Sammi: Good evening everybody and welcome to this evening’s Vaccinating Adult Patients: A Guide for GPs. My name is Samantha and I will be your host for this evening. So before we start I would like to make an Acknowledgement of Country. We recognise the traditional custodians of the land and sea on which we live and work and we pay our respects to Elders past and present. So I would now like to introduce our presenter for this evening, Dr Vicky Sheppeard. Vicky is a public health physician who has been working for New South Wales Health since 1999. Vicky’s current role is Director of the Communicable Diseases Branch for Health Protection New South Wales. This role includes overseeing surveillance of notifiable diseases in New South Wales, coordinating communicable disease control activities, oversight of immunisation programs including delivery of the school based adolescent vaccination program and representing New South Wales on Communicable Disease Network Australia. So welcome, Vicky.
Vicky: Thanks, Sammi.
Sammi: And also I would like to introduce our facilitator for this evening, Dr Tim Senior. Tim is a GP at Thurawal Aboriginal Corporation in South Western Sydney. Tim is also an RACGP Medical Advisor for the National Faculty of Aboriginal and Torres Strait Islander Health and a Senior Lecturer in General Practice and Indigenous Health at UWS. So welcome, Tim and thank you for joining us.
Tim: Thank you very much. Good evening everyone. It is nice to be here. I think tonight will be a really good webinar. Certainly it is the sort of stuff that I always need to look up each time I use it.
These are the learning outcomes for tonight, which is again, educational speak for what we hope to achieve this evening. So by the end of this online QI and CPD activity, you should be able to know which vaccines are recommended for adults and which vaccines are provided free to adults in New South Wales, and while some of it will be relevant for other states, some of it will just be New South Wales information. We will try to make that clear as we go through. Understand which medical risk factors require additional vaccinations. Understand the importance of accurate reporting of vaccinations, including adult vaccines to the Australian Immunisation Register. And recount the crucial components of vaccine cold chain management including New South Wales Health requirements and where to access resources and educational tools.
So I will hand over to Vicky for the start of the webinar.
Vicky: Thanks Tim, and you are right that it is a complex area and I cannot promise that you will not still need to go and look it up in the handbook because there is a lot of complexities with adult vaccination. But I hope that we can develop at least an approach so that you feel more confident in knowing when or when not you are likely to need vaccinations in adults.
So I thought we would just start with some epidemiology of vaccine preventable diseases in New South Wales. So, going through alphabetically, the first is diphtheria which is a rare infection. So in the past five years we have only had five confirmed cases. Noting that many of the diphtheria cases we get now are cutaneous. Even with the cutaneous infection, you can still get the toxin effects and one of the cases in this five year period did have neurological impacts from the diphtheria cutaneous infection, so that just emphasises the point that it is important to maintain that diphtheria vaccination throughout life.
Measles is the next one, and I hope you have all been hearing a lot about that. It is certainly an ongoing risk and most of the risk that we are experiencing in Australia is from young adults who are unknowingly under-vaccinated when they travel overseas to hot spots, and the current hot spot is New Zealand with almost 1,000 cases in their current outbreak. So it is really at quite extreme levels in New Zealand, particularly in Auckland at the moment. So this shows the age groups of people with measles confirmed in New South Wales in the past five years. There is a high number under five, but those are mainly under one, who are too young to be vaccinated. And then the next peak is in the 20 to 24 and 25 to 29 year age groups. And then once we get to people that were born before 1966, we do not see cases, so it shows the long term protection of circulating wild measles vaccine that was experienced before the vaccine program was recommended and the importance of insuring that all adults have received two doses of measles vaccine if they are born during or after 1966, and particularly if they are going travelling.
This is meningococcal disease. The first graph is meningococcal B. Same time periods, same age groups. Here you can see meningococcal B is not such an issue for adults, so the two peaks are in the under-fives and the 15 to 19s with also cases in 20 to 24. But quite a different pattern with meningococcal C, W and Y, which is mainly W and Y, where we are seeing similar numbers of cases throughout the age groups and you know, quite increased. You get a peak under five, a peak in young adults, but then quite persistent infection in people 50 years and older.
Whooping cough. Now we have got a very different Y axis here in that the tens of thousands of cases over the five year period. So while the adult age groups look relatively small, those are representing one to two thousand cases. So a couple of hundred cases per year in each five year adult age group. So it is still a significant, quite a significant burden of disease in adults of whooping cough.
