​Transcript for Immunisation Update Webinar

​

Jennifer: So, welcome everyone to this evening's twilight online webinar, Immunisation Program Update 2022. We are joined tonight by our presenter, Professor David Durrheim and our facilitator, Dr Tim Senior.

Before we kick of the presentation, 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 pay our respects to Elders past and present, and I would like to extend that respect to any Aboriginal or Torres Strait Islander people that may be joining us today.

I just wanted to introduce our presenter and facilitator for this evening. So, David Durrheim is the Director of Health Protection at Hunter New England Local Health District and a Professor of Public Health Medicine at the University of Newcastle. He currently chairs the Western Pacific Regional Measles Rubella Verification Commission and is a member of the World Health Organisation Strategic Advisory Group of Experts working groups on COVID-19 and Ebola vaccines. So welcome, David.

And 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 at UWS and an RACGP Medical Educator. So welcome, Tim.


Tim: Thank you very much.

 
Jennifer: I am just going to pass over to Tim now to run through our learning outcomes.

  
Tim: Good evening everyone. So these are our learning outcomes for tonight, so this is what we hope to get through in the next hour. So, by the end of this online activity, we will all have a better understanding of New South Wales Health immunisation programs. We will understand how COVID-19 vaccination has been incorporated into business as usual, have improved knowledge of the expansion of the pharmacist vaccination program, will understand mandatory reporting to the Australian Immunisation Register, including for birth dose hepatitis B vaccine. We will have received an update on childhood vaccinations. We will be provided with the most recent Aboriginal immunisation data. We will have received an update on the adolescent school vaccination program and have a better understanding of the process of adverse event monitoring. We will know how to report vaccine administration errors. We will understand zoster vaccination requirements for immunocompromised patients. We will understand vaccine supply issues and changes to the immunisation schedule, and we will know where to locate immunisation resources. So I am going to pass over to start on all that to Professor Durrheim. Thank you very much.


David: Thank you very much, Tim, and it is a great pleasure to be able to participate this evening from Awabakal Country. So I just want to pay my respects to Awabakal Elders, past, present and emerging. And it is delightful to share a space which is a passion of both public health medicine and general practice, which is really the ultimate in preventive care, and that is vaccination and particularly of children, but what COVID has shown us is, it is really a whole of life spectrum. So I also just want to acknowledge that Mareeka Hair, who is the Acting Head of the Immunisation Unit at New South Wales Health, is joining us. She is the smart one of all of us. She will be answering your very tricky questions in the chat.

So look, we could not talk about vaccinations without mentioning COVID-19 vaccines, and it has probably been the biggest source of my perpetual insomnia over the last two years, being on the SAGE working group for COVID vaccinations.  But it has been a remarkable space. I mean, if we think about where we were just two years ago and where we are now, we have got 32 vaccines that are registered and in use around the world that are COVID specific, 321 are in various stages of development at the moment. None of us knew which ones would be the winners. You know, when Astra Zeneca brought out their Oxford vaccine, that seemed to be an absolute winner, but little did we know and many of us really doubted whether mRNA vaccines would have a place because of their thermal stability issues. So it's been pretty amazing. And the vaccine development, the good news is that it continues because we may not have with these first generation vaccines, really got the ideal candidates for the long term BAU, business as usual. Now, we are not in business as usual yet. Some politicians would make us think that we are, but we are far from it. The fact that we have all, well, many of us have had our fourth dose of a vaccine and that we are having it three to four months apart, suggests that that is not going to be a sustainable way of routine vaccination into the future. What is clear though, is that we have missed the opportunity of eliminating this virus. It would have required a really successful roll out of very effective vaccines globally in a very short period of time. What we have done instead, is we have, through an inequitable process of vaccine sharing and everything that is gone with that, we have actually probably selected for escape variants, and they are proving to be superb at immune evasion. So each one of these variants, or variants of concern, has proven many fold more infectious than the original Wuhan variant.

What is clear though is that vaccination has worked for the short term severe disease. There is no question. The estimates vary in terms of death, maybe 12 fold decrease in the likelihood of death in adults, to ICU presentations, ventilator, the entire remit. So the vaccines have effectively disconnected severe outcomes from incidents. Incidents is incredibly high at the moment in Australia and New Zealand are sort of trying to outcompete each other as we do in all sports, in terms of our death rates, which is quite sad.

The big issue though that is still a bit of an unknown, is the post-COVID condition, long COVID. And clearly with increased transmission we are increasing the proportion. If it is 5%, and that is probably a conservative estimate, of people who get long COVID or post-COVID condition, the fact that we have really let transmission rip while we know that we are protecting most of the most vulnerable through vaccination, is probably not going to be very wise and general practice will have to deal with many of the outcomes of this.

