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NSW influenza vaccination update 2020

Sammi: Good evening everybody and welcome to this evening’s Influenza Vaccination Update for 2020. Our presenter this evening is Dr Tim Senior and I am Samantha. I will be your host for the evening.

Okay, before we jump in 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.

Before we jump in, I would like to formally introduce Tim for this evening. Tim is a GP at Tharawal Aboriginal Corporation in South Western Sydney. Tim is also an RACGP Medical Advisor for the National Faculty of Aboriginal and Torres Strait Islander Health, and a Senior Lecturer in General Practice and Indigenous Health at UWS. So thank you for joining us, Tim.

Tim: That is my pleasure. Good to be with you all tonight.

Sammi: Wonderful. And I will hand over to you now to take us through our learning outcomes for this evening, Tim and then we can move on with the rest of the presentation.

Tim: Thank you very much. So good evening, I hope you are all well. These are the learning outcomes for tonight which is what we hope to achieve through the evening, so that by the end of this online QI & CPD activity, we should be able to prepare for the 2020 influenza season. We should be aware of the factors contributing to varying influenza impacts in New South Wales in recent years, discuss the impact and outcomes of the 2019 influenza vaccine program including for children under five years of age. We should be able to recount the formulations of the 2020 influenza vaccine and their optimal use in eligible age groups including children under five and those aged 65 and over. We should be able to utilise the flu vaccination tool kit to optimise our vaccine supplies and maximise uptake of influenza vaccine.

So the first slide. This slide shows the influenza epidemiology across New South Wales over the previous years and as you can see, particularly I draw your attention to 2019 and 2017, particularly prominent seasons with less in 2018. So in 2017, there were 103 thousand notifications of influenza and that was predominantly in influenza A, and then much fewer in 2018. 2019, so last year, we had altogether 115 thousand, 760 notifications for 2019, and again that was predominantly influenza A. And it is also worth seeing in this that it was a relatively prolonged season, starting in April and lasting with quite high peaks through until later in the year. And that lasted much longer than in 2017.

So the next slide here shows us the epidemiology of influenza A and B across New South Wales last year, January 2019 to January 2020, and you can see particularly for influenza B on the bottom there, it predominantly affected the nought to four-year-old aged group, so children. Even for influenza A there was a large number of children who got infected, so there was infection right across the age groups, but particularly that is one of the reasons why we concentrate on vaccination for influenza in children as well as in older adults.

This is the Emergency activity. Actually, I think this might be the sentinel laboratory surveillance. But again, you can see the different coloured graphs show the different years, so you can compare year to year. So for example, you can see there 2019 starting early towards May compared particularly to 2017 and being quite a prolonged season as well. So the top graph is weekly counts of Emergency Department visits for respiratory illness, fever and unspecified infections, and then they do sentinel influenza swabbing to see how much there is around. The leading respiratory virus is actually rhinovirus. That was the most commonly one identified by the sentinel laboratories. And detections of other respiratory viruses were within the usual seasonal range for the time of year.

So if we look at the next slide, this is about severity and again, over the year and this is confirmed influenza hospital admissions through last year, so you can see where the peak is there. You can see that most of those were the yellow boxes, influenza A, but not typed. But a reasonable number of influenza B as well and then during the peak of the season a few people admitted to hospital with dual influenza A and B infections.

And so to summarise, each year New South Wales Health produces a report of the previous flu season, so last year was dominated by the influenza A, H1N1 virus. It started early, March/April, so around this time last year and last through until about September. And the severity was similar to previous years when H1N1 has been predominant. There was a good vaccine match with all strains, and importantly, the 450 institutional outbreaks reported, with 383 of those in aged care facilities, most of those again influenza A, but some due to influenza B, and at least 189 deaths were reported. And one of the important things in this is just the targeting of the elderly and we will talk about particular at risk groups including specific vaccines for the elderly later on. But New South Wales Health tell us that the residential aged care facilities have already received their vaccine, even though some of you may not have done yet.

The next slide shows us the impact in the under-fives. They have the highest rate of hospitalisation, together with over 65-year-olds. So that is typically within the range of six to 40 per 10 thousand for children younger than five years of age and especially those under three. That is quite a wide range, that six to 40, and there are deaths each year from influenza in children, mainly in those under five, and the 2015 report of the Child Death Review teams of the Ombudsman, highlighted that during 2005 to 2014, influenza was equal with pneumococcal disease being responsible for the highest number of child deaths in New South Wales, that was 15 for influenza and 15 for pneumococcal during that nine year period. So, again just emphasising children can get severe illness and although their numbers are quite low, immunisation of children is going to be important.

