatory bowel disease, rheumatoid arthritis, psoriasis, it’s really good to give the vaccine to these groups as long as we make sure first that they’re not on drugs that might be causing them severe immunocompromise.

Now younger patients may be prompted to ask about it once the information about the vaccine gets out and, you know, if someone in their fifties you know it’s going to give them individual benefit. So if they’re interested in the vaccine and they don’t have any contraindications you could certainly give them a private script. They might expect that they will need to have another booster that they might have to fund for themselves. The timing of that is not yet known but certainly it’s very unlikely that a vaccine administered in that age group will give protection out beyond 70. So they would need to be aware that a booster is likely to be required and they may even need to fund it themselves depending on when it’s required.

The 60 to 69 year old group would probably be really good to give it and it’s likely to have a good population level benefit. It didn’t cut the mustard as far as a cost benefit analysis under the PBS system but it’s still likely to have a really good benefit because you saw the higher level of zoster and post-herpetic neuralgia in that group but they will have to purchase the vaccine themselves.

People over 80, it’s not funded for this group, and we saw some of the earlier slides the vaccine’s not particularly efficacious in this age group so it’s probably not worth their while getting it but you’d have to discuss the relative benefits if anyone in that age group was interested.

TIM SENIOR:

So just on that slide there’s, in fact one of the questions I was going to ask is there at the top of the slide, patients with prior shingles. We’ve had a few people asking if they’ve already had shingles either recently or in the past is the vaccine recommended, and another questioner is asking about whether people need a booster.

VICKY SHEPPEARD:

Yeah, so the question about shingles, prior shingles is a common one because of course it is a common condition in this age group. There’s not a lot of data but the recommendation is that, yes even if they’ve had shingles once they are at risk of a recurrence. So you’d probably wait 12 months after an episode of shingles, at least 12 months and then it’s fine to give the vaccine and that should help prevent recurrences and prevent post-herpetic neuralgia. The need for a booster is a question that’s not known. We saw from some of those earlier slides that there is significant waning of effectiveness over time so the plan is, nationally is to monitor what we’re seeing in protection that we’re seeing in our population so it’s really, really important that the vaccinations given are reported to the Australian Immunisation Register and that will allow the Commonwealth to assess if vaccination starts to wane, you know, when that’s occurring so we’ll be able to look and see if people who are vaccinated at the rate at which they’re developing herpes zoster and post-herpetic neuralgia and then if it’s decided that a booster is needed then the Register could be used to facilitate recall at whatever time period it was decided a booster was needed. So I guess that again it’s important to point out to your patients that we don’t know yet but we’ll be gathering information and the best recommendation that we can for them.

TIM SENIOR:

And so for now the recommendation isn’t for a booster but that’s being monitored, that situation’s being monitored closely, is that right?

VICKY SHEPPEARD:

Yeah, exactly Tim.

TIM SENIOR:

And there’s a few questions coming through as well about, for patients where they would be outside the National Immunisation Program and so would have a private prescription, what’s the cost of the Zostavax?

VICKY SHEPPEARD:

It’s pretty pricey. My understanding is it’s close to a couple of hundred dollars depending on where you buy it. So it’s, you know, a major investment for the national program so it’s very important obviously with those patients to be able to discuss the risks and benefits of them being vaccinated.

TIM SENIOR:

Yeah, and so in light of that someone else has asked because the private vaccine costs a lot is it, would they be able to give the varicella vaccine at half the price and my instinct would be that that wouldn’t be efficacious and it may even be off-label.

VICKY SHEPPEARD:

Yes, it’s not registered for this age group I understand and it’s not going to help at all because it’s not going to stimulate T cell immunity. So it would be a waste of money.

TIM SENIOR:

So that wouldn’t be recommended. I’m just having a quick look through some of the other questions there. I think those are the main ones I can see for now. Excellent and I think the others will come up as we go through.

VICKY SHEPPEARD:

Okay.

VICKY SHEPPEARD:

So I just do want to talk about the Australian Immunisation Register because this is another very new thing that has been brought because of this Zostavax program. So it’s live and many of you will have noticed it. It became live on 1 October 2016. So by that date everyone in Australia who’s on Medicare from zero to 100 and whatever are on the Australian Immunisation Register. So there’s no longer the Australian Childhood Immunisation Register it’s just one register and receiving notifications of vaccination in all age groups. So any vaccines that you give and record on your Best Practice or Medical Director, as long as your software is up to date, those vaccinations should be being automatically reported to the Register. So whatever mechanism that you have used for the Childhood Register until now, so whether that’s automatically from your practice software, whether you’re going to the online portal or whether you’re doing paper notifications, you use exactly the same mechanism to report adult vaccines. So, yeah I guess this is our next really big message of the night, that it’s really important that vaccines, Zostavax that you’re administering is reported to the Register and, you know, of course this will help prevent things like duplicate vaccination if your patient is at more than one provider and it will be very important to monitor and evaluate the program. Tim, did you want to talk about some of the practice tips for using the Register?