You can see there a nice graphic which really just shows how the various waves, alpha, beta, gamma, delta, just came through, were more transmissible, and very effective at immune evasion. The very good thing that we have realised is, and we have seen this now with the fourth dose of an mRNA vaccine, is you get an enormous boost. In fact, we get levels of neutralising antibody that are considerably higher than following the initial two dose schedule, or the first booster. And they do appear to persist for a reasonable period of time, three to four months, that they may protect you against symptomatic or severe symptomatic illness. Clearly the T cells are what are doing it against severe disease, but as I said, we cannot really be boosting people every three or four months as variants pop up.  People wondered whether the solution may be in varying the vaccines, but so far, other than using vectored vaccines, and then following that with the mRNA vaccines, we have got very little experience. It does appear though, that the Novavax vaccine may be a very good follow up booster vaccine following an mRNA course, with equal neutralising antibody titers. So that work is yet to be published but it is looking very, very promising in the preprints.

What about variant updated vaccines? This is what people were very excited about because both Moderna and Pfizer are chasing this with some passion. And their initial BA1 variant with the original Wuhan strain gave a boost, but really was not that impressive compared to just a boost with the original vaccine. They are now both in trials with a BA5 Omicron and we will have to see what that provides.  But clearly the virus is moving quicker than we are.  And it is very unlikely we are going to get ahead of it. And that is why pan-coronaviruses or pan-sarbecovirus vaccines are rarely the Holy Grail. We probably need to get vaccines that provide coverage not against just these sub variants of Omicron, but that cover a broad range of SARS-CoV-2 and possibly other SARS-like viruses as well.

All right. Tim, should we continue or are they questions that you think we should deal with?


Tim: We should continue for now. There are no COVID vaccine questions coming yet, but I think we will probably get some on the way.

 
David: Sounds good, excellent. Thanks, Tim.

Alright. So look, let us talk about things that are happening closer to home, New South Wales. And one of the things which obviously seemed to many people to be a new innovation was the pharmacist vaccination program. But actually it has been in place for a pretty long time since 2015. At that stage, largely focused on influenza vaccine for adults. But we have seen it expanded to really include a range of vaccines now, and that includes influenza vaccines from five and up and including the oldies with the higher dose vaccine. MMR came in, and this was particularly prompted by the 2019 global resurgence in measles, and we realised that we needed to make as many opportunities available as possible for people to complete their course or get a booster if they were travelling and there are lots and lots of young Aussies who travelled internationally, and this could be a real challenge. We have seen massive gaps open up in many low-middle income countries in terms of their measles vaccination and everything is fit for another big global resurgence in the next few years. So maybe just a note if you get the opportunity to offer measles containing vaccines to young adults, particularly, but  younger adults and adolescents, it is a really good opportunity if they have not completed a course. There was further expansion with the recognition that our school program was struggling and we will talk a little bit more about this. One of the big impacts of COVID, one of the very successful immunisation strategies in New South Wales has been to reach kids in school, particularly with HPV and the DTPA combination vaccines, and then the single dose of the mening ACWY as well. And then obviously now with COVID, provide as many opportunities as possible for COVID vaccination. Pharmacists have become involved as well.

Now this is a bit of an uncomfortable space I think for GP sometimes, the fact that, you know, pharmacists are coming in and vaccinating our patients. But in some respects I think that the bulk of families will still get their vaccinations from a trusted GP, and that this will really be for many of the people who really struggle with access or where our programs are not able to reach them in the schools. And for those of you who are concerned about the quality assurance aspect, New South Wales Health has put in place in partnership with the Australian Pharmacy Council and the New South Wales Pharmacy Guild, are putting in place a whole lot of guarantees really to ensure the quality of the program. There is dedicated training. Every single vaccine that people will administer they have to be specifically trained for. Obviously they have to sign that they will comply and that they are aware of the vaccination standards, the handbook and the storage guidelines, and that they get an annual refresher. They remain up to date with the ATAGI and TGA advisories, which I am sure you folks all keep your heads around, and that they also complete CPR certification every 12 months. Obviously there is the, like there always is when vaccines are given, there is always the possibility that you may get an anaphylaxis, and it is very important that people know how to deal with it. So that is really the development in the pharmacy space.