The next slide shows us their rates of vaccination. These slides are likely to be an under-report, because not every report makes it to the Australian Immunisation Register. Hopefully all the different immunisation providers including ourselves are getting better at doing these reports. But these are cumulative, so the graph goes up and is all the total people who have had it by that point in the year and reported to the immunisation register. And you can see the different coloured lines that are showing us different aged groups. And then on the left is Aboriginal and Torres Strait Islander people and on the right is non-indigenous people in New South Wales. So I work in an Aboriginal medical centre, so I am quite pleased to see the rates in Aboriginal and Torres Strait Islander people are fairly high. The rates for both groups in the elderly are the highest and there is, yes, I think there is probably room for improvement in all of those, particularly with this very unusual year where with coronavirus going on, people would be vulnerable to dual infections. And certainly all of my patients have been asking for quite a few months now about the availability of the flu vaccine. So I think we may see greater uptake this year.

So this next slide shows us the advice from the Chief Medical Officer, and stressing the importance of an annual vaccination as being the most important measure to prevent influenza and its complications. And the recommendation from the Chief Medical Officer is that everyone aged greater than six months has a flu vaccine. However, that is not everyone that is funded to have flu vaccine. And so all Aboriginal people six months and older are eligible for flu vaccine on the National Immunisation Program, and every year, we have already had a question about this, this evening. We always wonder about the optimal protection and the timing of vaccine and whether we should do later ones. The optimal protection occurs during the first three to four months following vaccination and it can be a bit difficult to predict. As we saw last year’s epidemiology started slightly early, so early flu vaccine would have been fairly protective in that early stage. And I think we are getting a lot of questions from our patients about when to vaccinate. Harry Nespolon, the College President has been in the media recommending early vaccination and I think the most important thing is that it gets into people. That web link there is the ATAGI advice on influenza vaccines for this year, and that is actually well worth a read. It is a good summary of all the recommendations. It has a really good list of the chronic medical conditions that put people at higher risk of complications from flu. And I think this year, in light of the importance of flu vaccine, we are all thinking about the suddenly changed way of working that we all have in terms of keeping our distance from people, it is very difficult to do when we want them to have a flu vaccination, so I think a lot of us, it would be interesting to see if you are considering this, thinking about how we might deliver flu vaccines in slightly different ways. People coming up with flu vaccinations, drive through flu vaccination clinics in practice car parks and how we do that while maintaining the cold chain, how we do that while maintaining the patient safety in terms of waiting to look for reactions afterwards and how we are doing that in the context of Medicare billing and bulk billing incentives as well, which we all know we can bill for Telehealth now, the bulk billing incentive has been increased for patients on health care cards and pensioners. The other thing that New South Wales Health mentioned to us is that somebody has suggested that they will actually stop doing vaccination to prevent face to face contact with themselves and their staff, and so that will be interesting as well about how we are managing that and recommending flu vaccine particularly in the context if that is what we are wanting to do.

The next slide shows us the immunisation schedule, it will be very familiar to all of us. So that is the updated one for this year and the main change I want to draw to your attention to here is the change to the influenza vaccine for those over 65 years. We will be going into this in a bit more detail shortly, but for those over 65 years, it is Fluad Quad that is recommended. As we will see there are quite a few different brands of influenza vaccine that are licence for people over 65, but the Fluad Quad vaccine which is an adjuvant flu vaccine that gets a slightly stronger response. It is recommended for those over 65. And worth as well a quick reminder that those over 70 may also be getting Zostavax as well flu vaccine and there will be a proportion of patients as well who would be getting pneumococcal vaccine if they have not had it before or if they are Aboriginal and have not had it before, if they have only had one I think it is more than five years ago. So, I guess it is always us looking at our patients and seeing what else they might be due, as well as the influenza vaccine. And again, this year that might be slightly more difficult if we are doing vaccinations in different ways outside our consulting rooms. So again, that is something for us all to think about in our practices and with our practice staff and practice nurses.

So the next slide shows the changes in 2020. So every year the WHO consults on the composition that they recommend for the influenza vaccine, so they got together in September. That feels like many days long ago now. And so there were three changes from the Southern Hemisphere vaccine from last year, and there were two changes from the Northern Hemisphere influenza vaccine from their winter that they have just gone through.