I will just highlight to you a recent study that we have just had published in Clinical Infectious Diseases which drew on the 45 and up cohort which is a New South Wales cohort of older adults. So in that cohort we looked at over a thousand confirmed cases and over three thousand matched controls, and some of your patients may have been part of this study. In it we looked at the vaccination history of confirmed cases and their controls and found that the vaccine even in adults is at least 50% protective in preventing PCR-confirmed pertussis infection, and of course I am sure you will all be aware that whooping cough has quite a significant burden of disease in the elderly. Not as bad as children, but we certainly do see deaths and quite a bit of morbidity in older people from whooping cough.
Moving on to pneumococcal disease. Again, we see a peak in the under-fives, but then most of the burden of disease as far as numbers of cases go, are in adults with increasing from the mid-40s and peaking in the more senior years. This is a bit more detail on the pneumococcal disease notifications by age group. And so by looking at the breakdown in ages over time, those very young groups which are the bright pink and the blue and the red and the orange have markedly decreased with the introduction of the pneumococcal vaccine for children. And in fact, the numbers in adult age groups have not really shifted. Now of course we have had big population growth in this time, so the rates have decreased, but there is still quite a large burden of disease in adults and older adults from pneumococcal disease compared to children.
And then the final one that I am covering in this webinar is tetanus, so fortunately a very rare infection, with only three cases notified in five years, one of which was quite well publicised in a child, unvaccinated child, and the other two cases in older adults, both female which is an important thing to look at. So that female that is marked there, the one that is 80 to 84, just her story. So she sustained an injury while she was gardening and two weeks later presented with trismus and increasing difficulty swallowing. Now she had a documented dose of Boostrix five years before the wound, so it was not suspected that she had tetanus. But the hospital did suspect it when she eventually presented and arranged intravenous immunoglobulin. And she did survive following a lengthy stay in intensive care. And looking back, because of her age there was no evidence of her having received a primary course of tetanus which is not at all unusual. So some older people, particularly women may not have completed a primary course of some vaccines, particularly tetanus as when they were children those vaccines were not available. Men were often vaccinated if they joined the Armed Forces, but often women missed out. So that is something to keep in mind with those elderly people.
Okay. So moving on then. So assessing adult vaccination requirements. HALO is the pneumonic that we can use to remember, so Health factors, Age, Lifestyle and Occupation are the things that we are going to consider about what the vaccination needs of adults might be.
So the Health vaccine requirements are chronic health conditions, immunosuppression, asplenia or hyposplenia, transplant and pregnancy. So we will work through those now. So I am sure you are all aware of pneumococcal and the two category A and B as far as guiding vaccination recommendations. So this slide just summarises the category A risk conditions, so functional or anatomical asplenia, proven or presumptive CSF leaks which includes people with cochlear implants and a range of immunocompromising conditions, so these are all conditions that are in category A for pneumococcal vaccination. So the current recommendations for vaccination for people with category A risk differ according to whether they have had previous pneumococcal vaccination or if they are newly identified, the recommendation which is currently not funded is that they get a single dose, so a 13 valent, so Prevenar 13 which is followed at least two months later by Pneumovax and then a further dose of Pneumovax at least five years later and then if those people are under 50 years of age and Aboriginal or Torres Strait Islander, then they get a final dose of Pneumovax at 50 years. Or if they are under 65 and not Aboriginal and Torres Strait Islander, they get a final dose of Pneumovax at 65 years or at least five years after their second dose of Pneumovax. People who have had a previous dose of Pneumovax are now and are category A high risk are now recommended to have a dose of Prevenar 13 at least 12 months after their most recent dose of Pneumovax. Then a further dose of Pneumovax at least five years later and then a final dose at 50 or 65, depending on whether they are Aboriginal or not.
Category B risk is chronic cardiac disease, chronic lung disease, diabetes and Down Syndrome, alcoholism, chronic liver disease, pre-term birth which I guess is a childhood vaccination issue not an adult, tobacco smoking, and again in children a history of invasive pneumococcal disease. So the recommendations differ for category B risk. So those who are newly identified get a dose of Pneumovax at diagnosis, a further dose five years later and a final dose five years later after age 50 or 65 depending on whether or not they are Aboriginal. Or for those who have already had a dose of Pneumovax in the past, they should get a dose of Pneumovax at around 18 or at least five years after their most recent dose, a further dose five years later and a final dose at 50 or 65, at least five years later. So the category B patients are not currently recommended to receive Prevenar 13.
