Guidelines for the School-based Vaccination Program health.wa.gov.au Table of Contents 1. Executive summary 2 2. Purpose of guidelines 3 3. Scope 3 4. Guiding principles for school-based vaccination program 4 5. Legislation supporting school-based immunisation 4 6. Role of the Department of Health 6 7. Role and Responsibility of Health Services 7 Appendix 1 – Medication management guidelines for nurses and midwives 10 Appendix 2 – Annual nursing management responsibility 11 Appendix 3 – Access to clinical advice 13 Appendix 4 – Essential resources required for the delivery of a school-based vaccination program 14 Appendix 5 – Step-by-step implementation of the WA SBVP 15 Appendix 6 – Consent for vaccination 16 Appendix 7 – Supporting non-English speaking parents/guardians 20 Appendix 8 – Vaccination day preparation 21 Appendix 9 – Flow chart for needle-stick injury with body fluids 24 Appendix 10 – Ensuring a safe and sensitive environment pre-vaccination checklist 27 Appendix 11 – Arrival and set up at school 28 Appendix 12 – Preparing vaccines 29 Appendix 13 – Management of anxious students 31 Appendix 14 – Vaccination of students 32 Appendix 15 – Vaccines distribution, storage and cold chain maintenance 35 Appendix 16 – Adverse events following immunisation 38 Appendix 17 – Data collection 42 Sample Letters 45 Glossary 50 References 51 Guidelines for the School-based Vaccination Program 1 1. Executive summary Vaccination has proven to be a successful public health strategy in the control and elimination of communicable diseases. However, significant challenges exist to deliver a comprehensive school-based immunisation program across the Department of Health’s four Health Services, which include nine Population Health Units with varying modes of service delivery for which families have differing degrees of access. There is also the complexity of working through the numerous bodies – public, private and independent schools, school of the air, and Aboriginal community services – that provide education services in Western Australia. The school-based immunisation program is a funded national immunisation program that offers all eligible students the opportunity to become protected against vaccine preventable diseases. Vaccines offered to school students are: booster doses to vaccines already administered to students between the ages of 0-4 years, e.g.diphtheria-tetanus-pertussis (dTpa) vaccines to specific age groups, e.g. Human Papilloma Vaccine (HPV), which is only registered and eligible for female and male students from 12 years of age catch up vaccines where vaccines are given for a limited time until the cohort has caught up, e.g. chickenpox (varicella). The WA Immunisation Strategy highlights the fact that a robust immunisation service requires a coordinated effort, and human and physical resources from many stakeholders to ensure optimal vaccination coverage. The program success depends on services: offering an information consent pack to all parents/guardians in WA that includes information in different languages to encourage parents to acknowledge the benefits of immunisation and to ensure that their child is fully protected following up with parents/guardians of non-returned immunisation consent forms negotiating a date with each school to conduct an immunisation day alerting parents to the date and time of vaccination administering vaccines including catch up vaccination according to the WA Health immunisation schedule offering holistic care, e.g. consent checking, observation following immunisation, responding to adverse events following immunisation (AEFIs) reporting, contacting parents to advise them that their child has had an AEFI, collection of data and entering data into the school-based vaccination database in a timely manner Guidelines for the School-based Vaccination Program 2 2. following up absent students and negotiating alternative options for accessing immunisation providing parents/guardians with a final report of student’s immunisation encounters and an immunisation uptake report to each school. Purpose of guidelines The purpose of these guidelines is to assist Health Services and Public and Community Health Services to understand the key components required to deliver a school-based immunisation program. Key responsibilities include preparation, delivery, monitoring and recording of vaccines administered through the School-based Vaccination Program (SBVP) in WA. This guideline provides the following components: roles of Health Service managers roles of Department of Health, Prevention and Control (PCP) understanding adhering to the supporting Operational Directives gaining parental consent liaising with Educational bodies preparation for school based immunisation cold chain monitoring and transporting vaccines to school sites preparing for and managing anaphylaxis ordering and storage of vaccines data collection reporting Adverse events following immunisation working within the AHPRA framework and legislation check lists for daily activities. Detailed information relating to roles, responsibilities and recommended clinical practice for delivering a school-based immunisation program is included in the attached appendices for the purpose of assisting new immunisation team nurses. 3. Scope These guidelines apply to all health service staff involved in the delivery of a SBVP. Registered nurses employed by the Department of Health to deliver vaccines through child health immunisation clinics and school-based immunisation programs must have completed an endorsed immunisation certificate to demonstrate their knowledge, skill and competence required to deliver vaccination, as outlined in the department’s Vaccine Administration Code Regulations 37B (VACR) (refer to appendix 1, 2, 3). All nursing activities must take place in the context of the nurse’s scope of practice and agreed Guidelines for the School-based Vaccination Program 3 principles of delegation and levels of supervision at the local level – Guidelines for registration standards (external site). Immunisation activities should be supported by the policies, procedures and local protocols that have been developed in accordance with service needs and intended outcomes of the workplace (refer to appendix 4). All registered nurses are accountable for making decisions based on the Immunisation Handbook recommendations, and what is within their own competence and scope of practice (refer to appendix 1). 4. Guiding principles for school-based vaccination program Department of Health legislation, policy, relevant professional standards and Codes of Conduct will be adopted by health service and local government staff when implementing a SBVP (refer to appendix 1) to: promote a philosophy within the health services and local government council clinics to improve the efficiency and effectiveness of available personnel and resources ensure that the SBVP is offered to all eligible Year 8 students in Western Australia attending public/private and special/home school educational programs ensure that students attending Year 8 school programs in private/public and special schools will be offered a high-quality SBVP delivered by highly-competent registered nurses with expertise in immunisation. achieve vaccination coverage of 95 per cent of the eligible population. 5. Legislation supporting school-based immunisation Australian Nursing and Midwifery Council (ANMC). National Competency Standards for the Registered Nurse 2007 and the Enrolled Nurse 2002. ANMC Code of Ethics for Nurses (2008). ANMC Code of Professional Conduct Nurses (2008). (ANMC) National Framework for the development of decision making tools for nursing and midwifery practice 2007. ANMC Health Practitioner Regulation National Law (WA) Act 2010. Australian Government Department of Human Services – Australian Childhood immunisation Register 1996. Privacy Act 1988 (Commonwealth). Guidelines for the School-based Vaccination Program 4 WA Occupational Safety and Health 1984. WA Occupational Safety and Health Regulation 1996. WA Poisons Act 1964 and Poisons Regulations 1965, Vaccine Administration Code 2012. WA School Education Act 1999 (WA) and School Education Regulations 2000 (WA). WA Notification of Adverse Event after Immunisation Regulations 1995 (Regulation 4). 5.1 National documents Australian Nursing and Midwifery Council (ANMC). Medication Management Guidelines for Nurses and Midwives 2010. Australian Nursing and Midwifery Council (ANMC). National Competency Standards for the Registered Nurse (external site). Australian Childhood Immunisation Register website (external site). Commonwealth of Australia. Australian Immunisation Handbook 10th Edition 2013 (or current edition). Commonwealth of Australia. Australian National Vaccine Storage Guidelines ‘Strive for 5’ (external site). Commonwealth of Australia. Health (Notification of Adverse Event After Immunisation) Regulations 1995 (Regulations 4) (external site). 5.2 Supporting Department of Health documents Operational Directive OD 0415/13 Guidelines for Department of Health Vaccination Programs – School and Community Health Immunisation (or amended version) that advise registered nurses of their professional responsibility in working within the various legislative and professional body guidelines. WA Immunisation Schedule 2015 (amended periodically). Operational Directive OD 0355/11 Vaccine Cold Chain Guidelines. Guidelines for the School-based Vaccination Program 5 The DoH Vaccine Administration Code Regulations 37B (VACR) of the Poisons Act 1965 or subsequent regulations. Operational Directive 0488/14 Homeopathic Immunisation. Operational Directive OD 0429/13 National Hand Hygiene Initiative in Western Australian Hospitals. Operational Directive OD 0388/12 Health Care Worker Immunisation Policy. Operational Directive OD 0394/12 Policy for Health Care Workers known to be infected with Blood-borne disease. Operational Directive OD 0237/09 Hepatitis B Vaccination Program. Operational Directive OD 0385/12 National Recommendations for User-Applied Labelling of Injectable Medicines, Fluids and Lines. Rural and remote policies relating to the use of medications 2011. Clinical and related waste management-Clinical Wastes OD0259/09. Patient Information Retention and Disposal Schedule, version 4, 2014. Western Australian Vaccine Safety Surveillance (WAVSS). 