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NSW Influenza Update 2021

Influenza Vaccination Update 2021
Bethany: Good evening everyone and welcome to this evening’s influenza vaccination update of 2021. My name is Beth. I am your host this evening, and we are joined tonight by our presenter, Dr Tim Senior. So before we get started, I would just 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, present and emerging.
I would now like to introduce our presenter, Dr Tim Senior. 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 senior lecturer in General Practice and Indigenous Health and UWS and an RACGP medical educator. So welcome Tim, and I will now pass you over to Tim to take us through the learning outcomes.
Tim: Thank you very much, Bethany. And I would also like to thank Michelle Fernandez and Louise Baker who have helped put the slides together tonight so that we are giving you accurate information for this year. These are the learning outcomes for tonight, so this is educational speak for what we should get out of tonight. Someone is asking me that they cannot see me. It is much better that way if you cannot actually see me and you get to concentrate on the slides. I have my end-of-day hair look on. By the end of this online activity, we should all be able to prepare for the 2021 influenza season, be aware of factors contributing to varying influenza impact in recent years, discuss the impact and outcomes of the 2020 influenza vaccine program including children under five years of age. Recount the formulations of the 2021 influenza vaccine and their optimal use in eligible age groups including children under five and those aged 65 and over. And utilise the flu vaccination to optimise our flu vaccine supplies and maximise uptake of influenza vaccine.
So I should have control of the screen. I am looking for my buttons. Thank you, that is the next slide. This shows the epidemiology from over the last several years, so you can see going from 2011 through to December last year. And a few points to note, the most important thing on here is how last year’s flu season was pretty light on compared to other recent years. There were seven thousand, one hundred and 69 notifications for flu in 2020 and those were predominantly influenza A, H1N1. You can see the year before that, 2019, we had 116 thousand plus flu notifications, and again that was predominantly influenza A, H1N1. And it has varied year to year, but last year was very much light on for influenza and I think we all recognise the reasons for that.
And we move onto the next slide. This shows us, because last year’s numbers were relatively low, this combines the figures for 2019 and 2020 into one figure. Looking on the left at influenza A and on the right at influenza B, and those bar charts are split up by age groups, and the colours are male and female. So you can see 2019, obviously the bars are much higher than 2020, the paler bars next to them. But you can see, influenza A, there was a large number of children affected with that, particularly naught to four years, where there is a big rate, and there is another peak at 85 plus years. And then for influenza B, again we see quite a large peak for children, for those ages particularly five to nine years, and those give us guidance about who to target particularly for influenza with our vaccines this year.
There we go. Next slide. This slide shows us the epidemiology comparing last year to the previous five years. So you will see in both charts, those shaded blue areas. That is the range, the maximums and minimums, and then the average is the blue line. And then the red line shows the flu rates for 2020. And so, we can see on the left-hand slide, a lot more testing done for influenza, and this is actually the sentinel laboratory surveillance, but last year, lots more testing done for influenza. And again, we know the reasons for that. And the testing was actually higher than the maximum range for the previous five years. And so there was a lot of COVID-19 testing done as well, and alongside that often influenza testing was done, too. The chart on the right shows the proportion of tests positive for influenza but to last year. And so again, compared to previous years, the positive rate for influenza was very low, and again we all know the reasons for that.
And the next slide shows us similar data from FluTracking, which is symptoms that people had of fever and cough, influenza-type illness. And so, again the range for the previous five years shown in the shaded blue area and the average for the previous five years was much higher than through 2020 again. And the ED surveillance data, there are no figures for that there because the figures for those were very difficult to compare because COVID-19 just affected the presentation and the testing for people with influenza-like illness symptoms that suggested they might have had influenza. And so, again the next slide. Those low numbers mean that for positive influenza cases, positive test results, means it has actually been very difficult to determine the potential severity during the flu season. And we know that the Influenza Complications Alert Network reported seven admissions to hospital between April and October last year for influenza. Six of those were in a general ward, and one in intensive care for New South Wales. So again, those figures are much lower than we would expect for normal flu season.
I think I have gone backwards. There we go. So in summary, for the flu season last year, the 2020 influenza season saw very low activity dominated by influenza A virus, but the lowest number of cases since 2011. The influenza season started early last year and peaked in the week ending 2nd February. And again, I think we can probably put that down to the time when COVID-19 restrictions were put in place and we all started doing our social distancing. Given the low case numbers of laboratory-confirmed notifications for influenza, it is actually very difficult to say how effective the vaccine was last year, just because of low numbers. In 2020, there were 14 institutional outbreaks reported, nine were in aged care facilities. All of those were due to influenza A and there were two deaths in aged care facility residents in 2020.
