Sonja Elia

Hypersensitivity reactions to human papillomavirus vaccine in Australian schoolgirls: retrospective cohort study

Objective To describe the outcomes of clinical evaluation, skin testing, and vaccine challenge in adolescent schoolgirls with suspected hypersensitivity to the quadrivalent human papillomavirus vaccine introduced in Australian schools in 2007. Design Retrospective cohort study. Setting Two tertiary paediatric allergy centres in Victoria and South Australia, Australia. Participants 35 schoolgirls aged 12 to 18.9 years with suspected hypersensitivity reactions to the quadrivalent human papillomavirus vaccine. Main outcome measures Clinical review and skin prick and intradermal testing with the quadrivalent vaccine and subsequent challenge with the vaccine. Results 35 schoolgirls with suspected hypersensitivity to the quadrivalent human papillomavirus vaccine were notified to the specialised immunisation services in 2007, after more than 380 000 doses had been administered in schools. Of these 35 schoolgirls, 25 agreed to further evaluation. Twenty three (92%) experienced reactions after the first dose. Thirteen (52%) experienced urticaria or angio-oedema, and of these, two experienced anaphylaxis. Thirteen had generalised rash, one with angio-oedema. The median time to reaction was 90 minutes. Nineteen (76%) underwent skin testing with the quadrivalent vaccine: all were skin prick test negative and one was intradermal test positive. Eighteen (72%) were subsequently challenged with the quadrivalent vaccine and three (12%) elected to receive the bivalent vaccine. Seventeen tolerated the challenge and one reported limited urticaria four hours after the vaccine had been administered. Only three of the 25 schoolgirls were found to have probable hypersensitivity to the quadrivalent vaccine. Conclusion True hypersensitivity to the quadrivalent human papillomavirus vaccine in Australian schoolgirls was uncommon and most tolerated subsequent doses.

Pain management strategies used during early childhood immunisation in Victoria

The study aims to identify pain management practices used during scheduled childhood immunisation.

Establishing Intra- and Inter-Rater Agreement of the Face, Legs, Activity, Cry, Consolability Scale for Evaluating Pain in Toddlers During Immunization

BACKGROUND The Face, Legs, Activity, Cry, Consolability (FLACC) scale is a five-item tool that was developed to assess postoperative pain in young children. The tool is frequently used as an outcome measure in studies investigating acute procedural pain in young children; however, there are limited published psychometric data in this context. OBJECTIVE To establish inter-rater and intrarater agreement of the FLACC scale in toddlers during immunization. METHODS Participants comprised a convenience sample of toddlers recruited from an immunization drop-in service, who were part of a larger pilot randomized controlled trial. Toddlers were video- and audiotaped during immunization procedures. The first rater scored each video twice in random order over a period of three weeks (intrarater agreement), while the second rater scored each video once and was blinded to the first raters scores (inter-rater agreement). The FLACC scale was scored at four timepoints throughout the procedure. Intraclass correlation coefficients were used to assess agreement of the FLACC scale. RESULTS Thirty toddlers between 12 and 18 months of age were recruited, and video data were available for 29. Intrarater agreement coefficients were 0.88 at baseline, 0.97 at insertion of first needle, and 0.80 and 0.81 at 15 s and 30 s following the final injection, respectively. Inter-rater coefficients were 0.40 at baseline, 0.95 at insertion of first needle, and 0.81 and 0.78 at 15 s and 30 s following the final injection, respectively. CONCLUSIONS The FLACC scale has sufficient agreement in assessing pain in toddlers during immunizations, especially during the most painful periods of the procedure.

Immunisation rates of children with cystic fibrosis using the Australian Childhood Immunisation Register

Aim:  The Australian Immunisation Handbook (ninth edition) recommends children with cystic fibrosis (CF) receive routine scheduled immunisations plus annual influenza vaccine and an additional pneumococcal vaccine at both 12 months and 4–5 years. Adherence with these recommendations is unknown. This study aimed to determine the immunisation status of children with CF attending the Royal Childrens Hospital (RCH), Melbourne.

Immunizations under sedation at a paediatric hospital in Melbourne, Australia from 2012–2016

BACKGROUND Sedation for immunizations is of particular importance in a subset of paediatric patients with anxiety disorders, needle phobia, developmental or behavioural disorders. The Royal Childrens Hospital (RCH) Melbourne offers a unique immunization under sedation service for these patients. We aimed to evaluate the number and types of patients using inpatient sedation for immunizations, distraction and sedation techniques used, and outcomes of these procedures. METHODS A medical record review was conducted on all patients who had immunization under sedation between January 2012 to December 2016 in the RCH Day Medical Unit (DMU). RESULTS A total of 139 children and adolescents had 213 vaccination encounters. More than half of the vaccination encounters involved multiple vaccines. A total of 400 vaccines were administered. One third of patients (32.3%) had multiple DMU admissions for vaccinations. The median age of patients was 13 years. There were only 10 (4.7%) failed attempts at vaccination; all due to patient non-compliance with prescribed sedation. The majority of patients (58.9%) had a diagnosis of needle phobia. Sedation was most commonly adequately achieved with inhaled nitrous oxide (54.7% sole agent). Midazolam was often used as an adjunct therapy (42.8%). Local anaesthetic cream or play therapy, were used in only 5.9% and 3.9% of patients respectively, although this may reflect poor documentation rather than actual practice. CONCLUSIONS For a subset of paediatric patients for which standard immunization procedures have failed, distraction techniques and conscious sedation enable immunizations to be given safely and effectively. Future research will develop protocols to streamline immunization procedures under sedation.