Tim: We do have a few questions just around some of those. One is about why do we have to give Prevenar first and why do we have to wait 12 months after Pneumovax before we can give Prevenar? Why can we not give them together?
Vicky: Sure. So it is two months that we wait after the Prevenar to give Pneumovax. This will be, this is the way to optimise the immune response. Because Pneumovax is a polysaccharide vaccine, not a conjugate, it does not give the optimal initial immune response to the pneumococcal antigens. So, if it is a person who is naïve to pneumococcal vaccination, you will get the best long term protection by giving the Prevenar 13 first followed two months later by the Pneumovax and then the subsequent booster doses of Pneumovax.
Tim: Excellent. And a clarification. Lymphoma, that is included under a haematological malignancy?
Vicky: Yes, yes.
Tim: And just clarification around some of the risk factors, whether all smokers need pneumococcal vaccine if they have no other risk factors and whether obesity is a risk factor that would determine the pneumococcal vaccines?
Vicky: No. So obesity is not. So if they do not have other comorbidities, it is not a recommendation. But as far as tobacco goes, yes just being a smoker does put you at risk of pneumococcal disease, so it is recommended but not funded to be vaccinated.
Tim: Okay, lovely. So, just looking at the questions coming through, I think that answers them. I think we have covered those.
Vicky: Okay. And not wanting to confuse everyone but the pharmaceutical benefits advisory committee has recently re-considered pneumococcal vaccinations. So currently those vaccines which I just talked about for category A and B risk people, only Aboriginal people under 50 years of age are funded, with risk factors, are funded to receive those on the NIP. So the only funded vaccine at the moment for pneumococcal is for people, Aboriginal people with risk factors, Aboriginal people 50 years and over and all other people 65 and over. So, there are new recommendations which have been recommended by PBAC which does mean that they will go on the NIP, the Commonwealth Government has committed to that, but we do not know yet when that will happen. So, this will mean that all people from 70 years of age, so no longer at 65, will be eligible for a free dose of Prevenar 13. And that the risk groups, so the very high risk groups, so those with very high risk conditions which are the current category A as well as chronic respiratory disease or previous pneumococcal disease, will be eligible for the Prevenar and two doses of Pneumovax. And then also, children with high risk conditions are eligible for the additional doses of Prevenar and Pneumovax according to their risk factors. So that is not available yet, but it something that is on the horizon, probably in around 12 months. So you or some of your patients may have heard of this positive recommendation from PBAC so it will come through, but we are not sure yet when and the handbook will be updated before that comes in, so you will able to rely on the information in the handbook for the changes.
So, we were going to move on to now people with stem cell transplants. So I guess a fairly rare thing but very important to rebuild their immunity. So it is important that they need to become fully vaccinated. They cannot receive live vaccines within 24 months, two years of their transplant. And they may have a poor response to inactivated vaccines in the first six months. So obviously in consultation with their haematologist or oncologist. So, the list here is the vaccines that should be considered. So they need to be revaccinated with diphtheria, tetanus, pertussis, Hib, hepatitis B, HPV if they are going to be at ongoing risk, so depending on their age and their marital or partnership status, they may need HPV, polio, obviously annual flu, recommended to have both meningococcal ACWY and B, and pneumococcal and then when their specialist says it is okay, they should also receive the live vaccines, MMR and Varicella.
Solid organ transplant patients, so a little more common. It is slightly dependent on the transplanted organ because that will affect what immunosuppressive therapy they are receiving. It is ideal that they receive all their routine and scheduled vaccines before the transplant but if they do need vaccination afterwards, the live vaccine should be at least one month prior to transplant and the live vaccines are usually contraindicated afterwards. And you usually would leave six months after transplant for inactivated vaccines. And I will refer you to the table in the handbook about the recommended vaccines for people with solid organ transplants.
