2024 flu season and respiratory illnesses

Moderator:

Professor Paul Kelly

Head of the Interim Australian Centre for Disease Control (CDC) 

Panellist:

Professor Nigel Crawford
Chair of the Australian Technical Advisory Group on Immunisation (ATAGI)

[The visuals during this webinar are of each speaker presenting in turn via video, with Auslan interpreting signing at bottom of screen]

Professor Paul Kelly:

All right. That sounds good. We’ve got quite a few people in the room. I think we’re expecting about 750 people who have already registered and many of them have already arrived as I understand it. So we’ll get started I think.

So my name’s Professor Paul Kelly. I’m the Chief Medical Officer and the head of the interim CDC. I’m here in Canberra on Ngunnawal country and I just want to acknowledge the traditional owners of this land here, past, present and emerging Elders, and to acknowledge the non-ending and continuing association with this land from those custodians. I’d like to also acknowledge other Aboriginal and Torres Strait Islanders that are with us today and for the Elders and custodians of the land upon which all of us are part of this webinar.

I’m joined today by Professor Nigel Crawford who’s the Chair of ATAGI, Australia’s Technical Advisory Group on Immunisation. So welcome to you Nigel. It’s great that so many people have signed up and hopefully have joined and will be joining us in the coming minutes. I’ve got some messages there saying no audio. I hope people can hear me though. You can hear me all right Nigel?

Yep. Good. So we know that we’re on the cusp of winter. It’s certainly getting cold here in Canberra and so this is a time for us to consider particularly influenza and RSV that circulate as seasonal viruses and cause respiratory illnesses around this country as well as other parts of the southern hemisphere at this time of year. But also that COVID is still with us. If we look at the data for this year half of the reported notified respiratory diseases so far this year have been COVID and the other half roughly similar for flu and for RSV.

Just a couple of technical things. Live captions are available. You can press the button which I think is at the bottom of the screen. Links to any resources I mention in my update will be published after the event on the webinar page and that is the web page you used to access this Webex event. Of course we’re very happy to have our Auslan interpreter. Thank you very much for coming and we’re very happy to see you there. So thank you very much for that.

There is a Q&A time at the end of this webinar. In fact most of the webinar will be devoted to questions and answers, or a fair proportion of it. So please store up those questions. There is a function on the webinar page. We’ll be monitoring that and the team I have here in the room in Canberra will be prioritising those questions that appear to be the most popular. So it is a popularity contest for those questions. If you see questions in the chat you really want to hear about as well then please note that. Any questions that aren’t covered today, if we’ve run out of time, then we will take them on notice and they’ll be published on the webinar page as well.

So with that sort of brief introduction I just want to hand over to Nigel to introduce himself as well and then we’ll get cracking on the content. So Nigel.

Professor Nigel Crawford:

Yeah. Thanks Paul and thanks for the invitation to join today. I think it’s really good that we can start to talk about winter preparedness and particularly the vaccine, preventable diseases and ways we might minimise the impact of these infections. As Paul mentioned I’m Chair of ATAGI but I’m also a paediatrician here at the Children’s Hospital in Melbourne. And also acknowledge the land I’m on, the Bunurong people of the Kulin nation.

I’ve actually spent the last week working in our short stay unit so certainly seeing lots of these respiratory viruses circulating as well as exacerbation of asthma and some of the complications of these infections. So we know the impact it has both on primary care as well as our hospitals and the community more broadly. So discussing some of those preventative therapies and any questions that might arise, happy to do so. So back to you. Thanks Paul.

Professor Paul Kelly:

Thanks Nigel and great to have you here. So we’ll get cracking. A bit of background. I’ve already talked a bit about respiratory disease so far this year and what might happen. Of course those of us that do media are always asked the crystal ball question is it going to be a bad flu season, and we don’t know that really until after the fact to be honest. But what do we know is there has been quite a bit of influenza circulating already this year and that’s reflected in our national notifiable diseases data which is always an underestimate of what’s actually happening in the community. But we’ve had over 40,000 cases of flu already this year, inter-seasonal flu, and we’re obviously just starting to show an uptick in that in terms of notifications.

If I was a betting man it looks very similar to what we saw in 2022 which was a relatively early flu season, which again really for those of you who are practitioners and are involved with the flu vaccine rollout is a real wake up call to say let’s crack on with that and not wait. If we can get those high risk groups particularly in for flu vaccine, now is the time. There’s certainly plenty of product out there.

Looking back now to last flu season we actually saw a reasonably good match between flu vaccine and the circulating virus which is what we hope for each year. Again we won’t know that for sure for this year until after the season or certainly well into the season. But last year we know that influenza vaccine actually had a 68% reduction in hospitalisations and a need to visit GPs of 64%. So it’s not the perfect vaccine. We all know that. But it is very important for particularly those at high risk of severe disease.

Just back to this pre-season now, why those flu cases are up. We’re not really sure. Certainly people are travelling more so that link with the northern hemisphere is re-established. We hardly saw any flu during the COVID pandemic emergency period because of the lack of travel. But that’s certainly re-established. People are of course much more aware of the reason to get a test if you have a respiratory illness so we are seeing those testing rates increase. And so that’s another potential reason. Whatever it is, the reason for that, it’s not always the case that that will predict what happens in this flu season. But that’s something that we know about so far at least. We’re finding out those things.

