Transcript Post vaccination Care

Immunisation Update for GPs
27 April 2006
Immunisation Update
for Practice Nurses
Dr Peter Eizenberg
Director, ‘Doctors of Ivanhoe’
Executive Director, North East Valley Division of General Practice
Member, Scientific Advisory Committee, NCIRS
Member, NHMRC CCRE Immunisation Reference Group, RCH
General Vaccine update
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Current issues in vaccination
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New travel vaccines
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New vaccines coming soon
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‘Vivaxim’
‘Dukoral’
‘Boostrix-IPV ’
‘VIVOTIF Oral’
HPV vaccine
Herpes-Zoster vaccine
Rotavirus vaccines
Seasonal FLU & Pandemic FLU update
Australian Standard Vaccination Schedule 18 Sep 2003
AGE
Birth
/
VACCINE
1
Hepatitis B
2 months
Hepatitis B
2,3
DTPa
Hib
4 months
Hepatitis B
2,3
DTPa
Hib
6 months
Hepatitis B
2
DTPa
Hib
12 months
Hepatitis B
3
18 months
1,2
IPV
7vPCV
1,2
IPV
7vPCV
1
IPV
7vPCV
1,2
Hib
MMR
MenCCV
VZV
*****
1
23vPPV
2 years
4 years
10 – 13 years
15 – 17 years
50 years
and over
65 years
and over
DTPa
Hepatitis B
IPV
MMR
1
4
VZV
dTpa
dT
2
23vPPV
23vPPV
■ NIP funded from 1 Nov 2005
Influenza
2
(annual)
Influenza
(annual)
Current issues
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Childhood IPV combination vaccines
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Caution with ‘Varilrix ’ diluent
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1 April 2006
Influenza vaccine for infants 6 months to 2 years
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Need to reconstitute with pellet
‘Tet Tox ’ deletion from Drs bag
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Any dose ‘Infanrix–hexa’ requires 4th dose HIB vaccine at 12 mo
(‘COMVAX’); (TAS, NSW, SA, ?some VIC)
Australia currently recommends 0.125mL dose
Two doses recommended (at least one month apart) for children
aged under 9 years who are receiving influenza vaccine for the first time.
‘Vaxigrip Junior ’ 0.25 ml syringe
‘Pneumovax’ 23v PPS
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single 5-yr re-vaccination for all over 65 yrs
New travel vaccines
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‘Vivaxim ’
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‘Dukoral ’
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New chapter in Handbook update to NHMRC 8th Edition AIH
or monovalent ‘IPOL’ (Sabin supply to end soon)
‘VIVOTIF Oral’ now available (New Typhoid vaccine)
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Oral Cholera vaccine (inactivated)
2-dose schedule (for adults)
Effective against Cholera for 6 months
Effective against ETEC (Travellers Diarrhoea) for 3 months
‘Boostrix-IPV ’ now available (approx $70)
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Hepatitis A + Typhoid
3 doses, alt days, approx $50
? Other ‘new’ travel vaccines
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MMR - all travellers born >Jan 1966 (if not doc’ed 2 prior doses)
Influenza - ? all travellers, all seasons, all destinations
New vaccines
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Future vaccines coming soon
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Human Papilloma Virus
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Zoster vaccine
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RSV vaccine
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Rotavirus vaccine
General Vaccine update - resources
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Catch-up calculator (SA Imm website)
http://www.healthsa.sa.gov.au/immunisationcalculator/
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Applies to all state schedules,
children up to 7 years
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‘Strive for 5’ cold-chain publication
 Range 2-8 degrees C. …but STRIVE for 5
 Purpose-built vaccine fridges to replace domestic
fridges
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DHS newsletter April 2006
 Detailed update
Seasonal & Pandemic Flu
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Issues
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Seasonal FLU
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Pandemic FLU
Avian FLU
 Avian-mutant Influenza
 Human Influenza pandemic planning
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2006 Seasonal FLU
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Impact of Seasonal FLU – Australia (est. annual)
 Medical consults
1 million
 Hospitalisations
20-40,000
 Deaths
1,500
 Days off work
1.5 million
 Total economic cost
$600 million
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FLU Vaccination Effectiveness (during FLU season)
 70-80% effective against FLU illness
 50-60% reduction all RTIs (>65s)
 50% reduction hospitalisation, any cause (>65s)
 68% reduction death, any cause (>65s)
 40-50% reduction absenteeism during FLU season
2006 Seasonal FLU
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FLU vaccine components Season 2006
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A/New Caledonia H1N1
A/New York H3N2
B/Malaysia
Influenza vaccine for infants 6 months to 2
years
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Australia currently recommends 0.125mL dose
Two doses recommended (at least one month apart) for
children
aged under 9 years who are receiving influenza vaccine
for the first time.