So the next slide tells us what these strains are for any of you or your patients who are particularly interested in this. So this year, there is only quadrivalent flu vaccines available. You will remember that we have had trivalent vaccines, sort of a mix of trivalent and quadrivalent in previous years. All the vaccines available this year are quadrivalent and they cover two A strains and two B strains of influenza, and so there are the A strains and B strains. So there is an H1N1 Brisbane strain, which is a different one from last year. There is an influenza A H3N2 South Australia stain, changed from last year. And then the two influenza B strains, one has changed from last year, the Washington. And Phuket influenza B strain was present in last year’s vaccines too. It is always interesting as a GP looking at those and thinking, that is very interesting how they make those decisions. To some extent it does not make that much difference to us, we give the vaccines to as many people as we can.

So this year there are five quadrivalent vaccines available. All the vaccines are 0.5 ml, so there are no half doses being used. And the, I should wait for the slides to catch up with me. There are no half doses, there are no doses of 0.25 ml this year. So the vaccines are Vaxigrip Tetra, FluQuadri, Fluarix Tetra, Afluria Quad and Fluad Quad. And we will go through each of these and there is some difference in the ages that they are given, and this is always worth paying attention to and using the card shown on the next slide next to our fridge and in our practices, because every year, because it is a bit complicated there are some vaccines given to people in the wrong age group which technically they are not licenced for. So this shows the five different vaccines available. So the FluQuadri is licenced for all ages, as it the Vaxigrip Tetra and the Fluarix Tetra. So the Afluria Quad is only for those aged over five and the Fluad Quad is only for those aged of 65. So I think it is probably slightly more simple than it has been in previous years, but just a reminder to make sure that you are using the right vaccines in the right age group.

So we will go through the different vaccines. And I am just going to pause there and see some of the questions that we have got coming through at the moment. So I am going to come to the timing later on I think, because I think that is an important question that we ask ourselves every year. So there are a couple of questions on that about the timing and whether people have a second vaccine.

Sammi: Yes, and that is a common question we get every year isn’t it Tim, from people who are wondering about if people get vaccinated early in the flu season, whether it is possible, or if it should be recommended that after that three to four month optimal period of coverage, they should be receiving a second vaccination.

Tim: Yes, that is right. And so it is an important question. I will come to that later on actually and there are some good questions about whether the limitations on travel and things will have affected the strains of influenza circulating this year. It is a really good question, and I am not sure and I am not sure if anyone knows. I think what we may well see in the second part of this question and we are probably all wondering this, is that with social distancing and better hand washing and cough and sneeze etiquette that we are seeing this year, we may well see lower rates of influenza. But that is supposition rather than evidence, but we just do not know. Of course the advantage is that not only do we have those physical distancing measures, but we also do have the vaccine. So that should provide some protection. The other side of that coin that someone pointed out to me, is that we may well be doing more viral swab testing, so we may actually have more confirmed influenza if there is more testing going on. So just looking at some… and again, I am going to come to those questions later on because many of them are about repeating the vaccine later on and that is going to be an important issue.

Let us go through the different vaccines and the National Immunisation Program and then we will come back to some of the questions after that.

The first one is FluQuadri which is licenced for those six months of age or more. It is on the National Immunisation Program. This is funded for children six months to five years, all children. It is funded for Aboriginal and Torres Strait Islander people from six months to 64 years of age and for pregnant women and for those who have certain medical conditions. For children who between six months and nine years, if they have never had a flu vaccine before, then they get two doses of this one month apart. But only one of those is funded on the National Immunisation Program as far as I know.

The next brand is Fluarix Tetra. Again, licenced for use from six months of age and upwards. Funded for all Aboriginal persons six months and over, pregnant women, all persons with medical risk factors, five years to 64 years of age, and the same advice applies for children six months to nine years. If they have never had a flu vaccine before, then two doses of this, one month apart. And yes there is a question there on immunosuppression which is an important one, and actually the guidelines for that is that they should have, people who are immunosuppressed, either due to disease or their treatment, if they have asplenia they should have influenza vaccination.

Vaxigrip Tetra is the next one on the list. I will give a list of medical risk factors later on as well. So this is funded also, licenced for use from six months of age and it is funded for all children six months to five years of age. It is funded for all Aboriginal people five years and over, pregnant women and all persons with medical risk factors, five years to 64 years of age. And again, same advice as before for children six months to nine years, two doses one month apart if they have never had a flu vaccine before. And someone is asking can we give full dose, 5 ml not 2.5 ml to children? That is right it has changed this year, so everyone gets the 5 ml not the half doses for children.