6. Role of the Department of Health The DoH, Prevention and Control (PCP) will: oversee the procurement of the National Immunisation Program (NIP) vaccines for the SBVP, and the ordering and distribution of vaccines in Western Australia (refer to appendix 15) institute strategies to monitor the delivery and surveillance of post-vaccine reactions through the Western Australian Vaccine Safety Surveillance (WAVSS) reporting system to ensure that quality assurance standards in the delivery of the SBVP are of a high order (refer to appendix 15, 16) support and provide health services with supporting resource material and ongoing information to ensure the delivery of a high-quality SBVP. This includes NIP vaccines, consent forms and resource materials to promote the program at no cost to the school (refer to appendix 4, 5, 6, 7) establish strategic and policy frameworks for the SBVP authorise the SBVP vaccines through provision of a vaccine schedule and take responsibility to update or amend the schedule as necessary Guidelines for the School-based Vaccination Program 6 7. liaise with the Department of Education (DoE) at the start of each calendar year to download the Year 8 student enrolment data for public schools to populate the PCP school-vaccination program database (refer to appendix 11, 12) provide an annual Contract/Memorandum of Understanding (MOU) with each health service and local government council outlining the SBVP administration model for the nominated year (refer to appendix 1) provide a SBVP database for collation of vaccines administered and allow designated registered nurses/officers access to the database for the purpose of entering student vaccine uptake (refer to appendix 19) receive, validate and analyse vaccination data and provide parents with a report of vaccines given to their child in the Year 8 school program at the end of the school year (refer to appendix 19) undertake surveillance of adverse events following immunisation provide regular communication forums to offer SBVP coordinators the opportunity to raise concerns or issues and to provide them with NIP updated information (refer to appendix 14) provide schools and health services with an annual report of their SBVP uptake (refer to appendix 19). Role and Responsibility of Health Services Each region across the WA Country Health Services (WACHs) and Community and Adolescent Community Health Services (CACHs) and local Government Councils (LGCs) in the metropolitan area are responsible for coordinating the SBVP within their regional/geographical area. All health services and local government services shall: ensure staff are cognisant of, and comply with the: o WA governing legislation including WA Poisons Act 1965 and VACR 2014 o National Health and Medical Research Council (NHMRC) guidelines o Current edition of the Australian Immunisation Handbook o Strive for 5, Myths and Realities, Information for Providers and the WA Immunisation Schedule o Department of Health Operational Directives. ensure that the SBVP is delivered to eligible students in public, private and special/home schools in regional, remote and metropolitan WA provide vaccination teams of qualified staff in accordance with the department’s Vaccine Administration Code, Regulations 37B (VACR) of the Poisons Act 1965 or subsequent regulations (Refer to Appendix 1) promote best practice recommendations; that is, to have a minimum of two registered immunisation nurses to conduct immunisation. (One registered nurse is insufficient to administer vaccinations as well as deal with queries from staff, parents and students, Guidelines for the School-based Vaccination Program 7 fainters, adverse reactions, anxious students and reviewing any last minute consent forms. These hold-ups disrupt the flow of vaccinations and allocated time frames, disrupt school programs and could be seen to be unprofessional. However, if this is not feasible because of the remoteness of a school location and/or low numbers of students, alternative support should be provided, such as negotiating with DoE administration staff, teacher, health employee non-immunisers to assist the registered nurse.) ensure that this program is delivered under the delegation of the Public Health physician or the authorising medical officer in instances where registered nurses who do not have immunisation competency are employed on a temporary basis to deliver the immunisation program (refer to appendix 1, 2) be responsible for developing local protocols and standards relating to the administration of medications/vaccines according to the Registered Nurses and Midwives Boards of Australia (NMBA) and the WA Department of Health Poisons Act 1965 and Regulations 1964/65 (refer to appendix 1, 10) ensure that registered nurses are in keeping with the AHPRA recommendations Medication Management for nurses and midwives; and any delegation and/or supervision of any medication management (i.e. drawing up of vaccines) to others are in keeping with the other person’s ability and scope of practice. This means, according to the Registered Nurses and Midwives Board’s Scope of Practice Decision-Making Framework (2007), nurses need to be qualified and competent in delivering immunisation programs (refer to appendix 1, 2, 10, 12). The scope of practice for medication management includes: competence, accountability and autonomy ongoing professional development Being aware of the Health Practitioner Regulations law (WA) support for professional nursing practice delegation and emergency situations. providing nurses with sufficient time before vaccination day as best practice because it allows sufficient time to contact parents and discuss queries (the parent may need to phone back). This creates less stress on vaccination day, minimises disruptions, reduces mistakes and streamlines the day’s procedure (refer to appendix 13) providing support staff (e.g. administrative staff) to support the vaccination teams providing the necessary equipment and resources (e.g. purpose-built vaccine refrigerators, coolers/portable fridges, resuscitation equipment and computers, policy documents and transport required to deliver the SBVP effectively and efficiently (refer to appendix 9, 15). Immunisation team nurses should: coordinate the planning and implementation of the immunisation program within their area and include planning strategies for evaluating and reviewing the program Guidelines for the School-based Vaccination Program 8 negotiate with each school regarding arrangements and time frames for delivery of the SBVP (refer to appendix 4, 7,8,9,13) distribute consent forms provided by the department PCP to schools at the start of the new school term, and collect consent forms before school immunisation visit (refer to appendix 6) retain immunisation records according to WA Department of Health records policy enter the details of Year 8 students eligible to receive SBVP vaccines into the state Department of Health school database, including consent and vaccination records offer students who were absent on the immunisation day catch-up options (e.g. visit school again, refer to GP or community immunisation clinics) order SBVP vaccines according to department online ordering system (refer to appendix 15) maintain cold chain storage according to Department of Health PCP Vaccine Cold Chain OD 0355/11 and report all cold chain incidents and other wastage to the Public Health Unit (PHU), regional immunisation coordinator (RIC), who will collate and forward to Department of Health PCP (refer to appendix 15) ensure that all registered nurses are aware of their responsibility to report adverse reactions following vaccine to WAVSS (refer to appendix 16) work in collaboration with the DoH, PCP and RICs to: o improve immunisation coverage rates for the SBVP o improve program delivery o improve consumer confidence in vaccination programs o institute measures to prevent and manage clinical incidents and adverse events o provide Department of Health PCP with student numbers for private schools in September each year, and class lists in early February to populate the SBVP database o provide SBVP vaccine completion report to the RIC, Department of Health PCP at the end of the school year. Review of guidelines These guidelines will be reviewed on a three-yearly basis when the Immunisation Handbook is updated, or in the event of a recommended change to the content of the document. Guidelines for the School-based Vaccination Program 9 Appendix 1 – Medication management guidelines for nurses and midwives Registered nurses working in Department of Health community and public health programs should familiarise themselves with the scope of practice for registered nurses and midwives on the Nursing and Midwifery Board of Australia’s website (external site). Fact sheets are available on the Nursing and Midwifery Board of Australia’s website (external site) to assist nurses in understanding their responsibility to meet the recommended standards and codes. Registered nurse competency standards – January 2006 – rebranded* Framework for assessing national competency standards – October 2013 (external site). As the statutory body responsible for the regulation of nursing and midwifery practice in Australia, the board has developed the guidelines to improve the safety and quality of nursing practice and medication management in the provision of nursing programs. Nurses and midwives need to be aware of legislation relating to medication use which, in Western Australia, is the Poisons Act (1964) and the Poisons Regulations (1965) and the Vaccine Administration Code 2014. The Poisons Act (1964) and the Poisons Regulations (1965) provide clear instructions for nurses and midwives in relation to the administration of Schedule 8 (S8) and Schedule 4 (S4) medications (Reg. 38, and 42); verbal orders from medical practitioners (Reg. 50); and authority for nurses/midwives at designated remote area posts (Reg. 11). Hospital Standing Orders are not covered by the Poisons Regulations (1965). Enrolled nurses are not permitted to authorise S8 drugs due to the definition of a nurse under the Poisons Regulations (1965) (Reg. 42 (1) (f)). General Considerations Adhere to the 6 Rights of Medication Administration: 1. Right drug (vaccine) 2. Right individual 3. Right dose 4. Right time 5. Right route 6. Right documentation Guidelines for the School-based Vaccination Program 10 Appendix 2 – Annual nursing management responsibility Checklist for overseeing the delivery of a school-based vaccination program Check that all registered nurses: are registered with Australian Health Practitioner Regulation Agency (AHPRA) and have completed their immunisation certificate understand what is required in their role for the SBVP are able to demonstrate that they have read and understood the immunisation schedule. Also: ensure that nurses are registered with AHPRA in Division 1 and/or 2 of the Register file a copy of each of your staff’s nursing registration to ensure that staff administering vaccines are registered with APHRA ensure that the registered nurses have completed an annual immunisation update that includes the competencies list below in instances where registered nurses employed on a temporary basis to deliver the immunisation program and do not have immunisation competency, they must deliver this program under the delegation of their Public Health physician who will be the authorising medical officer ensure that registered nurses have completed and passed their annual