Issue 15 / 23 April 2012

FEELING in a penitential mood, I wondered which consultations are the worst — the heart sink patients.

Is it the narcotic drug seeker who gives the sob story about his dog chewing his authority script for OxyContin only 2 days into the 30-day course? Or is it the 160 kg diabetic smoker who just cannot understand why I cannot improve the circulation in his blue toes? Or is it that family who always books in one child and then expects me to see all four children every single time?

However, a new category of patient is threatening to overtake all of the above. Believe it or not, the typical description of the new patient is the young adult, fit, intelligent, well-spoken and so healthy that he/she has not needed to see me for about 6 years.

“Doc, I am about to do my first uni prac in hospital next week and they need you to fill in this card for me …”

At that point I usually become bradycardic, hypertensive and am reaching for the nearest ventriculoperitoneal shunt to ram into my own brain.

GP: “Did you bring in your immunisation records?”

Patient: “No. Mum said you’d have all the information.”

GP: “You did not start coming to my practice until you were 10 years old.”

Patient: “Don’t worry, Doc. The lecturer at uni said that if you do not have the records you can order a blood test or just give me a booster.”

By now my shunt is working, so I can mutter: “You do realise you may need five needles in that case?”

Patient: “Say I have the blood test?”

GP: “The results could take up to 2 weeks to come back.”

Patient: “But my prac is next week!”

GP: “How long have you had the form?”

Patient: “About a month.”

GP: “And why did it take you so long to bring it in?”

Patient: “I thought it would be easy to fill in.”

GP: “And did anyone explain to you that the TB testing has to be done via a hospital clinic or special TB clinic?”

Patient: “No.”

Given that it seems almost every family in Australia now has one member studying a health-related discipline, this scenario plays out for most GPs on a regular basis.

The university and hospital administrators have taken a pretty hard line on this documentation of late, but I wonder whether such a draconian approach is needed.

I can’t recall a single case of a student or clinician getting tetanus, diphtheria or mumps from a patient. The diseases we do fear catching — HIV, hepatitis C and most viral respiratory illnesses — have no vaccines.

And who should pay for this time-consuming chasing of past records, given that it’s a demand imposed by the administrators and not really a concern for most students?

It appears to be a classic cost-shift away from the hospitals and universities onto Medicare and GPs.

Serologies are slow and expensive. GPs are often expected to collate the results and pass them onto the students gratis. It’s another case of expensive, unpaid red tape for GPs.

Vaccines, too, are expensive.

As taxpayers we have to ask how many unnecessary serologies and vaccines we are funding. I wouldn’t be surprised if this is amounted to millions of dollars a year.

The ACIR (Australian Childhood Immunisation Register) is one example of a centralised bureaucracy that genuinely simplifies this sort of work for clinicians.

The ACIR keeps good records of vaccination up to the age of 7 years but it might be time to expand it to include all vaccinations for all age groups.

The universities and hospitals could then simply email or call the ACIR. It would save GPs and their student patients a lot of time and heartache … and sore arms!

Dr Aniello Iannuzzi is a GP practising in Coonabarabran, NSW.

Posted 23 April 2012

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9 thoughts on “Aniello Iannuzzi: Immunisation confessions

  1. What's it all coming to says:

    Not just students about to start prac in hospital! In looking to apply for a casual VMO position with the local area health service I find I’m supposed to prove I don’t have TB and that I can’t give whooping cough, diphtheria, mumps or measles to my patients. It’s a NSW Health standard application form, certainly new since I last applied for a VMO position. No way my current GP has the information and certainly will be time consuming for me to chase down “proof” if actually required. I was told to worry about it if and when the powers that be decided proof really was necessary.

  2. Sue Ieraci says:

    In my view, anyone who requires this information should provide an easy way to obtain it. I recently underwent screening in the public hospital where I work – funded by my employer. I was please to find that I was still immune to rubella and Hep B after decades post-immunisation, and I only needed DPT top-up (happy to get the pertussis during this time of relative outbreak). Vaccines required by employers should not only be internally funded, but should be linked to safety in the clinical workplace. Hep B would be virtually universally relevant, pertussis relevant, tetanus as required by exposure. If the strategy were clinically relevant and the employer/trainer facilitated the process and cost, there would be a lot less reluctance to comply.

