Issues of Parental Consent for Vaccinations

Can Albert consent to Mia’s vaccination without the consent of Mia’s mother? Should you go ahead and vaccinate the child after completing the pre-vaccination assessment and obtained consent from Mia’s father? Discuss and explain your decision.

According to most country’s legal systems, the legal age of consent tends to be 18 years of age (WHO 2014). Therefore, a child or adolescent in the age group of five to seventeen years of age cannot provide consent to vaccination and so consent is required from their parent or legal guardian (WHO 2014). Mia is five years of age, which means she needs consent from either of her parents or legal guardian. As albert is Mia’s biological father and shares equal custody over Mia, with Mia living with her father two out of every four weeks, he has the right and ability to give consent on Mia’s behalf.

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 As a nurse immuniser in the state of Victoria, there are requirements and responsibilities that the immuniser needs to abide by at all times in order to provide the service of vaccination (Australian Government Department of Health 2013). It is recommended that prior to any vaccination, the person giving the vaccination reviews the child’s vaccination history, determine the suitability for vaccination and lastly obtain valid consent (WHO 2014). Current practices of obtaining informed consent for vaccination, can be categorised into three approaches (WHO 2014). These include; a formal, written consent process; a verbal consent process; or an implied consent process (WHO 2014).

In regards to reviewing the vaccination history, the nurse immuniser should review Mia’s clinical record and Child Health Record book to determine vaccinations and doses required according to the NIP and/or the parent/guardians wishes (WHO 2014). Next, prior to immunising it is recommended that a thorough clinical assessment of the vaccine is conducted to ensure that they are medically well enough to be vaccination or have no medical contradictions to a specific vaccine (Victoria Government Immunisation Program 2009) It is the responsibility of the nurse immuniser to obtain valid consent prior to each vaccination. Furthermore, pre-immunisation procedures should always include the pre-immunisation checklist and the common reaction information (Victoria Government Immunisation Program 2009)

In Mia’s above scenario, there has been no court order between her parents. If there are no parenting orders in place, each of the parents has parental responsibility and neither parent has an obligation to consult with the other about major long-term issues before making a decision (Kaye 2018). Therefore, one parent, in this case Albert, could simply take the child to be vaccinated, knowing the other parent may well object (Kaye 2018).

There is specific criteria that Mia’s father, Albert, must meet in order for the consent to be valid. These include that the consent must be given by a person with legal capacity, and of sufficient intellectual capacity to understand the implications of being vaccinated; it must be given voluntarily in the absence of undue stress; a discussion must cover the specific procedure that is to be performed and lastly, it can only be given after the potential risk and benefits of each vaccine, the risks of not having it and any alternative options have been discussed to Albert (Australian Government Department of Health 2018a).

Before gaining consent from Albert regarding his daughter, Mia, the nurse immuniser needs to conduct a pre-vaccination checklist to ensure it is safe to proceed with the vaccination. In the above scenario, it is stated that a pre-vaccination assessment has been completed which is good. A pre-vaccination assessments includes making sure that the provider has the right person to be vaccinated, to a more in-depth assessment by checking any medical conditions that may prevent them having the immunisation (Victoria Government Immunisation Program 2009). One of the questions on the pre-vaccination screening checklist is “identifies as an Aboriginal or Torres Strait Islander person”. This is important to note as in the scenario it states that Albert requests Mia to be vaccinated against influenza, as he is aware that Mia has an added vulnerability due to her indigenous heritage (Australian Government Department of Health 2018b). This is important to note as Aboriginal and Torres Strait Islander people experience high rates of disease due to lack of previous exposure (Australian Government Department of Health 2018b). This is associated with lower standards of living, higher burden of chronic disease and poorer access to housing and health care (Australian Government Department of Health 2018b).

Furthermore, this scenario makes this situation within Mia’s family complicated due to Mia’s mother Rose has an objection to vaccinations, adding conflict to both Albert and the nurse immuniser as well as Rose. Albert still remains Mia’s biological father and both himself and Rose share equal custody over Mia giving them both equal rights to making a decision for Mia’s vaccinations. However, Albert has completed the pre-vaccination assessment and obtained valid consent and it has been noted of Mia’s indigenous heritage and as long as the nurse immuniser has followed all the requirements and responsibilities there should be no obligation to not go ahead at vaccinating Mia.

Lastly, I would speak to Mia’s mother Rose and explain the situation that has happened and also speak to her about the concerns she has in regards to allergic reactions and adverse events following immunisations so she has a better understanding. This will hopefully prevent any major conflicts between Albert and Rose.

Outline how you would counsel Mia’s biological mother, Rose, who is deemed to be ‘hesitant vaccinator’ or a ‘fence-sitter’, regarding vaccinating Mia.