The other thing that has changed and people are I think tired of mandates. We have seen that with face masks. Not a very large inconvenience, but no politician in the country wants to touch a mandate at the moment. And yet we know how effective particularly two masks are, but also a surgical mask, just in buffering the transmission of the SARS-CoV-2 virus. But this is mandatory. It is absolutely critical that we know who has been vaccinated against these priority vaccine-preventable diseases. So this bill has been passed. It is obviously a Federal Government bill. It requires all vaccinations, preferably to be to be lodged with the AIR within 24 hours, but at least within 10 days. So 10 working days, two weeks effectively. And that that now applies to all vaccines. It started with COVID vaccinations, was extended to influenza, then it was extended to the National Immunisation Program, but now it includes those as well as any that people are also purchasing privately. So it is very important that we actually do, do that. I think what we have seen is the smarts that have come out of the pandemic in terms of reminders and so on, which you in general practice rarely used very well in the past, are becoming such a critical part of healthcare delivery. And having people registered so that their status is known, particularly when you get importations of things like measles and so on, is actually very valuable.
 

Tim: Just to clarify, we have got a question on that. Do doctors need to inform AIR if Shingrix was given? As the patient says, it is not paid for by the government, so private vaccines or non-NIP vaccinations?

 
David: Yes, Tim. Great question. Yes, all private vaccines as well. So maybe yellow fever jabs too. So thank you, that is great.
 

In fact, this is one that is tricky. So hep B vaccine, the birth dose, is also meant to be reported to AIR, and that is part of this mandatory reporting. And it is tricky because obviously babies sometimes, people only decide on their name a week or two later. They do not have a Medicare number, and so this has been a real challenge, I think to general practice. And the good news is that one can either use the existing software, most of the existing software supports this, or actually the AIR secure site. You can actually log the new patient with just as many details as are possible that you have got available, which will allow matching a little bit later. Now, I have never done this, so if you have got a question on this, Mareeka will have to jump in and help us out. But it does sound as though it is quite plausible, and obviously it is a little bit messy and what you would need is that the two records later will actually be merged. Alright, no questions on that one in the chat. Okay.


Tim: No, no questions about that.

  
David: Excellent, thanks Tim. Look, this is really unfortunately one of the really negative and detrimental things of the pandemic is, you know, Australia probably has if not the highest, it is some of the highest vaccination rates in the world, something I think we can be really proud of. And the pandemic has really had an impact on us now. I have been reviewing reports from countries in the Western Pacific region over the last couple of days for the regional Measles Rubella Commission meeting, and the impact in places like Lao and PNG and the Pacific Island countries are profound. This looks fantastic when you compare it to some of our neighbours, but probably what that does mean is that diseases that have become quite rare in some of those countries could well resurge, and given the amount of movement in our neighbourhood, I think we really need to be on the alert that we are very likely to see introductions and outbreaks of diseases that may be quite rare. I mean, everybody is aware of diphtheria cases that were confirmed on the north coast recently, and really diphtheria is a disease that you should not see in a country with more than 60% routine vaccination. So I think we can prepare ourselves for some surprises, and that is why I think it is so important that we use the opportunities now as things normalise a little, and maybe when we get through the surge, and it looks like we may be peaking about now, as we get through the surge of BA5, is grab the opportunity to undo some of the harms that COVID has done.

Now, the bigger harm, so you will see there was an impact in 2020. It has continued into 2021. It has continued into 2022. There you can see our coverage at one year, two years and five years of age. Still good coverage at five years of age, although if you have a look at all children, you will see that it is below 95%, which is sort of the magical target that we can reach for measles in a population immunity. But it is close to 95%. But anything below 95%, measles can grab the opportunity to take off. But the thing that also particularly worries me is that at two years of age, have a look there, the Aboriginal kids. It has really dropped. The coverage in Aboriginal children. Now 90% coverage is fantastic, but we had closed that gap completely in New South Wales. The gap had disappeared and we were getting equivalent coverage in Aboriginal and non-Aboriginal kids, and obviously Aboriginal kids are at greater risk of many of these vaccine-preventable diseases, so we really do need to put an extra effort in, not only to reach all children, but particularly Aboriginal kids. I think that some of the COVID harms are also in the perceptions in some of our Aboriginal families and communities around the vaccine and may have a little bit of a lasting legacy, so it is going to maybe take a little bit of time and take trusted general practices to really reach out and again build confidence in Aboriginal families.