Recurrence risk of a hypotonic hyporesponsive episode in two Australian specialist immunisation clinics

BACKGROUND A hypotonic hyporesponsive episode (HHE) is a well-described adverse event following immunisation (AEFI) in young children. There is limited data regarding recurrence post re-vaccination. METHOD A retrospective analysis of HHEs reported to two tertiary paediatric hospitals in Australia: The Royal Childrens Hospital, Melbourne [2006-11] and the Childrens Hospital Westmead, Sydney [1997-2014]. HHE definition level of confidence was allocated according to Brighton Collaboration (BC) criteria and defined immediate if within 30 min post vaccination. The Australian Immunisation Register (AIR) was utilised to document current immunisation status. RESULTS 235 HHE cases (135 Melbourne, 100 Sydney) were identified: 47% were female and 67% (157/235) occurred following the routine dose one vaccines at 6-8 weeks of age. Median time following immunisation was 120 min (range 1 min to 14 days) An immediate HHE occurred in 43% (102/235) and by BC criteria, 74% (173/235) were level 1 (definite). Subsequent vaccines were administered under supervision in hospital in 37% overall (86/235); 43% (58/135) in Melbourne and 28% (28/100) in Sydney. HHE recurrence rate was 3% (7/235) [95% confidence interval 1-6%]. AIR records were available in 94% (221/235). At a median age of 3.1 years, 84% (186/221) were up-to-date with recommended vaccines. CONCLUSION This study highlights the importance of specialist immunization clinics in supporting the National Immunisation Program, through follow-up and management of serious adverse events following immunization.

No jab, no record: Catch-up vaccination of children in immigration detention: Vaccination in immigration detention

International Health and Medical Services (IHMS) are contracted to provide health services, including catch‐up vaccination, for individuals in immigration detention. Our audit of catch‐up vaccination in asylum seeker children who spent time in held detention demonstrates inadequate and suboptimal vaccine delivery in this setting, and no evidence that IHMS recorded vaccines on the Australian Childhood Immunisation Register at the time. We also found substantial shortfalls in vaccination for these children after they were released from detention. Immunisation in this cohort falls well below Australian community standards, does not demonstrate assurance in IHMS provision of care, and has implications for similar asylum seeker cohorts nationally as well as people in held detention.

Human papillomavirus vaccine uptake in adolescents with developmental disabilities

ABSTRACT Background: The Human Papillomavirus (HPV) vaccine is offered in Australia to all males and females at 12 to 13 years. In 2015 the national HPV coverage was 77.4% for females and 66.4% for males. There is no Australian coverage data for the subgroup of adolescents with disabilities. Method: We reviewed the HPV vaccine status of all 14 year-old adolescents who attended a developmental medicine clinic in a tertiary hospital in Melbourne during 2014. Motor function and intellectual impairment were also recorded. Results: Of the 72 adolescents in the audit, only 39.5% of males and 44.1% of females were fully immunised against HPV. Those with intellectual impairment had particularly low levels of HPV immunisation (16/47 (34%)). Conclusion: In this study HPV vaccine coverage in adolescents with developmental disabilities was found to be well below national levels. Larger studies of HPV uptake and exploration of the barriers to immunisation in this population are urgently needed.

Providing opportunistic immunisations for at-risk inpatients in a tertiary paediatric hospital

Attaining high immunisation coverage rates for children with medical conditions is vital. The Royal Childrens Hospital (RCH) Immunisation Service has the opportunity to check each inpatients immunisation status and provide opportunistic vaccines and/or bring the Australian Childhood Immunisation Register (ACIR) up-to-date. This paper highlights that during admission, one quarter of children were not up-to-date with routine scheduled immunisations and 42% of those inpatients due or overdue for immunisation were vaccinated. The model of establishing routine checking of immunisation records and reminding hospital staff about immunisation can result in improvements in vaccination coverage. Healthcare providers have a responsibility to check immunisation status and offer vaccines when necessary; however, often there are missed opportunities to immunise. This paper demonstrates that having a dedicated Immunisation Service, a partnership with a relevant government agency, and effective collaboration with inpatient clinical teams, opportunistic immunisation can be achieved for inpatients.