www.ncirs.usyd.edu.au

Deidre BroganClinical Nurse Consultant Immunisation NSW Immunisation Specialist Service (NSWISS)The Children’s Hospital at Westmead, Sydney www.ncirs.edu.au

Strategies to assist in

vaccinating needle phobic children

2017

NSWISS (NSW Immunisation Specialist Service) atThe Children’s Hospital, Westmead, Sydney

Specialist Service:• for in-depth consultation with a paediatrician

experienced in immunisation• Vaccination of needle phobic children• Telehealth consultation with remote areas

Drop in immunisation clinic staffed by experience nurse immunisers

1800 phone advice line to assist immunisation providers on vaccines safety and vaccination of patients with complex medical conditions

Why do we need a service for hard to vaccinate children?

Children with a disruptive behavioural or developmental disorders can react with aggression or defiant behaviour when faced with a medical procedure

There is an unacceptable risk of physical harm to the child or the person administering a vaccination to the child

These children can remain unvaccinated or have to wait until they have a general anaesthetic to receive their vaccines

Family assistance payments are now linked to immunisation status for Australian children

Australian Government Department of Health No Jab, No Pay – New Immunisation Requirements for Family Assistance Payments From 1 January 2016: Only parents of children (less than 20 years of age) who are fully immunised or are

on a recognised catch-up schedule can receive the Child Care Benefit, the Child Care Rebate and the Family Tax Benefit Part A end of year supplement

Children with medical contraindications or natural immunity for certain diseases will continue to be exempt from the requirements.

Conscientious objection and vaccination objection on non-medical grounds will no longer be a valid exemption from immunisation requirements.

NO EXEMPTION OPTION

To support these changes 1. Free catch-up for children less than 10 years of age on an on-going basis. 2. Free catch-up for young persons 10 to 19 years of age, of families who currently

receive family assistance payments (time limited until 31/12/2017)

CASE STUDY

15yo male Background

110kg, very strongAutism, mostly non verbalaggressive behaviour, GORD, hypertension

Medications: somac, melatonin, Olanzapine (prn) Overdue dose 2 MMR, MenC, dose 1 HPV Family financial incentive

How can we safely vaccinate ?

The current situation

Child difficult to vaccinate

Overdue or

incomplete vaccines

Previous attempts

failed

Safety concerns

Financial incentive

How can we help? STAGE 1

• Referral• Information gathering, medical/vaccination historyTRIAGE

• Initial consultation• Discuss information gathered at triage• Options discussed, distraction techniques, follow

on appointment for +/- sedation

ASSESSMENT & PLANNING

• Prepare the family and child• Staff, equipment and environmentPREPARATION

Medicationplan

STAGE 2

• Orientate child and family to treatment area and equipment

• Commence once appropriate level of sedation achieved

• ONE VOICE

VACCINATION

• Appropriate post vaccination observation time criteria met

• Plan for follow up vaccines arranged

DISCHARGE

CASE STUDY OUTCOME

Olanzapine 5mg wafer before admission Presented NBM on day of vaccination Midazolam 10mg oral – remained agitated Olanzapine wafer 5mg by mum

VACCINATED !

Observed 2 hours - sleepy

Clinic encounters by age

Total N – 26Visit 1Vaccinated – 17 ( pharm 14, no pharm 3)Not vaccinated - 9

Chart1

5

6

7

8

9

10

11

12

1321

1434

1531

1611

17

visit 1

visit 2

visit 3

age

encounter numbers

0

1

0

0

0

0

0

1

9

7

6

1

1

SUMMARY

DOBAGEINDICATIONVACCINE REQUIREDALLIED HEALTH INTERVENTIONINTERVENTION IN CLINIC - VISIT 1VISIT 2VISIT 3OUTCOMECOURSE COMPLETEDNOTES

7/31/0017ADHD/AUTISM/NEEDLE PHOBIAHPV/dTpaNONONE REFUSED NITROUSNOT VACCINATEDRefused - referred back to GP