So moving on to splenectomy or people with functional asplenia. So in addition to their routinely recommended vaccines, it is really quite crucial that they receive Hib vaccine, obviously annual influenza, both meningococcal B and ACWY and pneumococcal vaccines. So 13 valent conjugated Prevenar 13 followed by two doses of Pneumovax as we have just discussed. So the good news for this group of patients, so the PBAC has also recommended that the Hib, meningococcal and ACWY and the pneumococcal vaccines be included on the NIP for these patients. Once again, this is a positive recommendation. It will come on the NIP, we just do not know yet when that will be. So but obviously, if you currently have patients with these conditions they cannot wait. It is crucial that they do receive these vaccines due to their high risk of bacterial sepsis.
And then immunosuppression. So people with significant immunocompromising conditions are also recommended to receive three doses of HPV vaccine irrespective of the age of when the course is commenced. So as you know, if people are under 15, they can normally have a two dose course now, but if they are immunocompromised they still need to have the three doses, and if they are an older person starting HPV vaccine and at risk of HPV, they should recommend a course to them, not funded. Obviously annual influenza vaccine which is funded, and pneumococcal and meningococcal as well. Once again, people in this group with complement deficiency or taking eculizumab have been recommended to be provided meningococcal and pneumococcal vaccine on the NIP and once again, we do not know when that will start but you know hopefully in the next 12 months.
And pregnancy. We have talked about pregnancy in previous webinars, so just a reminder that women planning pregnancy should have their vaccination status reviewed to make sure they are immune to chicken pox, measles, mumps, rubella and hepatitis B, and then they should be funded during each pregnancy for flu and pertussis. We have recently communicated with you all that the recommendations for antenatal pertussis vaccine are now expanded from 20 to 32 weeks and also continue to be funded on the NIP.
So I think that is through the Health requirements, Tim. I saw a couple of questions there. One is also, is Pneumovax needed every five years? So no.
Tim: That is right.
Vicky: It is needed only those specified doses. So, if you start with Prevenar 13, two months later Pneumovax, five years later Pneumovax and then potentially five years later a final Pneumovax depending on the age when you start. So the maximum doses would be three.
Tim: Yes. And there is a couple of questions about drugs that people might be on and whether methotrexate and long term steroid use would count as being immunocompromised for the vaccines?
Vicky: Yes, they would. And those would have the pneumococcal category A recommendations that we discussed. But those people have not been, to my knowledge, they have are not being funded under the new PBAC recommendations. But certainly they are category A high risk with immunosuppression due to medication.
Tim: Yes. Just looking. Those are the main questions I think. We have covered quite a bit I think already. I think so. Some questions about pertussis, how many years do you repeat pertussis? We may be coming up to that. Vaccination and HIV patients, same as other immune suppression. So I guess you have to differentiate between HIV positive and those with AIDS. Those who are HIV positive may not necessarily be immunosuppressed.
Vicky: No, but they are also, well you are right, they may not be immunosuppressed. But my interpretation of the handbook is that anyone with HIV is category A for pneumococcal vaccination.
Tim: Yes. We had someone asking about, if someone presents to ED with traumatic haematoma of the spleen and may end up with a splenectomy, should the cap C antigen vaccine be given urgent prior to splenectomy? I happen to know the person who has asked that, who does quite a bit of work in Emergency.
Vicky: Right. Look I do not think there is any great advantage in giving it urgently pre-operatively. We know that vaccines are going to take a couple of weeks to be effective but there definitely should be a plan that the vaccines are given at a suitable time. The Hib vaccine recommendation is either pre-splenectomy or if it is planned, or a week afterwards, so depending on the condition of the patient, I think that is probably more important, but the main thing is to have a plan in place and to report them to the Register so that everyone knows what has happened.
Tim: Yes. And there are a few people actually just clarifying about people over 65 or people with COPD, whether they need just one pneumococcal vaccine or if that is still the same recommendation?
Vicky: Okay, so if you diagnose COPD for the first time over 65 and they have not yet received any vaccines, so that is a chronic respiratory condition, so that is category B. So they would receive two doses of Pneumovax five years apart.
Tim: Yes. Excellent. I am aware of time, shall we move on?
Vicky: Yes, we might move on and get to some more questions if we have time. I think that was the longest part anyway, the Health part is the most complicated.
Tim: That is right.