Afluria Quad is our next brand. Now this is slightly different to the ones that we have been looking at up till now, because this is only licenced for use in those aged five years and over, so this is not for the younger children. And again, that card on your fridge will tell you about this. This is free for all Aboriginal people five years and over, for pregnant women and for all people with medical risk factors five years to 64 years of age. Give two doses one month apart for children aged five to nine if it is the first year of receiving flu vaccine. And so just to reiterate, that is not for children less than five years of age.

And we will just do the last one which is the Fluad Quad. Now this is licenced for use in individuals aged 65 and over only. So this is not for anyone younger than 65 and you can see that clearly on the label there and it is on the card. So this is funded for all people aged 65 and over. And unlike last year, this is a quadrivalent vaccine. The adjuvant vaccine last year was trivalent. And so it has an ingredient in it that increases the immune response to the vaccine component. So it has improved immunogenicity, including the frail elderly. So studies indicate about a 25% reduction in influenza infection and hospitalisation compared to standard influenza vaccines. Because it gives a slightly stronger immunogenic response, recipients may experience more marked local reactions, so they may get a bit more fever, a bit more pain at the site, a bit more redness. The rate of severe adverse effect is not higher with this, it is just those relatively minor local effects compared with the normal quadrivalent vaccines. The other important thing about the adjuvant vaccine is that when you look at it, it is a milky white suspension. So it looks different in the syringe to the other vaccines which are clear, and that is important because sometimes you might be asked by people, oh is that off? It looks milky, should it look milky? This one should look milky.

And so, other changes in 2020. The adjuvented vaccine for people aged 65 and over is now quadrivalent. We have talked about it and appropriately trained pharmacists may provide influenza vaccination to persons 10 years and older, and they must advise patients if they are eligible for a free vaccine via their GP. And that is often a controversial thing among GPs, I am not going to get drawn into that tonight.

I will just have a look at the questions and I am just going to tell you about the diseases recommended by ATAGI, so this is that link I gave you earlier about the guidance from the Chief Medical Officer and the ATAGI committee. They have a really good list. So the categories are cardiac disease. Vaccines are strongly recommended for people with the following conditions: cyanotic congenital heart disease, congestive heart failure, coronary artery disease. People with chronic respiratory conditions such as severe asthma, cystic fibrosis, bronchiectasis, suppuratives lung disease, chronic obstructive lung disease and chronic emphysema. People with chronic neurological conditions, hereditary and degenerative CNS disease, seizure disorders, spinal cord injuries, neuromuscular disorders. Those with immunocompromising conditions, and this one is important. So immunocompromised due to disease or treatment. Asplenia, or splenic dysfunction, HIV infection. So they do not break that down more, I think they leave that up to our judgement as to how immunocompromised we think people are, but certainly it is recommended in people who are immunocompromised. And diabetes and other metabolic disorders. So both type 1 and type 2 diabetes and other chronic metabolic disorders. Renal disease, so those with chronic renal failure. Those with haemoglobinopathies. And children who are on long term aspirin therapy aged six months to 10 years. Because those children are at increased risk of Reye’s syndrome if they get influenza infection. So those are the conditions that they say are recommended to have influenza vaccines.

Sammi: And there were a couple of questions that have come through, Tim. There are two that I will bring up now. They are relevant to the different ones that we have just gone through. Someone had asked why none of them are licenced for use in children under six months of age?

Tim: Yes, that is a good question. I have got to take a slight guess at the answer because I am not absolutely certain, but I think the immune response to the influenza vaccine is actually not efficient at that age. One of the important things is for that very reason, that we cannot immunise those under six months, is immunisation of pregnant women, because they do get, mothers do pass on some immunity to their babies. So it is an important question. The legalities of it are, that if you were to give one accidentally, that is actually off-label because they are not licenced for that. And I think it is that there is not an efficient immune response.

Sammi: And then the other end of the spectrum. This might be one that we field offline, and just double check with New South Wales Health if you do not know the answer. They are asking why the Fluad Quad is only licenced for use in over 65s if it is a stronger vaccine and if people want to get in on the private market, is it possible?

Tim: It is not possible, because it is only licenced for those over 65. So, I do not know if that is because there are safety issues for those younger. It may be that the company decided that is who they wanted to go for the licencing and so that was their application. So it may be a choice of the company. The problem that they are trying to solve there is that the immune response among the elderly, particularly frail and elderly is often less with the standard vaccine and so this is trying to create a better immune response in those who are particularly vulnerable to influenza due to their age. It has an extra ingredient that promotes an immune response in people. So, I think the advantage in those younger is probably less because they mount a sufficient immune response to the vaccine itself, so there is not, you do not get a great deal of extra advantage in those who are younger than 65 with the Fluad. But the bottom line for us is that we, if we are recommending that to anyone else, we are recommending it off label with all the risks associated with that because it is not licenced for people under 65.