So the next slide. The impact in the under-fives again was difficult to evaluate because the numbers were lower. They were in the range typically within the range of six to 40 per 10 thousand children aged under five, and that is particularly higher in those aged under three. Most years, there are deaths reported from influenza in children, mainly in the under five-year-old age group, but last year, fortunately there were no reported deaths in 2020. And it is important for us to remember that previous studies have shown, particularly in the US have shown that children with known high-risk medical conditions are not the only children who can die from influenza. And certainly that actually only accounts for half of all deaths. Half are in children who would not be identified as being at risk. So, it does mean that for influenza, children are going to be one of our priority populations.
I am just having a quick look at the question box. Will planning and administration of flu vaccine and COVID vaccine be covered? A little bit. And we may take some questions on that later, but we will be concentrating on flu rather than COVID. But obviously this year things are going to be coincided.
This is the vaccine uptake, in ages greater than or equal to six months by age group, with at least one dose of influenza vaccine recorded on the Australian Immunisation Register for last year. And the reason that is at least one dose is that children who are getting their first dose, get two doses. Some people may well have been given two doses as well to cover for a later flu season. So, on the left is Aboriginal and Torres Strait Islander people in New South Wales. And so we can see the rate of influenza vaccine was greatest in those over 65 years who are clearly one of the target populations, and reached 78.1% and the next age bracket under, 56.3%, and again children six months to five years, 36% of those and slightly lower for adults and children older than five. And then the graph on the right is for all people in New South Wales. And again, the target population over 65, 60% of those were vaccinated and then the next one below that is children six months to five years. That is two of our priority populations. And again, those figures are not bad. We are seeing sort of priority populations it is interesting to compare the sort of vaccination rates we would need for COVID and getting everyone tested, and obviously that is going to impact our logistics this year, maybe favourably, maybe not favourably, but those are the rates that we have achieved last year.
We will move onto the next slide now. This is the, yes, someone is asking a really important question. Was there not a problem with pharmacy administered flu vaccine not being reported or recorded? That has been a problem as I understand it with some of the pharmacists administering flu vaccine, and that would mean that flu vaccines were under-reported. So those ones will be outside the National Immunisation Program, so would be often outside the priority population, being privately delivered. But that would under-report on these as well. Now interestingly, certainly for COVID vaccination early on, reporting to the Australian Immunisation Register will be mandatory and that is coming in I think in the middle of 2020, Michelle or Louise can help me out with that.
Michelle: It is actually from, when is it, Louise, 1st of?
Louise: From yesterday.
Michelle: From yesterday, that is it.
Tim: From yesterday.
Michelle: I was going to say, 1st March, so it is already mandatory for influenza and from the 1st July, all other MIP vaccines.
Tim: Excellent, thank you, that is really helpful. So that should not be a problem anymore with pharmacists. They should be reporting to the Australian Immunisation Register. And it will be interesting to see if we do get an uptick in those figures next year. We should all watch out for that.
This is the advice from the Chief Medical Officer about flu vaccination this year, and that link will allow you to read that advice in full for yourself. And reiterating, annual vaccination is the most important measure to prevent influenza and its complications. Annual influenza vaccination is recommended for all persons greater than six months of age, all Aboriginal people six months and older are eligible for flu vaccine on the National Immunisation Program, and optimal protection against influenza occurs during the first three to four months following vaccination. So again, that reiterates pretty much what we already know about flu vaccine.
And if we move on to the next slide, this is the immunisation schedule from New South Wales and I find this very helpful with all my patients. Sorry, I have just, can you move me back because I have just accidentally clicked on the slide and moved it on. There we go. And at the bottom there is the information about influenza vaccines and who is eligible for that on the funded National Immunisation Program and the New South Wales Immunisation Program. And I think that either has been sent to all practices or will be sent to all practices. COVID does not appear on that yet, but I am sure it will do as that comes out.
So the changes to the vaccine this year. The WHO, each year they get together to decide what should be in the vaccine for the Southern Hemisphere, for  us, and so this was held again for obvious reasons, as an online event on 16th September to 2nd October last year, and the WHO announced its recommendations. And there are two changes from the 2020 Southern Hemisphere influenza vaccines and three changes from the 2019-20 Northern Hemisphere influenza vaccines.