TIM SENIOR:

Yeah. So as far as I know if your practice software is up to date then it’s able to contact the Register. I think Best Practice and Medical Director are probably the ones that people are most familiar with but some of you will be using other software and it’s worth going back and checking in your practice that that’s working for your software. Certainly I’m in a medical position on Communicare and so I need to check that that’s working well for that.

For patients who aren’t regularly with you, it’s worth checking to see, with the Immunisation Register as to whether they’ve already received it in the same way that you might do with children and there are going to be updates to the Register over the next 12 months and the Department of Human Services is managing that. In terms of it being systematic and we’ll talk about this in a minute, it’s important to think of ways of how we identify the patients in our practice who would be eligible for the National Immunisation Program Zostavax and also because we’re good GPs and these aren’t the only immunisations we’re giving that might well be combined with other vaccines that we give, flu vaccination, or many of these patients will have other chronic diseases and multiple chronic diseases and so it’s something to think about in our regular management reviews of patients like that is remembering to think, oh yes Zostavax, if we’re doing say a review of a chronic disease management plan or seeing a patient for other reasons, and thinking how we develop the alerts, either sort of remember ourselves or having a practice nurse or practice manager develop reminder systems in the practice or in our software. It may be different for each of us but that will ensure that we’re systematic rather than just sort of ad hoc about patients who happen to walk through the door on a day when we’ve got vaccine in the fridge.

So we’re going to think about a case study and I think from the point of view of giving a patient who is say 72 coming in and their not immunocompromised, and what happens if we say, would you like the Zostavax and the patient says yes, for most of us that would be fairly simple. In my practice the practice nurse would often given that and that may be true for many of you too and I think in terms of explaining the benefits and the potential complications and side effects of the vaccine you will be pretty familiar with doing that and I think the other side of it that will make this work is what we need to do to identify and recall the correct patients and who we need to involve in doing that and how we ensure that the practice has the appointment capacity to do that and does your practice nurse have enough appointments available to do that. So I was just wondering if you have thoughts on how your practice might manage the sort of process and avoid giving it to any immunocompromised patients, what sort of things, and you can write this in your chat boxes, what sort of things would you do in your practice going back tomorrow to ensure that the patients served by your practice who are eligible would have the opportunity to have the vaccine and have it safely. So will you be doing letters sent out or SMS messages or are you confident in using the software to identify patients of the correct age? I’ve gone silent because I’m looking for people to write in the chat box.

VICKY SHEPPEARD:

A poster in the waiting room Tim, send out letters.

TIM SENIOR:

Yep. All right and I wonder if any patient education Vicky or promotional material that New South Wales Health will be doing?

VICKY SHEPPEARD:

Well it’s mainly coming from the Commonwealth Tim so yes there are some very dramatic looking posters and there are posters for the general cohort and also specifically for Aboriginal patients and I believe that, you know, there will be some promotion to patients from the Commonwealth about the program as well.

TIM SENIOR:

So that’s important to look out for and some patients might come in requesting it and the other issue mentioned earlier in terms of ordering vaccine and the supplies at the moment are a little bit limited and I think practices are limited to 10 per practice as an initial order.

VICKY SHEPPEARD:

Yes, and that’s right and that will increase. So perhaps at this stage not to be planning too much active encouragement of patients but supplies will increase once the Commonwealth give us enough vaccine and once that happens that’s right you can start doing active recall.

TIM SENIOR:

Yeah. So maybe we’re thinking now about what you’re going to do in the coming months when the supplies increase in terms of active recall and for now either doing it ad hoc on patients who happen to come in or thinking of your 10 priority patients and inviting them for the early adopters run.

VICKY SHEPPEARD:

Yeah, and obviously if some are coming in asking for it. So you need to leave some for them.

TIM SENIOR:

That’s right, and it’s probably worth thinking of who in your practice needs to know about it. So in terms of the GPs and practice nurse who may well be administering it and may well get questions about it too and whether receptionists need to know or not in terms of booking people in for appointments and what sort of appointments they need, and whether the practice manager needs to be across some of the logistics of doing this and storing and ordering the vaccine as well, as well as monitoring the potential adverse events as well.

VICKY SHEPPEARD:

Yeah.

TIM SENIOR:

So I think I’ve thought about this from the population of our patients before they get to the practice and how we’re going to manage that both in terms of active recall but also in terms of workflow of a potentially large group of patients coming in in a potentially small group of time with at the moment only a limited supply of vaccine and how we manage that going through our practices. It’s going to be different for each and everyone of us because all of our practices are different with different processes and different people.