Vicky: So Age vaccine considerations are pretty straight forward. So obviously older age groups are people 65 or 70. Certain age groups may be targeted for example, recommendations about pneumococcal disease and then young to middle aged adults may have missed out on vaccine doses so it is important to be aware of catch up vaccination in those groups. So the primary age associated shingles, so Zostavax is recommended for people 50 and over and as you would all be aware, funded for people at 70 ongoing, and we have still got catch up in place for those aged up to 79 out to October 2021. And just a reminder because we have dealt with this in a couple of webinars that Zostavax must not be given to people with significant immunocompromise and as we have had a death and some other very serious complications from giving the live vaccine to people with leukaemias and other conditions.
Pneumococcal, we have obviously already discussed that extensively, so one dose at 65 years of age or 50 years of age for Aboriginal people and if people have no comorbidities, they do not receive another dose of Pneumovax.
And influenza is of course funded for 65 and over every year. People with specified medical conditions and all Aboriginal people.
Tim: Excellent. We have just got a couple of questions. Zostavax is still a one dose injection?
Vicky: Yes, it is.
Tim: And any information on when the Shingrix will be available in Australia?
Vicky: Yes, well I believe that the PBAC has considered it once and found it not to be cost effective so while it is licensed here I do not believe it is actually being imported even on the private market, so I am afraid I do not know when it will be available.
Tim: Lovely. And what is the recommendation for Zostavax after shingles?
Vicky: Yes, it is certainly still recommended, because people who have had shingles are at risk of getting repeated.
Tim: From memory I think it is 12 months after the shingles infection that they can have the vaccine.
Vicky: I think you are right Tim, thank you. Okay, so this slide is just a reminder about the pneumococcal recommendations so that is pretty straight forward and I think we have covered that, and the reason that we went back to just one dose of Pneumovax for people who do not have risk factors is due to you know, a fairly significant risk of injection site reaction. So that is a risk and for someone without other risk factors it is considered the risk of injection site reaction is higher than the risk of them getting pneumococcal disease by not having a booster dose. But of course, these recommendations will change when the PBAC recommendations get listed on the NIP so the pneumococcal vaccination point will move to 70 with the Zostavax and it will just be a dose of Prevenar 13, but we do not know when that is going to start.
And sorry I did not cover the frequency of dTpa vaccination there, but basically the handbook recommends a booster every 10 years, so if people do not get it through tetanus injury boosters then you would consider offering a repeat dose of Boostrix or Adacel after 10 years but that is a privately funded vaccine.
So then moving on to Lifestyle factors. So considering that people, migrants and others may have missed vaccines because they have moved. They might need extra vaccines because they travel frequently, or other lifestyle risk factors that increase their risk of acquiring a vaccine-preventable disease such as smoking, male-to-male sex or injecting drugs. So fortunately refugees and humanitarian entrants are eligible under the NIP for some catch-up vaccines which is very good news. So they are free for diphtheria, tetanus and pertussis vaccination, polio, measles, mumps, rubella, hepatitis B and varicella. Now the course of diphtheria, tetanus, pertussis is usually given with pertussis for the first dose and then the subsequent doses are just diphtheria and tetanus.
People who are MSM, males who have sex with men or have sexual risk factors, sex workers and others, ensure they are immune to hepatitis B, and if they are not, offer an adult course. And this is funded in New South Wales for this very high risk group. So a three dose course at zero, one and six months. You should also offer hepatitis A, two lifetime doses and HPV, two or three lifetime doses depending on the age they commence their course. We are talking about adults so it would be three. So these are really important and back just a couple of years ago we had an outbreak of hepatitis A in MSM in Australia and a very big one over in Europe. In New South Wales we were quite protected because our sexual health services continue to offer hepatitis A vaccines to their clients. So it is important if you are seeing MSM that you do enquire about their hep A, hep B and HPV vaccination status.
So, questions there about is a hep B booster funded in New South Wales if they are not immune in MSM? Yes, you can use the state-funded vaccine for that. Any age limit for HPV? Look, I think it is recommended up to 40, but it really does depend on you know sexual risk factors. So, you know, highly promiscuous, you know people who are having a lot of sex partners over the age of 40 remain at risk of HPV and HPV cancers. So, that is I think you know a discussion to have with your patient about what they want to do to reduce their risk of encountering HPV and subsequently going on to getting cancers. Any of those other questions, Tim?
Tim: Just having a look. There are some about hep A lifetime doses. Is that just a single dose for life?
Vicky: So you have one dose and a second dose at least six months later, will give lifetime protection. If there is a longer period between the first and the second dose, that is fine, you do not need to repeat the first dose, but it is the second dose that will give prolonged protection against hepatitis A.