Mia’s biological mother, Rose, is deemed to be a ‘hesitant vaccinator’ or a ‘fence-sitting’ when it comes to vaccinating her daughter due to concerns about allergic reactions and adverse events following immunisation (AEFI). When parents have a strong belief in not vaccinating, health-care providers can experience difficulty when trying to change attitudes towards vaccines (Bedford et al 2012). Some of these parents may have strong feelings and be very confident in what they believe to be true about each vaccine or around vaccinating (Bedford et al 2012). However, some parents, just like Rose, are in the middle of the spectrum, who are either hesitant or uncertain and this is where effective communication is important (Bedford et al 2012). Poor communication can contribute to rejection of vaccinations or dissatisfaction with care (Bedford et al 2012).

It is important for the health-care provider to allow time to speak to these hesitant parents to address their specific concerns (Bedford et al 2012). We should discuss the benefits of vaccination, as well as the risk of not vaccinating. According to Bedford et al (2012) states that if we tailor the conversation to the parent’s concerns, it can positively affect the provider-parent relationship and gain trust. Health-care providers should talk to parents about managing any common side effects that may arise and what to do if something more serious happens to their child. It can also be helpful to provide written material explaining the risks and benefits so that they can visually see which may help with Rose’s educational capacity (Bedford et al 2012). Written resources can be available for Rose in electronic/online or paper format that can be printed (Bedford et al 2012).

You could also consider potential referral to a specialist immunisation clinic. If needed, vaccines can be given under medical supervision at a specialist immunisation clinic (Victoria State Government 2018). Clinics in Victoria are located at Royal Children’s Hospital Melbourne (for children), Monash Children’s Hospital (for children), and Monash Medical Centre (for adults) (Victoria State Government 2018).

Other approaches that could be used with Rose are principles of motivational interviewing. This can involve asking questions that will clarify the parent’s responsiveness to change and causes their own motivations to change. It is important for the health-care provider that every parent is different and not all methods of communicating work with each. However, some of these strategies may be able to be used with Rose, in regards to helping her choose the best for her child, Mia.

As a health-care provider/nurse immuniser, I would begin by

-          Listening to Rose’s concerns and acknowledge what she has to say first before explaining anything

-          Provide Rose with the most important points first and make sure she understands the information being told to her. I will then clarify and repeat what her beliefs are about immunisations

-          Discuss the benefits and risk with Rose of vaccine. Important to provide Rose with Vaccine Information Statements, written resources that are educational, and websites that are reliable.

-          Important to provide information to parents based on their cultural beliefs, vaccine concerns and literacy level

-          I would provide a positive approach and emphasise on the number of lives saved by immunisations rather than the lives lost

-          Talk to Rose about how Mia is at school now, and discuss the state laws for school entry with rationales. I would explain to her that vaccines benefit individual children and community through herd immunity.

It is also important to communicate effectively with Rose, in a way that she culturally understand as she has indigenous heritage in her. It is important to reflect without judgement before, during and after interacting with people whose beliefs, values and experiences are different to your own (Queensland Health 2015). For communicating with Aboriginal and Torres Strait Islander People, it’s important to be mindful of health literacy, language literacy, numeracy literally and keeping all explanations clear and concise (Queensland Health 2015). Firstly, building a rapport is important, and to introduce yourself in a warm and friendly way. In regards to language literacy, many do not speak English as their first language, therefore; avoiding using complex words, always use diagrams, models, DVDs and images to explain concepts, instructions and terms (Queensland Health 2015). Time is another aspect that is perceived different in Aboriginal and Torres Strait Islander cultures. Therefore, allocating flexible times and take the time to explain things is important (Queensland Health 2015).

Another aspect that could be discussed with Rose is about herd immunity and the safety of vaccinating her daughter to protect herself and her community (Pollard 2018). Herd immunity gives major protection to those people who are vulnerable such as new-born babies as they are too young to be vaccinated, elderly people because their immune system become less affective as they age, people on chemotherapy treatment who have a compromised immune system and people with HIV (Pollard 2018).

In conclusion, effective discussions with vaccine-hesitant parents requires clear and flexible communications strategies. It’s important to prepare to spend as much time with the parent and child, explore and address all concerns, discuss the benefits and risk of the vaccine and backing up all with resources to support your discussion

Articulate how you would identify and manage anaphylaxis following an immunisation encounter.

Anaphylaxis is the rarest but most severe form of allergic reactions and can be life threatening if it not treated immediately (WHO 2019). It is an allergic reaction that can involve more than one body system (WHO 2019). It’s important that you recognise the anaphylaxis early and start treatment immediately. In regards of identifying anaphylaxis, a nurse immuniser should know the warning signs from early warning signs such as itching, rash, swelling, dizziness, sneezing, vomiting to life threatening symptoms such as swelling in face, difficulty breathing, collapse and low blood pressure as well as weak or absent pulses (WHO 2019).