VICKY SHEPPEARD:

Yeah, but there’s some really good suggestions coming through actually about what practices are planning to do.

TIM SENIOR:

Excellent. I’m looking at those now. So yeah some people are sending out letters, some people are having a practice newsletter where there will be, whether they can put information about it in there inviting people to come in. I don’t know if any of you have practice Facebook pages or websites but it might be something that works well as a bit of information on that as well.

VICKY SHEPPEARD:

The next slide is about the next generation vaccine and of course some of your patients who spend a lot of time on the internet might have heard about this and look just so you’re aware of it, this is an inactivated vaccine or a subunit vaccine, so it’s not a live vaccine. It’s been developed by GSK. At the moment it’s looking incredibly effective, 97% effective across all age groups and requires two doses, but unfortunately it’s not yet registered in any country so we don’t know when we’ll be able to offer it at all. So, as you know to get registered and then to get onto PBAC, that process takes years by which, so I wouldn’t be advising patients in the eligible group to wait for that vaccine. So they could get the Zostavax now and presumably by the time the Zostavax wore off hopefully this new vaccine might be available, but you know, it’s early days yet. So that’s just so you’re aware in case some of your patients ask about it.

Tim, I just wanted to touch briefly on cold chain and it’s important with any vaccine but as we’ve already said this is a very expensive vaccine. So in New South Wales about 3.5% of the vaccines that we distribute each year do get wasted and unfortunately that comes to about $4 million of taxpayers’ money that is not profitably used. We collect, in the last financial year we had close to 800 wasted reports and these are mainly from general practice and we do record the reasons for the wastage. So about half of them are power failures and that’s very hard to prevent but there are some mechanisms that can be used depending on the reason of the power failure. Fridge malfunctions are about a quarter, human errors about 10%, storms very similar to power failure in the end is about 15%. So, you know, I guess I’d just like people to reflect on this and, you know, there are some things that can be done to circumvent this happening. I don’t know if you wanted to talk about that at all Tim.

TIM SENIOR:

Yeah, I’m struck at how high the power failure is as a reason and it makes me wonder how many of those could have been anticipated or prevented and it’s very difficult to know and also how high storm is, and I think that list just makes me think how many of those things could we actually anticipate and prevent.

VICKY SHEPPEARD:

Mmm. Look so we have got some tools that you might want to point your practice staff to looking at. We’ve now got a series of PowerPoint presentations on our website and available through the vaccine ordering system, and it’s about cold chain management, response to breaches, so just o help your practice implement these National Strive for 5 Guidelines, and you know, there are a few things that can be done to even reduce the risk of power failures for example, such as putting signs on the dedicated power point, please don’t unplug this fridge, for example. So we’ve got those kind of tips in there. There’s the National Strive for 5 Guidelines and we’ve also developed a vaccine fridge audit tool or a cold chain audit tool and I don’t know Tim, do you think that would be useful for accreditation or …

TIM SENIOR:

So I do. I mean I think in general audits are great. I’m always aware other peoples’ audits are really dull but audit your own practice and it’s always really interesting. An audit would be eligible for category 1 points under the College of QI&CPD system and I think, and would be cancers are a QI activity for that but would also be excellent for accreditation and really important in terms of being confident about your vaccine storage so I think that’s a really useful resource.

VICKY SHEPPEARD:

Excellent. I’m just conscious that we’re running out of time. So just a reminder, you know, if there is a cold chain breach isolate the vaccines that have been subject to the breach so that they’re not used but don’t discard them until you get advice, keep them in the fridge and then contact the Public Health Unit on their number. So don’t discard the new vaccines until you get advice from the Public Health Unit but if there’s privately purchased vaccines you need to talk to the manufacturer about what to do with them.

PENNY:

Excellent. Time has beaten us once again.

TIM SENIOR:

There is one question that is important to me because we forgot to cover it but Aboriginal and Torres Strait Islander patients, the national immunisation ages are the same as they are for nonindigenous patients as well. So that’s still in the 70 to 79 age group.

VICKY SHEPPEARD:

That’s right. Exactly.

PENNY:

Thank you. Thank you so much Tim and thank you so much to Vicky and thank you to all of you for joining us this evening. There are lots of questions that didn’t get to but what I’ll do is I’ll collate those and try and get back to you all with a bit of a fact sheet and answers to those questions after the webinar and if you’ve got any burning questions I did email you the email address and you can send them through to that and I’ll try and get those answered for you. Thank you again and thank you so much Vicky and thank you very much Tim.

VICKY SHEPPEARD:

Terrific. Thanks.

TIM SENIOR:

Thank you very much.