Influenza as I’m sure everyone online knows can be a serious illness. We had 39 people we know that died of flu last year. That’s always an underestimate for sure. Much less than people have died from COVID of course but that is of course of death again in particular groups. Nine children died. Nine children under the age of 16 died. That’s something that we need to stress for pregnant women and for parents of young children why it is so important for them to be vaccinated in that under 5 age group in particular.

Just a reminder that the National Immunisation Program does provide free vaccination for high risk groups and just a reminder again of who that is. That’s children over the age of six months, under the age of five years. It’s pregnant women, to protect them as well as their baby in those first six months. People over the age of 65 or Aboriginal and Torres Strait Islanders over the age of six months. And then a range of chronic diseases. I won’t go into them but it’s available on our website if you need a reminder, and of course it’s in the ATAGI advice and the immunisation handbook.

So the reasons why they are absolutely prioritised for flu vaccine is because those are the ones that are much more likely to get severe disease where influenza vaccine can be highly protective. Of course the ATAGI advice – and Nigel might go into this later – but does include anyone over the age of six months can and should consider getting a flu vaccine every year. The flu vaccine is slightly different every year and so that’s an important message. There are some state programs that are providing free flu vaccine for that wider group as well but that’s just a matter for those of you in different states to look at those programs that are run currently by those state health departments.

So I think that’s all on flu. We will keep going with these respiratory viruses. I think it’s important to consider COVID and RSV when we are talking about these things. Certainly our reporting now is based on all three viruses. And there are other viruses of course but they’re the three that we have interventions for as well as a need to monitor because of their nationally notifiable status.

So I’m going to pass over to Nigel now to talk a little bit about COVID vaccine advice which has changed a bit since last winter, and just a reminder about that. So I’ll pass over to you Nigel.

Professor Nigel Crawford:

Thanks Paul. Maybe just one quick comment around flu vaccine, I think sort of reinforcing the vaccination, particularly as I mentioned before my paediatrician hat. For the fully funded under five years of age on the NIP, we know it’s generally got around 30% to 50% coverage but we’d like to get that higher this year. So really reinforcing that vaccine for children is important, those with asthma and other risk factors as well. So I think if you’re seeing a patient for a different reason or they’ve come in for a check with those age points you can give the vaccines at that time as part of their routine 12 and 18 months as an example. So I think really important to keep flagging that vaccine for the children under five.

With regards to COVID we acknowledge it’s not quite as clear cut in terms of the seasonality certainly at least in the southern states compared to flu and RSV which we’ll also touch base on. But it certainly has had peaks over the winter months, a big burden we know both in primary care and the hospitals. So ATAGI’s continuing to constantly review the evidence around COVID infections and vaccine advice. We updated that advice in February and it has been published. The links will be provided which I’m sure people have seen.

We’re sort of expecting to see a potential increase so really important just to keep checking as mentioned that those at highest risk are protected, are up to date with their vaccinations and get the appropriate booster. So the key groups that have been called out of those that are at higher risk of severe disease, so particularly that 75 years and over are recommended to have a booster every six months. So then we’ve got to check that booster status, including those in aged care, to make sure that they’re up to date and had those doses. Less concern around previous infection or timing. Really just giving those two doses at six months apart over the year for the 75 and over is important. As well as those with severe immunocompromise, particularly 18 and over with severe immunocompromise are recommended those doses every six months, and recommended to consider for those 18 and over every 12 months to get a dose. So again similar to your annual flu vaccine. Everyone checking their status and getting their booster now. We’re into May. It’s a good time to get the dose if you’re eligible.

For children, COVID not as severe as infection in the older age groups, but definitely those that are severely immunocompromised are still recommended to get that booster dose this year. But children who are otherwise healthy and don’t have those underlying severe conditions are not recommended boosters at the moment. We know they’ve already had majority of primary schedule as well as that hybrid immunity, which is the combination of both vaccination and infection. So really important to acknowledge that the community does have hybrid immunity, but to continue that we continue to need to give vaccination particularly in those high risk groups.

I think the other question that comes up for those presenting for their vaccination, can you give all the vaccinations at the same time in terms of co-administrations? We haven’t got combined vaccines just yet. That might be coming in the future but not currently. But it’s certainly fine to get the COVID vaccine the same time as the flu vaccine. Those that are due a pneumococcal booster as an example, you can also give these vaccines altogether. The only one that it’s generally preferable to give them separate is the Shingrix vaccine. Whilst they can be given together often there’s a bit of a separation for those two vaccines. And Shingrix not obviously as time critical in terms of the winter protection. But I think reviewing all of the vaccines that your patients might be recommended by age and risk factors is really important and the sort of winter preparedness, getting ready for all of the viruses that might be circulating and getting optimal protection is really the key.

So I think I’ll pause there now Paul and back to you to focus a bit on RSV.

Professor Paul Kelly:

Thanks Nigel. So RSV as I’m sure most people would know can be a serious infection in similar groups to flu. So it’s particularly an issue for children in the first 12 months of life and in the very elderly as well as some other people with other chronic diseases. But those two in particular are a concern.