cardiopulmonary resuscitation (CPR) certificate note which staff have had prior experience conducting a school immunisation clinic. For new staff, Child and Adolescent Community Health Service, RIC or LGA should provide a school-based immunisation program update. ensure adequate nursing staff are available for school visits. It is considered best practice to have a minimum of two registered nurses with immunisation competency to provide the immunisation service at school. If this is not possible, one registered nurse on the vaccination team must be Immunisation Certified. In rural areas consideration needs to be given to the location of the school and the numbers of students to be immunised. Additional support should be arranged with the school to assist the nurse if only one registered nurse is used ensure that the registered nurse is deemed competent to deliver this service competency includes demonstrated knowledge and understanding in: o the storage, transport, handling of vaccines (cold chain) o the administration of vaccines according to National Health and Medical Research Council (NHMRC) o the process of gaining informed consent for vaccination o cardiopulmonary resuscitation (hold a current CPR certificate) o identify and management of anaphylaxis o documentation of vaccination and any critical incident Guidelines for the School-based Vaccination Program 11 o reporting of adverse events following immunisation supply the RIC/PCP with individual private school student’s numbers during the last quarter of the school year to organise the printing of consent forms (DoE provides the student data in public schools). Guidelines for the School-based Vaccination Program 12 Appendix 3 – Access to clinical advice Where to obtain clinical advice Enquiries about the SBVP in the metropolitan area should be referred to the team leader or the Central Immunisation Clinic on 08 9321 1312 between 8.30am and 4.30pm, or the regional immunisation coordinator in regional areas (refer to the table below). Process for managing clinical enquiries Clinical immunisation enquiries from students, parents, school or local government clinic staff should be directed to the local immunisation school team community nurses. Telephone numbers are provided to all schools and parents via consent information pack. Public Health Unit North Metropolitan (Perth) Telephone/Fax No. Public Health Unit Telephone/Fax No. Tel: 9222 8588 Fax: 9222 8599 Midwest (Meekatharra) Tel: 9981 0638 Fax: 9981 0650 South Metropolitan (Perth) Tel: 9431 0200 Fax: 9431 0223 (secure fax) Kimberley (Broome) Tel: 9194 1630 Fax: 9194 1631 Great Southern (Albany) Tel: 9842 7500 Fax: 9842 2643 Goldfields (Kalgoorlie) Tel: 9080 8200 Fax: 9080 8201 Southwest (Bunbury) Tel: 9781 2350 Fax: 9781 2382 Wheatbelt (Northam) Tel: 9622 4320 Fax: 9622 4342 Midwest (Carnarvon) Tel: 9941 0500 Fax: 9941 0520 Pilbara (Port Hedland) Tel: 9158 9222 Fax: 9158 9253 (secure fax) Midwest (Geraldton) Tel: 9956 1980 Fax: 9956 1991 Guidelines for the School-based Vaccination Program 13 Appendix 4 – Essential resources required for the delivery of a schoolbased vaccination program Nurses must ensure that they have: referred to the ‘Strive for Five’ guidelines (page 27) a dedicated fridge/vaccine purpose-built fridge for storage of vaccines and an esky or fridge/esky to transport vaccines to schools a digital minimum/maximum thermometer/data-logger for recording fridge temperatures checked the fridge data-logger temperature before packing vaccines a plan in place to check and record the fridge/ esky temperature hourly a vaccine temperature recording calendar enough ice packs in the freezer for your SBVP program activities cold chain vaccine monitors such as min/max thermometers, bullseye, freeze monitors, data loggers, etc. for storage and transportation the vaccine cold chain breakdown and vaccine wastage/incident report form a cold chain thermometer to use during transporting of vaccines consent packs and follow-up letters provided by Department of Health PCP for the SBVP. These are organised through the immunisation school-based vaccination coordinator emergency equipment, i.e. adrenaline, syringes, needles, adrenaline dosage chart in readiness for responding to an adverse event following immunisation (AEFI). copy of the pre-vaccination consent checklist a supply of school-based vaccination program after-care tear-off pads know the online AEFI reporting site information pad or letters for parents which notes and provides advice about: o missed vaccination o unwell on the day o faint o experienced an anaphylaxis o Operational Directives relevant to immunisation program. Guidelines for the School-based Vaccination Program 14 Appendix 5 – Step-by-step implementation of the WA SBVP The Department of Health will provide the Health Service RICs and LGAs with school-based program materials such as consent packs/fact sheets, tear-off pads, vaccination schedules, posters and a service agreement outlining funding. Department of Health consent forms should be delivered to schools either in the last few weeks of the school year or in the first few weeks of the new school year. Nurses should allow time for unavoidable delays at the beginning of the year such as delays with consent forms or changes to the schedule. Avoid booking the first visit too early in the first term – as you may have to end up cancelling and rescheduling. Plan your program to allow you to fit all visits to all schools within the current year. When arranging vaccination days, take into account school holidays and the difference between private and public schools, exam times, school camps and sports days, etc. Plan to allow for the minimum time interval between first, second and third doses of any three dose vaccine. Tips Send introduction letter to schools (sample Form 1), which can be used as fax back form with proposed visit dates and requirements. Include article for school newsletter (sample Form 3). Nurses may need to follow up with phone calls if fax back form isn’t returned or further details required from parents/guardians or to discuss visit dates. Confirm immunisation dates in writing to the relevant school contact person. Hold group information sessions for relevant staff in all schools. Tips Discuss requirements for vaccination day (as listed on fax back form) including room requirement, equipment and assistance on the day (may be administration support officer or each class teacher). Advise staff to encourage students to have breakfast on the morning of vaccination. This has shown to reduce the number of fainters. Ensure that team leaders, delegated immunisation person and the nurses providing the service are aware of what is required for this program for this year as detailed by the Department of Health and the proposed SBVP vaccination schedule. Guidelines for the School-based Vaccination Program 15 Appendix 6 – Consent for vaccination Implementing the consent process is a legislative requirement, and every effort should be made to ensure that this process follows the recommended standard as noted in the Australian Immunisation Handbook and the Consent to Treatment Policy for the Western Australian Health System 2011. To obtain valid consent from parents/guardians for the SBVP, assistance with translation may be required (see Appendix 7). To ensure best practice it is recommended a minimum of two registered immunisation nurses to conduct immunisation (noted on page 7). If this is not feasible because of remoteness of school location and low numbers of students, alternative support should be provided, such as negotiating with DoE administration staff, teacher, health employee non-immunisers to assist the registered nurse. Department of Health PCP will develop consent forms in consultation with ISPs and print and distribute to regional offices for distribution to schools. The immunisation team and teachers need to have a clear understanding of the Consent to Medical Treatment Bill 2006 (WA) and Consent to Treatment Policy for Western Australian Health System 2011, Department of Health, which regulates consent processes required for students. If a student is under 18 years of age parental/guardian consent needs to be obtained. If the child requests vaccination but the parent or guardian does not consent to vaccination, the child must not be vaccinated. As this is a school-based vaccination program, only parental/guardian consent is acceptable. Students younger than 18 years of age cannot sign their own consent form to receive vaccination (if parent refuses). These students must be directed to their GP for their vaccinations. In school-based vaccination programs, the parent or guardian usually does not attend with the child on the day the vaccination is given and written consent from the parent or guardian is desirable in these circumstances. However, if further clarification is required, verbal consent may be sought by telephone from the parent or guardian by the immunisation service provider. This should be clearly documented on the child’s consent form. Parents should be informed by the school of the day of immunisation (newsletter or telephone text, or formal letter). This allows parents to advise the school if there is any change in the student’s health status that could impact on provision of immunisation. Guidelines for the School-based Vaccination Program 16 The current edition of the Immunisation Handbook on valid consent for school-based vaccination programs states the following: “Consent is usually given for the entire vaccination program offered that year and is valid for the number of doses to be given during a schoolbased vaccination program.” Consent forms should be delivered to schools in a timely manner for distribution to the relevant year levels (Year 8). It may be necessary for the forms to be distributed and collected within one to two weeks before your visit date to the school to allow for the date to be entered and all consent forms checked for parental/guardian signature, allergies or incomplete forms. When consent forms are distributed to parents it is useful to include a note in the school newsletter to parents to inform them that they are giving consent to the course of vaccinations offered. Any change in the child’s medical condition should be reported to the school nurse before the nominated immunisation day. If consent forms are delivered some time before vaccination day then it is possible that the information on the form will be out of date at the time of vaccination and/or the forms may not be returned/or forms are lost and don’t get distributed. Make an appointment with school principal to outline your proposed program plan. Take this opportunity to discuss with the school contact person ways to maximise the return of consent forms. All consent forms should be returned whether consent is given or not given. Request each class teacher to attach a class list to the back of a large