Sammi: Great, thanks Tim. Let us keep moving.

Tim: Cool. So the next slide just shows some of the resources. I think you may well have been sent this by New South Wales Health. And it is sort of a whole pack of resources. It is available on that website there, and so some really interesting things on this and the next slide. There is a checklist and time line which helps produce, I think it is back on the previous slide actually Sammi, the checklist and timeline helps in organising practices to plan their clinic’s order of vaccines and then deliver them. I would imagine this timeline was written in a time before the coronavirus pandemic, so that probably makes some of the planning a little bit more flexible than it was before, but that idea of planning in advance is still really useful. The vaccine ordering worksheet is an excel spreadsheet that allows you to calculate the amount of vaccine that you need based on the number of patients at particular ages with particular conditions that you might have. So I had a little play with that this afternoon and that can be quite useful. There is a vaccine decision aid which is the flow chart on the right which takes you through about sort of recommending different vaccines.

On the next page, on the next slide, is the poster which takes you through the different brands in just the same way that we have. There are the stickers for the basket, again so that you are picking the right vaccine for the right patient at the right time, and delivering vaccines funded through the National Immunisation Program to those eligible for that, can delivering your privately funded vaccines to those not eligible for influenza vaccination program.

And just one other thing I will highlight. If you go back one slide please Sammi, is the Immunisation Specialist Service there. That is the website and they have a phone number as well, and they can offer advice and vaccination clinics for particularly difficult scenarios. Those children who may be difficult to immunise, where there are difficulties relating to allergies or you have got some particularly nutty problems you want help with over vaccination, they are a really useful resource as well.

Now that feels like very familiar advice all of a sudden, doesn’t it? This has been around for a little while, but suddenly that all feels very familiar and if we are lucky, because we have all been doing this anyway and our patients have too, if we are lucky, this combined with flu immunisation means that we will not have a particularly bad flu season this year. Fingers crossed, I do not think we need two viruses circulating at high levels.

And so this is the practice checklist essentially taking you through from pre-order vaccines. We all know how important the cold chain measures are in place and those of us who are in accredited practices will definitely have policies and procedures around that. I always think vaccination is a team sport, so making sure that all staff know and are up to date about who requires vaccines right from reception staff welcoming people in through the door, to our practice nurses and our practice managers and ourselves, and if we have registrars and medical students as well, so that we all know we are across what vaccines we have got and who they are for.

Upgrading the practice software is important because they are supposed to be reported up to the Australian Immunisation Register and where that does not happen, that gets reported to the Commonwealth. It gets reported to the State. It gets reported to the Public Health Unit who then go back and ask you in the practice about what was going on.

It is worthwhile vaccinating all the practice staff. And then we are targeting particularly people in the National Immunisation Program, so children six months to five years old, pregnant women particularly, Aboriginal people who are aged over six months, people with chronic conditions that we mentioned earlier and those aged over 65. So those are all the people in the National Immunisation Program.

I will just go through the next couple of slides about vaccine safety and then we will go back to some of the questions. So, they monitor the vaccine safety quite closely and so this is the safety data on children aged three years to five years who received influenza vaccine and it was reported by SMS. And 93.6% of over 14 thousand parents reported no adverse events. So that is a pretty good hit rate. 891 parents and carers reported one or more adverse events. And those commonly reported were fever, pain at the injection site, redness or swelling at the injection site. Some children became tired or irritable. Some complained of headache and some had a change in their sleeping pattern. It is worth remembering that even if the rate of adverse events is small, if we are managing to immunise large numbers of people, the number of people with adverse, minor adverse events, but adverse events nonetheless, may be reasonably high just because we have immunised a lot of people.

And each year we talk about this SmartVax system that helps monitor by SMS people who receive the flu vaccine so that they can text in whether or not they had a reaction to the vaccine and so New South Wales Health uses this to monitor adverse events to vaccines. So you can call that number on your screen to participate in that program should you wish.

Sammi: Before we jump in, we have got a couple of case scenarios that we are going to go through, but there is quite a few questions that have come through. There are a couple of themes Tim, that perhaps we can spend a couple of minutes on before we jump into them. They are around cold chain management, contraindications and optimal time frames for vaccinating pregnant women.