Rapidly emerging really over the last 12 months has been new approaches to preventing of RSV, and so roughly into two categories. There are immunisations which are starting to come onto the market around the world and including one here. So we have Arexvy which is on the private market at the moment now for people aged over 60 years of age. The other vaccines that are around including one for antenatal use is still going through the process of either licencing or through the PBAC process. And Nigel will know more about that.

We have for some years had a monoclonal antibody available for very high risk neonates which hasn’t been used a lot in Australia partly because it only lasts for a month, and so to give that full protection for that high risk full first six months if that’s during a winter period particularly needs five doses. And so that’s not been used so much but it has been available for quite some time in Australia. There’s a new monoclonal antibody known as Nirsevimab which is licenced in Australia. It’s not currently available nationally but there are some state programs. And I met with all the Chief Health Officers this week to get an update of where they were up to with that. So some states have quite wide programs, others are a bit more restricted, which have started for this year. Again if you are wanting to have further information about that you should approach your own state health departments.

So that’s an emerging issue. As I mentioned at the beginning we’ve had roughly the same number of RSV cases this year as we have had flu cases so far. That is increasing. I’m sure Nigel will talk about his experience in the last week of what he’s seeing there but that is an issue that is emerging particularly in the eastern states, not so much in the west at this time. It often is the harbinger of the flu season so we’re seeing an increase in RSV notifications over the last few weeks.

I’ll pass back to you Nigel perhaps to talk more about those options of RSV prevention.

Professor Nigel Crawford:

Yeah. Thanks Paul. So I think really important to know that this is now sort of newly vaccine preventable, immunisation preventable, which is excellent news. It’s been a long time for these products to come through to market. As mentioned a little bit of difference between the vaccines and immunisation. So the long acting monoclonal won’t provide longer term protection for the infant. Once it wears off they’ve sort of lost that protection. There are no infant vaccines just at the moment for RSV and there are some state programs and a look to have this reviewed for potential national programs moving forward.

With regards to the adult vaccines again Arexvy’s licenced for 60 plus, not yet on the national program but something to add to the mix to discuss with your patients as part of that winter preparedness. And not quite there yet as well with maternal vaccine, again aiming to give infant protection through transfer of antibody. These products have been used extensively in the northern hemisphere season so we will have additional information both in terms of the impact of these preventative therapies as well as the safety profile over the next 12 months. I’m sure there will be forums Paul where we can update the people listening through the different groups in terms of where they’re up to. But exciting news that they are coming and I think our winter preparedness is really strengthening with the arrival of these new products which is great news.

Professor Paul Kelly:

Thanks Nigel. And your experience during the last week. Is it RSV or flu or a bit of both?

Professor Nigel Crawford:

Yeah. A little bit of both. We’re certainly seeing some RSV cases presenting. We tend to see a bit of a peak more in the June month but it was a bit earlier last year. People will recall with the pandemic, similar to no flu we saw very little RSV circulating in 2020 and then sort of an out of season peak in 2021. But in ’22 sort of onwards we’ve gone a bit more back to our seasonal peak here in again as I mentioned the southern states. But I think acknowledging again Paul we’re a big country. The northern jurisdictions, I know Darwin in particular has a lot of flu cases recently there, and we know the seasonality is not quite as clearcut as you go a higher latitude, particularly in the northern parts of Australia. So thinking of protection and optimal protection is really important across the whole country. But yeah a mixed bag of flu and RSV just at the moment here at the hospital. Thanks.

Professor Paul Kelly:

Thanks Nigel. And could you just reinforce the high risk groups that we really want our clinicians to be concentrating on as we go into this winter season in terms of vaccine protection?

Professor Nigel Crawford:

Yeah. So I think as I mentioned a little bit with the COVID component it’s really the elderly. So 75 and over is the age group that’s strongly recommended to have their COVID vaccine as well as probably the priority as well for RSV. So the burden of disease for both COVID and RSV is higher in the 75 and over. Influenza, 65 and over is our funded program as well as the high risk conditions as mentioned. So again important for our primary care colleagues to make sure you’re reviewing the underlying risk factors of your patients and recommending vaccination for those age groups. And I think aged care facilities, again such an important group obviously through COVID but also with influenza and RSV. So I think aged care would be the other priority group. I think I already alluded to the paediatric population. So it’s both our high risk patients with underlying medical conditions as well as the younger age groups. These viruses, particularly RSV and flu, really target the youngest and the older members of our community so really important to optimise their protection. Thanks.

Professor Paul Kelly:

Thanks Nigel. So I think the last thing we want to just talk about is where you can get further information. And just back to the – if anyone’s interested in the RSV monoclonal antibody story then the National Centre for Immunisation Research and Surveillance, NSIRS, did a series of webinars a couple of months ago. They were very interesting. Had some overseas experience from the US and I think also from Europe. So I believe they’re still available on the NSIRS website.

Vaccination providers are also encouraged to review the ATAGI statement for this year. There’s three I think Nigel, one on each of the viruses. And giving advice about the administration of seasonal flu vaccines in particular and the 2024 program advice for health professionals, and that’s on the health.gov.au website. You can also provide a consumer fact sheet to your patients about the 2024 flu vaccine. This includes helpful answers to common questions and concerns that we have about respiratory viruses and protection measures. Again you can find that on health.gov.au/immunisation.

Additional resources about getting vaccinated against influenza are also available on the Health website. And if your patients need health advice after hours remember they can access the free general health advice from a registered nurse 24/7 through Healthdirect by calling 1800 022 222.