So I think we have spoken to this. We are doing a little bit of work between New South Wales Health and the Primary Health Networks to better understand why we have seen the drop off.  Now some of it has been structural. Obviously it has been harder to get into vaccinators to get vaccinated, but I think some of it has also got to do with people's perceptions, whether they perceive health settings as more risky, you know, that is probably one of the things that might have happened. Whether they have got, you know, concerns about vaccine safety because of all of the publicity around TTS and COVID vaccines. We try to understand that better so that the messaging is better targeted. But one thing that we know for sure is currently 85% of childhood vaccines are administered in general practice, and for that I need to solute general practice because that is a phenomenal effort. But, this is really a consistent message, anywhere where you look at vaccine acceptance in the world, and vaccine hesitancy in the world, where there are surveys done of parents, they almost inevitably say my GP. My general practice is the most trusted source of my vaccine information, which is a great thing. It means they are not trusting the Internet. Yes, there is a small group that get locked away in the wind canals in the Internet. But really when we look at this, and I have done some work with Margie Danchin down in Melbourne, and this is a consistent theme. GPs are trusted sources of vaccination information. So that that is a wonderful accolade, but at the same time it is also a great responsibility because really, a lot of rebuilding the faith in vaccines is going to come to general practice. So we would encourage you, and I know you are doing this already, but encourage you to take every opportunity to catch up kids, especially young kids. We know that if you get the first dose in, generally the other doses follow, so that is a really important reminder as well. Use your reminder systems to prompt parents to come in, probably provide reassurance that your practice remains a safe area. A lot of simple things that are done, you know, keeping mask wearing happening in general practices are sensible things. Screening people for coughs and colds and putting them somewhere else is a sensible thing. So, all of those things I think can help. But it may be that there will be a little bit of extra time required to encourage parents and reassure them about the safety of childhood vaccines as well. But they are in good hands. They are in your hands.

Okay. So we mentioned Aboriginal immunisation and you saw the coverage figures, and a lot of effort in New South Wales has gone into closing the gap in Aboriginal immunisation. It was stuck when I first started in New South Wales at about a rotten 7% in Hunter New England and we helped to pilot with Aboriginal health workers a program of pre-calling, making sure that Aboriginal mums were identified and Aboriginal babies were identified early. Pre-calling them by an Aboriginal immunisation trained immunisation health worker, and then helping them to find a safe, and culturally safe, practice or Aboriginal Health Service, where they could be vaccinated. And that was extended across New South Wales, and across New South Wales we saw the gap absolutely smashed. Now we have seen it has opened up a little bit with COVID and we need to do something. But the bigger concern, this is, as you can see, this is not at 12 months. So this is fully immunised at nine months. And the timeliness of Aboriginal immunisation, the gap seems to be opening again. You can see it had almost closed. Got down to about 2%. But in the last three years we have seen it slowly easing open again. And so we would encourage you, that is at nine months, then at 15 months again, at three months earlier, there is less of a gap there, but maybe there is the inkling that it might be opening up again, so these seem to be the kids to really focus on, all the younger children, and making sure that Aboriginal families feel really safe in your practice and that they are encouraged to have their children vaccinated early. And nothing worse than because one has delayed vaccination that the child gets a bout of whooping cough. That is just terrible.

Then if we look at 51 months, this is amazing actually, we are seeing high coverage with Aboriginal children and it is pretty timely too. So it is really those younger kiddies that are worth a little bit of extra effort just to make sure we get them protected as early as possible.

I mentioned, and this is a lovely photo which is another one of the impacts. I think one of the things we are going to see from COVID, and obviously I am going to take a vaccine lens to this, but I think the impacts on education globally are going to be just colossal. In Australia obviously they have been managed by the fact that we can actually do things virtually much better. But they are going to be parts of our community that have really missed out. You know, this is where socioeconomic harms occur, when people cannot afford an iPad and so on. So I think we are going to see some really nasty impacts on the education of children, but also on the vaccination of kids. You know, in 2020, the schools did not want our vaccinators in. They were scared, they did not want anybody in and they turned down our offers. And I mean, they were they generally welcome. This is something that schools across New South Wales, there are very few that do not invite the school vaccination team and strongly promote vaccination, and we have got really good coverage especially for HPV, which is very exciting across the state. But then of course the health orders in 2021 had kids locked away at home. And then they come back to school and then all was disrupted. And then of course in 2022 when we are putting a lot of effort across the state trying to reach kids in schools and do catch up, now they are off with COVID. They are off as close contacts. So it has been a nightmare couple of years I am afraid with the school program. And this is one of the reasons we have reached out as well obviously to pharmacies, and we strongly encourage general practice, and AMSs is to really provide vaccination checks whether the school aged, your nine, 11, 12 kids have been vaccinated. If not, please provide them with a catch up dose.

And look, the impacts have been enormous, but particularly for the vaccines that require a second dose. So here we have the Year seven young ladies and you can see, we can get one dose in, that is still traveling okay, tracking at 82%, but look what has happened to the second dose. And clearly, you know, that is as bad as it will get 23%, we are obviously investing heavily in trying to catch up these kids through extra visits to schools and so on, but what a tragedy it would be if with a very effective HPV vaccine we actually see a resurgence in cervical cancer down the track. I mean, that would be would be an absolutely horrible outcome. So the good news is two doses will give you probably lifelong protection. There is great cross protection as well, and so it is really worthwhile if there are any young people, young girls or young boys, you can see the same impact in young boys. Generally we find about 3% fewer boys take up the vaccine, obviously because it is sexually transmissible, there are greater benefits there to be had if you vaccinate boys and girls. But you can see the profound impact is down to 22% of coverage at the moment with the second dose. So your participation in reaching these kids is greatly, greatly appreciated.