envelope and as consent forms are returned, they can mark them off the list and place consent forms in the envelope. This also assists with following up students who have not returned forms. Discuss any queries with the school contact person. Ensure that schools have given you their class numbers/lists (they may not have been returned on the fax back form). If not, you will need to contact the school contact person. If possible, sight the room to be used and assess its suitability and available equipment. Ask for a helper on the day to assist with ensuring classes arrive at allocated times, find missing students and assist students to remain quiet and calm. This could be the contact person, staff member, teacher or parent. If a student refuses vaccination despite parental consent, the student must not be vaccinated. The parent must be advised that the student has refused vaccination despite their consent. Under no circumstances is a student to be forcibly vaccinated against his or her will. Guidelines for the School-based Vaccination Program 17 Return of consent forms Health services should ensure that nurses are allocated sufficient time before vaccination day to review all consent forms and follow up queries, clarify any uncertainties and determine if vaccination is contraindicated or not. The uptake of vaccines within the WA school program is about 75-85 per cent (this is due to some students being already vaccinated; others don’t want to be vaccinated at school and will be going elsewhere; there may be a conscientious objection; medical reasons or non-return of forms; and other various reasons). Concerns identified about possible vaccine contraindications should be discussed with your authorising medical officer. Tips Nurses should take the printed list of students and completed consent forms for each class to the school on the day as it makes it easier to answer queries or follow up with parents on the day. Nurses should check with school staff for information received from parents/legal guardians relating to a child’s change in health status. Withdrawal of consent In the event that parents withdraw consent for the student to be immunised, the consent form should be removed from the bundle of consent forms to avoid any errors in administration of vaccine. Nurses must write clearly on the consent form that consent has been withdrawn, by whom and the date received. The school-based vaccination database must also be updated to note that consent to vaccination has been withdrawn. In circumstances where the parent/guardian is unable to withdraw their consent in writing, the parent/guardian may telephone the school to do so. If this occurs, the school staff member responsible for coordinating the vaccination program at the school should relay this information to the immunisation school nurse who will follow up with the parent/guardian to confirm that consent to vaccination has been withdrawn and to seek clarification if this applies to all vaccines offered. A written record of the student’s name, year, specific vaccine, time and date withdrawn should be documented in the student’s record and the school-based database. Guidelines for the School-based Vaccination Program 18 If there is any doubt as to whether parent/guardian’s consent has been provided, the student must not be vaccinated. Request for vaccination (received on the day) requiring telephone consent If this situation occurs, the parent/legal guardian will need to be contacted to obtain verbal consent. The registered nurse who will be vaccinating the student should obtain valid verbal consent in the presence of a second person, e.g. nurse, DoE administrator, teacher, healthemployee. A phone number may be obtained from the student. Tips Due to privacy the school may not wish to give you the phone number, but may be happy to phone the parent and then hand over to the nurse to speak with them or may phone and ask the parent to phone back. Valid consent is obtained by two nurses (or nurse and supporting person) asking the parent/legal guardian if they received a consent form. Check with parents that they have they read and understood all the information including the benefits and risks of vaccination. Check if they have any questions for you. Check if they need any further information. Where possible, another nurse should also listen to the telephone conversation with the parent/legal guardian to validate that consent has been obtained by the registered nurse for the child in question. The parent/legal guardian should be advised that a second person is present and listening. If a second nurse is not available arrange for DoE administrator, teacher or health employee. The following should be documented on the consent form: name of the parent/legal guardian contacted that valid consent has been obtained by phone signature of both nurses, alternative or other, e.g. DoE administration staff, teacher date and time consent obtained. Guidelines for the School-based Vaccination Program 19 Appendix 7 – Supporting non-English speaking parents/guardians To obtain informed consent the following process must be followed: To obtain valid consent from parents/guardians for the SBVP, assistance with translation may be required. Community immunisation team nurses will discuss and identify with school staff those parents within the Year 8 grades that may require assistance in interpreting and completing the consent form. Community nursing immunisation teams to use informal or formal translation services (if necessary this could be a group session). Informal Methods: Formal Methods: Translated resources. Family members. Assistance can be obtained by contacting one of the services below (charges may apply) Community members. Bilingual health officers. Translating and Interpreting Services (TIS) – 13 14 50 Refer to the Public Health website for a copy of the consent form. Translated Resources The Victorian Government Health Information website (external site) has immunisation information and fact sheets in many languages: student must not be vaccinated. Guidelines for the School-based Vaccination Program 20 Appendix 8 – Vaccination day preparation A couple of days for vaccination day Contact the school to arrange times for the first class to present to the immunisation nurses on vaccination day. Tips Advise the school contact person about which Year 8 students they will need to organise at the start of the day. The time for each class will vary depending on the vaccines to be administered and the number of nurses available on the day. Be realistic with time allocation and adhere to booked times as this minimises disruption to the school. Vaccinating on the allocated day meets parent expectations and ensures students have the opportunity to have breakfast on the appropriate day. Phone school to confirm the day before the visit: arrival time starting time that the school has received the pre-arranged times for each class room to be used, room set up and resources required the school contact person available on arrival to assist name of helper who will be assisting on the day order your vaccine in advance. Do not arrange all of your school vaccination dates within one vaccine order period as it is hard to know how many vaccines you will need in total. If you order 100 per cent there is the possibility of wastage ordering vaccines accordingly reduces stock on hand and wastage check expiry dates of vaccines. Vaccine wastage can occur by: overcrowding of the fridge and cold chain failures large amounts of vaccine left at completion of school program vaccines expiring before next year’s program changes to the following year’s program and those vaccines will not be used vaccines must not be drawn up in advance off site. This is unsafe practice and a breach in standards. Guidelines for the School-based Vaccination Program 21 Pack required equipment Tips Have a dedicated container/trolley pre-packed (preferably on wheels). Leave a checklist for topping up the container on return from each school visit according to team leader’s file. Resources Current edition NHMRC Immunisation Handbook, 2013 National Vaccine Storage Guidelines – Strive for 5 Operational Directive – Guidelines for Department of Health School Vaccination Teams – OD 0415/13 Equipment mobile phone (in the case of an emergency), regional area stamp adrenaline kit in accordance with Appendix 16 forms – consent, incident report, adverse event report, feedback to parents, envelopes tissues hand wipes/Aquium hand gel (in case there are no hand washing facilities) clean area to work from – e.g. plastic cloth, plastic tray, receiver and single use disposable dental towels/blueys/towels (single use towels are disposed of after use) alcohol spray/liquid and disposable cloth to clean the work area before and after use syringes and needles (needle length and gauge according to handbook recommendations) cotton wool balls, micro pore and band aids – (band aids only for persistent bleeders as some children are allergic to band aids) yellow sharps containers large rubbish bags (large enough to include vaccine packaging) disposable gloves for blood spills/emergency water jugs and cups for students feeling ill or for fainters pillows and blankets for fainting area. Paperwork spare consent forms (parents/carers may present on the day wanting the student vaccinated) recommended follow-up letter for those students who missed any dose of a vaccine, especially HPV as a full course is required to gain protection follow up letters (sufficient for each student who misses vaccination) Guidelines for the School-based Vaccination Program 22 fainting/unwell/absent tear-off pads (to inform the parent so they can be aware for future vaccinations). Guidelines for the School-based Vaccination Program 23 Appendix 9 – Flow chart for needle-stick injury with body fluids Nurses should refer to the OD 0394/12 Has needlestick to blood/body fluid occurred? Complete workplace incident report NO YES 1. Wash thoroughly under running water. Complete workplace incident report and medical records 2. Bathe eyes or damaged skin with copious water and/or sterile saline if applicable. Is source known? Consult with Medical Officer NO YES Obtain consent from SOURCE/PARENT and serotest for: HIV antibody HBsAg HCV antibody Is source HIV positive or high risk? Obtain consent from RECIPIENT and serotest for baseline: HIV antibody HBsAg HCV antibody If previously vaccinated against hepatitis B If not vaccinated against hepatitis B Has record of seroconversion antiHBs . or = 10 mIU/mL Has no record of seroconversion need to determine HBS level. If 10 IU/mL Determine anti-HBs level immediately No vaccines required If anti-HBs levels less than 10 IU/mL give: HBIG within 72 hours If source is positive and recipient negative give: HBIG and hepatitis B vaccine (see Australian Immunisation Handbook for further recommendations). YES Obtain immediate advice from Infectious