Pharmacist talking points - a vaccination message from NSW Health - Anaphylaxis & Vaccination Audits

Anaphylaxis Response Kits

The NSW Pharmacist Vaccination Standards require that an in-date and complete anaphylaxis response kit is available prior to administering vaccines. Advice on preparing a response kit is available from the digital Australian Immunisation Handbook. This advice includes:

Before each vaccination session, check that you have the protocols, equipment and medicines to manage anaphylaxis. Always keep an anaphylaxis response kit on hand. This kit should contain:

adrenaline 1:1000 (at least 3 ampoules — check expiry dates)
at least three drawing-up needles
at least three 1 mL syringes and 25 mm needles (22 or 23 gauge) for intramuscular injection
cotton wool swabs
pen and paper to record the time the adrenaline was administered
laminated copy of Table. Doses of intramuscular 1:1000 adrenaline for anaphylaxis
laminated copy of Table. Recognising and treating anaphylaxis

Signs of anaphylaxis

The most serious immediate AEFI is anaphylaxis. Severe anaphylactic reactions usually happen rapidly, within 15 minutes of vaccination. Anaphylaxis after routine vaccination is very rare, but can be fatal.

All immunisation providers must be able to recognise all the symptoms and signs of anaphylaxis. Anaphylaxis is characterised by sudden respiratory compromise and/or circulatory collapse.

Early signs involve the skin — for example:

generalised erythema
urticaria
angioedema

Early signs can also involve the gastrointestinal tract — for example:

diarrhoea
vomiting

Severe cases may have:

circulatory collapse
altered level of consciousness
hypotension
weak or absent pulse
marked respiratory compromise from upper airway oedema or bronchospasm.

All immunisation providers must be able to distinguish between anaphylaxis, convulsions and fainting. A table providing further information is available from: https://immunisationhandbook.health.gov.au/resources/handbook-tables/table-clinical-features-that-may-help-differentiate-between-a-vasovagal

Management of anaphylaxis

Rapid intramuscular administration of adrenaline is the cornerstone of anaphylaxis treatment. Adrenaline is lifesaving and must be used promptly.

Antihistamines or hydrocortisone are not recommended to manage anaphylaxis in an emergency.

The recommended dose of 1:1000 adrenaline is:

0.01 mL per kg body weight (equivalent to 0.01 mg per kg or 10 µg per kg)
up to a maximum of 0.5 mL
given by deep intramuscular injection, preferably in the anterolateral (upper outer) thigh

Repeat the dose of 1:1000 adrenaline every 5 minutes until there is clinical improvement. The adrenaline dosage for management of anaphylaxis is age/weight dependent. A useful table is available from the digital Australian Immunisation Handbook: https://immunisationhandbook.health.gov.au/resources/handbook-tables/doses-of-intramuscular-11000-adrenaline-for-anaphylaxis

Factsheet on managing anaphylaxis.

Use of EpiPens

Adrenaline autoinjectors (EpiPen) are devices that administer a single, pre-measured dose of adrenaline.

Autoinjectors are usually not appropriate to include in first aid kits for general use. This is because:

they are single use only
they are dose-specific
multiple pens would be needed to allow for repeat dosing and varying ages/weights of patients

The above advice on the signs of anaphylaxis and managing anaphylaxis is available in the digital Australian Immunisation Handbook: https://immunisationhandbook.health.gov.au/resources/handbook-tables/table-recognition-and-treatment-of-anaphylaxis

Should people receive a second influenza vaccine in the same season?

The following advice is available from the National Centre for Immunisation Research and Surveillance (NCIRS) webpage (Q11): http://ncirs.org.au/sites/default/files/2020-04/Influenza-FAQs_7%20April%202020_Final.pdf

Annual influenza vaccination is recommended for everyone ≥6 months of age. Most people should receive 1 dose of influenza vaccine each year. However, the following people should receive 2 doses (4 weeks apart), children aged 6 months to <9 years receiving influenza vaccine for the first time and people of any age receiving influenza vaccine for the first time after haematopoietic stem cell or solid organ transplant. Pregnant women may be vaccinated with the next season’s influenza vaccine if it becomes available in the latter part of their pregnancy, even if they were vaccinated with the previous season’s vaccine prior to or earlier in pregnancy. There is not enough evidence to routinely support a second dose in the general population at this time, including the elderly and those aged >65 years, even if the influenza vaccine was given early in the season. Further information is available in the influenza section of the online Australian Immunisation Handbook and NCIRS FAQs and Influenza factsheets.

Vaccination audits - community pharmacies/pharmacists

NSW Health will soon recommence random audits of pharmacists and pharmacies that provide vaccination services.

A random selection of NSW pharmacies will be audited for compliance with the NSW Pharmacist Vaccination Standards. Vaccination auditors are authorised to conduct the audits under powers derived from the Poisons and Therapeutic Goods Act 1966.

Community pharmacies providing Pharmacist vaccination services must comply with the NSW Pharmacist Vaccination Standards.

The audits are assessing:

appropriate vaccination training,
correct vaccination procedures,
appropriate vaccination environment and equipment, and
appropriate record keeping of vaccinations.

The Auditor will advise pharmacy owners and vaccinating pharmacists about the outcome of the audit and will provide correspondance outlining recommended actions, including the process for addressing any major or critical issues identified.

Information on Pharmacist Vaccination Guidelines are available from:

NSW VACCINATION STANDARDS