Serena
Welcome everyone to tonight's webinar, Live Attenuated Intranasal Influenza Vaccine webinar. My name is Serena, your RACGP representative for this evening. We are joined tonight by presenters Dr Archana Koirala, Professor Nicholas Wood, Dr Sonya Ennis and facilitator Dr Tim Senior. Before we get started, I would like to make an acknowledgement of country. We recognise the traditional custodian of the land and sea on which we live and work and we pay our respects to elders, past, present and emerging. I would also like to acknowledge any Aboriginal and Torres Strait Islander colleagues that have joined us online this evening. I would like to introduce you to the presenters and welcome them, and I will now hand it over to Tim who will go over the learning objectives.
Dr Tim Senior
Thank you very much. Good evening, everyone. I hope you are all keeping well. It is lovely to have many of you online. Feel free to put your questions in, but there is a lot of you there, we may not get to all of them. These are our learning objectives for tonight. I am coming from Dharawal country, and I am sure everyone is coming from different countries across the nation. This is what we hope to get out of the evening, that by the end of this online CPD activity, we should all be able to outline the epidemiology of influenza in New South Wales, including the disease burden in children. We should be able to describe the key features of intranasal influenza vaccines as a needle-free alternative, including their formulation and target populations, both for funded and for private vaccines. We should be able to demonstrate effective communication strategies with patients and caregivers about the benefits and possible side effects of intranasal flu vaccination, and we should be able to apply New South Wales Health guidelines and protocols for the administration storage, and reporting of intranasal flu vaccines in primary care settings. I am going to hand straight over to start us off with to Archana. Thanks very much, Archana.
Dr Archana Koirala
Thank you much. I would also like to acknowledge that I work and live on the lands of the Dharug people and pay my respects to Elders past, present and to any Aboriginal or Torres Strait Islander folk attending the session today. All right, let us get started. I will talk about the epidemiology, clinical presentations and outcome of flu in children. Thinking a little bit about last year's flu vaccine coverage, and what is on the cards for 2026, including the LAIV. All right. This graph you can see showcases the flu cases between 2022 to 2025, and that dark blue line over here is 2025. You can see that it was a wide season, a lot broader than previous years, and higher than the normal rates out of the usual flu period. You can see there is a second peak in the spring into summer season, and this is in New South Wales. This is by influenza type, and dark blue is type A. You can see lots of type A, but a significant amount of type B as well, and initially, the type A was mainly H1N1, but then there was an H3N2 peak, and it is better seen here that H3N2 tail. This was an article looking at influenza notifications over the last couple of years, and you can see 2025 is on the right. That yellow colour is B, and then there is lots of As, and you can see that H3N2 coming up at the end of the year, and it is likely that we have imported that strain from overseas and then it circulated during that period in Australia. All right, this is just a reminder to all of you that children are overrepresented in notifications, and this is the graph for New South Wales and it encompasses July 2024 to January 2026, and you can see the green, grey, red, orange lines are much higher than the blue and the purple lines, really most flu occurs and is circulated by children under the age of five years. When you look at disease burden, you can see in blue are children admitted to hospital who have an underlying medical condition or a comorbidity, and in purple, it is kids without any or have an unknown comorbidity, and you can see that majority of kids that require hospitalisations do not actually have an underlying medical condition. The median age of admission was 5.1 years, and we know that, more children, those aged 16 and younger have been admitted to sentinel hospitals with influenza and RSV or COVID-19. It is a significant virus for this age group, and this is by the PAEDS hospital site. PAEDS is a hospital-based surveillance method, and it looks at CHW, which is the Children's Hospital at Westmead and SCH, and you can see CHW had a very high notification number of flu compared to other hospitals, and that is perhaps reflective of the fact that we are the most populous state. Okay, just a reminder of the clinical issues and to think about why children under five are more vulnerable to the flu. Well, they have an immature immune system, especially the very young. They have got smaller airways that can become inflamed and clogged with mucus more easily. There is an increased likelihood of cerebral irritation and that is actually quite a significant feature, and children with pre-existing medical conditions we know at our highest risk. You can see here the symptoms and complications and a couple of complications are more common in children than in adults such as febrile convulsions, Reves syndrome and also respiratory features such as a otitis media and croup. This graph is a 10-year review surveillance of Australian children, and when you look at what complications they have, you can see that encephalitis is quite significant. Most kids come in with pneumonia, but neurological complications are not insignificant. There are some kids who also have cardiac complications, and we know the younger you are, the more likely you have that cerebral irritation and the encephalitis or encephalopathy. Two thirds of these kids who developed complications were actually healthy prior to admission to hospital. This is just another reminder about flu related encephalitis. You can see these arrows showing increased enhancement