And the other thing that we have seen is particularly with teenagers. We see two spikes with meningococcal disease. The one is in preschool and the other is in older teenagers and young adults. So this is why the men ACWY program was rolled out in schools. And there, there is less of an impact, but it is only 60% coverage in 2021 in year 10, so a drop off of about 15% over recent years, and this is another group where obviously we will be trying to reach them and give them another opportunity, but where if they have left school, they may have missed their opportunity completely, and it would be fantastic if that could be offered in general practice as well.

So yes, not only a focus on those littlies, and particularly in the first two years of life, but also on adolescents that may have missed out on these wonderful vaccines that really protect them against very immediate harms in their particular age groups. So look, that is that is a little bit about vaccine coverage.

One of the other things that we have obviously become all very interested in, and the public has as well, I mean, the public has all become amateur epidemiologists. Everybody now loves a good line graph, and at the same time the public had become very interested in AEFIs. And if you had said AEFI in a general community setting, no one would know, now everybody is aware of adverse events following immunisation, AEFI. And Australia is a world leader in AEFI recognition.  Obviously for a long time we have had the passive reporting system, which is dependent very heavily on general practice. So these are the reports that you provide either to the Public Health Unit or to the TGA, and we encourage that to continue. But we have also got these active surveillance systems that actually ask people about their experience, Vaxtracker in public hospitals, Smartvax in general practice. Many of you would be aware of this where your patients actually register. They get a Smartvax prompt and get an e-mail or text and they actually fill in the survey, and that way we can monitor what is happening, whether there is anything untoward. New South Wales also has a very well developed syndromic surveillance system in our emergency departments that screens the triage text and with vaccine comes up with immunisation, it picks those and we can actually go looking for unusual presentations, and that has been very actively pursued obviously, during the last two years in all of our EDs across New South Wales, and that is called the PHRESS system. Public health, something, something syndromic surveillance, ED is in there.

Now, there are a couple of reasons why AEFI surveillance is so important. Obviously the key one is to monitor for the safety of vaccines.  So if we had not had that, the thing is, particularly with emergency use of vaccines, you know, you roll out a big trial, but you might have, you know 10,000 people, maybe 50,000 people, in a very big 100,000 people in a big phase three trial, but it is only when you really start rolling out to the millions that you might pick up very rare adverse events. So just a little perspective, I have served on the Ebola Working Group that advises the Director General of the World Health Organisation, and we rolled out vaccines that were vectored vaccines, adenovirus vector vaccines, with not detecting any signals whatsoever. Now they were being rolled out, obviously in tropical Africa where surveillance is very challenging, and the numbers were very small relative to what was rolled out. And was only when large numbers of these vaccines were rolled out that we started seeing signals of TTS thrombocytopenic syndrome and that was a surprise, but it was important that we had the surveillance in place and it helped us from a policy perspective in Australia to ratchet down the age limits that that people could actually use those vaccines. So incredibly valuable for measuring the safety of vaccines. Obviously in the United States, and Israel when they rolled out their mRNA vaccines, there appeared to be a safety signal in young males with a small excess in the number of myocarditis cases and that was very carefully then studied. And again I think that is just shows the value of the safety monitoring.

 

And obviously the TGA as a regulator really needs to know, because they put various warnings on products. We hope that if we keep doing this very well and AusVaxSafety is a great source, so if you go to the National Centre for Immunisation Research and Safety and you look at the AusVaxSafety website, they are providing real time data. And you can use that in your conversations with your patients, with your families.  And then obviously we want to get the message out. We want this to be widely available as surveillance data to the public, because that is the way that we build confidence and they see that we take action when it is necessary.

So AEFIs are very important and we really thank general practice for actually reporting them. Obviously it is a mandatory reporting condition like measles is under the Public Health Act. And the other thing that is important for reporting is vaccine administration errors. And you know, sometimes mistakes are made. Sometimes a person does not disclose that they are pregnant and they get vaccinated with a live attenuated viral vaccine. And sometimes it is done with their consent, yellow fever vaccine for example, although you would probably prefer not to do that. Sometimes a vaccine, for example, a live Zostavax vaccine, is given to a person who is immunocompromised. Or a vaccine results in an AEFI. Those are the things that we want to keep an eye on as well, really so that we can make sure that if these things are happening commonly, that corrections can be made in the program to try and avoid them, and that things can happen. Webinars can happen where we can talk through these things, and we will do a little bit of that right now.