And so for those who like to know the precise composition of the virus strains, that is, so this here, there are only quadrivalent influenza vaccines available. Some of you may remember a few years ago there were some trivalent ones. But only quadrivalents, they have got four flu strains in. It covers two A strains and two B strains of influenza, and so the list of that. The two A strains are the Victorian/Hong Kong strain, one of them an H1N1 and one of them an H3N2. Those are both changed from last year. The two B strains are Washington and Phuket influenza strain, unchanged from 2020. So that is what will be in the quadrivalent vaccines. And there are four available in the National Immunisation Government programs in 2021, and we will go through these in some detail.
All the vaccines have a 0.5 millilitre dose and that is the standard dose for everyone. So Vaxigrip Tetra and Fluarix Tetra will be eligible for all children aged six months to less than five years, and eligible people on the National Immunisation Program from five years to 64 years of age. Afluria Quad is just for people aged five to 64, so not for young children, and Fluad Quad is the quadrivalent vaccine with the adjuvant for all people aged 65 years and over.
So we will go through the different boxes for these, and as I understand it, you will be sent this graphic to your practices so you can put it by your vaccine fridges and have it easy to refer to. So, for those under six months, flu vaccine is not recommended. For those six months to five years, you can use Vaxigrip Tetra or Fluarix Tetra. For those five years to 64 years of age, you can use Vaxigrip Tetra, Fluarix Tetra or Afluria Quad. And for those 65 years and over, it is recommended to use Fluad Quad, but the others are actually all registered for people that age, but do not produce as strong an immune response.
So I think that hopefully makes it reasonably clear. And so if we go through each of them, this is the Fluarix Tetra. This is licenced for use from six months of age and this is funded for all children, six months to five years, all Aboriginal and Torres Strait Islander people, five years to 64 years, all pregnant women, all persons with medical risk factors, five years to 64 years, and there is a list of medical risk factors on the immunisation handbook website. And importantly for children aged six months to nine years, if they are having their first flu vaccine, they get two doses one month apart.
The next one is Vaxigrip Tetra, licenced for use from six months of age again, and like the previous one, universally funded from six months to less than five years. Funded for all Aboriginal and Torres Strait Islander people five years to 64 years, all pregnant women, and all people with medical risk factors, five years to 64 years of age. And it is the same again for children six months to nine years, if it is their first dose of flu vaccine, then they get two doses one month apart.
Next up is Afluria Quad. This importantly, this is licenced for use in individuals five years and over, so not children six months to five years, and you can see on the box a little pink circle that says five years or older only. And that is important. I think that is going to be one of the potential areas for error that we make, is giving this to the wrong people. So the way we sort our fridges out and have signs will be important for this. So this is funded under the National Immunisation Program for all Aboriginal and Torres Strait Islander people five years to 64 years, all pregnant women, all adults with a medical risk factor and children five years, up to 64 years. And same applies to five to nine years aged children, if it is their first influenza vaccine, they get a second one after that. Do not use that for children less than five.
And finally, Fluad Quad. For adults 65 years and over only. That is who it is licenced for. And it is funded under the National Immunisation Program for all persons aged 65 years and over. And the important thing about this is in elderly people who do not mount a strong immune response to the flu vaccine, the adjuvant actually increases that immune response, including in frail elderly and it appears from research that this gives a 25% reduction in influenza infection and hospitalisation compared to the standard influenza vaccines, and that is why this one is the recommended one for people older, for older Australians. The other vaccines are also licenced for use in this age group and again, last year I think there were supply problems for the Fluad Quad in the end, and so the other vaccines are eligible for use in this age, but are not as effective. The appearance is a milky white suspension, so that is important. That is the normal appearance of this vaccine, so it looks different to the others because of that adjuvant.
We have got a question come through specifically about this vaccine. Can you tell us about the adjuvant and its impact on risk of side effects? I think that is a really good question. Now my understanding of that, and Michelle and Louise, you may be able to help or take this on notice, my understanding is that there are not any particular long term side effects from the adjuvant. There is I suppose a risk of slightly more marked local reactions or fevers as people mount an immune response to it, as that is what it is designed to do. But certainly in my experience of using this, there were not particular side effects. We will come to some of the adverse event monitoring later on as well. Michelle, you would add anything to that?
Michelle: Yes, I am sure Louise can give some more information, but Fluad Quad is very well tolerated and I am pretty sure we do not see particularly more adverse events around this preparation. Louise, do you have any further information on that?
Louise: Just to confirm what you said. We saw very few last year for Fluad Quad. Very well, extremely well tolerated.
Michelle: Thanks, Louise.