So I think that’s all we have in terms of the formal presentations now. So we’ve got plenty of time for the Q&A session so I’ll look to my team now to triage the Q&A.

Professor Nigel Crawford:

Paul I might just jump in with a couple of things I saw on the chat just in terms of the new RSV products. We do have a real need to kind of make sure we’re minimising any errors of administration here because they are quite different populations that they’re licenced for. There’s one question about giving Arexvy to children. This GSK vaccine Arexvy is just licenced for 60 plus and over. It’s not a registered product for younger children. The long acting monoclonal just for children in the first two years life, so it’s Nirsevimab, not registered for older populations at this stage. And then the maternal vaccine which is going as mentioned through the PBA process, that is both a maternal vaccine as well as an adult 60 plus vaccine. But we’ll make sure the information as it comes out – we will have an RSV Australian Immunisation Handbook Chapter now it is preventable which will capture the information of these products. But very important for providers to be aware of the age groups that these products are licenced and recommended for. Thanks Paul.

Professor Paul Kelly:

Good. Thanks. I couldn’t really see the Q&A. So one question that I’ve got at the top of my list is around flu vaccine availability in northern Australia and timing of that in relation to other matters which are outside of the scope of this discussion I think. Is that something you can talk to about availability in northern Australia going forward, earlier availability of flu? Sorry. I’m just looking to my programmatic colleagues.

Professor Nigel Crawford:

I can jump in Paul. In terms of the vaccines it used to be that they ran out in terms of their expiry date on the 31st of December. They’ve all now been extended majority through ‘til the end of February. So the same vaccine is available now the whole year round and it is recommended for example during pregnancy for the whole year not just in the peak season, which we acknowledge in the southern states again different to the Northern Territory. But the same product of vaccine is now available pretty much 11 months of the year. It’s really only March where we have a short window where we don’t have a product in those jurisdictions. So certainly there’s been an extension of the expiry, acknowledging we do have a different vaccine each year. But certainly been efforts to make sure that those extended expiry allows vaccine to be used all year round from the influenza perspective.

Professor Paul Kelly:

Thanks. Thanks Nigel. I mean the other element from a global perspective is that there are constraints on having the timing of deciding for the next flu vaccine which usually happens around September, and then of course takes time to produce it for the southern hemisphere and then six months later for the northern hemisphere. So there is some constraints there in terms of supply. But certainly as Nigel has pointed out, it can be available from the previous years which is generally not a huge change from year to year of the different vaccines.

That’s the only question I’m seeing at the moment. Are there other ones that - - -

So keep coming through with your questions. We’ve got plenty of time now to answer those.

Right. Good. So a question about:

Q:        Can COVID vaccine doses be given close to six months for convenience, eg five months and one week at a regular GP appointment? I’ll pass that one to Nigel.

Professor Nigel Crawford:

Again I think there’s got to be sort of pragmatic use of these vaccines particularly as we mentioned for the 75 and over in an aged care facility. There is a scope I think even mentioned in our advice that there’s capacity to give the vaccines a little bit earlier than that six months. They’re a recommendation in terms of guidance but needs to be some flexibility depending on the situation and scenario which individual physicians can discuss with their patients.

Professor Paul Kelly:

Yeah. And again from a programmatic point of view we have plenty of vaccines so there’s certainly no shortage particularly of Pfizer at the moment, so go ahead.

So that’s that one. Another one. Jumping around a bit.

Q:        If people are travelling overseas and want a child COVID vaccine, can I give a half dose of adult COVID vaccine?

I think I’ll give that one to Nigel again.

Professor Nigel Crawford:

Yeah. Again the short answer for that is no. The vaccines as they were produced had a different amount of SARS-CoV-2 antigen depending on the age of the child. So the adolescent or 12 plus and over had a different amount of antigen to the five to 11 year olds and different again for the under five years. And that also varied by product. So the Pfizer and Moderna vaccines were a little bit different in terms of the antigen component. So in terms of primary schedule it was quite complicated and you can’t just give a half dose of an adult for that age group.

We have modified to a single primary dose. So again we used to have lots of ATAGI statements that you had to search through. Now there is a COVID-19 Chapter which again we can put in the link which captures the primary dose recommendations for those that haven’t had a dose yet, which we know is a small number, but a single dose is all that’s required for the majority. We recommend using the XBB monovalent COVID vaccine as the one that should be administered.

Just lastly need to acknowledge that for under 5 we don’t yet have that monovalent vaccine. We still have the historical original strain vaccine for the under 5s. We believe that will be available in the coming months. So the under 5, we don’t have that vaccine. But I think the final message is that age appropriate vaccine for that individual needs to be administered, not try and modify adult doses. Thanks Paul. 

Professor Paul Kelly:

Thanks Nigel.

Q:        If flu vaccines are not given on the same time or same day with COVID vaccine is it better to wait for two weeks?

That was a previous ATAGI advice but it’s no longer valid. I think that’s right Nigel isn’t it?

Professor Nigel Crawford:

Yeah. Correct. No need to wait two weeks. And actually don’t wait two weeks now. We’ve got the season already starting. So give them a couple of days later is fine but no need to wait for two weeks.

Professor Paul Kelly:

Okay. A controversial question.