So the usual reporting lines are to be followed. You have the Public Health Unit and there is this universal 1300 066 055 number. You can reach a Public Health Unit. The Public Health Unit immunisation nurses in New South Wales are amazing. They are generally very friendly, mine are anyway, and they are very helpful. And the other important reporting is through to the TGA. So the form is available online. The TGA takes us very seriously. I have been on an expert panel on vaccine adverse events in New South Wales during the COVID pandemic and the TGA really does take these reports very seriously. So, your reports will be will be followed up on. 

Sometimes you need clinical advice. Maybe a patient has had, you know, a complex reaction after a previous dose and maybe the person, we have had a child that I was on conversation yesterday afternoon with the paediatric immunologist, a child who had Guillain-Barre and now the parents wanted to make sure that the child was protected against flu and wanted them jabbed. The child was not fully recovered. Now there are places where you can, you are not alone. So there is a wonderful specialist service that is provided called NSWISS in New South Wales, and the number is there, or you can e-mail them. They provide a fantastic, there are paediatricians. They started as a paediatric service, but they have now got much broader, obviously with COVID vaccines, they have access to people who understand cardiology, neurology and so on. And the Public Health Unit again is another place where you can seek advice for complex cases or where you just want to make sure.  Obviously there are very helpful websites, and one of those is the Society for Clinical Immunology and Allergy as well.

And then, as I said, these are your go to vaccine resources.  The handbook is wonderful, it covers things very well. The online version is so much easier to use and I encourage you to use that as well. There is a very nice, for extra CPD points, there is a very nice online e-learning module called Sharing Knowledge about Immunisation. I think Professor Julie Leask was initially very involved in this. This is online. It is readily available and I would encourage you to use it. It is a way of really strengthening or checking if there is anything else that you can learn in your engagement with families in terms of providing them with reassurance. And then, the New South Wales Immunisation web page. That is a good place to go as well. I have already mentioned AusVaxSafety. There is a little infographic. Just Google AusVaxSafety and you can get real time data on immunisation coverage and any adverse events as well.

But this is one of the important adverse events that unfortunately has flared up. So Zostavax is a great vaccine.  It is funded in Australia for 70-year-old individuals and there is a catch up program which has been further extended because of vaccine availability to 31st of October so people in their 70s who missed out can get a dose. The problem is it is a live attenuated vaccine, so you cannot give it in people who are immunocompromised. So the reason is obvious. I mean you are going to get the viral replication that can lead to disseminated disease, and we have sadly had a number of deaths in Australia.

Now the zoster vaccine can be given with both influenza and pneumococcal vaccine. It is not contraindicated. And a lot of you will have be aware of Shingrix. Obviously it is only on the private market. The reason is, it has not yet gone through PBAC, and that has to be prompted by GSK actually submitting their dossier, so hopefully they will do that, because this is the vaccine you would use always in immunocompromised individuals, because it is not a live vaccine, it is a sub-unit herpes zoster vaccine. You need two doses, though. There are generally two to six months between them. But hopefully they will be progress in getting that onto PBAC as well.

Now. NCIRS did a very nice survey, that is the National Centre across GPs. Following our concerns about zoster vaccine, we wondered what the level of knowledge was. The good news is 90% of GPs knew that it was funded and the age group that it was recommended for. But 40% were not aware of the safety alerts that have been triggered by the Zostavax related deaths where it was administered to immunocompromised folks, and 10% of people incorrectly responded that immunocompromised was not a contraindication. So that is the reason we are talking about it tonight, is just to make sure that everybody on this webinar is very aware. And obviously there have been lots of efforts to get the message out, but it is something very, very important. There is very good information on contraindications available as well.

Now this is a more recent issue that has cropped up, and this is a very unusual genetic deficiency. It is the interferon alpha beta receptor 1 deficiency. And it is really prominent in some western Polynesian families. It is actually a recessive inheritance gene that one in about 2,000 Samoan families may carry the gene, Samoan individuals. So we have recently had a case series of seven Samoan, Tongan, Niuean cases, and sadly four of those individuals died. Now, what happens here is you get an overwhelming reaction. High fevers, shock, you can get neurological presentations as well, you can get basically a herpetic failure too. And it is triggered normally by viral infections. So things like measles can trigger it. SARS-CoV-2 can trigger it, too. But it can also be triggered by attenuated live viral vaccines. So MMR or yellow fever. There is a very strong ATAGI statement. It is very difficult to diagnose it before an exposure. But if one was to see a really lousy reaction in the week to two weeks after an attenuated live vaccine has been given, it may well be worthwhile consulting an immunologist. Now, ATAGI have of course said look, you are going to have measles, you are going to have this problem anyway, so the risk is much higher from infection than it is from the vaccine. As I say, the biggest case here that has been published today is seven individuals. But it is something where I think a whole lot more research is going to need to be done. So this is just a heads up that this is something that is new. That it is something that is been recently described.

