October 2022 correspondence

We are writing in response to the recent article ‘General practitioner knowledge gaps regarding live attenuated zoster vaccination of immunocompromised individuals: An ongoing concern?’ (AJGP July 2022).¹

We are disappointed that Australian Journal of General Practice has published articles that seemingly miss obvious contextual elements pertaining to contemporary Australian general practice. Firstly, general practitioners (GPs) are unlikely to memorise details of all vaccines, and nor should this be encouraged given the high likelihood of error. There are 62 different vaccines available for use in Australia.² Immunisation (for all and any reasons) only occurs in 6.7 out of every 100 encounters.³ It is our experience that the routine practice of most GPs is to seek clarification from an appropriate resource (eg the Australian immunisation handbook) when they are uncertain regarding a clinical decision pertaining to immunisation. The interpretation of the knowledge items in the questionnaire can only be interpreted in this context.

Secondly, the statement, ‘almost half of our survey respondents had not reported zoster vaccination data to the [Australian Immunisation Register] in the previous 12 months, consistent with a previous report identifying substantial under-reporting’¹ is quite likely a misinterpretation. The vast majority of GPs use electronic medical record systems that upload immunisation data from the patient’s clinical record to the Australian Immunisation Register without individual user intervention. It is entirely plausible that many respondents simply interpreted the question in a manner different to the intent of the investigators.

We encourage all researchers undertaking research in general practice settings to include sufficient context expertise in their teams, and ideally with a specialist GP academic co-investigator. Inclusion of specialist GPs will encourage production of research that is relevant and applicable to the setting. As GPs we are happy to collaborate as part of a research team – but, as our colleagues have stated, please ensure this research is ‘with us, not about us’.⁴

Authors

Mary Beth MacIsaac MD, CCFP, FRACGP, DCH, MPTHM, Senior Medical Officer – Primary Care,
Royal Flying Doctor Service South Eastern Section, NSW; Deputy Chair, The Royal Australian College of General Practitioners NSW&ACT Faculty Council; Research Affiliate, University of Sydney, NSW

Chun Wah Michael Tam BSc (Med), MBBS, MMH(GP), FRACGP, Director, Primary and Integrated Care Unit, South Western Sydney Local Health District, NSW; Conjoint Senior Lecturer, School of Population Health, UNSW Sydney, NSW;Deputy Chair, Sydney South West GP Link Ltd, NSW

References

1. Dey A, Rashid H, Sharma K, et al. General practitioner knowledge gaps regarding live attenuated zoster vaccination of immunocompromised individuals: An ongoing concern? Aust J Gen Pract 2022;51(7):529–34. doi: 10.31128/AJGP-09-21-6175.
2. Australian Technical Advisory Group on Immunisation (ATAGI). Australian immunisation handbook. Canberra, ACT: Australian Government Department of Health and Aged Care, 2022. Available at https://immunisationhandbook.health.gov.au [Accessed 22 August 2022].
3. Cooke G, Valenti L, Glasziou P, Britt H. Common general practice presentations and publication frequency. Aust Fam Physician 2013;42(1–2):65–68.
4. Tam M, Price K. Reality check: Inert placebo use rare in Australian general practice. MJA Insight. 9 December 2019. Available at https://insightplus.mja.com.au/2019/48/reality-check-inactive-placebo-use-is-rare-in-australian-general-practice [Accessed 22 August 2022].

Reply

Thank you for your thoughtful comments on our recent article.¹

We value the role of general practice colleagues in providing a key public health intervention through immunisation of our community. While immunisation is relatively commonly encountered in general practice, we do acknowledge that general practitioners (GPs) cannot be expected to have immediate recall of all immunisation clinical guidelines. However, awareness that this routinely scheduled zoster vaccine (Zostavax) is live attenuated and, as such, contraindicated in immunocompromised patients is critically important, particularly given that three patients have died in Australia since 2017 from disseminated vaccine virus disease following Zostavax administration. One in five GPs in our study either responded that immunocompromise is not a contraindication to Zostavax or were unsure, and two out of five were unaware of recent Therapeutic Goods Administration safety alerts.

Awareness that immunocompromise may contraindicate live vaccination is essential for provision of any immunisation service, as articulated in all existing practice guidelines. Indeed, if GPs are not aware of the risk of significant safety issues with select vaccines, at a baseline, they may be less likely to refer to resources like the Australian immunisation handbook. This highlights the need for ongoing communication of vaccine safety practice points to ensure that GPs can remain up to date. Our article emphasises the complexity of assessment of immunocompromised status and encourages greater awareness and use of the Australian immunisation handbook screening tool² prior to administration of Zostavax.

Although half of our survey respondents said they had not reported zoster vaccination data to the Australian Immunisation Register (AIR) in the previous 12 months, we agree that some could have misinterpreted the question given that many GPs report vaccination encounters to the AIR in a semi-automated way via their practice management software. However, previous studies comparing doses of Zostavax distributed or recorded in electronic primary care datasets have shown evidence of substantial underreporting to the AIR.^3–5

We agree that teams undertaking research in general practice settings should have sufficient context expertise and note that one of our two general practice–trained authors (RM) is an experienced practising GP. Our survey was part of a larger ongoing qualitative process conducted by Healthed involving feedback from several thousand GPs. Systematic discussions with content experts and GP educators, and positive feedback from the GPs who receive education developed from this process, indicate a strong alignment with the needs of the GP community.

We also engage regularly with academic GPs and look forward to doing so more on topics such as this for future studies.

Authors

Aditi Dey MBBS, DTM&H, GradDipApplSc (HIM), MPH, PhD, Senior Research Fellow, National Centre for Immunisation Research and Surveillance, Westmead, NSW; Senior Lecturer, Faculty of Medicine and Health, University of Sydney, NSW

Harunor Rashid MBBS, MD, FACTM Senior Research Officer, National Centre for Immunisation Research and Surveillance, Westmead, NSW; Associate Professor, Faculty of Medicine and Health,
University of Sydney, NSW

Ketaki Sharma MBBS, MPH, FRACP, Staff Specialist, National Centre for Immunisation Research and Surveillance, Westmead, NSW; Clinical Lecturer,  Faculty of Medicine and Health, University of Sydney, NSW

Anastasia Phillips MBBS, MPH, FAFPHM, PhD, Staff Specialist, National Centre for Immunisation Research and Surveillance, Westmead, NSW

Jean Li-Kim-Moy MBBS (Hons), DipPaed, FRACP, PhD, Staff Specialist Immunisation, National Centre for Immunisation Research and Surveillance, Westmead, NSW; Honorary Research Fellow, Faculty of Medicine and Health, University of Sydney, NSW

Ramesh Manocha MBBS, BSc, PhD, CEO, Founder, Healthed, NSW

Kristine Macartney MBBS, BMedSci, MD, FRACP, Director, National Centre for Immunisation Research and Surveillance, Westmead, NSW; Professor, Faculty of Medicine and Health, University of Sydney, NSW

Frank Beard MBChB, BA, MPH, MHA, GradDipAppEpi, FAFPHM, Associate Director, National Centre for Immunisation Research and Surveillance, Westmead, NSW; Associate Professor, Faculty of Medicine and Health, University of Sydney, NSW