Tim: Yes. There are a few questions about the HPV vaccine. Is there an age limit for HPV and is hep and HPV funded for men who have sex with men?
Vicky: No. They are not. Hepatitis A and HPV are not funded. So unfortunately that is counselling with your patient about what they would like to do. But the hepatitis A, if they cannot afford it, most New South Wales sexual health services will provide it for free. So, they could go there to get that, or could at least enquire to the local sexual health service if they would offer free vaccination.
Tim: Yes, and there is a question about people who remain negative on the hepatitis B antibodies after two full courses of hepatitis B. I know that there are some guidelines in the immunisation handbook about that.
Vicky: That is right, yes. So no further doses are recommended. The person should be aware that they may not be immune, so if they do have a risky exposure, they should get post-exposure prophylactic. The chances are they are probably protected, but we just cannot measure the antibodies.
Tim: Yes. Okay. I think we have covered most of those questions. Let us move on. If there is any we have not come to we will come back to them.
Vicky: Okay. Look, just a very brief summary of travel vaccines because we did do a webinar on that last year which is still available on the website. But the things to remember there for travel vaccines are the three R’s. So, check that the Routine vaccines are up to date and of course once again that is particularly two lifetime doses of measles vaccine, flu is also a key thing to remember for travel. Then there is Recommended vaccines such as hepatitis A, typhoid, cholera et cetera, depending on the travel, the destination and the nature of the travel. So what kind of accommodation et cetera, experiences that they will be having while they are away. And then Required vaccines which are just yellow fever for yellow fever endemic areas and meningococcal ACWY for travellers to the Hajj. Of course considering malaria prophylaxis and other sensible measures as part of your travel consultation. Carrying mosquito repellent, long sleeves, and care with food and water.
Tim: And we did have a question earlier about yellow fever vaccine. Any yellow fever vaccine recommendations in people over 60? As this is a relative contraindication.
Vicky: That is right. Yes, so we certainly should take great caution in vaccinating people over 60 and they can be eligible for an exemption because of the higher risk of adverse events in that age group. Though there is now a free online learning module through ACRRM available on yellow fever, so to become a yellow fever provider now in Australia you do need to do that online module, but it is freely available to all GPs and very comprehensive as far as the considerations about yellow fever vaccination. So we can send around the link to that.
Tim: Lovely. And there is a few questions coming about occupation so I think that is worth covering.
Vicky: Alright, so I was not going to cover it in any depth because we did do a whole webinar on it. So what were the questions, Tim?
Tim: So one was about whether there is any need for hepatitis B boosters every five years for high risk professionals?
Vicky: No, no. A full course of hepatitis B vaccine properly spaced according to age is highly effective and very likely to provide lifetime protection.
Tim: I think that was the main one we have got. Yes, so does two doses of MMR give life-long immunity?
Vicky: Yes. We do get some vaccine failures, but it can be assumed to be lifetime immunity.
Tim: And is MMR recommended for travel?
Tim: It is, yes. We have had a couple of people ask about the Q fever vaccination and what the recommendations for those are.
Vicky: Okay, and again I think we have covered that in a webinar, so
Tim: Yes, I think we have.
Vicky: So Q fever and we have got a picture here of a woman tending to cattle, so people who are in any animal related occupations or whose hobbies involve shooting or any work with animals, so that is native animals, cows, sheep, goats, even domestic animals, so vets, should be assessed for Q fever vaccination. So to assess them requires a history of any plausible past history of Q fever infection, skin testing and serology and followed seven days later reading the skin test and vaccinating. And we do have an online learning module, again hosted by ACRRM which is available free to all New South Wales GPs about diagnosing and vaccinating for Q fever and to access that module for free, you just have to put in the code New South Wales GP 18 and we can send that out with this webinar’s notes as well. It takes you through diagnosing, assessing the risk and gives practical tips about safely testing and vaccinating people for Q fever.
Tim: Excellent. So, a question about recommending checking measles serology prior to travel.