of areas in the brain and that is associated with a specific type of flu encephalitis called acute necrotising encephalitis, and you can also see this looking at modified Rankin score that a large proportion of kids, if they do get encephalitis, that they will develop quite marked disability. We have discussed that flu is quite high in terms of notifications in children. It can cause complications and hospitalisations, but when we look at the flu vaccine coverage in children, you can see that it is pretty low. The blue line is actually 2020, and the lines below that, and in particular the red line, is 2025. You can see it is half the rate of 2020, and in 2020, we really had no flu circulating. If you look at New South Wales specifically, you can see that only 25% of kids under five got the vaccine and 13.3% of kids between the age of 5 and 15, and when you compare that to other states, it is lower than the Australian average and other states, and then when we think about vaccine effectiveness, we know that the flu vaccine is not 100% effective. We know that other vaccines are much more effective than the flu, but it still has a significant prevention against hospitalisation, and when you break it down last year, H1N1 had a 51% effectiveness against GP visit compared to Flu B, which was 60%. Terms of hospitalisation, H1N1 was 42%, H3N2 60% and flu B 78%. although it may not have matched it perfectly, it was still a good vaccine and prevented a lot of people from coming into hospital. Now I come to 2026. We have the usual injectable flu vaccines. It is Trivalent, there is no more B-Yamagata circulating, and that has now been removed from the vaccines. You can see that we still have two A, it is H1N1 and an H3N2 and a B strain as well, and then with the cell-based vaccine, it is the same. You can see that again, there is slightly different strains and that is really because of the way that the virus grows in eggs, it has to be slightly different to the viruses that grow in cells because the virus needs to adapt to an egg to grow in that egg, but this is the same in terms of our previous vaccines. Apart from now, we do not have B-Yamagata. With the new kid on the block and what everyone is here to listen about is the LAIV, and that stands for live attenuated influenza vaccine, and the trade name is Flu Mist. It is an intranasal flu vaccine. It has been approved by the TGA for 2 to 17 year olds. It is not approved for any other age group, and in particular in Australia, it is not approved for 18 to 49 years old, whereas overseas it may be. It is a live attenuated virus, so it is not for immunocompromised children. It can be purchased in the private market, but there are state-based programs in New South Wales, Queensland, Western Australia, and South Australia. It has been used extensively overseas, and I will go through some of the data. It is been used since 2003 in the United States and 2013 in the United Kingdom through school-based programs. You deliver it, so it is one spray in each nostril and it does not exacerbate asthma or wheeze. It is also trivalent. You might see previous product information that has it as a quadrivalent, but this year it is also a trivalent, and similarly to the injectable vaccines, it contains two A and one B. It can be co-administered with other inactivated and live vaccines, and we know that children experience similar amounts of stress as measured by the secretions of cortisol whether they are getting one or two shots at the same visit, and hopefully with this, although it might be uncomfortable to inject it into the nose, it is much less painful compared to an intramuscular vaccine.
Now, how does it work? We know it mimics live infection. It is inserted into that nasal mucosa and it stimulates the nasal IgA and that mucosal tissue and it causes a mucosal immunity to occur. What are the benefits of LAIV vaccine? You can see here, this is a table that compares both the live attenuated and the inactivated influenza vaccine, and it is looking at the mechanism of immune protection, and you can see lots of pluses around nasal immunoglobulin A. we know that the LAIV establishes immunity via that attenuated infection, and it has a potential to induce local protection. It has been shown to induce this secretory IgA, and then it causes that mucosal response associated with that HAI titre, and this can persist up to six months. We know, and if you look at again, compared to the inactivated, that there is a lot more pluses around the CD4 T cells and CD8 T cells. It has a greater ability to elicit cellular immunity, and when it compared to IIV, greater activation of that CD4 and CD8 T cells, which is important because it is a viral infection, and we know that T cells are highly important for viral immunity. This is a good take-home slide in terms of, again, comparing the inactivated flu vaccine versus the live attenuated flu vaccine. Both of them are trivalent. One has an inactivated virus, and one has a weakened strain. The IIV is an IM injection, whereas the live attenuated is two sprays, one into each nostril. They are really both as effective as the as each other, and Nick will go through some of the AEFIs associated with LAIV, but most commonly with the injectable form, it is a fever and a headache versus with the LAIV, it is kind of just nasal and throat irritation. The injectable form is registered from age six months and over versus two to less than 18 years or 17 years for the LAIV, and we all remember that the injectable form is funded, the usual funding scheme applied, six months to less than five years and greater than 65 years in adults, and then those between five and 65, if you are Aboriginal or Torres Strait Islander, or you have a specified medical risk condition, and then the LAIV is not funded under the NIP, but in New South Wales, we will fund it between the ages of two and less than five years. If someone goes to WA, it is actually funded between two and less than 12 years of age, so there are differences in jurisdictions and some jurisdictions it is not funded as yet.