Tim: Thank you. I suspect it is likely that the adjuvant increases the immune response to similar to what it would have been at a younger age with the other vaccines, as opposed to being a sort of boosted immune response.
We have got a really important question. What specific medical conditions are considered to be included for the Government flu vaccine? And so, the immunisation handbook has a very good section on this. So people who have received a transplant, and otherwise these are funded under the NIP, immunocompromising conditions including HIV infection, malignancy, chronic steroid use, slid organ transplant, hematopoietic stem cell transplant, functional or anatomical asplenia, cardiac disease, chronic respiratory conditions and that includes severe asthma requiring frequent medical consultations or the use of multiple medicines, so not particularly moderate or mild asthma, chronic neurological conditions including seizure disorders, spinal cord injuries, chronic metabolic disorders, so including diabetes and there are some other rarer ones there like porphyrias and essentially inborn errors of metabolism which some of you may well have patients with. Chronic renal failure, long term aspirin therapy in children aged six months to 10 years, chronic liver disease, Downs Syndrome. Obesity, body mass index greater than 30, that is recommended but is not funded under the NIP on its own. Children born less than 37 weeks gestation, again recommended but not funded as an individual risk factor under the NIP. And harmful use of alcohol, again not funded but recommended. And I am just going to see if this allows me to put a link to that in the box. It may be that it does not. ]
Bethany: We can send that link about tomorrow Tim, if it is not.
Tim: Yes, very good. If it does not appear in your chat box which may have been disabled.
We have also got an interesting question. So essentially pharmacists can give Vaxigrip Tetra, Fluarix Tetra to 65 plus patients as well. They are, now my understanding is they are doing it entirely, they are not part of the National Immunisation Program. I think they do it entirely on the private market. I do not know if these are available to pharmacists through the private market or if it is just through the NIP and they source from elsewhere. Michelle or Louise, do you know the answer to that?
Michelle: Sorry. Pharmacists only have access through the private market and in our communications with them, we advise them not to give that vaccine to 65 years and over. We ask them to refer to their medical practitioners, however they have come back to us and advised that some patients would prefer to have whatever the pharmacist has in stock to save them the effort, blah, blah, blah. So yes, it is a work in progress.
Tim: Someone is asking about Hashimoto’s. I cannot see it listed specifically, but it is worth having a hunt on whether that would be covered. It does not seem to be one of the listed specific conditions. We have got some other questions, but we will be coming to the answers to those very shortly, hopefully.
Now this year, one of the important things is that the process for ordering vaccines has changed, and the most important thing about this from our point of view as GPs is that the first flu vaccine shipment is pre-allocated. Those are based on 2020 usage, discarded expired vaccine from practice and the delivery schedule into New South Wales vaccine centres. Now the most important step with this is that in order for you to receive your first shipment, you have to acknowledge that on the New South Wales vaccine website. So you will have a pre-allocated order which you must acknowledge on the New South Wales vaccine website in order for you to receive that order. That is different to previous years, and it is to help distribute the right number of vaccines to practices and to reduce vaccine wastage. As I understand it, someone is asking do we know how much unused flu vaccine there usually is at the end of each vaccination season? Certainly last year we had trouble keeping up with demand for our patients and actually getting enough vaccine. But I gather there were other practices that had vaccine that was unused at the end of the season as well. So this is designed to try and match demand to supply of the vaccines. As soon as that first order of vaccines has arrived at the practice and you acknowledge receipt of delivery, you can then order further vaccines. And that is going to be important because you cannot order extra in that pre-allocation. So the steps will be, acknowledge that pre-allocation and get that delivered to your practice, then confirm that you have received that, and then you can order more vaccine from New South Wales there. If there is an error made in the online process of sort of acknowledging the pre-allocation, or confirmation of receipt or anything, then call the New South Wales vaccine centre. Again, in order to make sure that demand can match supply, some of the subsequent orders will have, will not be unlimited supply, there will be restrictions on quantities.
A really important question here Michelle and Louise. I do not know if you will be able to answer this straight away. How does pre-allocation work in a clinic that is only opened this year?
Louise: It is Louise, I can answer that. So what we are doing, we are looking at the category of practice. So for example a small GP, a large GP, a super GP. So we will have a standard pre-allocation for any new practices. So we will not have any history, and they will still be able to acknowledge that and agree to that, because they may not have adequate storage capacity, or they may not want that many, so they will certainly have vaccine allocated to them.
Tim: And then if your first order, if you feel you have been under-allocated, then as soon as that delivery arrives you can ask for more.
Louise: That is correct, yes. Keeping in mind the whole time your storage capabilities, so.
