influenza immunization orientation powerpoint · complications can include pneumonia (bacterial and...

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2018-2019 Influenza Immunization Orientation

September 2018

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IntroductionThis PowerPoint is a tool for health care professionals to use as a self-learning tool in conjunction with annual influenza immunization orientation.

There is no requirement by the Province-wide Immunization Program, Alberta Health Services (AHS) to formally submit proof of completion to AHS. However, use may differ locally and therefore staff should follow instructions given at a local level for formal submission of the self-test.

For more detailed information it is important for staff to refer to other program resources such as: Vaccine Product Monographs and/or AHS Vaccine Biological pages AHS Vaccine Storage and Handling e-learning modules and Standard Guidelines for the reporting of adverse events following immunization Reporting requirements and data collection guidelines Alberta Influenza Immunization Program Policies.

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Section One Influenza Disease Learning Objectives

Learning Objectives:

The influenza immunizer will be able to:

recognize the symptoms of influenza describe self-care and prevention strategies for

influenza.

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What is influenza?

Influenza, commonly known as the flu, is a highly contagious infection of the airways caused by influenza viruses. It is often referred to as seasonal influenza because these viruses circulate annually in the winter season in the northern hemisphere.

The timing and duration of influenza season varies - outbreaks can happen as early as September, typically start in October but most often activity peaks in January or later. Late season outbreaks occurring in April and even May have also been reported.

PresenterPresentation NotesThe vaccine information sheets provided to our clients and available on AHS websites offer a summary of information about influenza and pneumococcal infections . The documents for your use, as HCW, such as this PowerPoint and Influenza Immunization Standard are more detailed to give you the information you need to answer questions posed by your clients.

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A, B and C influenza viruses Influenza A and B viruses cause seasonal epidemics, while type C

viruses cause mild respiratory illness Influenza A viruses are classified into different strains or subtypes

based on two proteins or antigens on the virus surface: hemagglutinin (H) and neuraminidase (N) e.g., H1N1 and H3N2

Influenza B viruses can be classified into two antigenically distinct lineages, Yamagata and Victoria like viruses

Influenza A and B strains are included in each year's influenza vaccine

The vaccine does not protect against influenza C viruses

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Influenza Types A and B

Type A(Seasonal, Avian, Swine influenza)

Type B(Seasonal influenza)

Can cause significant disease Generally causes milder disease but may also cause severe disease

Infects humans and other species (e.g. birds; H5N1) Limited to humans

Can cause epidemics and pandemics (worldwide epidemics) Generally causes milder epidemics

PresenterPresentation NotesWhile there are three types of influenza virusesA, B, and Conly two cause significant disease in humans (A and B). Type B influenza viruses are limited to humans, whereas Type A viruses can cause severe disease in humans and affect more species. Influenza Type A Type A influenza is considered to cause the most serious disease among the influenza viruses, although not all strains cause clinical disease. Influenza A can cause severe epidemics (as well as severe worldwide epidemics; or pandemics) among all ages. Influenza type A infects multiple species including people, birds, pigs, horses, and other animals. Wild birds are the natural hosts for these viruses. Influenza Type B Influenza B viruses are usually found only in humans. Influenza B viruses can cause some morbidity and mortality among humans, but in general are associated with less severe epidemics (chiefly among children) than influenza A viruses. Although influenza type B viruses can cause human epidemics, they have not caused pandemics. Because avian influenza and all pandemic viruses are of the Type A variety, we will focus this session on Type A influenza viruses.

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How strains change each year

Small changes in influenza viruses occur continually New virus strains may not be recognized by the body's existing

influenza antibodies within the immune system

A person infected with a specific influenza virus strain develops antibodies against that specific strain

In most years, some or all of the virus strains in the influenza vaccine are updated to align with the changes in the circulating influenza viruses

Annual influenza immunization is recommended to protect against infection from these changing influenza viruses

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Signs and symptoms of influenza

Sudden onset

Typically starts with a headache, chills and cough, followed rapidly by fever, loss of appetite, muscle aches and fatigue, runny nose, sneezing, watery eyes and throat irritation

Nausea, vomiting and diarrhea may also occur, especially in children

Fever may not be prominent in children under 5 years of age and adults 65 years of age and older

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Influenza, the Common Cold and Gastrointestinal InfectionType of infection Respiratory infection Gastrointestinal infection

Description / symptoms Influenza Common cold Stomach upset*

Virus involved Influenza A or B Many different kinds of viruses such as rhinovirus, coronavirus, adenovirus, etc.