My last few slides just show a little bit of data on the effectiveness of an LAIV. You can see this was a pilot study in 2014 and 2015 done by the Public Health England, and when they rolled this vaccine out, mainly through a school program actually, in primary schools, they found that it decreased GP visits for flu-like illness by 94%. It decreased A&E presentations by 74% and it decreased hospital admissions by 93% in primary age children. In addition, it actually reduced GP flu-like illnesses in other age cohorts, in particular adults by 59%. This is in Spain. We know that if there is a vaccine that is more palatable to the community, and we do not have a school-based program, but a lot of the European countries now do, you can see that it can increase coverage, and this is amazing in terms of if you look at the green bars, they are significantly higher than the flu vaccine coverage rates that we have in Australia. Whereas these jurisdictions have much lower measles vaccines cover. It is great that we have an alternate regiment to administer the flu vaccine. You can see this is just some effectiveness data that between the 2013 and 2016 season, it was around 50% against flu-related hospitalisation and 65% against lab-confirmed flu in 2023 and 2024, and these are numbers that are quite similar to the injectable form.
This is my last slide. There are some myths that you might hear that LAIV can revert to wild type flu and cause disease, but there has actually been no reversions has ever been observed despite millions of doses, and reversion would require multiple independent genetic mutations. It is extremely unlikely. Shedding of vaccine virus causes transmission and illness. No, shedding does not really equate to transmission. There has been one asymptomatic transmission that has been documented, but no cases of disease. Live vaccines can cause serious adverse events. Yes, we want to give it to the eligible population, but it is very well tolerated in those age groups and adverse events are usually mild and self-limited, and the last myth is that LAIV is only effective when vaccine strains perfectly match circulating strains. Yes, it is highly effective in that setting, but because it induces mucosal and cellular immunity similar to natural infections, it perhaps provides some superior protection against antigenically drifted strains in children compared with inactivated vaccines. Any questions, please put them in the chat and Tim can address, but now I would like to introduce my colleague, Professor Nick Wood, who will be speaking next.
Professor Nicholas Wood
Great. Thanks very much Arch for the introduction, and I will take over now with discussing some of the issues around the vaccine concerns, with general vaccines and a little bit around the flu vaccine. I will tell you a little bit about the declines in vaccine coverage, some about safety of surveillance systems in Australia, what we know about the safety of the flu vaccines and then some strategies to increase uptake. What we do know is that over the last couple of years since COVID, coverage has slightly fallen and it might not sound too much. This is coverage nationally and up to 2024 and the figures for the year of 2025 will be out very soon, but you can see that it has dipped by 3% points since 2020, and that is at ages of 12 months, 24 and 60 months, and that is a worry. What is probably more of a worry is the timeliness. This is showing you the timeliness for the second dose of the DTP and the first dose of MMR, and what that meant was that by the end of 2024, nearly one in three kids is not receiving the MMR vaccine at the correct time, and that is a worry since we have had measles circulating. This is puzzling to me because these vaccines that we have been using in routine infant program, the Infanrix, the Hexa, the Vaxelis, etc, the pneumococcal, the MMR, the Varicella have not changed really in much in the last decade, and there have been no new safety concerns with any of these vaccines. Why coverage is dipping is probably related in most part to the COVID pandemic, but I think what you can reassure patients and parents is that the vaccines we have been using for more than a decade in the childhood program, there are no new safety concerns. There is nothing hiding, and there are all the myths out there that vaccines are causing overwhelming the immune system, etc. There is not a credible reason to think that. In particular, when you think about the six in one infant combination containing vaccine, the coverage against six diseases in half a mil, and what I say to parents is that that vaccine is accepted very well by the baby's immune system. The immune system is not overwhelmed and the immune system is actually able to deal with the antigen that is given injectable into the leg and pick off polio virus type two antigen and make polio virus to antibody, and we know that from many of the vaccine trials that have been done, so concerns about the vaccines we have been using for more than a decade, I think you can be confident in reassuring people that there is no real issue.