‘Vaxigrip Junior’ 0.25 ml syringe
2006 Seasonal FLU
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High-risk: age >65 yrs
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High-risk: age <65 yrs
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NHMRC recommends: vaccn during any stage of pregnancy
Normal risk (age >6 mo)
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40% coverage rate
High-risk: Pregnancy
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80% coverage rate (DHS supplies enough to cover 110%)
NHMRC recommends Flu vaccine for:
‘anyone who wishes to reduce their risk of FLU illness’
Travel vaccination (age >6 mo)
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all people, all destinations, all seasons
Avian FLU – Human FLU
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Update on current avian FLU & Human infection
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Previous FLU pandemics & future modelling
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Anti-viral medications
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Pandemic FLU vaccine production
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What to do now (global & local)
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Current Govt (C’wealth & VIC DHS) preparedness
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Critical issues for GPs
Avian FLU – Human FLU
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Update on current avian FLU & Human infection
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FLU causes recurrent epidemics every 1-3 yrs, for >400 years
Avian FLU vs Avian-mutant influenza
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Human FLU types A, B, C
Birds are reservoir for type A FLU
Significant genetic variation amongst FLU strains
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?the next pandemic?
15 haemagglutanins (H), 9 neurominadases (N)
Current Avian FLU H5N1
Previous FLU Pandemics 1918, 1957, 1968
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Novel type A FLU virus with human & avian components
1918 (H1N1) mutation from avian FLU killed 20-40 million people
1957 – gene reassortment (H2N2) killed 1 million
1968 – gene reassortment (H3N2) killed 1 million
Mixing of avian & human FLU genome
Requires a host with both influenzae viruses for mixing to occur
Avian FLU – Human FLU
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This outbreak
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Initially in birds (geese, chickens, wild birds)
Spread through migration, importing
Host range broadened to include mammals (pigs, humans)
Hong Kong outbreak 1997 (18 human cases, 6 deaths)
Dec 2003: Sth Korea chicken deaths due to Avian FLU
Dec/Jan 2004: Vietnam 10 human cases, 8 children died
2004: also Japan, Indonesia, Thailand, Cambodia, China
2005-6: also Azerbaijan, Iraq, Turkey
Human toll
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To March 2006: total human cases 186, deaths 105
WHO >80% infections associated with direct bird contact
NB Mortality for 1918 Spanish FLU
2.5%
Avian FLU – Human FLU
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Clinical picture
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Usually contact with chickens
3 days to onset of illness
Fever, cough, SOB
Diarrhoea
Some sputum production +/- haemoptysis
Pleuritic chest pain
Lymphopenia
Thrombocytopenia
Chest infiltrate on CXR
Avian FLU – Human FLU
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Computer modelling:
Shows epidemic containable if:
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The number of people affected <30
The 20,000 people closest to them get prophylactic anti-virals
(must be within 21 days)
Based on people infecting only 1.6 other people
If more, household quarantine may also be necessary
Avian FLU – Human FLU
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Neuraminidase inhibitors
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N facilitates release of virus from cells
N-inhibitors reduces release of virus & shedding from patients
Needs to be given early – before viral transmission becomes
efficient
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Widespread resistance to Amantadine
Possibly due to use in birds in China
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Osaltamivir & Zanamivir currently being stockpiled
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? For use at site of outbreak
those at risk
Prophylaxis of contacts
Patients with confirmed disease
Avian FLU – Human FLU
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Vaccines
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Vaccine for birds
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Human vaccine: Current human vaccine against H & N proteins
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Vietnam 2005 20 million shots (aiming for 400 million)
Also China, Indonesia
A/New Caledonia H1N1; A/New York/Fujian H3N2; B/Malaysia
Humans should have human FLU vaccine
Should help prevent co-infection; reduce risk of genetic rearrangement
High risk individuals should also have Pneumovax
Human pandemic vaccine development
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USA, Australia
Tested healthy under 65s – good immunity
2 doses required
Actual strain not yet in existance
Avian FLU – Human FLU
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The global approach
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must assist 3rd world countries in controlling their disease
Urgency for vaccine development
Share stockpiles of vaccines & drugs
Control pandemic at source is the ideal approach
Current observations
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SARS an important ‘wake-up call’
Avian FLU spreading rapidly, but not a current threat to humans
Pandemic preparation currently rather disjointed & poorly
coordinated
‘Designated hospital’ concept provides a potentially useful
organisational structure
Role of anti-virals remains unclear
FLU Pandemic planning – issues for GPs
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Current surveillance expectations
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Relationships/partnerships in planning
? role of General Practice/Local Divisions of GP
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DHS definition for case for suspicion
 ? Is your practice appropriately prepared
with DHS
with regional Infectious Disease Depts
with GPDV/ADGP & C’wealth
Possible models of care, for discussion
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e.g. General Practice clinics to be ‘Flu-free’ zones
Patients with Flu illness go to ‘Fever Clinics’
Home-based care by GPs for mild Flu illnesses
FLU Pandemic planning – issues for GPs
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Pandemic planning issues
Communication strategies/efficiencies
 GP awareness
 consistency of info, access to updates, etc
 staff preparedness
 Human resource/staffing issues
 GP staffing of fever clinics
 Equipment stock
 Masks/gowns/anti-Flu medications
 Anti-Flu medication prescriptions
 (availability, role of Amantadine)
 Practice viability/sustainability
 Practice security issues
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