Disease Physician regarding HIV prophylaxis Hepatitis B vaccine within 7 days. Medical Officer gives results to Source. Counselling for Source. Repeat baseline serology in 3 months Guidelines for the School-based Vaccination Program 24 Exposure to Blood-borne Viruses HIV Specialist Contact Details Contact advice on using antiretroviral Facility Royal Perth Hospital Clinical Immunology Fremantle hospital Infectious Diseases Department Telephone Number (08) 9224 2899 (MondayFriday) Who to Contact Clinical Immunology Register (Monday-Friday) (08) 9224 2244 (Weekends, low activity days, public holidays and after hours) Page Immunology Registrar on call (weekends, low activity days, public holidays and after hours) (08) 9431 3333 Infectious Diseases Physician Clinical Immunology Registrar (Monday-Friday) Sir Charles Gairdner Hospital Microbiology Department (08) 9346 3333 Page Immunology Registrar on call (weekends, low activity days, public holidays and after hours) HIV Specialists are available on call – 24 hours a day via hospital switchboards. Guidelines for PEP for HIV Referral to an HIV specialist must be provided in all cases of HIV exposure. Exposure Percutaneous Treatment Recommended Guidelines for the School-based Vaccination Program Commencement of treatment Within hours (<72) Truvada® (300mg tenofovir and 200mg emtricitabine) (once daily for 4 weeks) Further points to consider Starter packs contain sufficient drugs for 7 days treatment 25 Ocular, mucous membrane or nonintact skin Non-blood stained urine, saliva, faeces Offered but not actively recommended Not offered Guidelines for the School-based Vaccination Program 26 Appendix 10 – Ensuring a safe and sensitive environment pre-vaccination checklist It is important to provide privacy and a safe environment for students during the process of immunisation. All information given by students should be considered and used in the context of the wellbeing of the student and, depending on the level of risk to the child and departmental policy, remain confidential. Guidelines to ensure that privacy and confidentiality are respected, and a safe environment provided: Ensure that the area and furniture provided by the school is acceptable for delivering a vaccination service and allows privacy for communicating with students. The student consent form should be checked with the student and any points of concern discussed and where necessary checked with the parent or guardian. Explain to the student the procedure and the vaccines that are going to be administered that day. Discuss any likely reactions and what the student can do to relieve symptoms and the importance of having the vaccination (risks and benefits). Ensure that the vaccine aftercare form for the parent is completed and that the information on the back of the form is explained to the student to give to the parent. Explain to the student that confidential information disclosed to a nurse (e.g. student might want to disclose drug or sexual matters) will be kept confidential. If a female student discloses that she is possibly pregnant or knows she is pregnant, explain to the student that she cannot have the HPV or the varicella vaccination that day and will have to delay vaccination until after the pregnancy. If the vaccine is not given, this should be documented on the class list and entered into the school-based vaccination database. The nurse will need to advise the student that the parent will be informed they were not vaccinated that day. Discuss with the student if the parent is aware of the specific situation, e.g. pregnancy, before telephoning or writing to the parent. The safety of the student must be considered when planning to contact the parent. Refer to your organisational protocol. These students who have disclosed confidential contraindications for immunisation may require further information, follow-up and/or support. Useful contact numbers Lifeline Sexual and Reproductive Health WA Kids Helpline School Counsellor 13 11 14 Free call (country) 1800 198 205 or 92276178 weekdays 10am to 4 pm. 1800 551 800 Follow-up, if applicable Guidelines for the School-based Vaccination Program 27 Appendix 11 – Arrival and set up at school On arrival at school, report to the school office to let the school contact person know you have arrived. Tips Arrive about an hour before first class is due to arrive for vaccination. Schools, for security reasons, require you to sign in and collect a visitor badge. Check the room set up and ask for missing or additional equipment and resources that will be required. Ensure sufficient screens for privacy, table and chairs for each team of nurses and also the administrative person. Check about access to a phone if you do not have a mobile phone. Check for hand washing facilities. Check that the waiting and observation area is appropriate and has seating available. It is useful to have an area close to the nurse for fainters to lie down. The school may be able to provide a gym mat for this purpose. Check with the contact person that classes are aware of the time to attend and that all classes are present (e.g. not away at camp or sport). Request an absentee list of students for that day. Set up equipment – syringes/needles, cotton wool balls/Band-Aids, hand washing. Have cleaning solution, stationary, sharps container, rubbish bag easily accessible to nurses. Place emergency equipment (container of three ampoules of adrenaline, 1ml syringes and needles and resuscitation mask) and adrenaline dose for age table where it is easily accessible to all nurses. Place esky where it is easily accessible to all nurses and check ice packs and thermometer regularly to ensure vaccines are kept within the correct temperature range. Clean work area. Source: NHMRC Australian Immunisation handbook Guidelines for the School-based Vaccination Program 28 Appendix 12 – Preparing vaccines Work health and safety issues Standard work health and safety guidelines must always be followed when preparing and delivering a school-based vaccination program to minimise the risk of needle-stick injury (refer to Australian Immunisation Handbook). Gloves should not be used when preparing and administering vaccines. Work practices must include the use of standard precautions to minimise exposure to blood and body fluids. If exposure does occur refer to the operational guidelines for post-exposure assessment and prophylaxis (0394/12OD). A new sterile, disposable syringe and needle must be used for each injection. Disposable needles and syringes must be discarded into a clearly labelled puncture-proof, spill-proof container that meets Australia standards in order to prevent needle-stick injury or re-use. Sharps containers must be placed in a position that is out of reach to students. All immunisation service providers should be conversant with the recommended procedure for the handling and disposal of sharps according to the National Health and Medical Research Council’s Australian Guidelines for the prevention and control of infection in Healthcare (2010). Hands must be cleaned before preparing vaccines using recommended hand hygiene procedure. Refer to National Health and Medical Research Council’s Australian Guidelines for the prevention and control of infection in Healthcare (2010). Check that the vaccines have been stored at 2˚C to 8˚C (refer to the current Australian Immunisation Handbook). Both vaccine diluent batch number and expiry dates must be checked before each immunisation clinic. Each registered nurse immuniser is responsible for preparing or supervising the preparation of his/her own vaccines. Vaccines must be drawn up (prepared) on the school site in two stages (i.e. separately for the morning and afternoon sessions). Prepared vaccines must be clearly labelled and stored according to cold chain recommendations and in appropriately marked containers (colour coded) on the desk and protected from light. Guidelines for the School-based Vaccination Program 29 Inspect each syringe/vial for foreign particles or vaccine discolouration before vaccine administration. The vaccine cap should be removed carefully to maintain sterility of the rubber bung. Do not wipe the rubber bung. Use the appropriate size gauge needle (e.g. 19/21 or gauge 18 blunt fill needle) to draw up the vaccine. Change to recommended size needle for administration (refer to current Immunisation handbook). Vaccines administered are given via sub-cutaneous (varicella) or intramuscular route (HPV/dTpa) Provided that the skin is visibly clean, there is no need to wipe the skin with antiseptic (alcohol wipe). If an alcohol wipe is used, the skin must be allowed to dry before administering the vaccine. Small air bubbles do not need to be expelled through the needle. It is not necessary to withdraw the syringe plunger before injecting the vaccine. However, if this is done and a flash of blood appears in the syringe, it should be withdrawn and a new site selected for injection. Ensure that the vaccine is injected slowly over a count of five seconds to avoid injection pain and muscle trauma. If required cover the injection site with dry cotton wool ball and tape and instruct the student to apply gentle pressure for 1-2 minutes. Guidelines for the School-based Vaccination Program 30 Appendix 13 – Management of anxious students Nurses should maintain a calm and reassuring manner with students, thus providing an environment that minimises student anxiety. Do not appear rushed, or too busy to talk to the student. Nurses should know the difference between vasovagal and anaphylaxis (current edition of the Immunisation Handbook) on the back of the adrenaline dose for age chart (see Appendix 16). Occupational Health and Safety Issues An awareness of Occupational Health and Safety (OHS) is of the utmost importance when immunising in a school setting and dealing with adolescents. Gently supporting the student’s arm to immunise maintains some control over the environment and prepares the immunisation nurse for any unexpected movement from the student that could possibly lead to inadvertently harming either the immunisation nurse or the student. It becomes a question of judgment for the nurse who feels that immunising the student poses a risk to either the student or the nurse’s safety. When safety and/or legal liability is in question, immunisation should never proceed. Nurses should: provide time for pre-immunisation discussion to allow time for students to raise their concerns before administering immunisation be prepared to respond to a student who is anxious or distressed. seek out information from the teacher as to which students are known or likely to be distressed and to respond to these students first. reassure the students that they will be with him/her ideally these students are better seated than standing for students who faint, follow your organisational protocol, e.g. complete an incident form if the student continues to be