5/21/0116EPILEPSYHPVNON20N20DISTRACTIONVACCINATEDCompleted with NSWISS

5/23/0215ANXIETYHPV/dTpaNONONE REFUSED NITROUSNOT VACCINATEDRefused - referred back to GP

6/10/0215AUTISM/NEEDLE PHOBIAHPV/dTpaNONO2N20N20VACCINATEDCompleted with NSWISS

7/1/0215ADHD/ANXIETY/NEEDLE PHOBIAHPV/FLUNONO2N20VACCINATEDContinuing with GP

7/17/0215NEEDLE PHOBIAHPV/dTpaNON20N20VACCINATEDContinuing with GP

8/22/0215AUTISM/NEEDLE PHOBIAVZV/HPV/dTpa/HepA/FluNOGENERAL ANAESTHETICVACCINATEDIncomplete lost to follow-up

21/02/200215AUTISMMMR, MenC, HPVNOMIDAZOLAMVACCINATION CONTINUINGcoordinated approach, olanzipine and midazolam pre admission

3/11/0314NEEDLE PHOBIAHPV/dTpaNOFreaked out when on NO2NOT VACCINATEDRefused - referred back to GP

1/26/0314ADHD/AUTISM/NEEDLE PHOBIAHPV/dTpaNONO2N20N20VACCINATEDCompleted with NSWISS

11/3/0214DOWN SYNDROME/NEEDLE PHOBIAHPV/dTpaNONO2N20N20VACCINATEDCompleted with NSWISS

3/4/0314NEEDLE PHOBIAHPVNOVACCINATED IN NSWISS CLINIC WITH NO INTERVENTIONVACCINATEDCompleted with NSWISSdose 1 at school, dose 2 at GP,

9/13/0215NEEDLE PHOBIAHPV/dTpa/VaricellaNONO2N20N20VACCINATEDCompleted with NSWISS

6/23/0314ANXIETYHPV/dTpa/VaricellaYESLMX/EMLAVACCINATEDIncomplete lost to follow-upemail sent to facs case worker re f/u

2/28/0314FAINTHPV/dTpaNOLMX/EMLAVACCINATED IN NSWISS CLINIC WITH NO INTERVENTIONVACCINATED IN NSWISS CLINIC WITH NO INTERVENTIONVACCINATEDCompleted with NSWISS

4/20/0413NEEDLE PHOBIAHPV/dTpaNOFreaked out when on NO2NOT VACCINATEDRefused - referred back to GP

1/29/0413ADHD/ANXIETYHPV/dTpaYESNONE REFUSED NITROUSNOT VACCINATEDRefused - referred back to GP

5/2/0413NEEDLE PHOBIAHPV/dTpaYESNONE REFUSED NITROUSNOT VACCINATEDRefused - referred back to GP

12/4/0313AUTISM/NEEDLE PHOBIAHPV/dTpaNONONE REFUSED NITROUSNOT VACCINATEDRefused - referred back to GP

2/1/0413BIPOLAR/ANXIETY/NEEDLE PHOBIAHPV/dTpaYESOTHER MEDICATIONSNOT VACCINATEDRefused - referred back to GP

10/21/0313NEEDLE PHOBIAHPV/dTpaNON20N20DISTRACTIONVACCINATEDCompleted with NSWISS

10/14/0313NEEDLE PHOBIAHPV/dTpaNON20N20VACCINATEDIncomplete lost to follow-upDNA for visit 3

2/17/0413ADHD/ANXIETY/NEEDLE PHOBIAHPV/dTpaNON20VACCINATEDContinuing with GPdose 1 at GP, dose 2 at NSWISS mo will complete at GP

06/04/200413AUTISMHPV/dTpa/VZV/FluNOMIDAZOLAM + NO2VACCINATEDcoordinated approach, olanzipine and midazolam pre admission

