Immunisation Best Practice · 1. Turner N, Charania N, Chong A, Stewart J and Taylor L (2017) The...
Transcript of Immunisation Best Practice · 1. Turner N, Charania N, Chong A, Stewart J and Taylor L (2017) The...
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Immunisation Best Practice
2017 Immunisation WorkshopLisbeth Alley, IMAC Northern Regional AdvisorTrish Wells Morris IMAC educator
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Immunisation progress!
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% c
over
age
Year
2003 National Immunisation strategy
2002 Priorities for action report
1999 NHC report
1995 strategy
1993 PHC report
2007 National Health targets 2010 Parliamentary
Enquiry
2012 95% target set by the Better Public Services Programme
2005 NIR
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Equity gaps are closing!
11% gap
2.5% gap
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Why high immunisation coverage?
• Individual health and community protection
• To protect those who have not been vaccinated, either by choice, or for medical reasons
• Where possible to eradicate the disease e.g. smallpox, polio, measles, rubella
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2017 immunisation target and indicators
• 95% of 8 month olds (target) , two year olds, and five year olds (goals or indicators)
3 for infants & young children fully immunised
• 75% of girls born in 2004 are fully immunised for HPV (goal)
Human Papillomavirus
vaccine
• 75% of those aged 65 and over receive influenza vaccine (goal)Influenza
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National coverage data – 3 months June 2017
6 months - 80%
8 months - 92% timeliness
12 months - 94%
18 months - 85%
24 months - 93% coverage
5 years - 89%
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Immunisation equity June 2017
92 9389
93 94 918892
8795 96
9198 97
9187
80 82
0
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8 months 24 months 5 years
NIR 3 month datasets
allNZEMaoriPacificAsianOther
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Provider immunisation culture
Reception is welcoming and updates contact details
Cold chain is well managed – failures prevented
Primary care vaccinators are authorised, supported, educated & knowledgeable
Internet, social media and text reminding are available and used
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Provider immunisation culture
Leadership using a team approach, collaboration with other providers and local resources
Efficient interface of Practice Management System (PMS) with NIR
Positive engagement with family/whānau from pregnancy/early post natal period
Action plans improve vaccination literacy, reduce equity gaps & enable opportunities
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• Accept birth nomination message from NIR within three days • Enrol under the B code• Connect with family and send an appointment at 4 weeks of age
for 6 week immunisation event• Update enrolment code by next quarter
Early newborn enrolment – on time
• Pre-call two weeks before due to ensure timeliness• Reminder day before if appropriate ? Txt/phone call
Pre-calls
• Identify children due or overdue for immunisation – add PMS alert• PMS alerts highlight due/overdue immunisations• Facilitate/promote opportunistic immunisation
Alerts
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Prompt referral to OIS for families experiencing barriers
Provider
NIR
Outreach provider
Child
3 attempts to contact parent/ caregiver or asap if no current contact.Use multiple methods as appropriate
Refer promptly
Referral sent to outreach provider
Vaccination event completed
Provider notified via NIR
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Value the NIR/PMS data
• PMS & NIR communicate with each other
• Know how to contact the local NIR administrator
• Each vaccinator needs an Authorised User agreement
• Notify NIR of staff and patient transfers in and out
• Fix errors promptly – ‘correct now’
• Do status query on each child to update the PMS
• Be cautious about decline and non responder codes
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On time!
4 in a row!
By 4 years 1 month!
All up to date by age 14Check boosters
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14 year old immunisation check
• Has had:
11 year old Boostrix?
2- 3x HPV vaccines?
2x MMR vaccines?
All other vaccines eligible for
Eligible for additional special group vaccines?
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20 special groups funded for vaccines• Asplenia• Post chemotherapy• Cochlear Implant• Error of metabolism - at risk of major
metabolic decompensation• Stem cell transplant• Hepatitis A & B* contact• Hepatitis C positive• Immune deficiency/ immune-
suppression >28 days, pre, post, household contacts
• Influenza• Kidney disease
• Liver disease• Meningococcal disease• Needle stick• Non-consensual sexual intercourse• Pneumococcal increased risk*• Pregnancy • Rubella risk• Solid organ transplant pre & post• Tuberculosis**Includes some newborns
IMAC factsheet: Funded vaccines for special groups July 2017
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Pregnant women
• Increased coverage needed!• Do you receive IAN bloods/early
scan results?• Do you have a Pregnancy Register?• Recall for: Influenza vaccine anytime during
pregnancy. Pertussis containing vaccine 28-38
weeks each pregnancy. MMR after delivery if no record of
receiving 2 doses
IAN = initial antenatal blood test
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Informed consent and communicationWelcome, be client centred, develop rapport and trust
List every disease antigen for consent
Discuss benefits & risks, allow time for questions
Use resources/images to reinforce messages
Check preferences for minimising discomfort
Keep the conversation open
RECOMMEND immunisation!
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If a choice is made to decline:
•Formal discussion required •Written information is provided •Document discussion, information and
resources provided• Inform caregivers:
How to minimise risk of diseaseThat calls will continue for subsequent immunisation eventsWhen there is a disease outbreak parents will be calledHealth professionals will continue to discuss immunisationImmunisations can be given in the future as a catch-up
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Vaccine administration 7 “Rights”
Right person
Right vaccine and diluent (if applicable) check the cold chain!
