Dr Steve Hambleton, Speech to the PHAA National Immunisation Conference

The AMA is a strong advocate for immunisation and it welcomes the review of the National Immunisation Strategy.

It will provide an opportunity to develop a planning framework that will enable us to build on and enhance initiatives in immunisation and vaccine-preventable disease now and for the future.

The first national immunisation strategy, which underpins the National Immunisation Program, was developed by the National Health and Medical Research Council in 1993.

It was further added to in 1997 as part of the Seven Point Plan to Immunise Australia launched by then Minister for Health and Aged Care, the Hon Dr Michael Wooldridge. 

Many of us who were around then remember the AMA had quite a fiery relationship with Dr Wooldridge.  For this, though, he receives a bouquet.

This very successful plan recognised the unique role that GPs play in ensuring high levels of immunisation coverage.

The plan provided financial drivers for parents in the form of: 

• the Maternity Immunisation Allowance; and
• Child Care Benefits payable only on confirmation of full immunisation.

The plan also provided incentives for GPs for vaccination of their patients and reporting those events to the Australian Childhood Immunisation Register (ACIR).

The third leg of the tripod was childcare, pre-school and school entry requirements that additionally reminded parents of the need for immunisation.

It now seems inconceivable that, despite best efforts, in 1989-90 only 53 per cent of children were fully immunised.

GPs and parents working together were supported and encouraged to achieve full immunisation of 90 per cent of the children attending their practices.

In addition to the improvement in vaccination rates, we are now confident about the potency of vaccines being delivered with documented attention to, and monitoring of, cold chain in our practices.

We can still do better, however.

In June this year, to get the ball rolling on discussions about the National Immunisation Strategy, the AMA provided a submission to the Government outlining a number of issues that should be considered for the strategy.

Many of the organisations represented here today will also be contributing to the process.

We all should think broadly about what it is we want to achieve over the next five years, and how it can be safely, effectively and efficiently delivered - then monitored and evaluated.

In 2010, the AMA continues to support population vaccination delivered by the family doctor

We are no less committed to working with the Government on the development and implementation of an improved National Immunisation Strategy.

GPs see 93 per cent of children in the 0-6 year age group seven times a year, on average, and are ideally placed to carry out this important work.

GPs have also contributed to quality data collection by notification to the ACIR of each completed immunisation episode.

Despite these gains - or maybe because of these gains – the Government removed one of the immunisation incentives to family doctors in the 2008-09 Federal Budget.

One of the legs of the immunisation tripod was being sawn off.

That incentive encouraged GPs to review the immunisation status of their child patients and no doubt contributed to further opportunistic vaccinations when required.

In our view, Budget cuts of this type downplay the role of family doctors in immunisation.

The AMA has warned that the tripod may collapse - and immunisation rates may either fall or the rates of reporting of immunisation episodes may start to fall.

Without population data, our efforts are hamstrung.

When moving beyond childhood immunisations, we know from a recent survey that 88 per cent of Australians have a regular GP, and this once again provides unique opportunities for the delivery of vaccines to targeted or vulnerable population cohorts.

What GPs are missing, however, is a mechanism for confirming immunisation status for anyone over the age of 8 - more about that later.

Vaccine Fridges

We urgently need an agreed standard for vaccine fridges and funding to support moving to that standard.

At least we now know when vaccines have frozen or when they overheat.

Our data loggers tell a grim tale about what must have been happening in the past, but we did not know about it.

Each week I am sure we are disposing of tens of thousands of dollars worth of vaccines.

One of the standards must mandate that vaccine fridges will stay cold for a minimum period of time during a blackout.

I have a very stylish glass fronted vaccine fridge, which gets hot within 30 minutes of power loss.  This is not good enough.

Nurse incentive changes

If there were concerns raised about direct GP incentives then there are now concerns raised around the Practice Nurse funding initiatives.

The major parties have different approaches to practice nurses but at least both parties recognise that they need more support.

The proposed removal of practice nurse MBS items for immunisation may negatively impact on immunisation programs.

For example, practice owners who may be non-medical may divert nurses to generate income via other means rather than for immunisation.

While there is continued expectation for general practices to ensure their nurses have appropriate immunisation training and to have quality cold chain management practices in place, there is no direct support for this to occur.

The key point here is that, prior to any unilateral decision by the new Government, the AMA should be consulted to ascertain the potential risks and impacts of their decisions.

Current Statistics

Still, we are pleased that the June ACIR statistics show a significant jump in immunisation rates for children at 60-63 months between March 2010 and June 2010.

The AMA would still like to see these figures improved – or at the very least maintained.

In that light, the AMA believes that developing the National Strategy should embrace the following issues.

Australian Childhood Immunisation Register (ACIR)

The ACIR is a valuable source of data, which can help identifying gaps where improvements may be necessary.

For the ACIR to maintain its value, as alluded to above, the Government must restore the incentive for GPs to report completed courses of a vaccine to help with maintaining the integrity of the ACIR - at least as an interim measure, until a whole of life register can be established.

Together with ACIR, we must also acknowledge the role of local divisions in this area who supported GPs to increase efforts when ACIR revealed less than desirable vaccination rates at the local population level.

