APPENDIX 1
Influenza and Influenza Vaccination
Influenza is a highly contagious respiratory viral illness spread mainly by coughing
and sneezing. The incubation period is about 1 to 4 days. Typical influenza is
characterised by the sudden onset of fever, myalgia, headache, severe malaise,
non-productive cough, sore throat, and rhinitis. Fever, cough, and fatigue are more
specific indicators of influenza than other respiratory viral illnesses. People are
infectious from about 1 day before to 5 days after the onset of symptoms.
Typical influenza resolves after several days, although cough and malaise can
persist for 2 weeks or more. Influenza can exacerbate underlying medical conditions
(e.g. lung or heart disease) or lead to secondary bacterial pneumonia or primary
influenza viral pneumonia. Influenza has also been associated with encephalopathy,
transverse myelitis, Reye syndrome, myositis, myocarditis, and pericarditis.
An estimated 100 to 300 West Australians die from influenza each year. Infection
rates are highest in children, but rates of serious illness and death are highest in
people 65 years of age or older and people of any age with high-risk medical
conditions. Hospitalisation rates in children less than 1 year of age are similar to
rates in people 65 years of age or older.
Influenza vaccination is the best way to prevent influenza and its complications and
is recommended for people 65 years of age or older, people of any age with high-risk
medical conditions, and health care workers and household members who have
frequent contact with these high-risk groups.
Influenza vaccination has been associated with reductions in:

hospitalisation and death in high-risk groups,

respiratory illness and medical consultations in all age groups,

work absenteeism in adults.
In WA, about 80% of people 65 years of age or older had an influenza vaccination in
2003.
Influenza vaccine usually contains two type A strains and one type B strain,
representing the influenza viruses most likely to circulate each winter. The vaccine
is made from highly purified, inactivated influenza viruses grown in embryonated
hens’ eggs and may contain trace amounts of egg protein, preservatives, stabilisers,
or antibiotics. Product information leaflets should be consulted for each vaccine to
determine its exact composition.
The influenza vaccine for the 2004 Australian season includes A/Fujian/411/2002
(H3N2)-like, A/New Caledonia/20/99 (H1N1)-like, and B/Hong Kong/330/01-like
strains.
When the vaccine and circulating viruses are antigenically similar, influenza vaccine
prevents influenza illness in approximately 70% to 90% of healthy adults less than
65 years of age. Vaccination of healthy adults has also resulted in decreased work
absenteeism and decreased use of health-care resources, including the use of
antibiotics.
Among elderly persons living outside of nursing homes or similar chronic-care
facilities, influenza vaccine is 30% to 70% effective in preventing hospitalisation for
pneumonia and influenza. Among elderly persons residing in nursing homes the
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vaccine can be 30% to 40% effective in preventing illness, 50% to 60% effective in
preventing hospitalisation or pneumonia and 80% effective in preventing death.
Vaccination of health care workers has been associated with a decrease in deaths
among nursing home residents.
Women in their third trimester of pregnancy have a hospitalisation rate similar to
non-pregnant women with high-risk medical conditions. Thus, 1-2 hospitalisations
may be prevented for every 1,000 pregnant women vaccinated. Women who will be
>14 weeks gestation during the influenza season should be vaccinated. Pregnant
women with other high-risk medical conditions should be vaccinated before the
influenza season, regardless of the stage of pregnancy. Although influenza
vaccination of pregnant women has not been associated with adverse foetal effects,
some experts prefer to vaccinate during the second trimester to avoid a coincidental
association with spontaneous abortion, which is common in the first trimester.
Reference
Centers for Disease Control and Prevention.
Prevention and control of
influenza:recommendations of the Advisory Committee on Immunization Practices
(ACIP). MMWR 2001;50 (No. RR-4).
Patient Influenza & Pneumococcal Vaccination Programs
Yearly influenza vaccination and five-yearly pneumococcal vaccination is
recommended by the National Health and Medical Research Council for
non-indigenous people 65 years of age or older, indigenous people 50 years of age
or older, and indigenous people 15 to 49 years of age with a high-risk medical
condition.
The Australian Government funds free influenza vaccine for these high-risk groups
and free pneumococcal vaccine only for the indigenous high-risk groups.
A number of strategies can be adopted within hospitals to ensure that as many highrisk patients as possible are vaccinated against influenza or pneumococcal disease:

Patients hospitalised with influenza have a significant risk of readmission during
subsequent influenza seasons. High-risk patients should be vaccinated against
influenza and pneumococcal disease, as appropriate, preferably before they are
discharged from hospital.