Tim: Yes, okay. So the optimal time for vaccinating pregnant women is now. So if you have your vaccinations in, target your pregnant women. If a woman becomes pregnant and you have flu vaccines, give her a flu vaccine. The current vaccines have an expiry date on them up to February 2021, so actually if you have still got a supply, if someone becomes pregnant late in the year, so late in November, you can actually still immunise them with the flu vaccine this year. I think one of the recommendations I saw from ATAGI was that if a woman has flu vaccine and then becomes pregnant, they do recommend re-immunising her because that is also protective, but of course the second immunisation will not be available on the National Immunisation Program. Mind you, if the first vaccine was private, the second one will be available on the National Immunisation Program. It is important to tackle that question about timing, so the advice leaves quite a bit to our clinical judgement, and I have seen it go both ways, so if we are due for an early flu season like last year, then early vaccination would be really useful in protecting up to the peak. Similarly, if we are due for a prolonged flu season like last year, there may well be benefit in doing a second immunisation, say four or five months after the first. Now that is based, my understanding is that that is based on the sort of knowledge of the length of time that the flu vaccine works for, but there have not been any trials investigating whether that is an appropriate way of going about things. It is a sort of evidence-free zone I think. It is not covered by the National Immunisation Program, so patients would have to pay for a second vaccine. I think it may well be that for some patients who would be particularly vulnerable, like sort of immunocompromised people to a prolonged flu season, then it may well be worth doing a second immunisation if the patient can afford it. But the guidance seems to leave it a bit to our clinical judgement, because it says yes, it may be useful to give a second immunisation but they stopped short of providing a recommendation to actually do that. Related to that is the question of vaccine timing. My feeling is that the most important thing is that it actually gets into people, and so we are giving vaccines now in quite a lot of them just to make sure that people are covered early on. There will not be particularly bad things happen by delaying for a month or six weeks, and that may protect later in the season, but again it is all operating in a bit of uncertainty because we do not know when this flu season is going to start particularly or indeed if it is going to be a bad flu season or not. Hopefully it will not be. So I am afraid I cannot give a definitive answer because all the advice leaves quite a good deal to our clinical judgement about whether we do that or not. And there was a third question mentioned Sammi that has come up quite frequently as well.

Sammi: The cold change management. Contraindications.

Tim: Ah, contraindications. Essentially there are almost none. So previous anaphylaxis to the flu vaccine, that would be a contraindication. People who have an egg allergy, it is worth ascertaining whether it is like a proper, severe anaphylactic allergy to eggs. If it is, then the advice is give the flu vaccine in a service that has the facilities and is familiar with management of anaphylaxis. So that may well be you, but I think for a lot of us, that would be contacting the specialist New South Wales Immunisation Service to seek their advice, and they may well want to give that. Apart from that, there are not really contraindications to flu vaccine. If people are allergic to eggs but it is a more minor allergy, then the recommendation to us is it is safe to give. I would probably be speaking to the New South Wales Immunisation Service just making sure on that advice, because you would not want to have a minor rash turn into a major anaphylactic shock on you. That would be pretty scary. And I guess the only other contraindication is a patient who does not consent to having it. Otherwise it is recommended for pretty much everyone.

Sammi: Great. And for people that are still asking further questions about cold chain management, there is a cold chain management tool kit on the New South Wales Health Immunisation website. So, let us move on to our first case study.

Tim: Yes, so the case studies will be helpful just in thinking about particular patients and what we do, and it will probably help answer some of their questions coming up. So, in this scenario Felicity presents to our practice with her son Shaun, daughter April and her father Ron who lives with them. She is worried about herself and her family, especially with COVID-19 circulating. She has heard that the influenza vaccine may help stop her and her family becoming unwell with COVID-19, and wants to know if they should be vaccinated. So, some details about them. Felicity is aged 38 years of age and has no medical risk factors. Shaun, aged eight years of age. He is on long-term aspirin therapy and he received one dose of flu vaccine last year. April, aged four and a half years and has no medical risk factors. She has not received the flu vaccine before. And Ron, aged 72 has a past history of prostate cancer. So, we are going to stop on that slide and I am going to invite you to type in to the box for Felicity, Shaun, April and Ron, what you want to do for them.

Sammi: And we have already had someone come through and say Felicity not eligible.

Tim: I feel like I should have some hold music while you do this.

Sammi: Lots of people coming through saying Felicity not eligible for the funded vaccine but a private flu vax should be recommended, which is absolutely correct. We have got some ones coming through about Shaun now, that he is eligible for a funded vaccine is what we are seeing come through so far which is also correct. April, two flu shots one month apart. Heaps coming through and it looks like everyone has been paying fantastic attention because everyone is pretty much bang on the money with this coming through. So I might jump onto the next slide Tim, just to confirm what would be recommended for each of those family members.