Tim: Yes, absolutely. Absolutely.
 Louise: And keeping them in their original packaging.
Tim: Yes, indeed. Thank you. So we will move on. We may get more questions on that later on I think, because that is one of the changes from previous years, and it will be important to let our practice nurses or practice managers, whoever helps manage that process in our clinics to manage that.
Now this is going to be something that is really important this year, and certainly there is a question come through about this. Because our influenza vaccination will be occurring about the same time as COVID vaccine, some of you may well have put in expressions of interest for COVID vaccination as well and be trying to sort of gather information about how that is going to work. Do if you get the chance, do the online, well you will have to do the online training for delivery of COVID vaccination. I did it this weekend and I found it quite helpful actually. So the routine scheduling of the influenza vaccine and the COVID vaccine on the same day, is not recommended. And they are recommending a 14 day interval between influenza vaccine and between any of the COVID vaccinations at the moment. There may well be some circumstances where you have to do it in less than those 14 days or even do it on the same day, and you may consider that based on individual circumstances and your knowledge of the patient. There is no particular requirement or recommendation about which should go first, influenza vaccine or COVID vaccine, so I think that is going to be determined by logistics for the practice, logistics for the patient, and the supplies we have of vaccinations. And that is true also for the first or second dose of the COVID-19 vaccine. So I can imagine circumstances where we might go, influenza, two weeks later COVID-19, 12 weeks later second COVID-19 if you are using AstraZeneca. Or first COVID-19, two weeks later influenza, and 10 weeks after that, 12 weeks after the first COVID another second COVID vaccine, or giving 12 weeks COVID two weeks after that influenza. Any of those could happen.
If we inadvertently give vaccines, influenza and COVID on the same day or with a shorter interval of 14 days, then re-vaccination with either vaccine is not necessary. So we do not need to re-give either the COVID or re-give influenza. We probably just need to check that the patient is okay, but it should be okay. Really important question coming through. I did training this weekend as well and on that training it said seven days between flu and COVID immunisation. Now I gather that has just been changed back today to 14 days. We were expecting ATAGI to change their advice, the Australian Technical Advisory Group for Immunisations, we were expecting them to change their advice from 14 days to seven days, and actually that did not happen, and instead of that, ATAGI have kept their advice at 14 days and so they actually changed that recommendation in the training program from seven days to 14 days, and I think that happened today. Certainly I did the training at the weekend and it said seven days then as well. So this feels as GPs, this is such a rapidly evolving space.
So just looking at some of the other questions that we have got coming through. Some good questions that we will tackle later. So how long does the COVID vaccine course take to complete? If it is AstraZeneca, then they are recommending 12 weeks between doses but a minimum of three weeks, and no particular maximum. If it is Pfizer, they are recommending three weeks I think it is, sorry did I say three weeks for AstraZeneca? I meant four weeks. But a recommendation of 12 weeks and a minimum four weeks. If it is Pfizer, then the dose interval is three weeks, 21 days between the two doses.
Michelle:  Tim it is Michelle. I think they are asking how long did the actual Commonwealth training course take?
Tim: Oh, I have missed that question. It took me, it was, it took me probably two or three hours over the weekend. I did not do it in one go. Yes. Sorry, I misread the question. I am doing too much multitasking.
So this is the information about the influenza vaccination toolkit. You will get sent these, I think that is with your first order of vaccines. Is that right, Michelle?
Michelle: Can you just repeat that? Can you just repeat that?
Tim: So this is the influenza vaccine provider toolkit that I think will be sent in hard copy with your first order of vaccines.
Michelle: The stickers will be provided with the orders. The vaccination toolkit should be live on our website.
Tim: So you have to go to the website to have a look.
Michelle: Shortly, yes. Is that correct, Louise?
Louise: Yes it is.
Michelle: It is. Thanks, Tim.
Tim: Okay, that is worth going to and having a look. It has all the sort of checklist time lines, a provider tool kit, a decision aid for flu vaccination for adults again, based on previous years’ feedback. I think that website may well be live now and the National Centre for Immunisation Research has an Immunisation Specialist Service for advice as well.
Oh I pressed it twice, sorry. So these are further resources. There is a poster for putting up by the fridge so we hopefully do not make any mistakes about who, which age groups get the correct vaccinations. And again, stickers for the baskets in the fridge, to make sure we are picking the right vaccinations for the right patients.