Norovirus (Norwalk-like viruses) is the most common.

Fever Usually high, beginning suddenly and lasting 34 days.

Sometimes Rarely

Headache Usually, can be severe. Rarely Sometimes

Chills, aches, pain Usually, and often severe. Rarely Common

Loss of appetite Sometimes. Sometimes Frequently usually nausea, vomiting and diarrhea occur as well.

Cough Usually Sometimes Rarely

Sore throat Sometimes Sometimes Rarely

Sniffles or sneezes Sometimes Usually Rarely

Extreme tiredness Usually tiredness may last 23 weeks or more.

Rarely Sometimes

Involves whole body Usually Never Stomach and bowel only.

Symptoms appear quickly Yes More gradual Yes

Possible Complications(Health problems)

Pneumonia, kidney failure, swelling of the brain and death.

Sinus infection or ear infection. Dehydration (losing more fluid than you take in).

Vaccine Yearly vaccine provides protection against two influenza A strains and one influenza B strain in the TIV and two B strains in the QIV.

No vaccine available. No vaccine available.

Immunize Alberta http://www.immunizealberta.ca/sites/default/files/downloads/flu-comparison-sheet.pdf

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The myth of the stomach flu

Many people use the term "stomach flu" to describe illnesses with nausea, vomiting, or diarrhea. These symptoms can be caused by many different viruses, bacteria, or even parasites

While vomiting, diarrhea, and nausea can sometimes occur when people have influenza (particularly children), these problems are not the main symptoms of influenza

Influenza is a respiratory disease - not a stomach or intestinal disease

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How serious is influenza? While the majority of those who become ill will recover, it is estimated

that influenza causes about 12,200 hospitalizations and 3,500 deaths in Canada each year. Influenza is among the top ten leading causes of death in Canada.

Some individuals are at higher risk of developing complications from influenza, including:

Seniors Infants and young children Adults and children with existing chronic health conditions Healthy pregnant women Indigenous peoples Obese personsComplications can include pneumonia (bacterial and viral), ear and sinus

infections, dehydration, and worsening of chronic medical conditions, such as congestive heart failure, asthma, or diabetes.

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How serious is influenza?

The Centers for Disease Control and Prevention (US) conducted a study to assess the effectiveness of influenza vaccine in decreasing influenza related deaths in children (6 months to 17 years of age) Between July 2010 and June 2014, 358 children died from infection

with influenza; researchers were able to confirm the vaccine status of 291 of these children: Of the 291 children 74% were unimmunized The study concluded that influenza vaccination was associated

with reduced risk of laboratory-confirmed influenza-associated pediatric death

Increasing influenza vaccination could prevent influenza-associated deaths among children and adolescents

Flannery B, Reynolds SB, Blanton L, et. al. Influenza Vaccine Effectiveness Against Pediatric Deaths. Pediatrics. 2017. DOI: 10.1542/peds.2016-4244).

PresenterPresentation NotesReal Life Example

A child in Alberta was hospitalized; he was eligible to receive influenza vaccine but his parents declined. The child went through many invasive tests to determine a diagnosis , he was diagnosed with panencephalopathy, which is caused by a viral infection. For this child the virus that caused it was influenza.

http://pediatrics.aappublications.org/content/early/2017/03/30/peds.2016-4244

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How is influenza spread?

The virus is spread mainly from person to person when those with influenza cough or sneeze (droplet spread) The droplets are propelled about 3 feet through the air

People may also become infected by touching an object or a surface that has the influenza virus on it and then touching their mouth, eyes or nose

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Influenza incubation

Individuals with influenza are infectious 1 day before symptoms develop and up to 5 days after becoming ill The period when an infected person is contagious depends on the

age and health of the person Young children and people with weakened immune systems may

be contagious for longer than a week

The time period from exposure to development of symptoms is about 1 to 3 days, with an average of about 2 days

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Influenza infectivity

People infected with influenza can spread the disease to others before they know they are ill, and while they are ill

Some people can be infected but have no symptoms These individuals can still spread the virus to others

This is important information for those caring for others, such as parents and all health care workers

In one published study, 59% of health care workers tested had evidence of recent influenza infection but could not recall having symptoms

PresenterPresentation NotesAll Health Care Workers includes those working in health care facilities and those working in the community.