Tim: Yes, that is brilliant. And it is probably also worth remembering that COVID-19 is going to be a driver of people in, but the influenza vaccine does not protect people against COVID-19. So that is a common misconception out there, that none of you would have thought, but by having the influenza vaccine she can protect herself and her family against influenza and maybe stop them getting a dual infection as well. So as you said, Felicity is not eligible for funded vaccine, but it is still recommended that purchase a private vaccine. Shaun, eligible for funded vaccine because of the risk of Reyes Syndrome because of the aspirin. April, eligible for funded vaccine. She is less than five. Second dose required four weeks later because it is the first week she is receiving it. And Ron is eligible for funded vaccine as he is over 65. So he should receive the Fluad Quad. Lovely, I think you all did very well. Let us move onto the next scenario.

Sammi: Perfect. Just while we are on this one, because it does have COVID-19 mentioned, and just because it has come up a couple of times in the COVID-19 webinars that we have been running, and people are asking about can Tamiflu be used? And there is no efficacy for the use of Tamiflu for the treatment or prevention of COVID-19.

Tim: Yes, that is right. It seems a little controversial in the treatment of flu. So, the case study two. Luciano presents to your practice and wants to know if he can have his annual flu vaccine. He is obese with a BMI of 32. He wants to know if he needs to pay for the vaccine again this year, as he turned 63 last month. He also wants to know if he can have the pneumococcal vaccine as he has heard it will help protect him from pneumonia if he gets COVID-19. You know Luciano’s wife Maria as you have previously treated her, too. You ask Luciano if she is going to come in for her vaccine, but he advises that she cannot have it as she is allergic to latex. You know that she is 61 and has coronary artery disease. So what will you do for Luciano and Maria?

Sammi: And responses coming through. Luciano can have flu vaccine but has to pay. Maria can have the free flu vaccine. Luciano is not eligible, but a private script is recommended. Maria, approved for government-funded vaccine. Yes, so that is great. Perfect. That is the consensus from everyone online to encourage Luciano to receive a private script and that his wife would be funded.

Tim: Yes, and also people are correctly saying that the allergy to latex is not an issue in this case so we can reassure them both that she can have the vaccine. So there we go, confirming on the next slide what you were saying. Luciano is not eligible for the funded vaccine as he does not have medical risk factors that might make him eligible for the funded vaccine and he is not over 65. But we would be recommending the vaccine for him. And also the question that he asked about the pneumococcal vaccine. It protects against pneumonia caused by Streptococcus pneumoniae, but there is no evidence that it provides protection against COVID-19 associated pneumonia. And Maria is eligible for funded vaccine because of her coronary artery disease, and none of the vaccines contain latex, so there is no reason that Maria cannot be vaccinated though you may want to think about using a different pair of gloves if you have latex gloves in the surgery.

Sammi: Wonderful. Let us move onto the final case scenario.

Tim: So this is case three. Arjun comes to your clinic because he wants to get the flu vaccine. He explains that he is concerned about his wife Anika and their three-year-old daughter Sahana as neither of them can have the flu vaccine and he wants to help protect them. You discuss with Arjun why his wife and daughter cannot have the vaccine. Arjun explains that his wife is pregnant and Sahana has never been able to have the vaccine as she has an egg allergy. So Arjun is 28, smokes 15 cigarettes a day and has mild asthma. Anika is 25. She is eight weeks pregnant. Sahana is three and she gets a rash after the consumption of egg. So what do you think for Arjun, Anika and Sahana?

Sammi: Okay, Arjun not eligible, recommend a private script. Anika is highly recommended to receive the vaccine. Arjun not eligible. Anika eligible. Sahana eligible. So yes we have got most of them coming through and we have got comments coming through, explore reason for egg allergy.

Tim: Spoken like a true GP.

Sammi: Perfect, yes. All similar responses coming through saying to ask more questions about the egg allergy, but because it is not an anaphylactic reaction, it should be okay for her. Alrighty, let us move on to the responses slide, just to reconfirm what everybody is already saying in the chat box.

