PART FOUR - RECOMMENDATIONS YY /\ Sa YF 81, The Commission would respectfully make the following recommendations: MMR Vaccination Coverage (reference is made to paragraph 25 of the Report) () In any review and strengthening of the immunisation standards and procedures we believe that the declining rates in the target immunisation coverage for MMR vaccinations should be addressed; Samoa National Immunisation Programme (see paragraphs 33 and 38) (ii) The Commission commends and fully supports a collaborative effort of all ‘organisations and sectors concermed, led by the Ministry of Health, to explore and put in place an operational framework for a multi-disciplinary approach to strengthening the EPI in all its aspects; In light ofthe tragic events the subject of this Inquiry, we recommend an immediate ‘and wholescale review and update of the Samoa National Immunisation Programme Policy, in particular to consider adequate provisions in the Policy document relating to the training activities for the elaboration and greater understanding of the Policy provisions. Thereafter, we think the Policy requirement for an annual review and update should be adhered to. If the Immunisation Advisory Committee has not already taken action, we believe it should act quickly on the matter Immunisation Protocols (MMR vaceines) (see paragraph 40) (iv) The provisions of the Jmmunisation Protocols (MMR vaccines) should be comprehensively reviewed and updated, informed by the events at Safotu, so that they can offer more explicit guidance and assistance for the implementation of the EPI as a whole and to all who administer vaccinations in Samoa; ‘COMMISSION OF INQUIRY REPORT [RSE]Adverse Event Following Immunisation Protocol (see paragraph 44) (v) We believe there is need to review this Protocol and its provisions made more explicit and redrafted as necessary to provide for needed responses to emergency situations and fatal events like those which occurred at Safotu and towards their prevention for the future; Samoa National Immunisation Programme Policy (sce paragraph 47) (vi) The Commission considers there is need to take early action to review and update the provisions of the Policy and Protocols and, more critically, for immediate steps to be taken to conduct a full review of the current training programmes and for new and targeted training regimes to be devised and implemented; Safotu Hospital (see paragraphs 50, 52 and $3) (vii) The adequacy and functioning of necessary communication systems for Safotu Hospital uding telephones, require attention and rectification; (viii) The Commission believes that the outreach work at village and family level is, essential and invaluable in the exchange of knowledge with parents and families and in ‘grounding the national immunisation programme and its benefits in the understanding, and confidence of the community. Further improvements and developments to the outreach effort should therefore feature in importance in any review and strengthening ofthe national immunisation programme; (ix) Given the circumstances and as a response to the events which occurred, the ‘Commission considers it necessary that there should be a full review of the operational standards of the Safotu Hospital, including its staffing adequacy and needs, training of all staff and the care and security of vaceines, drugs and other provisions and equipment; Injection of babies at Safotu Hospital (see paragraphs 59 and 60) (x) Immediate consideration should be given to the formulation of new standards and response-guidelines to provide guidance to the nursing staff in the event of adverse effects following injections and other emergency situations, especially where there is ‘COMMISSION OF INQUIRY REPORT [RSE]Stoppage of EPI Vaccinations: no resident or available doctor. We believe there should be multi-diseiplinary engagement in the consideration and formulation of such new standards and guidelines (see also paragraphs 33 and 77 of the Report); (xi) Similarly, immediate consideration on a multi-disciplinary basis should be taken for the review of nursing staff training and performance in CPR (or cardiopulmonary resuscitation), as well as the review of essential and functioning equipment, to assess ‘and to ensure that nurses in the district hospitals are adequately trained in up-to-date and advanced life support skills, and able to respond effectively in resuscitating infants and children suffering from adverse effeets following injections or ABFIs; (xii) We would recommend an immediate review of the emergency resuscitation drugs, facilities and associated equipment available and stocked at all District Hospitals to enable an up-to-date and accurate assessment of the need for all these provisions to be present and stocked at these hospitals, or for any changes necessary; to assess and. determine the required staff development and training needs to ensure improved safe practice and high and adequate professional standards; and to review and put in place standards and guidelines for the instruction and assistance of nursing staff in the care and use of emergency resuscitation drugs; ublic Confidence (see paragraphs 65-68) c effective preventive strategy; and the complete safety of vaccines, including the MMR. ‘We welcome the EPI Report 2018. We agree that there is need for more, and sustained, efforts to reassure the public of the need for MMR vaccinations and their safety. To ‘We endorse the emphasis on the public immunisation programme as a highly ‘minimise the risks and to ensure as many children as possible are protected, we endorse the suggestion for a ‘mass vaccination special programme for the benefit of “defaulters’ and those who remain un-vaccinated since the stoppage of the MMR vaccinations; (xiv) Noting the range of practical difficulties being experienced with respect 10 requirement for “medically supervised immunisation” under the EPI (and, thus for MMR vaccinations as well), and noting also the fact that the EPI is a traditionally nurse- ‘COMMISSION OF INQUIRY REPORT [RRSEAled and nurse-driven programme, the Commission believes that there is substantive reason and justification for carly re-consideration of this requirement with a view to its abandonment. Given the multiple policy and related aspects for consideration we j believe that re-consideration on a mul isciplinary basis would be productive and worthwhile; (av) We consider the EPI Report 2018 as correctly drawing attention to the dangers and real risks with the current suspension of the MMR vaccinations; and the ‘Commission is in support and would recommend the resumption of MMR vaccinations immediately; and Parental Consent (see paragraphs 70-72) (xvi) We think the procedure with respect to parental consent needs to be explicitly dealt with in the Samoa National Immunisation Programme Policy document and in the supporting Protocols to recapture and sustain public confidence and re-assurance through the provision of full information and their understanding and forthe safety and protection of all concerned, parents as well as nurses and other health professionals who ‘work in this area: (avii) The time of obtaining parental consent and the procedue for it, whether on the occasion of the child's first vaccination after birth or later, requires clarification and clear provisions should be stated in the poli and protocol documents on the matter; ‘Training (see paragraph 76) (xviif) While the events of Safotu point to serious human error, itis error which reflects directly on staff performance and the system as a whole. The Commission considers that the failures of Safotu need to be addressed in the most responsive and comprehensive ‘manner to ensure requited modifications and sustaining training regimes for the future. Ifnot already arranged, we believe there will be need to consider short-term training or technical support to ensure prompt attention to matters of priority (for example, needed steps to re-vitalise the immunisation programme; steps to shore up public support, and the confidence of nursing staff and healthcare providers) and, for the longer term, for more sustaining training and support programmes. As we have advanced in COMMISSION OF INQUIRY REPORT [QRREH)Recommendation paragraph 81 (x) above, we believe the development and undertaking of new training and support programmes should be on a multi-diseiplinary basis (see also paragraphs 33 and 77 of the Report). Dated at APIA this 29" day of March 2019 Tey Judge Tuiloma Neroni Slade Leo’o DrJohn Adams _Lealaiauloto Liai losefa-Siitia Chairman Member Member COMMISSION OF INQUIRY COMMISSION OF INQUIRY REPORT [RRRES)