Q:        Is Flucelvax better than any of the others?

My short answer to that is it is not. The efficacy is the same. There is a theoretical advantage in Flucelvax insofar as some of the components tend to have less drift during the manufacturing process which might give a slight improvement in that if the flu that is circulating during the season is different from the one that we’ve predicted. That’s my kind of idea. What do you think of it Nigel? I know you’ve been very heavily involved with this one.

Professor Nigel Crawford:

Yeah. Thanks Paul. So this has been reviewed through ATAGI and we do put up our sort of assessments of the evidence. And as Paul mentioned it’s quite hard to compare different flu vaccine brands because there is variations in both the circulation of the viruses and the way the studies are looked into. This is not a randomised trial. This is sort of seasonal observational studies looking at the flu vaccines. But essentially there may be some variation year to year but we consider them pretty clinically equivalent in terms of their vaccine effectiveness. So I think the key thing from a programmatic point of view is that you should be receiving a vaccine that’s on the National Immunisation Program. These are fully funded vaccines according to your age. Again as mentioned with the COVID vaccines there are some different high dose vaccines or adjuvant vaccines for older Australians. So making sure you’re using the right vaccine for the right age and it’s on the national program, it’s fully funded. Thanks Paul.

Professor Paul Kelly:

Thanks Nigel. Next question is on medications actually.

Q:        So is Paxlovid and Lagevrio still an authority medication for this winter?

Short answer to that is there’s no change from previous winters so whatever you were doing to get those treatments into the correct patients at the correct time please keep going. There’s still several thousand doses being used every month. And so these are life saving medications for those high risk groups. The second part of the question is:

Q:        I notice Tamiflu is not an authority medication. Would you recommend Tamiflu for RSV in adults?

We’ll take the first one as a comment. But Tamiflu and RSV for adults, I don’t know the answer to that one. Nigel have you got any comment about that?

Professor Nigel Crawford:

No impact. So Tamiflu doesn’t work against the RSV. Different virus to influenza. There have been antivirals that have been trialled against RSV, not proven to be particularly effective so we don’t have any kind of current therapies to provide RSV management at the moment. It’s really supportive care in hospital for bronchiolitis for example, the main RSV presentation in young children. Hence even more important to think about these preventative therapies because we don’t have active treatments for the RSV virus. We need to prevent the infection in the first place.

Professor Paul Kelly:

Great. Thanks. And I’ll get you to answer the next one too Nigel which is around flu and COVID vaccines with Shingles vaccine. You did mention that earlier but do you want to reinforce that message?

Professor Nigel Crawford:

Yeah. I think the main thing with the Shingles vaccine is it is associated with some local reactions and can be a little bit more painful than some of the other vaccines, but providing excellent protection against Shingles in the future. So because of some of those local reactions there’s a little bit of a preference to separate those vaccines. It’s not winter preparedness Shingles. It can occur any time of the year so they can be separated. Having said that, if someone presents and they want all their three vaccines on the same day, or even it could be four given we talked about three viruses plus Shingles, they can all be administered on the same day. So coadministration is still okay. We know they work effectively. It’s a little bit about the local reaction management for Shingles is the main reason. Thanks.

Professor Paul Kelly:

And pneumococcal I suppose.

Professor Nigel Crawford:

Correct. Yeah. Exactly. Add a bacteria to the mix, not just respiratory viruses. And definitely again from a hospital experience we’re seeing the viruses come, then you get the secondary bacterial infections on top including pneumococcus. So if you don’t get the virus in the first place you’re not going to get those severe secondary bacterial infections. But being protected from the bacterial infection is also important, so making sure children have all their timely vaccinations for pneumococcus at two, four and 12 months as well as adults at 70 years having their pneumococcal booster is really important to try and minimise that invasive infection as well. Thanks.

Professor Paul Kelly:

Next question is about Arexvy which is the only RSV vaccine currently available or listed on the Australian register of Therapeutic Goods, but only for people over the age of 60. So a question about can you give it to infants. The answer would be no.

Thank you. The next one is a comment I think.

Q:        Thank you for holding the webinar.

Okay. The question.

Q:        Is there anything stopping us from having advice much earlier, eg October/November the year prior? This would help with logistics and messaging especially around COVID and influenza.

Sure. We can think about it. There’s no definite limit or specific timing for these things. We generally have these webinars when supply is available in all your fridges and through states and territory warehousing etcetera so that it’s front of mind. But we can certainly think about having updates. I think towards the end of this year we probably will have updates on RSV. I think that would be good timing. And of course there’s always new stuff to talk about with COVID even if people don’t want to talk about it. So thanks for that suggestion.

Next question is:

Q:        I thought Western Australia are going to vaccinate children for RSV.

So that’s with Nirsevimab, the monoclonal antibody. There’s almost 4,000 children in WA have received that. So that’s going quite well. It’s the largest of those programs that are being rolled out by states and territories at the moment in Australia. Do you have anything to comment there Nigel?

Professor Nigel Crawford:

Yeah. Thanks Paul. So I think again for the national audience, yes Western Australia has a program for all infants to have it either the start of the season or those under six months that are born during the season trying to get that dose very close to birth, maybe around the same time as the Hep B and Vitamin K administered. That’s certainly what’s happened in other countries including Spain which have had successful RSV immunisation programs. Queensland also has an infant program, and can look up the sort of parameters around the state-based programs. New South Wales has what we’re calling a high risk program, so those at high risk of severe disease which includes infants who are born prematurely as well as infants with congenital heart disease or those who’ve had prematurity and lung issues are a really high risk group. So again through your state health department you can look up those programs.