If it is not feasible to vaccinate high-risk patients before they are discharged from
hospital, then they should be vaccinated during Outpatient or General Practitioner
discharge follow-up appointments. Vaccination recommendations should be
included in the patient’s notes and discharge letters.

High-risk patients should be routinely assessed in Outpatients for influenza and
pneumococcal vaccination and either vaccinated on site or referred to their
General Practitioner for vaccination.

Hospitals that have the capacity to do so should write to the General Practitioners
of previously-admitted influenza high-risk patients each year reminding them to
recall the identified patients for influenza and pneumococcal vaccination, as
appropriate.
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Staff Influenza Vaccination Programs
Many hospitals have established staff influenza vaccination programs to reduce
nosocomial infections and staff sick leave.
In general, at least 60% staff influenza vaccination coverage is required to reduce
nosocomial infections and staff sick leave.
Hospital influenza vaccination programs are best managed by designated infection
control and/or occupational health staff. These programs require consistent
administrative and collegiate support to maximise vaccine coverage.
The objectives of these programs include:
1.
Promoting staff influenza vaccination,
2.
Offering free influenza vaccination to staff, and
3.
Measuring the effectiveness and costs of the program
1.
Promoting staff influenza vaccination
Successful staff influenza vaccination programs require routine promotion activities
including emails, letters, pamphlets, posters, vaccination stickers, broadcasts and
direct support from team leaders.
Some influenza vaccine companies routinely provide hospitals with staff influenza
vaccination promotion materials.
2.
Offering free influenza vaccination to staff
The most successful staff influenza vaccination programs include the provision of
free vaccine and a free, convenient, vaccination service.
The most successful staff vaccination services usually utilise a mobile vaccination
team visiting each ward or site, or an on-site staff vaccination clinic to maximise
convenience.
Some influenza vaccine companies subsidise the cost of influenza vaccine or
vaccination services for staff vaccination programs.
3.
Measuring the effectiveness and costs of the program
Influenza vaccination programs should be evaluated each year with data including
staff vaccine coverage, staff sick leave and costs, and vaccine and vaccination
costs.
Advice
Expert advice on implementing and evaluating staff vaccination programs is
available from staff immunisation coordinators of the major WA teaching hospitals or
from vaccine consultants.
In Western Australia, the following companies have influenza vaccine consultants:
CSL
Aventis Pasteur
GlaxoSmithKline
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9328 7322
0404 467 807
0412 538 774
3
Staff Influenza Vaccination Consent Form
Please read the following information about influenza vaccination and then complete
and sign this form if you want to be vaccinated against influenza.
CONTRAINDICATIONS TO INFLUENZA VACCINATION
Inactivated influenza vaccine should not be administered to people known to have
anaphylactic hypersensitivity to eggs or to other components of the influenza
vaccine. Prophylactic use of antiviral agents is an option for preventing influenza
among these people.
However, people who have a history of anaphylactic hypersensitivity to influenza
vaccine components but who are also at high risk for complications of influenza can
benefit from vaccination after appropriate allergy evaluation and desensitisation.
Information regarding vaccine components can be found in package inserts from
each manufacturer.
People with an acute febrile illness usually should not be vaccinated until their
symptoms have abated. However, minor illnesses with or without fever do not
contraindicate the use of influenza vaccine, particularly among children with mild
upper respiratory tract infection or allergic rhinitis.
SIDE EFFECTS AND ADVERSE REACTIONS
Local Reactions
The most frequent side effect of vaccination is soreness at the vaccination site
(affecting 10% to 64% of patients) that lasts less than 2 days. These local reactions
generally are mild and rarely interfere with the person’s usual daily activities.
Systemic Reactions
Fever, malaise, myalgia, and other systemic symptoms can occur following
vaccination and most often affect people who have had no prior exposure to the
influenza virus antigens in the vaccine (e.g. young children). These reactions begin
6 to 12 hours after vaccination and can persist for 1 to 2 days.
Recent placebo-controlled trials demonstrate that among elderly people and healthy
young adults, administration of split-virus influenza vaccine is not associated with
higher rates of systemic symptoms (e.g. fever, malaise, myalgia, and headache)
than with placebo injections.
Immediate - presumably allergic - reactions (e.g., hives, angioedema, allergic
asthma, and systemic anaphylaxis) rarely occur after influenza vaccination. These