The other thing that you may, and this is less new, but it may have been missed because of COVID, are some of these changes in the National Immunisation Program schedule. So very, very exciting was the funding for First Nations or Aboriginal Torres Strait Islander kids at two, four and 12 months of age for Bexsero. And Bexsero, the important thing to realise is, you do not have to wait to two months. It can be administered at exactly the same time at six weeks as you do with the first dose of the other vaccines. It can be administered at the same time. And the reason we do this is that effectively Aboriginal infants and Aboriginal pre-schoolers are at fourfold higher risk of getting invasive meningococcal B disease versus non-indigenous kids. So that is why it is a funded vaccine. Obviously if the children are at risk and there are a whole lot of conditions, either genetic, functional asplenia, other things that are immunosuppressed that put the child at risk, then an extra dose is needed, and anybody not only First Nations kids who are in those risk groups are also entitled to get the vaccine for free.

The other thing that is worthwhile being aware of is the incredibly complex pneumococcal schedule. And I would not even try, if it is not in front of me I do not even speak to it. So you will find the Public Health Unit, the public health nurse or physician will actually have the schedule in front of in front of them. Maybe worth your while printing it out, but obviously as it spans the life course and as it deals with people that are increased risk and the conditions of increased risk, there are very, very good resources that are immediately available on the web as well that you can print off.

Worthwhile just acknowledging that there have been some vaccine supply issues that have affected New South Wales, affected the country. I mentioned Zostavax earlier, that is in the process of now being on-flowed, but they did have impacts on ordering and resulted in the extension of the catch up dose for the 71 to 79-year-olds. Also Infanrix Hexa, which is such an important vaccine for kids at six weeks or two months, four months and six months, and there have been shortages as well. There is a solution which I am about to share with you, possible solution in the pipeline. And then unfortunately, the measles containing vaccines have also, there has been a global shortage and that does not bode well when we know what might be around the corner. So there are some restrictions again on those vaccines and we apologise that sometimes the Vaccine Centre has to put on restrictions, but normally there is a good reason, it means they are trying to distribute it as equitably as possible.

And this I mentioned. So these are some of the things that are around the corner. There is this Vaxelis vaccine which has been recommended for inclusion on the National Immunisation Program, so that means it is going to be funded, and that is very exciting. That gives us another vaccine that can be given at two, four, and six months of age, which basically has the same constituents as Infanrix Hexa. It is helpful always, you seldom get a stock out by all manufacturers, and I mean this is probably one of the big impacts of having almost a single supplier left only in inactivated polio production globally, which really had a major impact on the rollout of a single dose of inactivated polio in countries that were still using oral polio vaccines. So, that is a very exciting development as well, so that is just around the corner.

We said that we would also just point you again, and for many of you, you would be aware, but I would refer to most of these during the talk. So clearly ATAGI, the ATAGI regular statements are a really good resource but they are not always that easy to find, so it is well worthwhile having this link saved as a favourite. NSWISS, incredibly good clinical referral source. And there are good guidelines about what you need to do if you experience an adverse event. The adverse events that we are particularly interested in are the severe ones. So, obviously a death, a hospitalisation, or something unusual, or something that leads to ongoing disability, those are the adverse events which we really do need to focus our attention on.

This is the research paper that we mentioned on general practice Zostavax awareness, so that is an important one. That Zostavax screening form is incredibly useful. So there is a part that gets filled in by the prospective vaccinee, and then the second part of the form provides really good guidance in terms of screening out the high risk conditions, the immune suppression conditions, or other things like fever, and deciding to wait, or a person is in the in a bout of zoster at the moment and they think that this is going to be very good for their post-herpetic neuralgia. It is not going to. All of that guidance follows. So it is a really useful form and I am sure many of you have used it before.

So look, this was the ambitious list that Tim put up.  I think we have sort of covered most of it, but there is a couple of minutes left Tim, where we might be able deal with any questions that Mareeka or I might need to respond to. Thanks very much.


Tim: Thank you very much indeed. That was good. We have got a few questions covering quite a wide range of topics, so let us see how many we can cover. Can a patient have Shingrix after Zostavax a few years ago? So what are the risks and benefits?

  
David: Interesting. Mareeka, you are across the policy on that one?

