PAS 10 - Immunisation (Preventative Medicine)

What are the equipment requirements for vaccine storage?

1) Monitoring and recording the vaccine refrigerator temperature twice daily and after power outages. 2) Monitoring & adjusting of equipment e.g. data logger, thermometer. 3) Equipment maintenance including − servicing the refrigerator & data logger − changing the logger & thermometer batteries − checking accuracy of the thermometer − cleaning the refrigerator 4) Freezer storage for ice pack/gel packs (in case of power failure or outreach immunisation sessions).

26 year old Post Doctoral student in Veterinary Medicine presents for immunisation in preparation for a trip to Thailand. He will be in Thailand for 3 months including during the rainy season. He will be spending 2 weeks in Bangkok and the rest of the time in rural Northeast Thailand with occasional visits into Chiang Rai. He will be working with livestock (cattle and buffalo) in an agricultural area. He says he has had all the usual childhood immunisations but does not have a childhood vaccine record. He provides proof of vaccination against Rabies/ABL with positive titres and has been vaccinated against Q fever following negative antibody serology and a negative skin test. A. Which of the following vaccines will you recommend? - Hepatitis A - Hepatitis B - Influenza - Typhoid - Cholera - Yellow Fever - Japanese Encephalitis - Rabies - MMR - Tetanus - Q Fever B. What vaccine preparations will you choose and why? C.What other chemoprophylaxis will you offer him?

A. Hepatitis A yes, include patient education on food/water borne illness. Hepatitis B yes, OR verification of HepB immunity via HepBsAb or documentation of vaccination prior to attending vet school. Influenza yes, seasonal Typhoid yes, include patient education on food/water borne illness. Cholera no, see page 179 in Australian Immunisation Handbook, 10th Edition 2013 Yellow Fever no, not indicated for this region Japanese Encephalitis yes, rural Asia, wet season, travel for >1month, outdoor activities. Rabies as above MMR offer 2nd dose Tetanus yes, booster as >10 years since last dose and going to high risk area Q Fever as above B.(see table 3.2.1 page 123-126 in Australian Immunisation Handbook, 10th Edition, 2013) C. Malaria prophylaxis (see page 113-114 in Australian Immunisation Handbook, 10th Edition, 2013

Case #1 David is 6 months old and is not an Aboriginal or Torres Strait Islander. His mother has presented today for his routine immunisations. He is well and she has no complaints. David has the following immunisations recorded on his medical record: Birth: Hep B 2 months: HepB- DTPa-Hib-IPV, 13vPCV, Rotavirus 4 months: HepB- DTPa-Hib-IPV, 13vPCV, Rotavirus A. What will you give him today? B. When does he need to come back for his next immunisation? C.What will you tell mum about adverse reactions to vaccinations? Case #3 Look back at case #1. Suppose David had come in at age 9 months with the following immunisation record. Birth: HepB 2 months: Hib-HepB, DTPa-IPV, 7vPCV, Rotavirus D. What will you give him today? E. What is the plan to catch him up by age 24 months?

A. Regularly scheduled 6 months immunisation series for non-indigenous children: HepB-DTPa-Hib-IPV, 13vPCV, Rotavirus (third dose depends on vaccine brand used) B. Age 12 months C. Most common side effects from vaccination are: transient pain, redness, swelling at injection site, low grade fever. Often children will develop firmness or nodule at injection site in the following week. All of these indicate good immune response to the vaccine and do not need to be evaluated unless severe. May treat with paracetamol and/or cool compresses. More severe reactions, redness, swelling involving a large part of the limb, hives, fever above 39.4C, other GI or respiratory symptoms are rare and should be evaluated and an adverse event report sent to TGA. D. Australian Immunisation Handbook recommends catch up vaccines be given "as quickly as possible". Today give: 4 month series: Hib-HepB, DTPa-IPV, 13vPCV Rotavirus vaccine should not be administered after age 24 weeks for the two dose vaccine (Rotarix) or after 32 weeks for three dose vaccine (RotaTeq) E. Age 10 months for DTPa-IPV, HIB, 13vPCV Hep B: Minimum dosing interval between dose #3 and dose #4 is 8 weeks. Recommend 4th dose be given at age 12 months. At 12 months: HIB, Hep B, MMR, Meningococcal C At 18 months: Varicella

Case #2 Sienna is a 4 year old Aboriginal girl who presents with her aunt for her immunisations. She has been ill with a URTI for the past 3 days. She is otherwise well and has no history of asthma or allergies. On examination she has clear runny nose, temp of 37.6C and loose cough with a few scattered coarse crackles on auscultation of the lungs. Tympanic membranes (TM) are pink with a scattered light reflex. No pus is visible behind the TM. Neck is supple with no lymphadenopathy. The following immunization record is provided: 2 months: Hib(PRP-OMP)-HepB, DTPa-IPV, 7vPCV, Rotavirus 4 months: Hib(PRP-OMP)-HepB, DTPa-IPV, 7vPCV, Rotavirus 6 months: DTPa-IPV, 7vPCV, Rotavirus 12 months: Hib(PRP-OMP)-HepB, MMR, MenCCV 18 months: Varicella, HepA 24 months: HepA, 23vPPV A. Will you vaccinate her today? If so, what will you give her? B. Does she need a catch-up Hib vaccine? Why or why not? C. Her Aunt asks if Sienna requires any more vaccinations. What to you tell her? D. What will you tell her aunt about adverse reactions to the vaccinations administered today?