Right time (age, interval and vaccine expiration time/date)
Right dosage
Right route (including correct needle angle, length and technique)
Right site
Right documentation
Ref: Adapted from Immunisation Action Coalition
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Pre-vaccination screening -safety/optimum response
• Significant illness or fever reschedule Unwell today
• ContraindicationSerious reaction to this vaccine
• ContraindicationAnaphylaxis to a vaccine component
• Check intervalDate of last dose
• Consider vaccinate in secondary careApnoea last vaccination –preterm baby
• Avoid pertussis containing vaccineUndiagnosed neurological condition
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Pre-vaccination screening -safety/optimum response
• Check recommended route & precautions
Bleeding disorder –thrombocytopenia
• Up to date? Delay conception for live vaccinesPlanning pregnancy
• Delay some vaccines till deliveryPregnant
• Avoid live vaccines for intervalBlood products or Ig
• Delay for 4 week intervalLive vaccine <4 weeks
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Pre-vaccination screening -safety/optimum response
• Check if live vaccines OKSteroid therapy
• Avoid live vaccinesImmunosuppressive therapy (IT)
• Check if live vaccines OKBaby of mother on IT during pregnancy
• Check if live vaccines OKLowered immunity
• Develops post vaccine rash - avoid contact
Household contact of immune-suppressed
person
? Specialist advice
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Immunisation best practice recommendations
Wash/sanitise hands (gloves not required)
Clean non-touch technique
Do not mix different vaccines
Prepare vaccine after informed consent obtained
Identify the correct site and needle length
Multiple injections in different sites/muscles by one vaccinator
Promote administration of all eligible vaccines at one visit
Confident and calm Ref: ACIP (2017) General Best Practice Guidelines for Immunisation MOH (2017) Immunisation Handbook 2017 App. 3 & 7
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Use the correct route for safety and effectiveness
Oral
Rotavirus
Intramuscular
DTaP-IPV- Hep B/Hib, DTaP-IPV, Tdap,Td
PCV
Hib
HPV
Subcutaneous
MMR
Varicella
IPOL
Intradermal
BCG
See Immunisation Handbook Table 2.8
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Anatomical identification of injection sites
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WHO key pain mitigation strategies
Avoid syringe aspiration
Encourage breastfeeding during vaccination
Administer vaccines in order of increasingpain
Neutral verbal cues – calm explanations, avoid excessive reassurance & anxiety
promoting terms
World Health Organisation (2015) Reducing pain at the time of vaccination WHO position paper
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Other pain mitigation strategiesGive rotavirus vaccine
first
Young child
Abdominal breathing
Use distraction
• High sucrose• 6 weeks & 3 months
• Sit upright• Hold comfortably• Explain prior to visit
• Anxious children and parents
• Toy or book• Bubbles held by child• Counting or talking
IMAC (2016) Mitigating vaccination pain and distress factsheet
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Holding and positioning
• Baby cuddled – avoid lying on their back• Infant on parent/caregivers knee• Child sit upright, positioned side on, front on
or straddled • Secure hold - avoid restraint (as increases anxiety and risks injury)
• Clear instructions and encouragement for parent/caregiver
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Post vaccination
Verbal Written
Inform about expected responses
Who to contact for assistance
After hours number
Book next immunisation appointment
Document on PMS & in WCTO Book • Vaccine batch & expiry• Injection site & route• Needle length and gauge• Informed consent vaccination
and NIR• The vaccinee was well • Known allergies• Adverse event(s)• That they waited 20 minutes
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Vaccine hesitancyVaccine Hesitancy - a dynamic
continuum• Start with a presumptive
recommendation• Client centred conversational style
vs lecture• Be prepared to understand concerns• Counter misinformation with
evidence based facts & pro stories• Some do change their mind• Don't neglect acceptors, support
their decision ↑ resilience • Avoid repeating myths - refer to risk
of disease and protection provided by vaccines
Accept all vaccines
Accept but
doubts
AcceptDelay someRefuse
Vaccine deniers
VaccineRefusers
High demand low demand
Vaccine hesitancyRefs: Diagram adapted from SAGE report on vaccine hesitancy
MacDonald N, (2017) Vaccine hesitancy – definition and dimensions
WHO (2016) Best practice guidance - How to respond to vocal vaccine deniers
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Communication to influence behaviour
• Handbook, factsheets, best practice sites, social media Can be learned – be proactive
• What do you think about vaccines?Use open ended questions
• I understand . . . Use affirmations
• You are concerned by . . .Listen reflectively, communication is a 2 way process
• . . . to change behaviourKnowledge is important but not enough . . .
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Tell compelling stories………..
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IMAC factsheets
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References:
1. Turner N, Charania N, Chong A, Stewart J and Taylor L (2017) The challenges and opportunities of translating best practice immunisation strategies among low performing GP to reduce equity gaps in childhood immunisation coverage in NZ
2. MOH (2017) Immunisation Handbook 2017 App. 3 & 73. Turner N, Taylor L, Chong A, Horrell B. (2017) Identifying factors
behind the general practice use of the term ‘decline’ for the childhood immunisation programme in New Zealand
4. A Taddio et al (2015) Reducing pain during vaccine injections: clinical practice guideline CMAJ
5. Kroger AT, Duchin J, Vázquez M. (2017) General Best Practice Guidelines for Immunization. (ACIP)
6. MacDonald N (2017) Vaccine Hesitancy: Definition and Dimensions7. WHO Sage Vaccine Hesitancy and Pain Mitigation recommendations