reactions probably result from hypersensitivity to some vaccine component, most
likely residual egg protein.
People who have developed hives, have had swelling of the lips or tongue, or have
experienced acute respiratory distress or collapse after eating eggs should consult a
physician for appropriate evaluation to help determine if vaccine should be
administered.
People who have documented immunoglobulin E (IgE)-mediated hypersensitivity to
eggs — including those who have had occupational asthma or other allergic
responses to egg protein — might also be at increased risk for allergic reactions to
influenza vaccine, and consultation with a physician should be considered.
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Hypersensitivity reactions to any vaccine component can occur. Although exposure
to vaccines containing thiomersal can lead to induction of hypersensitivity, most
patients do not develop reactions to thiomersal when it is administered as a
component of vaccines, even when patch or intradermal tests for thiomersal indicate
hypersensitivity. When reported, hypersensitivity to thiomersal usually has consisted
of local, delayed-type hypersensitivity reactions.
Guillain-Barré Syndrome
The 1976 swine influenza vaccine was associated with an increased frequency of
Guillain-Barré syndrome (GBS). Among people who received the swine influenza
vaccine in 1976, the rate of GBS that exceeded the background rate was less than
10 cases per 1,000,000 people vaccinated.
Evidence for a causal relationship of GBS with subsequent vaccines prepared from
other influenza viruses is unclear. Obtaining strong epidemiologic evidence for a
possible small increase in risk is difficult for such a rare condition as GBS, which has
an annual incidence of 10 to 20 cases per 1,000,000 adults, and stretches the limits
of epidemiologic investigation. More definitive data probably will require the use of
other methodologies (e.g., laboratory studies of the patho-physiology of GBS).
During three of four influenza seasons studied during 1977 to 1991, the overall
relative risk estimates for GBS after influenza vaccination were slightly elevated but
were not statistically significant in any of these studies.
However, in a study of the 1992 to 1993 and 1993 to 1994 seasons, the overall
relative risk for GBS was 1.7 (95% confidence interval = 1.0–2.8; p = 0.04) during the
6 weeks after vaccination, representing approximately 1 additional case of GBS per
1,000,000 people vaccinated. The combined number of GBS cases peaked 2 weeks
after vaccination. Thus, investigations to date indicate no substantial increase in
GBS associated with influenza vaccines (other than the swine influenza vaccine in
1976) and that, if influenza vaccine does pose a risk, it is probably slightly more than
one additional case per million people vaccinated.
Cases of GBS after influenza infection have been reported, but no epidemiologic
studies have documented such an association. Substantial evidence exists that
several infectious illnesses, most notably Campylobacter jejuni and upper-respiratory
tract infections in general, are associated with GBS.
Even if GBS were a true side effect of vaccination in the years after 1976, the
estimated risk for GBS of approximately 1 additional case per 1,000,000 people
vaccinated is substantially less than the risk for severe influenza, which could be
prevented by vaccination among all age groups, especially people aged >65 years
and those who have medical indications for influenza vaccination.
The potential benefits of influenza vaccination in preventing serious illness,
hospitalisation, and death greatly outweigh the possible risks for developing vaccineassociated GBS. The average case-fatality ratio for GBS is 6% and increases with
age. No evidence indicates that the case-fatality ratio for GBS differs among
vaccinated people and those not vaccinated.
The incidence of GBS among the general population is low, but people with a history
of GBS have a substantially greater likelihood of subsequently developing GBS than
people without such a history. Thus, the likelihood of coincidentally developing GBS
after influenza vaccination is expected to be greater among people with a history of
GBS than among people with no history of this syndrome. Whether influenza
vaccination specifically might increase the risk for recurrence of GBS is not known;
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therefore, avoiding vaccinating people who are not at high risk for severe influenza
complications and who are known to have developed GBS within 6 weeks after a
previous influenza vaccination is prudent.
As an alternative, physicians might consider the use of influenza antiviral
chemoprophylaxis for these people. Although data are limited, for most people who
have a history of GBS and who are at high risk for severe complications from
influenza, the established benefits of influenza vaccination justify yearly vaccination.
Source
Centers for Disease Control and Prevention.
Prevention and control of
influenza:recommendations of the Advisory Committee on Immunization Practices
(ACIP). MMWR 2001;50 (No. RR-4).
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