In regards to managing an anaphylaxis, the following steps should be used:

-          Send for additional medical assistance,

-          Dial 000 and state that there is a case of anaphylaxis,

-          Lie the patient, ideally with legs raised unless the patient as breathing difficulties, in which case the patient may prefer to sit up

-          If there are any respiratory and/or cardiovascular symptoms or signs of anaphylaxis, give adrenaline 1:1000 at a dose of 0.01 mg/kg IM in the lateral thigh (maximum 0.5 mg).

-          Administer oxygen if available, administer by facemask at a high flow rate

-          If there is inadequate response, or an immediate life-threatening situation or deterioration then repeat IM adrenaline injection every 3-5 minutes as needed or start an IV infusion as per protocol. Monitor BP closely.

-          If the patient is unconscious an airway should be inserted, if the patient stops breathing, resuscitation should be performed.

-          All patients should be transferred by ambulance to hospital, with monitoring and resuscitation capability for a minimum of 4-6 hours of observation (Browm & Kirkbirght 2012)

Any adverse event following immunisation (AEFI) is an unwanted or unexpected event following an administration of a vaccine (Victoria State Government 2018). Therefore, in Victoria, AEFIs should be reported to the surveillance of adverse events following vaccination in the community (SAEFVIC) (Victoria State Government 2018). SAEFVIC is a specialist service that helps immunisations providers and the community manage people who have had an AEFI (Victoria State Government 2018). It also provides clinical backup and individualised support to manage future vaccination, which increases the confidence of patients and their immunisation providers (Victoria State Government 2018). It is important to report all significant or rate or unexpected AEFIs in both children and adults to SAEFVIC (Victoria State Government 2018). However, you do not need to report common/minor or expected AEFIs. Lastly, SAEFVIC reports all notifications to the Australian Adverse Drug Reactions System (ADRS) at the Therapeutic Goods Administration (Victoria State Government 2018).

Within the above scenario, it is important to speak to Rose about anaphylaxis and that this may occur even though it’s rare, it can be serious and this is why there are protocols in place within each facility to ensure it is identified and managed immediately to prevent life-threatening consequences.

Explain how you would advise Rose regarding Mia’s future vaccination recommendations following AEFI.

An adverse event following immunisation (AEFI) is any negative reaction that follows a vaccination. These reactions may be caused by the vaccine or may occur by chance. It is important to educate Rose of the common AEFIs and how to manage them if it was to occur. The most common adverse evets are at the injection site, which may include:  pain, redness, itching, swelling or burning (Australian Government Department of Health 2018c). This is usually mild and usually last for 1-2 days. A low-grade fever or tiredness are also common after many vaccines (Australian Government Department of Health 2018c).

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More serious reactions that may occur include seizures, thrombocytopenia, hypotonic hypo responsive episodes, and prolonged crying, which all need to be reported (Australian Government Department of Health 2018c). Most sever vaccine reactions do not lead to long-term problems. Anaphylaxis, while potentially fatal, is treatable without leaving any long-term effects (Australian Government Department of Health 2018c). It is important to advise Rose about the known, but rare, AEFIs. If a person has had a serious AEFI, it is important they seek advice from a specialist immunisation clinic (Australian Government Department of Health 2018c). This advice is important to determine the relationship of the reaction to the vaccine, consider the benefits and risk of further vaccination and possible planning for receiving additional doses of that vaccine if needed (Australian Government Department of Health 2018c). It may be beneficial for Rose to take Mia to a specialist immunisation clinic for future vaccinations to receive vaccines under close medical supervisions. It is important to report negative reactions to a vaccination. In Victoria, AEFIs should be reported to the surveillance of adverse events following vaccination in the community (SAEFVIC) (Victoria State Government 2018).

In regards to the scenario, where Mia is due for her Diphtheria, Poliomyelitis and influenza vaccine, the person administering these vaccines should explain to Rose the potential side effects of each vaccine. These may include: redness or pain at the injection site, drowsiness, or muscle aches (Australian Government Department of Health 2018d). Even though these are minor side effects and are non-serious, it is important to educate the parent, Rose, of the potential side effects so that Rose is prepared and if any further discussions or concerns are addressed, then they can be answered during the immunisation session.