What we do know is that people are reporting these barriers and some of them are logistical, such as not being able to get an appointment, some of the costs associated with vaccines. Then there are more psychological things about not believing that the vaccine will help themselves or their others, and two important things that people report are not believing that vaccines are safe and effective, and Arch has shown you some information about the effectiveness of the injectable flu vaccine, and also what we know from decade or of use of the live attenuated vaccine in the US and the UK that is about 50%, maybe up to 70% effective on an annual basis. I think you can reassure parents when they ask you, is this effective? Well, you can say it has been used for a long time in the US and the UK, and this is how effective it is. In terms of safety, we also know that safety is also reassured and I will show you that in a minute. New South Wales was ahead of the curve and asked NCIRS to survey some parents about the upcoming LAIV program, and this is real world data from real world people who are reporting some of the things they wanted to find out and wanted to support them getting the vaccines, and one of the interesting things that people reported was that because it was never really brought up in my appointment or conversation with the doctor, I just assumed that it probably was not necessary, and some other parents were saying, I do not really go to the doctor just to get the vaccine, but if it was in the flu season and the doctor recommended it, yeah, I would get it. That is the guess to the idea of promoting vaccine importance and reminding people when they turn up in the clinic about the flu vaccine, particularly when it becomes available, and giving a clear recommendation to vaccinate. When asked how effective are vaccines, the flu vaccines, I think you can use the information that Arch has shown you to answer that one, and then when asked how safe are the flu vaccines, this is some of the ways you can answer. What I often say to parents is that we have a really strong and robust safety surveillance system in Australia, and we do that in several ways. The first way is the passive or spontaneous reporting system, which is managed by the TGA, and you can say to parents that, I, as a provider, if I am thinking there may have been an adverse event from a vaccine, I am reporting it through to the state health department and then onto the TGA, and through our works, working with the TGA over many years, they look at this data on a daily basis. That is one system. The other system is an active system, which is called AusVax Safety. Many of you may be participating in this through your clinics and I will show you bit of the data about that one, and then we also have a clinical side with the specialists, some support services, and these exist in different states and territories. You as a provider are encouraged to report adverse events, and as we start to roll out the LAIV vaccine to that age group in New South Wales, it will be important that if you think there is an adverse event that you report it through to the system using the national reporting form and information on the New South Wales website as shown there. In terms of the active safety surveillance system, as I mentioned, some of your clinics may be involved in participating in this. Why I bring this up is that you will be able to very shortly after the program starts, be able to show parents in near real time how the LAIV vaccine is performing. One potential tool you may have is when they say how safe it is, you can log onto this website, and you can choose the age group. Sometimes what we do in the clinic is we actually show this screen to the parents to say, look, we have been monitoring this vaccine since it started to roll out, and here are survey results from several thousand parents, and this is how we know that this is an example of the 2025 vaccine was performing, and these are some of the common side effects that you might expect. This will become available in 2026 and as it has been for the last five years or so for you to use in your clinics to show parents how the LAIV vaccine is performing in near real time. Some of the common side effects of the LAIV, Arch mentioned them, include a runny nose. Occasionally they might get wheezing, but that is not that common. Headache and low-grade fever, similar to the inactivated vaccine, and sometimes some vomiting and muscle aches. There is an ATAGI statement that will be coming out soon with additional advice on the flu vaccine and its use. In terms of communicating with parents, one of the additional resources that you may have seen, if not, you could find this very useful, is the SKAI website. SKAI stands for Sharing Knowledge About Immunisation. There are lots and lots of information on that website. There is a section there for the public, but there is also a section for providers, and you can see there the different resources across the different age groups, and there is now some different languages available in Arabic, Chinese, English, and Vietnamese, and more coming. There is also an adolescent web page being added and a SKAI First Nations page, and there is lots of information on that website also for flu.