Obviously at a national level we’re hoping to learn from those programs in 2024 and there are reviews underway as mentioned in terms of how that might look like in a national picture in 2025. So I agree Paul. Maybe a review or discussion with this kind of forum in October/November as we sort of get some of those lessons learnt this year will help inform what we look to do for the winter preparedness in 2025. Thanks.

Professor Paul Kelly:

Thanks Nigel. Next question is about testing and whether balancing the health dollar cost with the clinical benefit – I’d also point to environmental costs of those things – and particularly given that even mycoplasma lower respiratory tract infections are still managed with supportive care and the usual antibiotics for LRTIs. It’s a very good point. Obviously as a public health person and responsible for national decision making it’s useful to have surveillance. It doesn’t need to be 100 percent of people 100 percent of the time. And we do have our sentinel surveillance systems which give us good information on that. So from my perspective I think it’s a clinical judgment issue as much as anything but I think it’s not necessary to be testing everyone at this stage, except I would say for those at the high risk end of COVID who may benefit from antivirals, so older people and people with chronic disease etcetera. As talked about previously it is still important to have a test because that’s part of the authority to be able to prescribe.

Nigel any other clinical comment there?

Professor Nigel Crawford:

Yeah. I think the only other comment is around the sort of mycoplasma. So certainly we have seen some atypical infections again from the hospital perspective, but again I think in primary care I agree, it’s really that supportive care. For the hospitalised cases these are different antibiotics. Mycoplasma won’t necessarily respond to Amoxil so we do tend to use a macrolide for that particular condition. And just thinking of the different lower respiratory infection is important but I agree at the population level it’s really a case by case clinical decision.

Professor Paul Kelly:

Thanks. Someone’s put in the chat a link to the poster about vaccines for COVID. So I think that’s just for everyone else to see. And some other resources have been put in by the team here in relation to that. There’s also the recordings from NSIRS that I mentioned about the RSV and some very useful FAQs. I went to those. They were terrific and really helped my knowledge so I would recommend them.

Another question.

Q:        So if you’ve had a flu vax in April do vulnerable people need a second vax this flu season?

I’ll put that one to Nigel.

Professor Nigel Crawford:

Yeah. Thanks Paul. So we’re not currently recommending a second dose of the flu vaccine. This has been flagged in previous seasons particularly those that are for example severely immunocompromised and the duration of protection. But because flu vaccine is being given annually every year you’re getting constant boosting even though there are minor changes in those strains directed by the WHO every six months for the southern and northern hemisphere, we’re not currently recommending a second dose. But again always observing the evidence and looking whether those recommendations need to change. But at this stage it’s just a single funded flu vaccine for those groups as mentioned.

Professor Paul Kelly:

Thanks Nigel. Next question is about coadministration. I think we’ve answered that one. Essentially yes, coadministration is fine.

There’s a very specific patient question here. I think just a caveat that it’s really a clinical decision at the bedside. But do you want to take that one? Can you see that one Nigel about the 76 year old patient travelling on a cruise ship, which personally I wouldn’t do, but that’s personal choice. Have you got that one Nigel, or do you want me to read it out?

Professor Nigel Crawford:

I think it’s sort of similar to the previous discussion. I agree with you. It’s for a 76 year old. It’s recommended they get a dose every six months. Obviously we’ve got the XBB vaccine at the moment so we’ll be keeping up to date with any changes in the vaccines that may be forthcoming. But I think as best you can sticking to that six monthly cycle is appropriate for this age with some flexibility depending on their individual circumstances which the local doctor can take into consideration. Thanks.

Professor Paul Kelly:

Next one’s about private cost of Arexvy.

It’s I think around we’ve heard $300 give or take, but I’m not selling it. So I think best to check that in with your local pharmacy to find that out.

Q:        How long does Arexvy give protection for?

I’m not sure we know that do we Nigel?

Professor Nigel Crawford:

Yeah. It’s currently just a single dose recommended. So this is not an annual RSV vaccine program at the moment. We’re just getting some data now coming for that second season protection for these products. So certainly getting good protection over the six to 12 months for this year if they’ve had an adult 60 plus RSV vaccine. We believe that will flow into the second year for protection. What that means in third and fourth years is very much unknown hence the need to continually monitor these products and evaluate what the program might look like. But at this stage 12 to 24 months protection we’re expecting at a minimum.

Professor Paul Kelly:

Yeah. Thanks Nigel. Just as I said earlier these are brand new products and so we need to wait and see to an extent. The next question relates to that as well.

Q:        Will the RSV vaccines be subsidised by Government later?

So remembering just to be clear there’s vaccines and there’s monoclonal antibodies. Monoclonal antibodies are being subsidised by some state and territory Governments at the moment, or state Governments actually. What might happen in the future from the national programs is being considered but I can’t say anything else about that at the moment. It’s all very new and lots more information to gather. That’s the monoclonals. In terms of the vaccines, so for things to be listed on the National Immunisation Program that has to go through a process through the TGA, through ATAGI and through the Pharmaceutical Benefits Advisory Committee. And all of those considerations are live at the moment in terms of a couple of the different vaccines.