A. Yes. URTI, even with low grade fever, is not generally a contraindication for administration of vaccines. It is recommended that this patient be vaccinated at today's visit. There are only two absolute contraindications to vaccination; immunosuppression and prior anaphylaxis with vaccine B. DTPa-IPV, MMR C. No. This patient has been vaccinated with Hib PRP-OMP formulated vaccine (COMVAX or liquid PedvaxHIB). This vaccine is given as 2 primary doses at age 2 and 4 months, followed by a booster at age 12 mos. If a PRP-T formulated vaccine (Infanrix hexa or Hiberex) is used 3 primary doses are required at 2,4 and 6 months, followed by a booster at 12 mos. The PRP-OMP formulation is recommended for Aboriginal or Torres Islander children in QLD due to its ability to elicit protective antibody response after the first dose (as opposed to PRP-T which requires at least 2 doses to achieve the same effect). PRP-OMP formulations are recommended for use in populations that experience high Hib attack rates associated with early peak disease onset as is the case in QLD. D. She will receive HPV and dTpa as part of the school based program between the ages of 10 and 15 years.

Which vaccines are damaged by exposure to heat or light?

Both heat and light: - OPV - Measles/MMR Light sensitive only: - BCG

What monitoring device is included in vaccine transportation of vaccine supplies?

Data Logger - data can be stored by the system and downloaded to a computer

Name 5 vaccines that are damaged or destroyed by freezing? Page 13 of the "National Vaccine Storage Guidelines: Strive for 5"

Most vaccines are destroyed by freezing, including: - DPT - Hepatitis B - DT - TT

What are the pros and cons of using a domestic refrigerator to store vaccines in a general practice?

PROS - Modifiable (Domestic refrigerators need to be modified to reduce the risk of adverse vaccine storage events) - Different compartments for vaccine storage/freezer packs in freezer as back up CONS - Domestic refrigerators are designed and built for food and drink storage - not for the special temperature needs of vaccines - The temperature within the different compartments can vary significantly. Every time the door is opened, the temperature fluctuates and temperature recovery is slow - The temperature rises during the automatic defrosting cycle in frost-free refrigerators. - The cabinet temperature is affected by ambient temperature - The temperature is set using a dial; this is crude and inaccurate (as there is no digital indication on the refrigerator of set temperature) - The internal space has several areas that are inappropriate for vaccine storage, including the door, the crisper and areas within 40 mm of the back and sides of the compartment For these reasons, domestic refrigerators are not recommended for vaccine storage. If a domestic refrigerator is the only vaccine storage option, it is possible to take steps to reduce the risk of vaccines.

How and how often should thermometers be checked and maintained?

Re-set regularly (up to twice daily on working days) Annual accuracy and battery checks/battery replacement How to check thermometer accuracy: 1) Fill a polystyrene or plastic cup with cold water. 2) Place the cup in the refrigerator freezer until a fine layer of ice forms on the top and small sections of ice form within the fluid (this may take up to 2½ hours). The presence of ice is an indication that the temperature of the water has reached 0°C. 3) Place the temperature probe into the middle of the container (be careful not to let the probe touch the container). 4) Observe the temperature on the display screen after two minutes

What is the main requirement for vaccine fridge thermometers?

The ability to record the max and min temperatures reached in a 24 hr period

What is the immunisation cold chain? What are the stages in the chain?

The system of transporting and storing vaccines within the temperature range of +2 degrees Celsius to +8 degrees Celsius from the place of manufacture to the point of administration. Stages: 1)Manufacturer 2)Supplier 3)Transportation to vaccine distribution center 4)Transportation to clinic 5)Administration to patient

How would you pack a cooler to run an outreach vaccination clinic? You will have to store the vaccines for 8 hour to cover the travel and clinic time.

pg. 29 For 8 hours or more, I would use a vaccine cold box is a purpose-built product. It has thick walls and is significantly more expensive than a cooler. 1) Chill the inside of the cooler by placing ice packs/gel packs inside for a few hours. 2) Place insulating material in the bottom of the cooler 3) Place minimum/maximum thermometer in the centre of the vaccine stock 4) Surround the vaccines with packing material and place conditioned ice packs/gel packs on top before closing the cooler At least 24 hours before each outreach session, check the number of ice packs/gel packs in the freezer and replenish as needed Freezing episodes can occur in all coolers, usually in the first 2 hours after packing. The minimum size cooler recommended for storing vaccines is 10 litres Polystyrene coolers provide limited insulation and are suitable only for storing vaccines for short periods of time (up to 4 hours). When using a cooler, store vaccines in their original packaging For a mobile service where there is no electric power supply or refrigerator, take an extra cold box containing additional ice packs/gel packs to replace the melted ice packs / gel packs. During outreach clinics the minimum/maximum temperature of the cooler or cold box should be monitored hourly.