And the next slide. So this in the influenza campaign information. This poster will be familiar to you because it will be the same one used, and fascinating now that sneezing into your elbow, clean your hands, stay at home, is really familiar advice and is probably why the flu season had such small numbers last year, because we were all doing that for other reasons. It shows that it works, I guess.
So this is a practice checklist, again just making sure that we are thinking about the logistics of how we are ordering and administering vaccines. So calculate the vaccine requirements for our practice. Confirm our cold chain measures are in place and prepare the fridge to receive vaccines. In-service for all staff on new vaccine types and indications, particularly those who are going to be involved in giving the vaccines and discussing vaccines and recommending vaccines with patients. Make sure that the practice software is up to date and upgraded. Make sure that the Australian Immunisation Register, that the reporting is correctly done for that. As we just heard, that is mandatory now. Must make sure, and this is a new step compared to last year, confirm the pre-allocation order with the New South Wales Vaccine Centre when that allocation review opens. You need to do that in order to receive your first allocation of vaccines. Offer influenza vaccine using NIP for eligible staff and private vaccine stock for non-eligible staff, to all practice staff to protect them from influenza. Only re-order what can be used in a maximum four week period and plan to maximise uptake in children from six months to 59 months, six months to five years, pregnant women, Aboriginal and Torres Strait Islander people six months and up, people with chronic conditions and people over 65 years of age. And so being able to use our practice recall systems will help with that, and develop lists of patients to target and when to come in would be really helpful.
We have had a few questions come in about this, this is really important and I might touch on the COVID vaccination safety monitoring as well. So the safety data for 2020 monitored children aged six months to under five years who received influenza vaccine after the 9th April, and a lot of parents and carers responded to an SMS they received about their child’s health a few days after their influenza vaccinations. The vast majority reported no adverse events and two thousand, nearly two thousand three hundred parents or carers reported one or more adverse events. The most commonly reported adverse events following immunisation were fever, injection site pain, injection site swelling or redness, irritability, sleeping pattern change and rash And so that is the way the monitoring was done, particularly for children last year and SmartVax is a software program, again uses SMS that follows up people to see what the adverse events following vaccination are like, do it more systematically than relying on people to present. So the public health unit, the local public health units, or phoning 1300 066 055 if we are interested in participating in that. Now my understanding, now again just touching on COVID, mandatory reporting of adverse events following COVID vaccination is mandatory, because it is such a new vaccination. And so if you know of any, I think they are operating a similar system to this for COVID vaccination monitoring as well, and certainly if you are aware of a patient having an adverse event, then we are required to report that to the public health unit and through them to the TGA.
So we have got some case studies to go through. Just looking through some of the questions. A patient with a history of COVID infection, can they still Pfizer or AstraZeneca? Slightly off topic, but yes they can and it is recommended that they do at the appropriate stage in the vaccine rollout.
Does AusVax about the safety, only contact a sample or everyone? I am not sure about the answer to that. I think if it is attached to your system, I think they are capable of contacting everyone through SMS that you had a vaccine on, but I am not sure of the details of that. Louise or Michelle, do you know that?
Michelle: Louise, do you want me to answer?
Louise:  Yes, sure.
Michelle: So if the system is, if your system is integrated, with Ausvax, with Vaxtracker, or what is the GP system, Louise? What is that one called?
Louise: AusVaxSafety.
Michelle: Is it AusVaxSafety? There is another GP program I thought. But anyway, if it is synchronised then. Oh sorry, I just realised I read that wrong. AusvaxSafety collects all the information that is sent through. That is correct, is it not, Louise? So anyone that responds to the texts, or anyone who reports an adverse event.
Tim: And they send a text to everyone who has immunisation?
Michelle: If your program is linked to a feedback system, yes.
Tim: So if you are linked to it through your program, then everyone will get a text and so the response rate looks like it is about 70%, 74% of people who receive a text. So potentially that is quite a large number of people. So just clarifying, do GPs need to report adverse events with COVID to TGA and to PHU? No. So I think technically I think we are supposed to report to TGA because it is them who is looking for it, but if we report to the PHU, then they are reporting that, they are collating that and reporting to TGA. The paperwork is the same, essentially it is the AEFI vaccine reporting which I think is also online now as well.
Louise:  Yes, it is. That is right, Tim, that has just recently changed that form, so there is a newer online version that is a little bit more easier to fill out, but we do prefer them to go through the PHU because then they can follow up as well. And then we send them off daily to the TGA.
Tim: So you do not need to do double entry.
Louise: No, definitely not, no. Because we end up with duplication and then we end up with you know, trying to match cases up that have gone to the TGA.