When faced with the parents who are declining or hesitant about getting a vaccine, this is some of the approach that we use in our clinic. We try and resist what we call the writing reflex, and what we try and say is if they say something that you do not agree with, we do not really want to just jump on that and say, well, no, that is wrong. What we prefer to do is to gather all of their questions up and then offer to share knowledge about the immunisation and explain to people why I recommend vaccination, and what I often do is, might sound like a slightly strange thing to do, is often use what I call the tetanus hook, and what I say to parents who are worried about vaccines, is that yes, you may live life as a hermit and not see anyone else in the world and therefore not be exposed to communicable diseases, but you can still be exposed to tetanus because tetanus is not a person to person transmission, and often you can twig their minds by saying, once the child is mobile and starts to run the risk of getting injured, and having exposed to rusty nails and that sort of thing that you really want them to be protected against tetanus, And so, often that can be a little bit of a trigger for parents to say, yes, that is right. He is pretty mobile and he does run the risk of cutting or injuring himself, and I do not want to have to suddenly charge around and find tetanus immunoglobulin, etc. Sometimes that might be enough just to sway them to get one vaccine in and we do not really want to split up the DTP. Often our approach in the clinic is that we can get at least one vaccine in and it goes well, then we are away and running. Tetanus is one I often start with if I think it might work. The other one I often say to parents, a couple of the diseases I am particularly worried about are meningococcal and pneumococcal disease. I often explain to them about the severity of those two diseases, and the good thing about those is that they are very low reactogenic vaccines, so you can build confidence by giving one of those and the parents having a good experience and then away you go. Important to remember that you really as a clinician are a very strong source of information for parents and this can be backed up by lots of information with fact sheets which are available on the SKAI website here. This goes into lots of detail about the diseases, how the vaccines work and the safety and effectiveness of them. You, as a clinician, are a trusted source of information. What I would recommend that you can trial different approaches with your own style and keeping the door open at the end of the conversation for people to come back. There are specialist immunisation services around the country. These are usually staffed by paediatricians, infectious diseases specialists or allergy and immunology specialists. The one in New South Wales is the New South Wales Immunisation Specialist Service or NSWIS. We have a children's clinic attached to that at both Randwick Children's Hospital and Children's at Westmead. We can see parents and their child in person or if not, we can arrange to see them via telehealth. The types of kids that we like to see are those that have had a previous adverse event. Those who have got complex medical conditions, those that might be difficult to vaccinate for a range of reasons, whether that be severe anxiety, needle phobia, or because of disability and it is a safety issue with trying to give a vaccine. We do also see families with vaccine concerns or hesitancy. We have a clinic in Sydney with remote telehealth opportunity. There are also similar clinics that exist in each of the states around the country. If we do get unusual severe reactions, then these cases can be taken to a national clinical discussion forum, which we host and organise, and that can be useful to give some complex adverse events advice and peer support. There is an email which we can share with you that you can email us to ask questions online about that. There will be lots of information coming out in the next little while about LAIV and the flu statement. NCIRS will have updated data which we can provide information on how to access that, and you will be able to get some of the latest information. I think that might be it from me and I will hand over to Sonia. There is the website for NCIRS that you can have a look at. I will hand over to Sonia.
Dr Sonya Ennis
Thanks very much, Nick. Hi, everyone. Lovely to be talking to you tonight regarding this exciting program that we are about to roll out. As I am sure you have gathered, New South Wales Health will roll out a state funded programme for children aged 2 to under 5 this year. Not every jurisdiction in Australia is funding this program. As you are aware, flu vaccines are already funded under the National Immunisation Program, but some jurisdictions have been able to roll out a state funded program in an effort to try and improve vaccine uptake in young children, which has been very low even despite being funded under the national program. The other jurisdictions that are funding the program are Queensland, South Australia and WA as well as ourselves. The Australian Technical Advisory Group on Immunisation is supportive of strategies to improve vaccination coverage through the LAIV. As you know, flu vaccine has been funded under the NIP for many years but uptake still remains very low. This is an effort by our government to try and improve uptake in young children. The pros of this program, it is a rapid needle-free vaccination and it is ideal for young children. One of the main cons about the vaccine is that it requires careful storage due to the short shelf life. It is stored at 2 to 8 degrees but we will receive it into the State Vaccine Centre batch thawed. Once it is thawed, it has a shelf life of around either 13 to 15 weeks depending on the batch that we receive. We will make sure we have clear information about the expiry date of the vaccine when you receive it.
There have been some questions on the chat whether it will be available privately. AstraZeneca have advised yes, they will make a certain number of doses available. It has been registered for people up to 17 years of age, but we do not know if or when AstraZeneca will submit an application to the Pharmaceutical Benefits Advisory Committee for inclusion of the vaccine on the NIP, hence, only having four jurisdictions this year rolling out a state funded program. It will be a targeted rollout of a program to the children in 2 to under 5 years of age. I see that in the chat some of you have already asked what about older children. I am afraid due to the supply that we were able to purchase, it has only been made available to children 2 to under 5 years of age, which mirrors the same cohort that is recommended under the National Immunisation Program. It will be a time limited programme. I have mentioned the short life of the vaccine 15 weeks post-thaw, but it is stored at 2 to 8 degrees and you will receive it thawed. It will be available from early April and that is also depending on when it will be approved by the TGA and delivery into the State Vaccine Centre warehouse. For this program though, due to the limited supply that we have, we have had to do a vaccine allocation process rather than providers openly ordering the vaccine. The reason for that is, is we want to ensure access in areas where there is high density of young children. What we have done to inform that distribution is used data for children at 18 months and 4 years of age, also overlaying by Aboriginal children where they would receive Bexsero vaccine. We have given extra amounts to those areas where we have higher numbers of young families residing. We did send out a pre-allocation advice. Please check your emails. It was sent out last week for you to confirm your pre-allocation. If you do not confirm your pre-allocation, then you will not receive your vaccine. There will be no way to order this vaccine except through the pre-allocation. Please check your inbox for the advice that was sent out last week. The rollout will be supported by clinician and consumer resources. Our focus is to ensure equitable vaccine distribution. We will allocate the vaccine to GPs, Aboriginal Medical Services, some community health centres or our community health services and also children's hospitals. Pharmacists will be involved in the program. However, there will be a different logistics for that program. A parent can still attend a community pharmacy and have their child vaccinated there, but there will be different logistical processes from our end of how that will work.