 

Mareeka: Thanks Dave. So I was actually having a little look on this one and we may have to take this one offline. So, currently the recommendations in both the Australian Immunisation Handbook and the product information for Shingrix is that there are not recommendations for booster doses at this point in time. But I think, you know, we have all seen some of the efficacy data in relation to Shingrix versus Zostavax, et cetera, so I was not able to find anything quickly while we were talking, but I think that we can take that offline and perhaps check with our colleagues at the National Centre and maybe provide some advice back out, or at least see if we can get some further information from them.

 
David: Yeah look the important thing, thanks Mareeka, the important thing to stress is that Zostavax is a single dose vaccine, generally. Shingrix, the CDC in the US, where obviously it has been available for a longer period of time was recommended as a two dose schedule. So I think that hybrid, I have not seen anything actually published on the hybrid, and I think Mareeka is right, we will need to get back to you on that one.


Tim: We have got a couple of questions on COVID and wait. Why is there a wait of three months for COVID booster following current infection, when we are retesting patients for COVID four weeks later for reinfection?

 
David: It is a very good question, and it is really at the moment, it is probably based on good sense rather than good science. So we do believe that the natural, or the mixed infection, the fact that one has had a vaccine, then you get a COVID boost effectively through natural infection, probably will last, will provide a boost in neutralising antibodies that probably last the same period of time as another jab, which is effectively three months. Clearly there is no contraindication to another jab if a person has fully recovered. So there is no technical reason not to have the jab, but the ATAGI advice is three months, and that is largely based I think on good sense.


Tim: Thank you. What would you advise a non-Aboriginal adult patient with no risk factors, asking about getting a pneumonia vaccine, pneumococcal vaccine?

 

David: Mareeka, are you going to pull up the schedule?

 

Mareeka: Thanks Dave. So, currently for that particular group it would not be funded without any risk factors under the National Immunisation Program. So I suspect, I did see the question in the chat, so I suspect that this is probably more around an individual looking to protect themselves and pay for the vaccine, because they are not eligible under the NIP. And I guess that in that particular circumstance, it would come down to risk factors, you know, being travel and things like that, and I guess it would be a decision to be made on a case by case basis. But at this point in time, it is not currently recommended, I am sorry, provided, under the NIP for that particular circumstance.

 
Tim: Thank you, I will mention the decision tree that Professor Durrheim mentioned a few times. Mareeka did post into the answer to some of the questions. So if you could not see those answers, let us know because we will put it back in so that everyone can see that link.

Given the mentioned shortage and lack of availability of MMR vaccine, how can GPs provide opportunistic vaccination for travellers?


Mareeka: I was partway through answering that one in the chat.

 
Tim: So sorry.

 
Mareeka: No, no, that is fine. It is currently only affecting the MMRV, so the measles, mumps, rubella, varicella vaccinations, and there is only constrained supply at this point in time. So the MMR vaccine still remains available. So please do encourage anyone who is particularly travelling or may not have had their two doses, please encourage them to have that vaccine. And in terms of the MMRV, it is actually only licensed for people 14 years and under, but if for some reason you are unable to access it at this point in time, we do still have the MMR and a single dose varicella, so you can do a combination that way if we absolutely had to. But we do have supply of both at this stage. Thank you.

 
Tim: Thanks, that is great. We may have just time for a quick answer. How soon after COVID-19 infection can Zostavax be given? I suspect there is not much advice on that specific question.

 
David: I think we will have to send that one to ATAGI, Mareeka?

 
Mareeka: Yes, I think currently ATAGI are essentially saying that vaccines can be co-administered if you needed to. So for example, if you thought that there was going to be a reason the patient might not come back and have the vaccine, then you would weigh up that risk. But they have said that there is not a lot of data at this point to support that you should not, but ideally you would give a little bit of a break between the two. But if you thought that there was a risk they would not return, then certainly consider co-administering.

 
Tim: And this is a question that infection rather than vaccination, so I suspect that the advice is, once people have recovered from the febrile illness and they are able to have vaccinations.

 
David: Yes, that is the general rule, I think Tim, that is a good one.

 
Tim:  Yes, and I would be keen to get it in once we can. Lovely. We have hit 8:29, so the other questions probably would take us over time, so we might leave it there. And thank you both very much for answering the questions and taking us through such a large topic in this evening. Thank you very much indeed.

 
David: Great pleasure.

 
Jennifer: Thank you. So I would just like to extend my thanks both to Tim, Mareeka and David for presenting this evening, and also everyone who has joined us online. We hope that you did enjoy the session and also hope you enjoy the rest of your night.


Current as at: Tuesday 4 April 2023
Contact page owner: Immunisation