Tim: Thank you very much for being so chatty in the chat box, it is really nice. So Arjun as you said is not eligible for funded vaccine. It is only severe asthma that would classify him and he has mild asthma. Again, recommended but not funded. Anika is eligible and it is very much recommended because she is pregnant. And importantly, the vaccine has been demonstrated to be safe in all stages of pregnancy. And Sahana is under five, so she is eligible for funded vaccine. A rash is a non-anaphylactic allergy and therefore she can safely receive the vaccine, and as I saw some of you are pointing out, it is the first year that she will be receiving the vaccine so she will require a second dose four weeks later. Sorry, I saw a few of you commenting on that as well. So excellent, and it is really good that you are all typing that in so well and have a really good understanding of who is getting the vaccine and who is not.

Now I have got four minutes left, Sammi. Were there any other questions that people wanted answered?

Sammi: Most of them we answered earlier that are relating to learning outcomes, but there is a bit of surprise that mild asthmatics are not eligible for funded vaccines, or the funded flu vaccine I should stipulate. 

Tim: Yes, that is right. On the ATAGI guidance it does say severe asthma. And that would be a classification like in the National Asthma Council Asthma Handbook. Is GBS, I am assuming that is Group B Strep, a contraindication to influenza vaccination? Or does that stand for something else? Guillain-Barré, sorry.

Sammi: Yes.

Tim: I do not think it is, but I might need to check that just to be certain. I am sure there are a lot of people on the webinar who know, but I do not remember seeing it there when I was looking at contraindications.

Ssmmi: We can confirm that in our post-webinar email when we send out the slides. I will put a note in there about that one after we have followed up just to confirm for those people asking about GBS.

Tim: Some good questions there about people who are visitors. Maybe say international. Are they eligible for the flu vaccine? We would have to check with New South Wales Health. I think in previous years they have said that they do not mind it being given to them, but they may be cross with me for saying that if that is not the case, that people might need Medicare cards. But it is State funded, not Federal.

The other important question I just saw, I will just clarify again, reiterate flu vaccine does not offer any protection for COVID-19 but it will help stop people getting a dual infection.

Sammi: There are a couple of questions coming through regarding PPE Tim, and obviously that is not in regards to getting the flu, but because of the close contact and with COVI-19, there are people asking about what PPE precautions would be recommended for them to follow when administering flu vaccinations this season.

Tim: Yes, they encourage you to follow your own practice policies so at the moment you are screening people with temperature and symptoms when they come in and so that would determine to some extent out use of PPE. Immunisation itself is not an aerosol generating procedure, so I would not have thought vaccination itself would be. I would stand to the side rather than in front of the patient, so I think there is sort of some common sense and probably general advice around PPE.

Sammi: Yes, and there is also on the New South Wales Health website for immunisation and PPE so I might include that in our post webinar email as well for the people asking about PPE. I will include that when I circulate the presentation to you all.

Tim: Yes, absolutely. So there is the slide. We are all prepared for the 2020 flu season and when we go back to our practices, we will prepare our staff as well. We are aware of the factors contributing to varying influenza impact in New South Wales in recent years. We have discussed the impact and outcomes of last year’s flu vaccination program, including children under five years of age. We have gone through the formulations of this year’s vaccines and their optimal use in eligible age groups including children and those aged over 65 and we have looked at their flu vaccination tool kit which you can all get online and will I think have copies in your practice to optimise our vaccine supplies and maximise the uptake of influenza vaccine. And so with that, it is time to finish. Thank you very much, everyone. I hope you have got something out of tonight. Have a good flu season, and please do all stay safe and look after each other. These are strange times we are living in. Thank you very much Sammi for fielding the questions and the technology. And I hope everyone has a good evening.

Sammi: That is great. Thanks Tim and thanks to everybody that joined us this evening. We really hope you enjoyed the session and enjoy the rest of your evening.

Other RACGP online events

Originally recorded:

17 March 2020

This webinar focuses on factors contributing to varying influenza impact in NSW in recent years. Additionally we discuss the impact and outcomes of the 2019 influenza vaccine to children under 5 years of age program. We take you through which formulations of the 2020 influenza vaccine are available and their optimal use in eligible age groups, and how to utilise the NSW Health Flu Vaccination Tool Kit to optimise your vaccine supplies and maximise uptake of influenza vaccine.

Self Record

Presenter

Dr Tim Senior
MBBS, FRACGP

Tim Senior works as a GP at an Aboriginal Community Controlled Health Service in South West Sydney, and is involved in teaching medical students and GP registrars, and is active in policy development and advocacy in Aboriginal and Torres Strait Islander Health. He is an award winning writer on General Practice and Public Health, and is a contributing editor and member of Croakey Health Media. He is active on social media, and was named as one of the top 10 health users of Twitter in Australia.

© 2020 The Royal Australian College of General Practitioners (RACGP) ABN 34 000 223 807