As Nick has mentioned, there will be information made available. We have been actually meeting with Queensland, Western Australia and South Australia around a program rollout to make sure that we have a consistent messaging across the four jurisdictions. We do acknowledge that there will be cross border issues as well with children residing in border areas. That happens when you have a state funded program and some jurisdictions and not through the National Immunisation Program. We will have community-facing resources. They are being currently finalised at the moment. Parent and carer factsheets and a web page. AstraZeneca have prepared a clinician video, which will be very helpful and we will make sure that is released in time as well. We are also having preparations that are under way for 2026 Winter Respiratory Campaign, which will promote influenza vaccine to children under 5. We are currently working with the other three jurisdictions to align our messaging. There were questions around whether children in their first year will need two doses. That is a very pertinent piece of information that will be provided soon. We are waiting for the ATAGI annual influenza statement to be released. We are hoping it will be released this week. As previously mentioned, the vaccine will be available between April and June, or it could finish earlier until stocks run out. Remembering though that there still is the injectable vaccine if stock is depleted due to high demand. We have forecast the number of doses that we need for a good uptake in children under 5. However, demand may exceed this, so there will still be the injectable vaccine as well and other resources made available. I think that is really all that I had for my slides. Thanks very much, everyone.
Dr Tim Senior
Excellent. Thank you very much, everyone. That was a really good scoot through. We have had loads of questions come through the Q&A chat. Thank you very much for all your questions, all really important. Thank you for the answers. I am just going to highlight some of the questions that we have had through that I think is worth clarifying. Feel free to keep sending through questions. We do have about 15 minutes. Feel free to send through your questions as well. Sonya, I will throw back to you straight away. We have got some queries about the pre-allocation process and whether people will be able to reorder once those 40, is there clarity around the 40 doses? Is that 40 doses like the pair for each nostril and will people be able to order when they have finished that, they will be able to order more?
Dr Sonya Ennis
Unfortunately, there will not be any more stock. I mentioned before that we have a limited supply. We have allocated it across New South Wales. We have used the data to do the pre-allocation to where young families are residing. Every provider will have been given an allocation, some more than others. If you are a super GP practice with many more GPs, you will receive more than a single GP practice versus a children's hospital. We have a very small buffer supply, but our chief health officer has made it very clear that she wants to make sure that we are reaching areas where there are young families residing to improve uptake.
Dr Tim Senior
Thank you very much. We have had quite a few people just clarifying that issue with intermuscular flu vaccinations. Will children having their first one need a second one, the first time they receive it? We have had a few people asking if that is the case for the LAIV. I have seen the answer come through, but if you just want to state the answers that everyone is really clear about what we know and do not know about that so far.
Dr Sonya Ennis
We are waiting for the advice to come through from the Australian Technical Advisory Group on Immunisation. They met last week and we understand that the annual influenza advice will be coming out as well as the influenza chapter in the handbook will be updated, and when that is released, then we will finalise all of our resources. The information will be made available well in advance of the program coming out.
Dr Tim Senior
Watch this space everyone. That is going to be updated any minute now. We have had some good questions, which I think will be common questions around children generally being snotty and having things up their nose and how much of a problem that is going to be in an internasal vaccination. Archana, maybe that is one for you.
Dr Archana Koirala
Kids are snotty, that is fair, and they sneeze and we also know that intranasal vaccine can sometimes be an irritant into the nose and so it will most likely cause a sneeze. We know that it is absorbable. You just give a dose and if it runs down or if it sneezes, we do not repeat it.