But Nigel do you want to comment further not so much on whether we will subsidise them but where you think that’s up to and where it might be leading?

Professor Nigel Crawford:

Yeah. Thanks Paul. So I think this again feeds into the Pharmaceutical Benefits Advisory Committee review of these products in terms of coming onto a national program. I think the agenda when these vaccines are going for consideration are available and can be circulated once they’ve got to that level of they’re to the Committee for deliberation. So we know they’re all in the pipeline and ATAGI’s involved in providing advice to the PBAC on these products in a program but I think we’ll have to defer to the PBAC for the timelines of when those evaluations might occur and then decisions which would then go to Government if they got a positive recommendation from PBAC. They can be considered to go onto the National Immunisation Program but that step needs to be obviously endorsed first before that consideration can happen.

Professor Paul Kelly:

Thanks Nigel.

Q:        Any advantages on the cell-based flu vaccine?

I did mention that earlier. Essentially the key message here for clinicians is that anything that’s on the National Immunisation Program for flu, recognising there are a range of products, some of them quite specific for specific age groups for example, you should follow that advice. And then whichever of those products is in the fridge is the one that’s best to give on a particular day. And so technically there is no difference between the cellular-based ones and the traditional egg-based ones from that point of view.

Any comments there Nigel?

Professor Nigel Crawford:

No. Nothing to add thanks Paul.

Professor Paul Kelly:

Great. It’s flipped around a bit. Okay. The next one.

Q:        What about young people who choose to get vaccinated with AstraZeneca, two doses, etcetera, and only had one Pfizer dose. Do they need the second Pfizer with increased risk of myocarditis etcetera?

Thank you for commenting. So AstraZeneca is no longer available on the program. That’s finished. So we do have Pfizer. But probably one for you Nigel about that for young people.

Professor Nigel Crawford:

Yeah. Thanks. So again I think it’s the risk benefit discussion at individual level is very important. So as mentioned those 18 plus can consider an annual COVID-19 dose. The risk of myocarditis does decrease with a number of doses. It’s not just something that’s been seen with the MRNA vaccines. So for this case would be a fourth dose. The risk would be relatively low compared to the highest risk we’ve seen with the second dose of COVID-19 vaccine. So again I think it’s the risk benefit discussion for that individual which would change if they have an underlying severe immune suppression. You would be recommending a booster dose. If they have a lower risk or don’t have those other risk factors and are healthy then I think it’s back to that individual discussion. So I think it really needs to be a risk benefit for the individual. Thanks.

Professor Paul Kelly:

Thanks Nigel. The next two are kind of similar about gaps specifically in relation to Shingrix, COVID and flu. Do you want to just reinforce that message?

Professor Nigel Crawford:

Yeah. I think back to the Shingrix it’s okay to give them altogether. So that’s again just the first point saying you can co-administer. The key thing is that the Shingrix is a two dose schedule. So our previous Zostervax live attenuated vaccine was a single dose. To get optimal protection from Shingrix you need two doses. And we know that the local reactions can impact people coming forward for their second dose. So by sort of minimising that co-administration and particularly the local reactions we’re hearing from providers that they often are separating them out, giving the winter vaccines and then giving the Shingrix separately, acknowledging that may mean another visit. So very much to our colleagues to think about what’s best for that individual patient in terms of the timing. If you do separate, normally five to seven days, a week would work well in terms of logistics, but there’s no set timeframe you have to be strict with if that helps clarify. Thanks Paul.

Professor Paul Kelly:

Thanks Nigel. A question about taking into account whether someone has had a likely COVID infection in the last six months and how that accounts to vaccine timing. That was previous advice from ATAGI. No longer an issue. I guess if someone’s had COVID last week you do wonder whether it’s worthwhile having a second boost so quickly but there’s no formal advice about that. I think that’s right Nigel?

Professor Nigel Crawford:

Yeah. Thanks Paul. I think that relates a little bit to the testing. We’re not doing obviously as much testing as we were in terms of confirming positive COVID and also reflecting I think on for example aged care. Someone had an infection four months ago but you’re going into vaccinate a cohort within aged care, would you wait for another two months for the six month interval. And the short answer is no. We want to maximise protection for those at highest risk. So you’re right. If you did have an infection one or two weeks ago and it was definite, maybe wait a few more months. But don’t need to bring that into the deliberations too formally anymore. Just no harm and need to maximise protection for those who are most at risk.

Professor Paul Kelly:

Great. The next one’s on ATAGI advice as well, about the wording ‘Can consider’ being interpreted as not recommended. I’ll leave you to explain that one Nigel.

Professor Nigel Crawford:

Yeah. So we’ve worked really hard acknowledging my colleagues. Michelle Giles and Katie Flanagan have led lots of our COVID-19 work and we don’t think that ‘Can consider’ should be not recommended. That’s not the case. We’re trying to use the word ‘recommended’ to push those that we consider truly at highest risk. So as I’ve mentioned a few times now it’s the 75 and older or those with severe immunocompromise, at risk of severe COVID. But ‘considering’ means it's open to administration and you have a risk benefit discussion as we’ve gone through. So very much can be an annual vaccination for adults across Australia. And I think Paul you already mentioned there’s plenty of supply of vaccine doses so if there’s a request and you have that individual discussion you definitely can consider administer. We’re not saying don’t recommend. Thanks.