That’s two bouquets I have sent today – maybe I have a temperature.

Immunisation Promotion

More support for GPs is necessary for them to promote to their patients the benefits of immunisation.

We had a live example recently with the pandemic vaccine roll- out.

When the pandemic and its potential effects were front of mind, vaccination rates were up.  But when mainstream media stopped reporting on Pandemic Influenza, vaccination rates went down.

Unfortunately, there are still vaccine fridges full of pandemic vaccine right across the country.  That vaccine should be in patients’ arms.

Similarly, vaccine preventable diseases in many cases are gone from living memory.

We now have a generation of doctors who have never seen measles, never heard whooping cough, and certainly have never seen a case of polio, or even tetanus.

These are immunisation success stories that must be told and retold.

An ongoing pro-active public relations program is vital to improve the public’s understanding of the benefits of immunisation, both to the individual and to the community.

It would also help counter false claims circulated by the anti-immunisation lobby and promote the evidence-based benefits of full immunisation. 

The material should complement existing patient information, should be easily accessible, clearly written, and be available in a range of languages.

It should recommend online links for additional information and encourage parents and carers to discuss any concerns with their GP.

Establishing a Whole of Life Immunisation Register

Given the large number of different vaccines a person may receive, except for those up to age 7 and those who have received the HPV vaccination, there is no single data source to identify what, where, and when particular vaccines were administered.

A central register would:

• reduce wastage by avoiding duplication;
• provide information to patients about vaccines they have received throughout their life;
• provide data re herd immunity;
• provide information to doctors that will assist in providing quality care to facilitate completion of vaccinations schedules; and
• create a link between providers, including workplaces and schools, that ensures records are provided to the patient’s GP.

It is hoped that e-health and the electronic health record may solve some of the problems alluded to already, and should certainly make the register more affordable, 

Unless that information can be aggregated, the population health benefits of the register will be lost.

Adverse event reporting

The public

To improve early identification of any problems with a vaccine, the public should have an opportunity to, and be educated to, report an apparent adverse event (reaction) associated with a recent vaccination.

A robust reporting system is necessary to reassure the public that any problems will be quickly identified and acted upon early.

The recent halt to the flu vaccination program proves we are serious about adverse events and prepared to put our concerns in the public domain as necessary.

These sorts of responses will go a long way towards improving consumer confidence about the safety of vaccines.

Parents who are confident that a vaccine is safe for their kids are more likely to ensure their kids receive their vaccinations.

GPs

As well as enabling the public to report adverse events, it is also important to streamline the reporting process for GPs.

An easily accessible, centralised national reporting mechanism that maximises e-health capabilities from the GP’s desktop, with the likes of pre-populated forms, would facilitate accurate and timely reporting.

GPs constantly record information on their practice databases that may be critical to detect an adverse event signal.

While on the subject of adverse event reporting, under-reporting or delayed reporting is also a problem.

Playing a wait and see game regarding a possible adverse reaction delays identification of a potential problem and suitable assessment. 

Rather than the old adage ‘if in doubt, leave it out’, in this regard it should be ‘if in doubt, report it’.

Timely identification of any potential problem with a vaccine is fundamental to ensuring patient safety and the integrity of the immunisation program.

Universal annual influenza immunisation program

A universal annual influenza immunisation program offering vaccination to all children would not only benefit them but provide greater herd immunity and protection to the vulnerable of any age, as the risk of transmitting preventable disease is reduced. 

The Australian Immunisation Handbook.

This is an excellent reference that is relied upon by all vaccination providers.

Handbooks can however become an unreliable resource as, inevitably, recommendations lose their currency.

Maintaining such an excellent resource should be a Government priority and part of the strategy.

Rather than complete rewrites, which are very resource hungry, updates to chapters of the handbook should be made available online on a regular basis to solve the currency issues.

Immunisation of Health Care Workers

To reduce the risk of transmitting preventable diseases to vulnerable people, a push to promote higher rates of vaccination among health care workers is needed.  Once again, the AMA is a strong supporter.

Indigenous

Implementing culturally appropriate strategies, in particular delivery and communication strategies, will achieve improvement in the rates of immunisation for Indigenous Australians.

Further development and then implementation of appropriate reporting programs to monitor coverage, delivery effectiveness, and communication effectiveness will identify areas requiring increased resources.

Older people

Immunisation programs with appropriate recording mechanisms that assist the treating doctor need to be established in aged care facilities.

In its ‘Key Health Issues for the 2010 Federal Election document, the AMA called for

“...adequately equipped clinical treatment areas that afford patient privacy, and information technology to enable access to medical records...”

These should be part of the accreditation standards and will help us deliver better care to the aged Australians.

Conclusion

These are just some thoughts about issues that will need to be considered in the development of the National Immunisation Strategy. 

There are clearly many issues that others will cover also, although I have no doubt there will be common themes.

I look forward to participating in the consultation process.

More importantly, I look forward to a National Immunisation Strategy that will provide the framework for sound systems and processes to keep the burden of disease and incidence of adverse events in this country at a minimum.

I know family doctors have an important role to play in this space and the AMA will continue its efforts to ensure that there is appropriate support for them in this regard.

 

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19 August 2010

 

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