Dr Tim Senior
Thank you. That is really helpful. I think for clarity as well, we put the contraindications in the comments as well so that people can see that when it was on the slide, but just for clarity, it is a live vaccine, children with immunocompromise cannot have it. What sort of conditions and medications comprise immunocompromise that would be a contraindication to LAIV? Anything that would immunosuppress you. The main medications that most children can be on is prolonged steroids. We do not want to give kids immunosuppressive steroid doses, and anything that is immunosuppressive like chemotherapy. There are lots of monoclonal antibodies that are also now used in children with autoimmune conditions like Crohn's disease, arthritis, things like that, monoclonal antibodies, rituximab, infliximab, anything that would lower your immune system, please do not give LAIV, but the most common one is steroids.
Professor Nicholas Wood
Just to add, Tim and Archie, there will be more detail within the ATAGI statement when it comes out on that sort of thing. The other important part is, it was a good question about the use of this vaccine when there is a family member who is immunocompromised, and although the virus can be shed, as Arch said, it is an attenuated virus, and it is not likely to cause any significant issues in any immunocompromised family, host or contact. We are happy with that part of the puzzle.
Dr Archana Koirala
Also, something else that came up was the egg allergic individual. We know with the injectable vaccine that vaccines are grown in eggs, but that we can give it safely even in egg anaphylactic individuals. Again, I just wanted to say, watch the space, as the audience has rightly flagged that it is grown in eggs and it may contain trace amounts of ovalbumin, but globally there have been different guidances on egg allergic individuals and most guidances have permitted that. We will just have to wait and see what ATAGI says.
Dr Tim Senior
Thank you. We did have a question as well about allergies and whether the just been approved, Neffy, the intranasal adrenaline for anaphylaxis is able to be used if there is anaphylaxis to the LAIV. I know the ageing overlap will only be those who are 4 years old to under 5 because that is where Neffy comes in and the ASCIA are updating their anaphylaxis guidelines at the moment so that may be another watch this space. Another question that was interesting is about people having flu symptoms after the vaccine. We have had one comment that lab PCR tests will not be able to distinguish from the LAIV and infection in the event that a child develops influenza symptoms within 14 days of LAIV vaccination. Within 14 days, that could be false positive flu PCR test. Again, that is worth knowing. Just having a look at some of the other questions.
Professor Nicholas Wood
That is similar, Tim, to being able to detect the rotavirus in the stools after the oral rotavirus vaccine, not unusual to have that sort of detection.
Dr Tim Senior
Absolutely. The issue that many of us might well have is just about communication about the expected side effects where children have a runny nose afterwards and people say the vaccine did not work, they had it and then straight away got flu. Actually it is not, it is just a runny nose after without the flu.
Professor Nicholas Wood
You might find that similar to the injectable vaccine that most times the fever we see in the first 48 hours. If you see a fever a week later, then that is nothing to do with the vaccine. Similarly, if you see a cough and runny nose a week later, that will not be the vaccine. It is normally in the first 48 hours that you might see particularly the fever, which is in a systemic response to the antigen. The body is dealing with the antigen, creating an inflammatory response, making, as Arch said, the mucosal antibody and the systemic antibody, and that is all. Once parents are expecting that or have been forewarned about it, then they will think, well, that is the vaccine working.
Dr Tim Senior
Absolutely. Being able to advise people about expected side effects in the time course of that is actually really valuable in promoting future vaccine uptake. Interesting question about the length of protection from the vaccine. We saw a really late flu outbreak late last year. Those stats were backed up by what I was seeing clinically, definitely. If children have the LAIV funded by New South Wales Health, will they be eligible for a NIP flu vaccine later on in the year?
Dr Sonya Ennis
Do you mean if they require a second dose, Tim, depending on their target advice?
Dr Tim Senior
GPs have always wondered about having a second dose that has never been available on the NIP, despite the protection. I do not know whether it is recommended, but actually it might end up being available because they have not had a vaccine on the NIP.
Dr Sonya Ennis
The state funded vaccine is funded by New South Wales Health. They would technically still be eligible for an NIP vaccine because if they have an LAIV, then that has been state funded.
Dr Tim Senior
One vaccine is wonderful, everyone. The important question here about non-Medicare card holders, will they be eligible for the LAIV?
Dr Sonya Ennis
We have forecast doses based on our cohort of children under 5 years of age. The population of the children's cohort has been used for that and a state-funded vaccine, we do not differentiate between Medicare versus non-Medicare, if we could use the RSV program of nirsevimab as an example.
Dr Tim Senior
Excellent. Thank you very much. There is an important question about the software availability and uploading to AIR. I assume that AIR will be reporting the LAIV in the same way that would be reporting other vaccines to the immunisation register.
Dr Sonya Ennis
As they understand that the AIR has been or will be in the process of being updated by Services Australia. With regard to the GP practice software, I would have to probably take that question on notice. I think it is a local issue and it would be dependent on the practice software. I am sorry, I am not familiar with the practice software.