uncooperative and obviously distressed, do not proceed with immunisation parents should be informed by telephone or letter as to the reason why the student was not immunised and offered alternative options such as the parent accompanies the student to a local immunisation provider (GP or community health/local government immunisation clinic) as soon as possible. Guidelines for the School-based Vaccination Program 31 Appendix 14 – Vaccination of students Preparation of Students Tips As each class arrives, nurses may decide to separate female and male students if appropriate. Nurses may wish to give a brief talk to the students about the vaccination and answer any questions. Ask students to remove jumpers, roll up sleeves (or take arm out of sleeve as appropriate) and line up alphabetically. Encourage students who have not had breakfast to have something to eat and drink before vaccination as this reduces the number of fainting episodes. Students are requested to systematically check in with administration person. Tips Tick the student’s name off the list of those who have consented and are due for vaccination. This check should pick up errors of students presenting when list indicates no consent. This can then be clarified by the nurse. Give student their consent form to take to the nurses. Nurses to then check each student’s name, checklist for contraindications, consent for which vaccinations and any questions from the pre-vaccination checklist. Ask the student their full name, date of birth, address, and parents’ name (without prompting “are you . . .”). This avoids mix up of students with same or similar names. Ask the student if they are aware of any allergies and if they had any reactions from previous injections. Students present to nurse for vaccination. Nurse checks the individual’s name, checklist for contraindications, the consent form is signed and which vaccinations have been signed for. (This is the second consent check for the day). Asking the student their parents’ names is sometimes used as another check that you have the correct student for the consent form. Position student, fully exposing the upper arm (may require complete removal of top or just rolling up the sleeve). Administer vaccines according to consent form. Dispose of sharps in sharps container. Consider all waste as hazardous material (e.g. cotton wool balls, vaccines, blood and body fluid) to be placed in sharps container, not school bins. Guidelines for the School-based Vaccination Program 32 Documentation Both student and Department of Health record should have all the following details: name of student date of vaccination brand name batch number dose number if applicable injection site given nurses sign both records and give the student their record and after care form to take home nurses to tend to students who faint or feel unwell as the situation arises nurses to complete the fainting form (tear-off pad) and attach to the student’s record of immunisation to be taken home to parent student should be directed to observation area and wait for 15 minutes before returning to class students must sit down and must be supervised (either by teacher or administration assistant, for example) if student looks pale or faints, lay the student down on the floor (on a gym mat), raise their legs on a chair and monitor them until they recover students can be sent back to class when they demonstrate that they are well enough. Alternatively, arrange for student to be sent to the school sick room document fainting episode with student’s consent card for future reference. This can also be done by placing on the consent card a red dot (e.g. a sticker for) to note fainter. At completion of each class The immunisation administration person checks with the school contact person for absentees as this allows time to track down students who did not present at the requested time. T Tips For absent school students, place appropriate follow up letters into envelopes and give to the contact person to send home or address the envelope ready for posting. This saves time on return to the office. If time allows, the administration person may be able to collate statistics – (it is easier to do one class at a time as you have at your fingertips all the returned forms for the class, number of students in each class, number vaccinated on the day, number absent on the day and number previously vaccinated. This also saves time on return to the office). Guidelines for the School-based Vaccination Program 33 Packing up at completion of the school visit Nurses to: complete a vaccine audit, checking number of students vaccinated with the specific class lists vaccines used matches the number of specific vaccines used return vaccines to esky place all rubbish in a bag and return to your centre waste system. Use the alcohol and disposable cloth/towel to wipe down the work area (plastic cloth, tray, etc.) then discard cloth towel pack things back into the trolley/container/box leave room tidy check on any students who are not well, fainted or in the sick room. Provide direction to the school staff on their care, contact parents where required thank contact person and helpers/assistants return to work site unpack vaccines and equipment. Guidelines for the School-based Vaccination Program 34 Appendix 15 – Vaccines distribution, storage and cold chain maintenance Ordering Vaccines Vaccines for the school program (e.g. HPV, dTpa, and Varicella vaccine) can be ordered through the online ordering website. For more information on vaccines orders, phone Department of Health PCP on 08 9388 4835. Receiving vaccines With each vaccine delivery a cold chain monitor (CCM) card is enclosed to ensure that the cold chain has been maintained during transport. The immunisation provider is responsible for ensuring that these monitors are checked on receipt of the vaccines at the vaccine storage location. Accepting vaccine delivery at storage point Vaccines are delivered directly to the nominated community health centres responsible for delivering school-based vaccination. One designated person must be responsible for accepting and storing the vaccine at each storage point. Cold chain monitors (CCM) that accompany vaccines during transport must be checked immediately to certify that the cold chain has been maintained (i.e. not exposed to temperatures below 2oC or above 8oC). Vaccines must be stored in their original packaging. Stock with the shortest expiry date should be paced at the front of the storage area and used first. The temperature recording chart must be completed at the start and end of the day. Any concerns relating to the storage of vaccine must be discussed with your regional immunisation coordinator. Backup power supply and alternative storage facilities must be planned and clearly displayed for reference in the event of a power outage. Guidelines for the School-based Vaccination Program 35 Storing and transporting vaccines Vaccines should be stored at the provider’s site according to the current edition of the NHMRC Australian Immunisation Handbook and National Vaccine Storage Guidelines – Strive for 5 (external site). Vaccines should be transported by the immunisation provider from the storage location site to the school according to the guidelines in the current edition of the NHMRC Australian Immunisation Handbook and National Vaccine Storage Guidelines – Strive for 5. All unused vaccines are to be returned to the vaccine storage location maintaining cold chain at all times. Ensure that all eskies are packed for transport according to the National Vaccine Storage Guidelines – Strive for 5 recommendations (page 33-35). Ensure that all cold packs have been sweated for one hour before placing in eskies according to National Vaccine Storage Guidelines – Strive for 5. Use a max/min thermometer to monitor your vaccines. Ensure that you have: sufficient vaccine for students to be vaccinated, packed appropriately according to cold chain requirements (NHMRC Australian Immunisation Handbook current edition and the National Vaccine Storage Guidelines – Strive for 5) additional vaccines for any extra consent forms received on the day. It is useful to consider the enrolment numbers when considering the number of vaccines to pack for the school session a minimum/maximum thermometer in the esky for transporting vaccine temperature recording chart to be completed at the start and at the end of the day. Tips Min/max thermometer should be stuck to the outside of esky where the reading can be easily seen and monitored without removing the lid. The probe is placed appropriately in the esky in a vaccine box. Place shredded paper in a sealed plastic bag (the same size as the esky). This saves time and can be used repeatedly to separate the vaccines from the ice blocks. Ensure that ice blocks have sweated for up to an hour before packing into the esky. If you don’t have time to sweat the ice packs, ice blocks/packs can be placed in several layers of bubble wrap to prevent vaccines getting frozen. Take extra frozen ice blocks to the school in a separate esky in case the icepacks with the vaccines became warm. Guidelines for the School-based Vaccination Program 36 Preparation of vaccines Vaccines transported in mobile eskies require appropriate packaging to ensure cold chain is maintained. There is a risk that inappropriate packaging may lead to freezing of the vaccine. The National Cold Chain Storage Guidelines – Strive for 5 must be referred to for the storage and transportation of vaccines. Tips If you choose to remove vaccines from packaging to take to the school, special care must be taken. They must be placed in a container with a sealed lid and protected from light. Consideration should be given to vaccines with different batch numbers. All vaccines removed from their packaging must be labelled as per OD. In the event of a cold chain breach (heating or freezing) Exposed vaccines to be kept in the fridge, but isolated (by the vaccinator) by placing in plastic bag and clearly marking the outside with a label stating: Cold Chain Breach (CCB) exposure – DO NOT USE UNTIL FURTHER NOTICE. Contact your school-base immunisation coordinator on 9224 3719 or 0424 756 920 for the metro area and your Regional Immunisation Coordinator in rural areas to discuss the vaccines that may have encountered a CCB exposure. If you have been advised by your immunisation coordinator that the vaccines are not to be used, these vaccines must be disposed of according to usual policy for sharps and amount recorded on the cold chain report wastage form to be submitted to RIC/PCP. An assessment needs to be conducted to identify those students vaccinated with the affected vaccines and a course of action determined in consultation with your immunisation coordinator, medical immunisation expert and line manager. In the event that these students require re-vaccination, a formal process should be undertaken, e.g. the parents