Vicky: Yes, it is, the cheapest way to do it is to rely on a vaccination history, so if someone has had two documented cases of measles vaccine, then they do not need another dose. If they do have two documented cases and they are born during or after 1966, the vaccine is free in New South Wales. So we would recommend just to vaccinate them if they do not have two documented doses in they are 53 years of age or younger. If the patient wishes to have serology, then you could do that prior to but that is perfectly fine to do that, but it depending on your discussion with your patient. The National Centre for Immunisation Research has just published an algorithm about MMR vaccination and again I am very happy for that link to go out and it includes when you might consider serology.
Tim: And we have either had two questions about it or we have had the same person asking twice, but about whether it is possible to check pneumococcal antibody levels to assess their requirements if the history of pneumococcal vaccination is not clear. My understanding is that that is not possible.
Vicky: Yes, it is not really useful and of course we have got so many serotypes of pneumococcal disease so no, it is really just a matter of establishing the vaccination history, establishing the risk factors and vaccinating accordingly.
Tim: Lovely. And there are a few people asking about recommendations for family and close contacts of pregnant women and pertussis or MMR.
Vicky: Yes well it is certainly quite safe to give MMR to the contacts and a good idea if they are not protected, and free in New South Wales for people who do not have two documented doses. People who are likely to be carers of infants, so the dads, grandparents, other people, are recommended to be vaccinated against if they have not received a pertussis containing vaccine in the past 10 years. But that is not funded.
Tim: Lovely. So I am just aware of time. We are nearly at 20 past eight. We might move on and see if we can get back to some of the questions.
Vicky: Alright. So this slide is just summarising the vaccines that are funded by New South Wales Health. So we have talked about most of these already, so these are on top of NIP vaccines. I want to point out there, there might be HPV for refugees up to 26 years of age, so that is an additional one that is not on the NIP. And of course, we do provide post-exposure rabies vaccine and immunoglobulin for people who have rabies exposures. And all this information is on our website.
So, you know a lot of the questions we have had tonight are, how do we know if people have had these vaccines et cetera. And you know, until now that has been a challenge. So now, since 2016 we are able to record all vaccines for all people, except for Q fever, on the AIR. So that is a fabulous thing and I really, really encourage you all to ensure that all vaccines that you are giving to every patient does get transmitted to the AIR. And using practice software, I understand if you use the same fields that you use for your childhood vaccines, then it will just happen automatically. But I have got here a couple of links to webinars that have been developed by the National Centre and by the Department of Human Services if you need some information about how to, the mechanics or the electronics of getting those vaccines transmitted. That will give you more information.
But just a couple of examples of what we are seeing. So, this is looking at influenza doses that are recorded on the register for people 65 and over in New South Wales, so in 2019 up to the 31st July we had 739 thousand doses recorded which is better than the same period in 2018 when we had only had 616 thousand doses recorded. Yet, we have distributed well over one million doses for that cohort in both years, so we are only at about 63% of the doses that have been distributed have been reported to the AIR, which is good. So about two thirds have been reported, but it looks like it could be up to a third of adults over 65 Fluad doses not reported. So, you know this is of course really important if you have vaccinated patients and they see another colleague or another practice, they are able to check whether or not they have received the vaccine.
Similarly with the Zostavax in the evaluation that was done, in the first 18 months 34% of 70-year-olds and 26% of the catch up cohort had an added dose recorded. Yet during this period, and this is in Australia, there had been 1.3 million doses distributed. So only 36% of them had been recorded on the register. So even more crucial that vaccines such as Zostavax are reported so that it is not inadvertently repeated. So you know, I think with the register available now, it is really important that all the vaccines are reported to the register.
Tim: And we have got a question. Do private flu vaccines given by pharmacists get reported to the register?
Vicky: Yes, well in New South Wales a requirement for pharmacists to be able to vaccinate is that they report every dose to the register. So we have made that one of the conditions of being able to, for a pharmacist to be able to vaccinate in New South Wales.
Tim: Excellent. And we have got another question. Can GPs have access to the AIR to check immunisation states of a new patient? My understanding is that they can access through Proda, the professionals online or through the MyHealth record.
Vicky: Yes. Yes so certainly that is the idea, that once a patient is with you, you are able to access their record using their Medicare.
Tim: So it is doable? It may not always be as simple, but the more you do it the easier it gets I think.