Tim: Cool. We have got someone asking, are we expecting gaps in supply like last year? My impression would be…
Louise: We certainly hope not. We are trying our hardest to avoid that.
Tim: And that is one of the reasons for changing the system of allocation this year I suspect.
Louise: That is correct. We have some fairly significant expired vaccine disposal issues, in the hundreds of vaccines that we have discarded, so we have taken all that into account and looking at that, and trying to ensure that everybody gets an equitable supply this year.
Tim: Yes. And when will the allocation be open online for people to accept that?
Louise: That will be next week.
Tim: Lovely. So just time for people to talk to their practice staff and then get that done. Louise or Michelle, if you have a link to the new adverse event form, we can post that to the chat or after the webinar.
Louise: I will load it to the chat, that is no problem.
Tim: And someone is asking, which adverse events are we required to report? For the influenza vaccination that is the more severe ones and unexpected adverse events. But for COVID, all of them, every single one. So including predicted ones. If you hear about an adverse even with COVID vaccination, then report that through to the PHU.
We have got a few case studies that we will do. So for each of these, just have a think about the people in each scenario, the different people, what the advice is likely to be. So Felicity attends your practice with her son Shaun, daughter April and her father Ron who lives with them. She is worried about herself and her family with COVID-19 circulating. She has heard that the influenza vaccine may help stop her and family becoming unwell with COVID-19 and wants to know if they should be vaccinated. Felicity is 38, has no medical risk factors. Shaun is eight, he is on long term aspirin and received one dose of flu last year. April is four and a half, and has no medical risk factors. She has not received a flu vaccine before. And Ron is 72 and has a past history of prostate cancer. So quickly, what will you be doing for each of those four people? Giving you time to think on that. The next slide gives the answers. And I am seeing some people writing answers coming through which is excellent. So I am going to move on to the answer for that one. Obviously everyone is worried about COVID, but influenza vaccine does not protect against COVID itself. But it does obviously protect against influenza and it may help keep their immune system strong which may be helpful if they are exposed to COVID-19. Certainly I do not know if that is the evidence, but you certainly would not want two infections at the same time. So Felicity is not eligible for a funded vaccine but it is still recommended that she has one on the private market, because she is an adult but has no medical conditions. Shaun is eligible for the funded vaccine due to the risk of Reyes Syndrome because of his long term aspirin use, and that is one of the conditions specifically mentioned. He will require one dose because he had a dose last year. April is eligible for the funded vaccine because she is less than five. A second dose is required four weeks later because it is the first time she has had flu vaccine. And Ron is eligible for the funded vaccine because he is over 65. And he should have the Fluad Quad because of his age. Sao hopefully that is nice and clear.
Case study two. Luciano presents to your practice and wants to know if he can have his annual influenza 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 to 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 she cannot have it as she is allergic to latex. You know that she is 61 and has coronary artery disease. So what do you want to do for Luciano and Maria? I will just give you some time there to put those in. So if we go to the answers for this one. Luciano is not eligible for the funded vaccine because he does not have medical risk factors, as you remember. So obesity means it is recommended but not funded. Oops sorry, move it back, thank you. Sorry, can you move me back to the answer for Luciano and, before we give everyone the answers. Sorry, that is me being too eager on my mouse button. So Luciano is obese. It is recommended for him, the flu vaccine, but it is not funded, so we should encourage him to have a private market influenza vaccine. He is not eligible for pneumococcal until he is 65, either. And Maria, she is eligible for the funded vaccine because her coronary disease puts her at risk. And there are no worries about latex and the vaccines, because it does not contain latex. And the only allergy contraindication is people who have had anaphylactic reactions to previous vaccines.
And next case study. Arjun comes to your clinic as he wants to get the flu vaccine. He explains 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 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 aged 25, she is eight weeks pregnant. And Sahana is aged three and she develops a rash following the consumption of egg. So what would you like to do for Arjun, Anika and Sahana? You know when you are in an audience of GPs when the answer is discuss smoking cessation. True generalists. So the answers for this one. Arjun, he is not eligible for a funded vaccine because he only has mild asthma which does not put him at high risk. The vaccine is recommended but funded because of his mild asthma and because he is a smoker. So he should have it private. Anika, she is eligible for funded vaccine because she is pregnant and in fact the flu vaccine is highly recommended for pregnant women at any stage of pregnancy and is safe for all stages of pregnancy. And Sahana is eligible for a funded vaccine because she is less than five. Her allergy to egg is non-anaphylaxis allergy, so she can safely receive the vaccine. Again, it is her first year, so she will have a second dose four weeks later. So I think those cases are pretty clear. Someone is commenting, they all get done. The kid gets two unless she reacts badly to the first, unlikely. That is right.