should be advised via a telephone call and in writing using your departmental letterhead. The school should also be notified of the situation and the possibility of scheduling further dates for re-vaccination. Daily monitoring of the vaccine temperature and checking their data-logger before you vaccinate will reduce the risk of cold chain incidents and the risk of using compromised vaccines. Form - Refer to the website for OD 0355/11. Guidelines for the School-based Vaccination Program 37 Appendix 16 – Adverse events following immunisation Anaphylactic reactions following routine vaccination are rare but they can be fatal. Any health professional delivering a vaccination service must be able to distinguish between anaphylaxis, convulsions and fainting. True anaphylaxis and anaphylactic reactions can occur up to 60 minutes after exposure to the vaccine but the most severe cases occur during the first 10-15 minutes after the vaccination. It is important to ensure that all students vaccinated remain close to medical attention within the first 15 minutes following vaccination. An adverse event following immunisation (AEFI) is an untoward or unexpected medical event occurring after administration of a vaccine. Such an event may be caused by the vaccine or by chance after vaccination (that is, it would have occurred regardless of vaccination). Some vaccines can cause minor adverse events such as low-grade fever, pain or redness at the injection site (refer to Immunisation Handbook, page 91). In the event of a student experiencing an adverse reaction following immunisation in the school, nurses should take the following steps. Attend to the student, which includes following the management of anaphylaxis recommendation in the Immunisation Handbook (page 89) and repeated on the back cover of the Immunisation Handbook. Fainting is common in adults and adolescents but rarely occurs in young children. Any sudden loss of consciousness should be considered an anaphylactic reaction unless there is a strong central (carotid) pulse. The health professional carrying out the vaccination must be able to distinguish between anaphylaxis, convulsions and fainting. In addition, immunisation nurses must report any incidents that occur (e.g. vaccine errors, adverse reaction to vaccine, such as fainting, allergic symptoms-rashes, swollen lips and anaphylaxis) to their health service clinical incident reporting process and as appropriate to WAVSS. Nurses must report to their managers and WAVSS: any significant event following immunisation any reaction to a vaccine that requires referral to a doctor/hospital any parental/guardian feedback expressing concern about a student’s post-vaccine reaction complete the adverse events report online electronic reporting form or forward to the Central Immunisation Clinic using fax (08) 322 5955 Guidelines for the School-based Vaccination Program 38 the Immunisation School Program Coordinator, RIC or LGC officer will personally followup with all parents of children who have had a reported adverse event following immunisation. Recognition of anaphylaxis Refer to the tale below for a comparison of systemic signs and symptoms between anaphylaxis and a vasovagal episode. An anaphylactic reaction occurs if any of the following symptoms or signs develops, and most cases will have more than one system involved (see current edition of the Australian Immunisation Handbook). Clinical features which may assist differentiation between a vasovagal episode and anaphylaxis Table 1.6.1 Onset Symptoms/signs Skin Respiratory Cardiovascular Neurological Vasovagal episode Immediate – usually within minutes of or during vaccine administration. Generalised pallor, cool clammy skin. Anaphylaxis Usually within 5 minutes, but can occur within hours of vaccine administration. Skin itchiness generalised skin erythema (redness) urticarial (wheals) or angio-oedema (localised oedema of the deeper layers of the skin or subcutaneous tissues). Normal respiration; may Cough, wheeze, stridor, or be shallow, but not signs of respiratory laboured. distress (tachypnoea, cyanosis, rib recession). Bradycardia, but with Tachycardia, weak/absent strong central pulse (e.g. central pulse. Hypotension carotid). Hypotension – – sustained and no usually transient and improvement without corrects in supine position. specific treatment Sense of light – headedness. Loss of consciousness – improves once supine head down position. Guidelines for the School-based Vaccination Program Sense of severe anxiety and distress. Loss of consciousness – no improvement once supine head down position. 39 Management of anaphylaxis If the patient is unconscious, lay him/her on the left side and position to keep the airway clear. If the patient is conscious, lie supine in head-down and feet-up position (unless this results in breathing difficulties). Give adrenaline by intramuscular injection (see below for dosage) if there are any signs of anaphylaxis with respiratory and/or cardiovascular symptoms or signs. Although adrenaline is not required for generalised non-anaphylactic reactions (such as skin rash without other signs or symptoms), administration of intramuscular adrenaline is safe. Call for assistance. Never leave the patient alone. If oxygen is available, administer by facemask at a high- flow rate. If there is no improvement in the patient’s condition within five minutes, repeat doses of adrenaline every five minutes, until improvement occurs. Check breathing. If absent, commence basic life support or appropriate cardiopulmonary resuscitation (CPR) according to the Australian Resuscitation Council guideline (external site). Transfer all cases to hospital for further observation and treatment. Complete full documentation of the event, including the time and dose(s) of adrenaline given. Experienced practitioners may choose to use an oral airway if the appropriate size is available, but its use is not routinely recommended, unless the patient is conscious. Adrenaline dosage The recommended dose of 1:1000 adrenaline is 0.01 mL/kg body weight (equivalent to 0.01 mg/kg), up to a maximum of 0.5 mL or 0.5 mg, given by deep intramuscular injection into the anterolateral thigh. Adrenaline 1:1000 must not be administered intravenously. The use of 1:1000 adrenaline is recommended because it is universally available. Adrenaline 1:1000 contains 1 mg of adrenaline per mL of solution in a 1 mL glass vial. Use a 1 mL syringe to improve the accuracy of measurement when drawing up small doses. The following table lists the doses of 1:1000 Adrenaline to be used if the exact weight of the person is not known (based on the person’s age). Doses of 1:1000 (one in one thousand) adrenaline: 10-12 years (approx 40 kg) 0.4 mL >12 years and adult (over 50 kg) 0.5 mL For more detailed information, see 2.3.2 Adverse events following immunisation. Modified from The Brighton Collaboration Case Definition Criteria for Anaphylaxis, and an insert published in Australian Prescriber (external site) in August 2011. Guidelines for the School-based Vaccination Program 40 Recommended dose of 1:1000 adrenaline is 0.01mL/kg body weight. Always use a 1mL syringe when administering small doses of adrenaline. Adrenaline may be repeated at five minute intervals until you get a response. Adrenaline kit contains: table of recommended adrenaline doses for age (ensure the table specifies the strength of adrenaline) if oxygen is available administer by facemask at a high flow rate three or more ampoules of adrenaline 1:1000 minimum of three 1ml syringes and 25mm length needles (for IM injection) pen and paper to record time of administration of adrenaline laminated copy of recognition and treatment of anaphylaxis form (inside back of the current edition of the Immunisation Handbook). Please note that an oxy viva or air viva is not part of the WA Department of Health emergency kit. Antihistamines and/hydrocortisone are not recommended for the emergency management of anaphylaxis. Source: NHMRC Australian Immunisation Handbook Emergency assistance Dial 000. When using a mobile phone and 000 does not work, dial 112 to be connected to emergency services through another service network. Do not use any other telephone number. Guidelines for the School-based Vaccination Program 41 Appendix 17 – Data collection 1.1 Data collection (Refer to the Department of Health SBIP database for more detailed information) When a child is vaccinated at school personal information (such as name, date of birth, address and details of vaccines received) is collected by the Department of Health. Service Providers are required, under their Service Provider Agreement, to collect and enter the vaccination details of students vaccinated in the School-based Vaccination Program onto the state database. 1.2 Entering data on the database The database is located on the WA School-based Immunisation Program webpage. Please download, print and read the database guidelines (link found on the database homepage) and instructions below before entering data. All students enrolled in Year 8 in a WA school are eligible to receive the school-based vaccines and should be captured in the database regardless of whether they have returned a consent form. Access to the database can be requested by emailing the Prevention and Control Program, Communicable Disease Control Directorate (CDCD). See Section 1.8 regarding the different levels of access to the database. Service Providers should enter data into the database as consent forms are returned and following each vaccination clinic. Details of the vaccination event recorded on the database must include: student’s full name, date of birth, Medicare number11, gender, address, Indigenous status, current school, consent for vaccination, date of vaccination, vaccine and dose administered, batch number of vaccine, Service Provider details and location in which vaccination took place. Ensure all fields are completed – a record that does not have all mandatory fields completed will not save on the database. For more information about the database, email the Prevention and Control Program, CDCD. 1 The Australian Government has announced its requirement for Medicare numbers to be reported for each student that receives HPV vaccinations. Guidelines for the School-based Vaccination Program 42 1.3 Vaccinations given to adolescents by a GP To ensure complete vaccination records for all adolescents it is important for any schoolbased vaccinations given by a GP to be recorded on the SBVP database. The GP practice administering the vaccine is responsible for completing and faxing the Government-Procured Vaccines used in General Practice for Adolescents/Other Groups form to CDCD, a copy of which can be found at www.health.wa.gov.au A Service Provider that is made aware of vaccinations given by a GP by the parent/legal guardian can also record this information on the database if it is validated. Choose GP Provider, and enter GP provider number (enter ‘unk’ if unknown) and ‘Immunisation given outside of school’ for location in which vaccination took place. 