1. Immunisation Update for Practice Nurses
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

2. General Vaccine update
Current issues in vaccination
New travel vaccines
‘Vivaxim’
‘Dukoral’
‘Boostrix-IPV ’
‘VIVOTIF Oral’
New vaccines coming soon
HPV vaccine
Herpes-Zoster vaccine
Rotavirus vaccines
Seasonal FLU & Pandemic FLU update

3. Australian Standard Vaccination Schedule 18 Sep 2003
■ NIP funded from 1 Nov 2005

4. Current issues Childhood IPV combination vaccines
Any dose ‘Infanrix–hexa’ requires 4th dose HIB vaccine at 12 mo (‘COMVAX’); (TAS, NSW, SA, ?some VIC)
Caution with ‘Varilrix ’ diluent
Need to reconstitute with pellet
‘Tet Tox ’ deletion from Drs bag
1 April 2006
Influenza vaccine for infants 6 months to 2 years
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
single 5-yr re-vaccination for all over 65 yrs

5. New travel vaccines ‘Vivaxim ’ ‘Dukoral ’
Hepatitis A + Typhoid
‘Dukoral ’
Oral Cholera vaccine (inactivated)
2-dose schedule (for adults)
Effective against Cholera for 6 months
Effective against ETEC (Travellers Diarrhoea) for 3 months
New chapter in Handbook update to NHMRC 8th Edition AIH
‘Boostrix-IPV ’ now available (approx $70)
or monovalent ‘IPOL’ (Sabin supply to end soon)
‘VIVOTIF Oral’ now available (New Typhoid vaccine)
3 doses, alt days, approx $50
? Other ‘new’ travel vaccines
MMR - all travellers born >Jan 1966 (if not doc’ed 2 prior doses)
Influenza - ? all travellers, all seasons, all destinations

6. New vaccines Future vaccines coming soon Human Papilloma Virus
Zoster vaccine
RSV vaccine
Rotavirus vaccine

7. General Vaccine update - resources
Catch-up calculator (SA Imm website)
Applies to all state schedules, children up to 7 years
‘Strive for 5’ cold-chain publication
Range 2-8 degrees C. …but STRIVE for 5
Purpose-built vaccine fridges to replace domestic fridges
DHS newsletter April 2006
Detailed update

8. Seasonal & Pandemic Flu
Issues
Seasonal FLU
Pandemic FLU
Avian FLU
Avian-mutant Influenza
Human Influenza pandemic planning

9. 2006 Seasonal FLU Impact of Seasonal FLU – Australia (est. annual)
Medical consults 1 million
Hospitalisations ,000
Deaths 1,500
Days off work million
Total economic cost $600 million
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

10. 2006 Seasonal FLU FLU vaccine components Season 2006
A/New Caledonia H1N1
A/New York H3N2
B/Malaysia
Influenza vaccine for infants 6 months to 2 years
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

11. 2006 Seasonal FLU High-risk: age >65 yrs High-risk: age <65 yrs
80% coverage rate (DHS supplies enough to cover 110%)
High-risk: age <65 yrs
40% coverage rate
High-risk: Pregnancy
NHMRC recommends: vaccn during any stage of pregnancy
Normal risk (age >6 mo)
NHMRC recommends Flu vaccine for: ‘anyone who wishes to reduce their risk of FLU illness’
Travel vaccination (age >6 mo)
all people, all destinations, all seasons

12. Avian FLU – Human FLU Update on current avian FLU & Human infection
Previous FLU pandemics & future modelling
Anti-viral medications
Pandemic FLU vaccine production
What to do now (global & local)
Current Govt (C’wealth & VIC DHS) preparedness
Critical issues for GPs

13. Avian FLU – Human FLU Update on current avian FLU & Human infection
FLU causes recurrent epidemics every 1-3 yrs, for >400 years
Avian FLU vs Avian-mutant influenza
?the next pandemic?
Human FLU types A, B, C
Birds are reservoir for type A FLU
Significant genetic variation amongst FLU strains
15 haemagglutanins (H), 9 neurominadases (N)
Current Avian FLU H5N1
Previous FLU Pandemics 1918, 1957, 1968
Novel type A FLU virus with human & avian components
1918 (H1N1) mutation from avian FLU killed 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

14. Avian FLU – Human FLU This outbreak Human toll
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
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%

15. Avian FLU – Human FLU Clinical picture 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

16. Avian FLU – Human FLU
Computer modelling: Shows epidemic containable if:
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

17. Avian FLU – Human FLU Neuraminidase inhibitors
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
Widespread resistance to Amantadine
Possibly due to use in birds in China
Osaltamivir & Zanamivir currently being stockpiled
? For use at site of outbreak
those at risk
Prophylaxis of contacts
Patients with confirmed disease

18. Avian FLU – Human FLU Vaccines Vaccine for birds
Vietnam million shots (aiming for 400 million)
Also China, Indonesia
Human vaccine: Current human vaccine against H & N proteins
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
USA, Australia
Tested healthy under 65s – good immunity
2 doses required
Actual strain not yet in existance

19. Avian FLU – Human FLU The global approach Current observations
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
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

20. FLU Pandemic planning – issues for GPs
Current surveillance expectations
DHS definition for case for suspicion
? Is your practice appropriately prepared
Relationships/partnerships in planning ? role of General Practice/Local Divisions of GP
with DHS
with regional Infectious Disease Depts
with GPDV/ADGP & C’wealth
Possible models of care, for discussion
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

21. FLU Pandemic planning – issues for GPs
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