So those are the case studies for tonight. Those are the learning outcomes. We have got a few minutes just to see if there are any final questions that have come through. Hopefully we have covered all those learning outcomes for you. We have got, any idea re timeline for availability of privately funded COVID and flu vaccines? So I am not sure when the flu vaccine, the privately funded flu vaccines come out, I am sure we will be seeing adverts in pharmacies pretty shortly, as soon as they are. There is not any privately funded COVID vaccine in Australia. All those vaccines will be free to people and given through the established programs which are state-based and GP based, and Aboriginal medical service based. And as we move into phase two of that, there will be more practices involved in that too and hospitals.
Louise: Tim it is Louise. I did hear from a pharmacist that they were starting to get their deliveries this week.
Tim: Right, so we will see those. That is starting. So pharmacies will be getting them this week and our allocation system opens up next week, so do get online and see that.
We have got a couple of legitimate comments I think about some of the difficulties we have about the different medical conditions and whether around severe asthma compared to mild asthma, and comparing that to other medical conditions. That does make some of our discussions hard with patients, and also I would imagine it is based on the evidence around who is most at risk. But linked to that is recommending vaccine but not making it available on the National Immunisation Program, and I shall say I do not particularly have a good answer to that, because if it was me I would just be giving everyone a flu vaccine, but that is why I do not control government budgets. So those are sort of political choices I think as much as medical decisions.
After allocation, how long will it be till practices get the delivery? Do you know?
Louise: It is Louise again. We are anticipating getting the vaccines into our warehouse from late March, so we are looking at late March most likely for the first orders to start going out.
Tim: Yes. And I think certainly the timing of flu vaccine and usually each year we have questions about whether we should be doing a second vaccination to cover the full flu season with waning immunity, and certainly there is no evidence either way on that, and it is not funded under the National Immunisation Program, so the Program recommends just a single vaccine still. So we should not worry too much about it coming out later than that, because that will protect people for the most of the actual flu season.
Any advice re timing of vaccine admin of pneumococcal and COVID? Again, ATAGI is suggesting two weeks apart between COVID vaccination and any other vaccine, so that would include pneumococcal as well.
And several recommended comorbidities, an obese, mild asthmatic with hypertension and poverty? That is such a good question. And as far as I know, they do not become additive like that, even if we think that adding them would actually put them at higher risk, and certainly this multiple morbidities is one of the common things we see.
I am just looking at the clock and our time is up. Thank you for being so engaged in the question box. I think this is going to be an interesting year for all of us as GPs doing this in conjunction with a pandemic and COVID vaccination as well, the logistics of doing that in our practices and advising our patients is going to be slightly different to previous years, but I think there is an opportunity there for us to really protect our patients well and particularly those elderly, the children, pregnant women and those with chronic conditions where we can make a real difference to them. Thank you very much everyone. Thank you, Michelle and Louise for helping answer questions so well as well. Thanks to Bethany for running the PowerPoint so well. There will be an evaluation going out when the session closes so please do fill that out. And I think if we have not answered any questions, we will try to answer those later on and will be sending around some of the links with the answers to people’s questions as well.
Bethany: Perfect. And I will just say thank you again to you, Tim for presenting and to Louise and Michelle for answering questions and coming on here tonight, and thank you to everyone online.
Tim: Thank you very much, goodnight everyone.
Louise: Thank you Tim, thanks Beth.

Other RACGP online events

Originally recorded:

2 March 2021

This webinar will focus on factors contributing to varying influenza impact in NSW in recent years.

Learning outcomes

  1. Prepare for the 2020 influenza season
  2. Be aware factors contributing to varying influenza impact in NSW in recent years
  3. Discuss the impact and outcomes of the 2020 influenza vaccine program including children under 5 years of age
  4. Recount the formulations of the 2021 influenza vaccine and their optimal use in eligible age groups including children under 5 and those aged 65 and over
  5. Utilise the Flu Vaccination Tool Kit to optimise your vaccine supplies and maximise uptake of influenza vaccine
This event attracts 2 CPD points

This event attracts 2 CPD points


Dr Tim Senior

Dr Tim Senior is a GP at the Tharawal Aboriginal Corporation in South West Sydney. He is Medical Advisor to the RACGP in Aboriginal and Torres Strait Islander Health and is a clinical senior lecturer in general practice and Indigenous Health at the University of Western Sydney.


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