  3. Sally says:

    I remember on the first day of medical school 10 years ago, we all lined up for hours in the medical building to get our serology tests and the following week the same thing for vaccines… Provided by professors from the dept of micro & immunol. Guess I am one of the lucky ones!

  4. Anonymous says:

    This really does seem to be a case of risk-averse organisations attempting to diffuse the responsibility for that risk to other people, elsewhere.

    Furthermore, it’s probably not even appropriate/legal for this to be put onto Medicare. Sect 13.6 of Medicare Explanatory Notes reminds us that Medicare is not liable for examinations for entrance to education or for vocational purposes. Is there a Medicare offence here?

    Seems to me that these organisations should define their own risk profiles, decide if testing is cost-effective, perform and pay for their own testing and then take responsibility for the results of these tests (as used to happen with the internal Medical School testing, described above).

    If the organisations were to own and pay for the whole process, their attitude to this sort of thing might change….

  5. Sue Ieraci says:

    Anonymous – there may be a degree of risk aversion here, but it’s important to remember that the immunisation is for the benefit of patients encountered by those students in health care institutions (almost exclusively public hospitals). For blood-borne diseases in particular, there is a strong case for knowing whether one has immunity before exposure to the health care environment – where there is risk of needlestick injury.

  6. Judy says:

    Medical professinals are aware that serology is not proof of immunity. That is, some individuals have a high antibody level and still get the infectious disease and others have a low antibody level and do not get the disease after exposure.If Sue (or any medical professional) can provide the models from controlled clinical trials that demonstrate the level of antibodies required to provide protection against a particular disease, it would be greatly appreciated. Alternatively could you please provide the evidence of a patient getting an infectious disease (for which there is a vaccine) from a health professinal. Please could you define this risk to the public with proof. The policy requiring health students to get up-dated with multiple vaccines does not provide evidence of the risk to patients from unvaccinated practitioners. As Aniello Iannuzzi describes above, practitioners themselves have not seen the evidence for this policy.

  7. Sue Ieraci says:

    Judy – while nothing in human life is 100% consistent and invariable, a level of specific antibody IS regarded by people who understand immunology as evidence of immunity. No, it’s not invariable. One can also have clinical infection and then acquire the same infection again. IN relation to disease transmission in health care – you largely have it back-to-front – the Hep B vaccination is done to protect the clinician FROM the patient – not vice versa. While there have been rare cases of blood-borne disease transmission from clinician to patient, the majority of concern is for health care workers – and the employer’s potential liability if the worker contracts an infectious disease from a patient – either by respiratory transmission (such as influenza) or by needle-stick injury. Lastly, I’m not sure why you are asking me to provide the evidence for the link between antibody levels and immunity – the papers are easy to search. I expect you may have come across them as part the extensive research that you report having done in the area.

  8. Judy says:

    Sue – the evidence I am asking for is the empirical evidence from a controlled clinical trial that exposes vaccinated and unvaccinated individuals to the infectious agent and the antibody level that is demonstrated to protect against the disease. Could you please direct me to this study as this is the evidence that is needed to support the policy of vaccinating clinicians/students and it is not easily found. Most studies provide a recommended antibody level stated to be protective but I am asking for the empirical evidence demonstrating that the levels are protective.

  9. Dr Michael says:

    @Judy – I suspect that you are being deliberately argumentative. It is unreasonable to expect that any ethics committee (or anyone that has ethics) would expose people to potentially very dangerous or debilitating illnesses, purely for research purposes. On the other hand, the success of vaccination schemes in reducing those same debilitating and deadly outcomes is very easy to observe. The introduction of Haemophilus Influenza B vaccine reduced the numbers of epiglottitis and HIB meningitis dramatically and abruptly. This was not due to the disease suddenly disappearing (except that it was no longer passed on by those protected) but instead by the protection that it offerred. Many other disease (e.g. measles, polio) have also had the same abrupt change with the introduction of vaccines confirming that they are effective.

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