Professor Paul Kelly:

Great. The next one’s about Abrysvo which is another one of the RSV vaccines. Is it available in New South Wales? I don’t think so at the moment. So that’s still going through the process of availability. We understand it will be licenced in a similar way to Arexvy but that’s a matter that’s being considered by PBAC at the moment. That right Nigel?

Professor Nigel Crawford:

Yeah. So that’s 60 plus. But this is also the maternal vaccine. So it is also licenced for administration antenatally during pregnancy. So that’s covering both maternal adult as well as 60 plus. Yep.

Professor Paul Kelly:

But not yet through the PBAC process.

Professor Nigel Crawford:

Not available on the private market yet either we don’t believe.

Professor Paul Kelly:

Yeah. Not yet available. So watch this space. A lot happening in RSV as we mentioned earlier. The next question’s about Moderna vaccine.

Q:        Will it be coming back into the rollout or will it be only Pfizer moving forward?

There is a gap as I understand it. Do you have anything else to say there Kelly?

Kelly:

At the moment Pfizer is the vaccine that is the highest availability.

Professor Paul Kelly:

So I’m just asking my team here. So Pfizer’s the go to at the moment. Moderna of course is opening a local facility we’re hoping next year and that’s when we expect that the Moderna COVID vaccine will become available again. But watch this space. If people need to be vaccinated now it will need to be with the Pfizer vaccine.

The next question is:

Q:        Will you recommend who had the flu vaccine in April in Australia travelling to Asia area in December/January to have another flu vaccine to cover?

Nigel?

Professor Nigel Crawford:

Yeah. Again at this stage it’s just the single dose is recommended. We also get the question about if you’re travelling to the northern hemisphere should you get the northern hemisphere dose when you land there? Again it can be considered and probably a good idea if you are staying for a period of time over their winter. But at this stage it’s just an annual recommendation for the seasonal Australian version of the flu vaccine. Thanks.

Professor Paul Kelly:

Great. Thank you.

Q:        What is the current mandatory number of COVID-19 vaccinations for staff working in community care?

I’ll just note that it’s never been mandated by the Commonwealth Government which we’re representing here so you’d need to look at whatever’s the issue within your own state and territory. My understanding is there is no mandates anymore for any workers. But have you got anything else to say there Nigel?

Professor Nigel Crawford:

No. Nothing additional thanks Paul.

Professor Paul Kelly:

In terms of moving away from mandates to recommendations, I think we’ve gone through that. Six monthly for high risk and annually consideration for others is the answer to that question.

The six monthly flu vaccine. I think we’ve talked about it already. No. It’s one once a year.

Q:        Are we likely to see a rollout of RSV vaccine in Victoria? Missed the RSV part.

So these are matters at the moment for state and territory Governments. I am aware, and Nigel’s spoken to this, there is a state funded RSV monoclonal antibody for young children under the age of six months essentially in WA and in Queensland. There is a first phase of a similar thing, I think is how the New South Wales Government is stating what they are doing. They have some supply. Some but not all of the other states and territories have a very minimal supply for high risk neonates, so very premature or children with severe cardiac conditions in particular. But this is all new. It’s brand new in the whole world. It was only last winter in the northern hemisphere that these new long acting monoclonal antibodies were used to great effect in some places but supply is limited. And so these are new products for Australia. We’ll keep looking very carefully and closely at how that rolls out in those states that have started those programs.

Q:        Any word on funding of RSV vax this year or next?

I think I’ve answered that one.

Q:        What can you say to patients and their families to encourage them to get a COVID-19 booster when they are hesitant?

Yeah. This is really tricky. And I really appreciate the work that people are doing on the frontline on this. It’s a challenge as I kind of mentioned earlier. No one wants to talk about COVID anymore, feel it’s over. It isn’t over. We’ve had over 100,000 notified cases this year. We’ve had hundreds of deaths from COVID already this year, either with or of COVID. So it’s still there. People at high risk of COVID still their best protection is to have a booster every six months. And so I think encouraging as much as you can. But it is a challenge. We recognise that, that there is hesitancy particularly and including in aged care, and it’s just a matter of trying to make sure that it is available and those conversations are happening with guardians as well as patients themselves and providers. We’re certainly doing our part from the Commonwealth perspective.

I think we’ve kind of run out of time pretty much now. I’m getting a thumbs up from my team. I think just to say firstly thank you to Nigel and to Mikey our Auslan interpreter for the work on this panel.

I hope it’s been helpful. We’ve got through quite a lot of the questions but there are still some outstanding. Apologies for those that we didn’t quite get to. But we’ll take those on notice and we’ll be putting the answers somewhere. On the website. Okay. So wherever you dialled into this is where you’ll find the answers to your questions and we’ll get onto those as quickly as we can. So I think that’s it for now. We’re always open to and happy to talk to people in these sort of formats. How many people did we have online? Do we have a number?

Close to 300. Okay. So please spread the word and as we said I think we’ve got the suggestion of coming back later in the year to talk about RSV in particular and that sounds like a really good idea to me. So thank you everyone and have a good day.

Professor Nigel Crawford:

Thanks Paul.

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