Dr Tim Senior
It has been an issue with a particular software, I gather. It is not one I use regularly, but some uploading to AIR, which is a bigger problem just the LAIV because all our vaccinations are supposed to be reported to the immunisation register now. Just looking through the other questions as well. Questions around pre-allocation. We have got so many people online. It is fantastic. We have had so many really excellent questions. The shelf life is shorter for the LAIV. Just reiterate this, the storage for the vaccine.
Dr Sonya Ennis
It is still 2 to 8 degrees. We will receive it. It is stored frozen and once it is thawed it has, depending on the batches that come into the State Vaccine Centre, the first batch will be 13 weeks shelf life and the second batch that will come into the State Vaccine Centre will be 15 weeks, but we will make sure that is very clear. That is why it will be a time limited program, but providers will receive it thawed to be stored at 2 to 8 degrees. I would imagine that it will be used up pretty quickly. I cannot imagine there would been lots of this vaccine leftover and going past this expiry date. That is why it is a time limited program as well.
Dr Tim Senior
Would it be the same requirements if people are doing outreach vaccination clinics? I know some practices do that. The same procedures that they are familiar with for their vaccines.
Dr Sonya Ennis
Exactly the same. You have 2 to 8 degrees.
Professor Nicholas Wood
Good question, Tim, about what is our target coverage for this? Sonya will probably say, oh, she does not want to have any left in the factory by the time she has bought them all. Arch showed you the coverage at 20-25% and that has been stable for the last four years. If we could get to 40% and above, that would be fantastic. That would be a good achievement. Remember the LAIV is in the 2 to under 5, but importantly, the primary school age kids, 5 to 12, they are also important part of the transmission of this. We need to get the coverage up in those guys as well. Although they might not get as sick as the under 5. If we can increase the coverage, reduce the transmission, we will do better in getting less kids going to hospital.
Dr Tim Senior
Absolutely. It is really interesting to see that data from the UK about preventing GP presentations in adults as well. Presumably, I expect children bringing home less flu when they are immunised. That is really good. I would imagine that the overall vaccination coverage is what is important and that having LAIV available should help us to increase the vaccination coverage in total. We still have the traditional vaccination methods. That is really important for over 5s, but it is still an option for under 5s as well where parents watching them may be uncomfortable with an intranasal because that can be hard to give to children too. We have had a few questions coming through about the cost of the LAIV on the private market. We do not know yet. I did a quick hunt on the Chemist Warehouse website as well. It is not available there. We are not clear yet on what the cost will be. We have hit 828, so we have a couple of minutes left to go. Do any of you have any final comments to the questions that you have seen come through or want to reiterate any points from the webinar?
Dr Archana Koirala
I can go first. I just wanted to thank everyone for being on this webinar. Again, because the ATAGI Guidance has not been confirmed and published, I just implore you that this was a taster and this is just an introduction to thinking about what has happened in the previous years and then this new vaccine that will be available for us, but really to go through that ATAGI Guidance in detail, in particular around the questions that you have brought up in terms of a child getting the flu vaccine the first time, one versus two doses, things like that will be a lot clearer once the guidance is out. One last thing, and I think Nick reiterated it, but it is just that we know time and time again, even in this state where coverage is declining, that a trusted health professional is the best source of information. You are it, and GPs, immunisation nurses and now pharmacies are the workhorse of immunisation. Thank you.
Dr Tim Senior
Any comments, Nick?
Professor Nicholas Wood
No, nothing extra really. Arch summed it up very nicely. More information coming to answer more explicitly some of your important questions but you guys are the engine room to help drive up the coverage, to reverse the coverage in all vaccines which is slightly declining and to bump up the flu coverage as well.
Dr Tim Senior
Thank you. Sonya, do not want to leave you out.
Dr Sonya Ennis
Just to reiterate that we have had a certain amount of LAIV vaccine made available. I understand that some practices may not be terribly happy with their allocation, but the allocation has been based on where we see most young families residing and that will also be available through community pharmacies. If you run out, there may still be available doses through a community pharmacy if parents have not attended there. It will be available across New South Wales, but Just to reiterate, we only have a certain amount of vaccines for this program that have been purchased by the New South Wales government.
Dr Tim Senior
Thank you very much. It is exciting to be involved in such a new thing. Watch this space, everyone. I will hand back to Serena.
Serena
I would to extend my thanks to Archana, Nick, Sonya and Tim for presenting, and also to everyone who joined us online. We do hope you enjoy the session and you also enjoy the rest of your evening. That brings us to the end of the session. Thank you and good night, everyone.
Dr Tim Senior
Thank you, good night everyone.