In general, most children who have a non-serious reaction to a vaccination can be safely re-vaccinated by their vaccination provider (Australian Government Department of Health 2018e). This should be addressed by Mia’s vaccinator to Rose in regards to it is ok to continue Mia’s future vaccinations. If Mia were to experience a more serious reaction after her vaccinations, it would be harder to determine whether Mia should be revaccinated would be more difficult. If the adverse reaction was directly from the vaccine, then possible further testing can be done to isolate what ingredients were in the vaccine that caused this reaction to happen (Australian Government Department of Health 2018e). Therefore, Mia can see an immunisation specialist’s which are available in most states. They can advise whether Mia needs more testing or precautions before receiving her future vaccinations (Australian Government Department of Health 2018e). This can be spoken to her nurse immunisation provider who can contact them or give more details about the services (Australian Government Department of Health 2018f). If there is no clinic, there is often a paediatrician or infectious diseases specialist who will assist families with vaccination concerns (Australian Government Department of Health 2018f).

Documentation of AEFI is crucial in order to correctly track adverse events and adequately prepare for future vaccinations (Australian Government Department of Health 2018g). This documentation is covered through the pre-vaccination checklist which will ask a range of questions but also ask about any previous AEFI, which will determine if it is safe to continue the next vaccination/s (Australian Government Department of Health 2018g). The pre-vaccination check list is conducted at every vaccination (Australian Government Department of Health 2018g).

In conclusion, as long as Mia has not had a previous anaphylaxis, or any other serious adverse event following an immunisation, then it would be still recommended to Rose that she continues with Mia’s future immunisation schedule.

References

• Australian Government Department of Health 2013, National Immunisation Strategy for Australia, viewed 10 January 2019, https://beta.health.gov.au/file/1421/download?token=5D5ntadj
• Australian Government Department of Health 2018a, Preparing for vaccination, viewed 10 January, https://immunisationhandbook.health.gov.au/vaccination-procedures/preparing-for-vaccination
• Australian Government Department of Health 2018b, Vaccination for Aboriginal and Torres Strait Islander people, viewed 10 January 2019, https://immunisationhandbook.health.gov.au/vaccination-for-special-risk-groups/vaccination-for-aboriginal-and-torres-strait-islander-people
• Australian Government Department of Health 2018c, After vaccination, viewed 16 January 2019, https://immunisationhandbook.health.gov.au/vaccination-procedures/after-vaccination
• Australian Government Department of Health 2018d, Comparison of the effects of diseases and the side effects of vaccines on the National Immunisation Program, https://immunisationhandbook.health.gov.au/resources/handbook-tables/table-comparison-of-the-effects-of-diseases-and-the-side-effects-of
• Australian Government Department of Health 2018e, Reporting and managing adverse vaccination events, viewed 16 January 2019, https://beta.health.gov.au/health-topics/immunisation/health-professionals/reporting-and-managing-adverse-vaccination-events
• Australian Government Department of Health 2018f, Who can be immunised, viewed 16 January, https://beta.health.gov.au/health-topics/immunisation/getting-started/who-can-be-immunised
• Australian Government Department of Health 2018g, During the visit, viewed 16 January, https://beta.health.gov.au/health-topics/immunisation/getting-vaccinated/during-the-visit
• Bedford, H, Cheater, F, Jackson, C, Kinnersley, P, Leask, J & Rowles, G 2012, Communicating with parents about vaccination: a framework for health professionals, viewed 11 January 2019, https://bmcpediatr.biomedcentral.com/articles/10.1186/1471-2431-12-154
• Brown, S & Kirkbright, S 2012, Anaphylaxis: Recognition and management, viewed 12 January, https://www.racgp.org.au/afp/2012/june/anaphylaxis-recognition-and-management/
• Kaye, M 2018, Immunisation Disputes in the Family Law System, viewed 10 January 2019, http://classic.austlii.edu.au/au/journals/UTSLRS/2017/28.html
• Pollard 2018, Herd immunity- herd protection, viewed 12 January 2019, http://vk.ovg.ox.ac.uk/herd-immunity
• Queensland Health 2015, Communicating effectively with Aboriginal and Torres Strait Islander people, viewed 12 January 2019, https://www.health.qld.gov.au/__data/assets/pdf_file/0021/151923/communicating.pdf
• Victoria Government Immunisation Program 2009, Guidelines for immunisation practice in local governments, viewed 10 January 2019,
• http://docs2.health.vic.gov.au/docs/doc/792CED34C9A708BACA2579110002788C/$FILE/guidelines_immunisation_practice_local_governments.pdf
• Victoria State Government 2018, Adverse events following immunisation reporting, viewed 12 January 2019, https://www2.health.vic.gov.au/public-health/immunisation/adverse-events-following-immunisation-reporting
• World Health Organization (WHO) 2014, Considerations regarding consent in vaccinating children and adolescents, viewed 10 January 2019, https://www.who.int/immunization/programmes_systems/policies_strategies/consent_note_en.pdf?ua=1
• World Health Organization (WHO) 2019, Adverse events following immunization, viewed 12 January 2019,https://www.who.int/vaccine_safety/initiative/detection/AEFI/en/