Vicky: Okay, thanks Tim. So, we are up to a couple of case studies now. So we have gone through most of the content and we are nearly out of time, my goodness. So, this is about Amir and Fatemah who are refugees from Iran. They have got no vaccination records and no way to get them. So what do you consider for this couple? And Fatimah is thinking of starting a family. So, under the NIP they are eligible for three doses of diphtheria and tetanus and the first dose should also contain pertussis. Three doses of polio. Two doses of MMR. Three doses of hepatitis B and two doses of varicella. So, advise Fatemah not to get pregnant within 28 days of receiving the live vaccines and then if she does fall pregnant, she will be eligible for another dose of pertussis vaccine which she should have at around 28 weeks gestation. And also important to test her for hepatitis B infection. So you do the hepatitis B serology on the first visit, start the vaccination course and if they are already immune or are infected, then they do not need any further doses of hepatitis B.
The second one is Victor who has recently turned 70 and he is going to go back packing for three months in South East Asian. He has got diabetes and asthma. He is a patient of your colleague and he does not recall, there is no record of any vaccinations and he thought he had a vaccine about 15 years ago after an accident. He does not think he needs any. So what does Victor need? So, routine vaccines. So, Zostavax, flu, they are funded. Pneumovax, he has got a category B risk factor, diabetes, so one dose now, a second dose in five years, those are funded. Consider dTpa because it has been more than 10 years since he had his last dose that he reports and if the money is an issue, then probably just diphtheria tetanus which you could just get from the doctor’s bag, and you know it is really crucial before he travels that he has particularly the tetanus. Then recommended South East Asia, you would be thinking hepatitis A, typhoid and possibly Japanese encephalitis because he is going back packing for a few months so presumably out in areas that are at risk of Japanese encephalitis and you know, depending on the time he is travelling it would be peak season May to October. Those are not funded. You might discuss rabies risk because any bites he got from dogs or cats would be at risk and depending on how rapidly he can access medical care, it might be wise for him to pay for pre-exposure prophylaxis. Then of course the other factors we talked about.
Alright, with three minutes to go. The third one, Cathryn, a 49-year-old female. You find that she has recently had a splenectomy and she and her husband are just retired to a hobby farm outside Coffs Harbour where they are raising cattle. So luckily on the AIR, the following vaccines were recorded by the hospital. So she has had Prevenar 13. She has had Hib vaccine and she has had menACWY. So what do you recommend to Cathryn with regards to her vaccinations? So, she has got to finish her pneumococcal vaccination course, so two months after the Prevenar 13, she needs a dose. That is not funded. She will need annual flu vaccine. She should have a second dose of meningococcal ACWY eight weeks after the first dose and also recommend meningococcal B vaccine which is not funded. And then Q fever because she is working on a cattle farm. You should discuss with her assessing her risk of Q fever and vaccinating her.
So sorry to rush through those and gosh we are up to cold chain. What do we want to do Tim? Two minutes?
Tim: Yes, I think the cold chain is really important. There have been issues recently in New South Wales around this, we got prominently reported so let us remind everyone that the National Vaccine Storage Guidelines, ‘Strive for 5’ in New South Wales are there. It is part of College accreditation as well that you need to have the cold chain. I am wondering if participants need us to go through this particularly again in detail now?
Vicky: I think there are known facts about it and just a new requirement for New South Wales that at least one staff member in practices that receive government funded vaccines must complete our online module which is available for free on our website. And following these incidents we are going to be conducting cold chain audits of general practices. So.
Tim: Excellent. That is probably what people need to know. I suspect that most of the people who would choose to come to webinars such as this are actually right across what they are doing in the cold chain in their practices. So the onus on everyone on the webinar, is tell all your friends. Which brings us to 8.30.
So these again are the learning outcomes. You have been a fantastic audience tonight, lots of questions coming through. Sorry we have not quite got to all of them. We have done our best to cover the common questions. We hope that we have achieved the learning outcomes for you tonight, that we do know which vaccines are recommended for adults and which vaccines are provided free to adults in New South Wales. We hope you now understand which medical risk factors require additional vaccinations. Understand the importance of accurate reporting of all vaccinations including adult vaccines, the Australian immunisation register and you all already knew the crucial components of vaccine cold chain management, including the New South Wales Health requirements and ways to access resources and education tools. And if you do need to, do just contact the College for any further information about that.
Thank you very much Vicky, and thank you to Sammi running the technology behind.
Vicky: Great. Yes, thanks Tim and thanks everyone, thanks for your attention. Good night.
Sammi: That was great, thanks everybody.