24/12/200412ADHD/AUTISM/NEEDLE PHOBIAHPV/dTpaYESMIDAZOLAM + NO2NOT VACCINATEDcontinuing with counselling

8/7/116VASOVAGALInfanrixIPV/MMRNONO2VACCINATEDCompleted with NSWISS1 visit required

VALIDATION FIELDS

VACCINATED

ANXIETYHPVYESVACCINATED IN NSWISS CLINIC WITH NO INTERVENTIONVACCINATED IN NSWISS CLINIC WITH NO INTERVENTIONVACCINATED IN NSWISS CLINIC WITH NO INTERVENTIONVACCINATION CONTINUINGCompleted with NSWISS

ADHDdTpaNODISTRACTIONDISTRACTIONDISTRACTIONNOT VACCINATEDContinuing with NSWISS

AUTISMvaricellaLMX/EMLALMX/EMLALMX/EMLAContinuing with GP

NEEDLE PHOBIAHPV/dTpaMIDAZOLAMMIDAZOLAMMIDAZOLAMRefused - referred back to GP

AUTISM/NEEDLE PHOBIAHPV/dTpa/VaricellaFreaked out when on NO2Freaked out when on NO2Freaked out when on NO2Incomplete lost to follow-up

ADHD/AUTISM/NEEDLE PHOBIAInfanrixIPVMIDAZOLAM + NO2MIDAZOLAM + NO2MIDAZOLAM + NO2continuing with counselling

ADHD/ANXIETY/NEEDLE PHOBIAMMRMIDAZOLAM+ No2 + LMXMIDAZOLAM+ No2 + LMXMIDAZOLAM+ No2 + LMX

DOWN SYNDROMEInfanrixIPV/MMRGENERAL ANAESTHETIC FOR ANOTHER BOOKED PROCEDUREGENERAL ANAESTHETIC FOR ANOTHER BOOKED PROCEDUREGENERAL ANAESTHETIC FOR ANOTHER BOOKED PROCEDURE

DOWN SYNDROME/NEEDLE PHOBIAVZV/HPV/dTpa/HepA/FluNONE REFUSED NITROUSNONE REFUSED NITROUSNONE REFUSED NITROUS

ADHD/ANXIETYHPV/FLUNONE REFUSED ALLNONE REFUSED ALLNONE REFUSED ALL

BIPOLARHPV/dTpa/VZV/FluOTHER MEDICATIONSOTHER MEDICATIONSOTHER MEDICATIONS

BIPOLAR/ANXIETY/NEEDLE PHOBIAMMR, MenC, HPVN20N20N20

EPILEPSY

FAINT

Sheet3

AGEvisit 1visit 2visit3

50

61

70

80

90

100

110

121

13921

14734

15631

16111

171

Sheet3

visit 1

visit 2

visit 3

age

encounter numbers

What next?

For those unable to be vaccinated-evaluate current approach- investigate other pharmacological options- ? Further counselling

Australian Government consideration for exemption of children who have attempted but are unable to be safely vaccinated on time

Develop resources that can be used to assist vaccination in the community setting.

www.ncirs.usyd.edu.au

Acknowledgements:

Assoc Prof Nicholas WoodDr Lucy DengCNC Karen OrrRosemary Joyce

Strategies to assist in vaccinating needle phobic children 2017NSWISS (NSW Immunisation Specialist Service) at�The Children’s Hospital, Westmead, SydneyWhy do we need a service for hard to vaccinate children? Australian Government Department of Health �No Jab, No Pay – New Immunisation Requirements for Family Assistance Payments Slide Number 5CASE STUDYThe current situationHow can we help? STAGE 1Slide Number 9Slide Number 10STAGE 2 CASE STUDY OUTCOMESlide Number 13Clinic encounters by ageWhat next?Slide Number 16Acknowledgements:��Assoc Prof Nicholas Wood�Dr Lucy Deng�CNC Karen Orr�Rosemary Joyce