1.4 Obtaining private/independent school students details There is currently no agreement between the Department of Health and private/independent schools to electronically transfer student details to populate the SBVP database. However, Service Providers can request electronic student lists from each private/independent school (see excel template below). It is up to each individual private/independent school if they provide the data to the Service Provider electronically. All electronic lists can be emailed to the Prevention and Control Program to be uploaded on to the database. The excel headings to provide private/independent schools to populate is set out in the table below: Last Name First Name Middle Name DOB Sex (DD/MM/YYYY) (M, F, U) School Name School ID If an electronic list cannot be obtained from the private/independent school student details will have to be individually entered onto the database by the Service Provider using class lists and returned consent forms. 1.5 The National HPV Vaccination Program Register The Register (external site) takes calls from Service Providers wanting to know students previous HPV vaccinations. The number is 1800 HPV REG (1800 478 734). Guidelines for the School-based Vaccination Program 43 A parent/legal guardian of students aged less than 18 years can also phone the HPV Register in the same number. To access information they need to provide their full name, date of birth and Medicare number. 1.6 Levels of access to the School-based Vaccination Program Database Data viewer – can enter data only. Suitable for clerical staff responsible for data entry. Report viewer – can view data and reports but can't enter data. Suitable for managers/directors. Administrator – can view data and reports and enter data. Suitable for nurses involved in giving school-based immunisations – the majority of database users. System administrator – has access to system admin console. Limited to Prevention and Control Program only. Team Leader – can view data and reports and enter data in current and previous years. Has limited access to system admin tab. Suitable for Team Leaders and Regional Immunisation Coordinators (RICs). Guidelines for the School-based Vaccination Program 44 Sample Letters Sample Letter Government of Western Australia Department of Health Public Health and Clinical Services Communicable Disease Control Directorate Dear Principal VACCINATIONS FOR YEAR 8 STUDENTS The Department of Health nursing teams will conduct vaccination for year eight students over four school terms. This is to accommodate the administration of three doses of HPV vaccine. Children are eligible to have HPV (three individual doses) Diphtheria, Tetanus, Whooping Cough (one dose) and Chickenpox vaccination. The four dates allows for the HPV program and any catch-up vaccination to be offered to your students. Hence the fourth visit will mainly be HPV vaccination for this student group. Immunisation consent information packs for parents will be delivered or posted directly to your school by your local Population Health Unit. The dates allotted for your school are: Visit 1 Visit 2 Visit 3 Visit 4 Please check that these dates are on the School Planner. If this date is not suitable please contact on BEFORE THE END OF TERM and leave a message with the receptionist. One of our immunisation nurses will call to arrange an alternative date. Please email class lists for the Year 8s, sorted by gender to The required fields are first name, surname, and date of birth. Please also include the name of your designated immunisation school coordinator. The requirements for the vaccination program to run safely at your school are as follows: Guidelines for the School-based Vaccination Program 45 A large open space with a minimum of two access doors, e.g. the library. A large clean table and seven adult chairs. Two or three mobile screens may be required which will allow privacy for the children being vaccinated. A table/desk and chair for administrative work. Supervision of the children waiting for their immunisation by your teaching staff. This helps allay the children’s anxiety. This person with whom they are familiar can also reassure the children. Following immunisation, as a safety requirement, the children will need to sit quietly for 15 minutes, under staff supervision. If you have any queries, please contact your local Regional Immunisation Coordinator. Yours sincerely Dr Paul Effler MEDICAL COORDINATOR PREVENTION AND CONTROL PROGRAM Guidelines for the School-based Vaccination Program 46 Sample Letter Government of Western Australia Department of Health Public Health and Clinical Services Communicable Disease Control Directorate Dear Parent REMINDER LETTER Earlier this year [the Department of Health or Local Government] nurses visited your child’s school to give the Human Papilloma Virus vaccine (HPV). Three doses are required four to six months apart. The [2nd or 3rd] dose of the HPV vaccine is now due. This letter is to remind you that your child should not be immunised with the [2nd or 3rd] dose of HPV vaccine if she/he has had a known anaphylactic reaction to any component of the vaccine; or if your child developed hypersensitivity symptoms after receiving the first dose of HPV vaccine. If unsure or concerned, please contact your immunisation team nurse to discuss. The HPV vaccine is not recommended for use in pregnancy. Should you have concerns following your child’s last immunisation or wish to report a change in your child’s health and therefore wishing to postpone immunisation, please ring the nursing team on Tel……………...................................... to discuss alternative options. Please contact [enter name and phone number here] Yours sincerely Dr Paul Effler MEDICAL COORDINATOR PREVENTION AND CONTROL PROGRAM Guidelines for the School-based Vaccination Program 47 Sample Letter Government of Western Australia Department of Health Public Health and Clinical Services Communicable Disease Control Directorate Dear Parent/Guardian The City of Joondalup, in conjunction with the Department of Health, is offering free HPV (Human Papilloma Virus) Chickenpox, Adolescent Diphtheria, Tetanus and Whooping Cough vaccinations for all Year 8 students within the City of Joondalup. If you would like your Year 8 child vaccinated at school, please read the accompanying information and complete both sides of the consent form, then return this form to your child’s school as soon as possible. If you do not want your Year 8 child vaccinated at school, you can have your child vaccinated at a City of Joondalup Immunisation Clinic. Appointments are essential. You should notify the City of Joondalup immediately if you choose to withdraw your child from the program after submitting a form. If you have any questions or wish to make an appointment to bring your child to a clinic please contact our Immunisation Team on 9400 4938 or 9400 4954. Guidelines for the School-based Vaccination Program 48 Sample Letter Government of Western Australia Department of Health Public Health and Clinical Services Communicable Disease Control Directorate Newsletter Some parents may be aware from media releases that there are currently measles cases/outbreaks occurring in Australia. In order to be fully protected your child should have had two vaccinations, at age 1yr and again at age 18/12 months or 4 years of age. If your child has not been vaccinated with two doses MMR we encourage you to take the time and get your child’s vaccination completed. The Health Department has identified a cohort of young adults who may not be fully protected. If you were born between 1966-1980 you may have only had one measles vaccination at age one. A booster for this group of children is recommended now and is available from your doctor (you may have a consultation fee but vaccine is free). Kindy and Pre-school Measles, mumps, rubella (MMR) vaccinations are due for all children who are aged 18/12 and over. If your child has not yet had the second MMR now would be a good time to organise this to ensure that your child is protected. Please inform the school when vaccinations are given to ensure that their record is up to date. Further information can be obtained from the school or school nurse. Thank you. Guidelines for the School-based Vaccination Program 49 Glossary HPV SBVP DoH WAVSS ED MOU VACR CACHS PCP AHPRA APRA MMR RICs TIS NIP OHS ACIR CDCD dTpA NHMRC ACI CPR LGAs CCM CCB CALD TIS Human Papilloma Virus School-based Vaccination Program Department of Health Western Australian Vaccine Safety Surveillance Education Department Memorandum of Und Vaccine Administration Code Regulation Community and Adolescent Health Services Prevention and Control Program Australian Health Practitioner Regulation Agency Australian Practice Registration Association Mumps, Measles, Rubella Regional Immunisation Coordinators Translating & Interpreting Services National Immunisation Program Occupational Health and Safety The Australian Childhood Immunisation Register Communicable Disease Control Directorate Diphtheria Tetanus Pertussis National Health and Medical Research Council Accredited Immunisation Course Cardio-Pulmonary Resuscitation Local Government Authority Cold Chain Monitor Card Cold Chain Breach Culturally and Linguistically Diverse Population Translating and Interpreting Services Guidelines for the School-based Vaccination Program 50 References 1. Australian Government Department of Health and Ageing. Australian Immunisation Handbook.10th Edition 2013. 2. Australian Government Department of Health and Ageing. National Storage Guidelines. Strive for Five. 2013. 3. Australian Government Department of Health and Ageing Myths and reality. Responding to arguments against vaccination. A guide for providers. 2013. 4. Western Australia Department of Health Vaccine Administration Code 2014. 5. Australian Health Practitioner Regulation Agency (AHPRA). Framework for assessing national competency standards - October 2013 6. Nursing and Midwifery Board of Australia. Scope of practice for registered nurses and midwives. 7. State Law Publisher 2005, Poisons Amendment Regulations, Western Australia. 8. State Law Publisher 1965, Poisons Regulations, Reprint 2000, Western Australia. . Guidelines for the School-based Vaccination Program 51 This document can be made available in alternative formats on request for a person with a disability. © Department of Health 2014 Copyright to this material is vested in the State of Western Australia unless otherwise indicated. Apart from any fair dealing for the purposes of private study, research, criticism or review, as permitted under the provisions of the Copyright Act 1968, no part may be reproduced or re-used for any purposes whatsoever without written permission of the State of Western Australia.