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Health Care Workers

Health care workers (HCWs) who have direct patient contact should consider it their responsibility to provide the highest standard of care, which includes annual influenza immunization

In the absence of contraindications, refusal of HCWs who have direct patient contact to be immunized against influenza implies failure in their duty of care to patients

NACI Statement 2018

PresenterPresentation Notes

Immunization of care providers decreases their own risk of illness, as well as the risk of death and other serious outcomes among the patients for whom they provide care

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Treatment of influenza

Treatment recommendations for non-complicated cases include: rest analgesics fluids time

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Self care during influenza season Get the influenza vaccine every fall. Cover your cough with a tissue, or cough or sneeze into

your upper sleeve, not your hands. Then, clean your hands, and do so every time you cough or sneeze.

Wash your hands well, and often. Avoid touching your eyes, nose, or mouth. Germs are

often spread when a person touches something that is contaminated with germs and then touches their eyes, nose, or mouth.

Clean and disinfect high touch areas. Exercise. Drink plenty of water. Eat well and do not

smoke. Avoid crowds when influenza season hits your area.

PresenterPresentation NotesWash your hands well and often

Avoid contact with ill people. You cannot avoid contact with people related to your employment, but you have choices with your social contact with ill people.

Become immunized against influenza

Practice good health habits

High touch areas include doorknobs, phones, remotes

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Influenza prevention hand washing

Wet hands with water Use regular soap antibacterial soap is

not necessary. Rub hands vigorously for at least 15

seconds covering all surfaces (Sing Happy Birthday !!).

Rinse your hands under running water. Dry hands with clean or disposable

towel.

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Self care at work Frequently wipe down your keyboard, mouse and phone (for example

with low level disinfectants not with antibacterial wipes). If you are ill, stay home from work so you do not spread illness to

others. Children who are ill should stay home from school and daycare.

Use hand hygiene frequently, especially after using copy machines, fax machines, someone elses computer or phone, or after sneezing or other contact with your own secretions.

Wash your hands before eating or drinking during breaks.

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Review Questions Section 1

1. During which time period are individuals who have been infected with influenza contagious?

2. Which individuals are at highest risk of developing complications from influenza?

Note: Answers can be found at the end of the PowerPoint.

Section One - Influenza Disease Knowledge Check

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Section Two Influenza Vaccine Learning Objectives

Learning Objectives:

The influenza immunizer will be able to:

describe the influenza immunization program within Alberta identify the target client population for this program administer influenza vaccine in accordance with local protocols.

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Influenza vaccine development Each February, the World Health Organization (WHO) provides a

recommendation on the strains to be included in the influenza vaccine for the northern hemisphere

Two influenza "A" viruses and one (trivalent vaccine) or two (quadrivalent vaccine) influenza "B" virus are selected based on the characteristics of the current circulating influenza virus strains

A new vaccine is reformulated each year to protect against new influenza infections

Each vaccine lot is tested on healthy individuals to ensure the vaccine is safe and effective

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Influenza vaccine development (contd)

There are currently five trivalent inactivated influenza vaccines (TIV) licensed for use in Canada; one of these is adjuvanted

There are currently three quadrivalent influenza vaccines licensed for use in Canada Two are quadrivalent inactivated influenza vaccine (QIV) One is a live attenuated influenza vaccine (QLAIV)

For the 2018-2019 influenza immunization program, Alberta will be using a QIV product from GlaxoSmithKline and a QIV product from Sanofi Pasteur

PresenterPresentation NotesFor more information on influenza vaccines licensed in Canada refer to the NACI statement.Quadrivalent inactivated vaccines - Flulaval Tetra(GSK) and Fluzone (Sanofi)

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How does inactivated influenza vaccine work?

Both humoral and cell-mediated responses play a role in immunity

Administration of inactivated influenza vaccine results in the production of circulating IgG antibodies to the viral haemagglutinin as well as a cytotoxic T lymphocyte response

Humoral antibody levels, which correlate with vaccine protection, are generally achieved 2 weeks after immunization and immunity usually lasts less than 1 year Initial antibody response may be lower in the elderly and the

immune-compromised

PresenterPresentation NotesQIV is an inactivated (killed) vaccine and therefore you cannot get influenza disease from the vaccine. It is grown in hens eggs, inactivated, broken apart and highly purified. It can be given to people 6 calendar months of age and older (do not compress this age by using 28 day months). Administration of this vaccine results in the production of circulating IgG antibodies to the viral hemagglutinin as well as a cytotoxic T lymphocyte response. Both humoral and cell-mediated responses play a role in immunity to influenza. Humoral antibody levels, which correlate with vaccine protection, are generally achieved 2 weeks after immunization and immunity usually lasts less than 1 year. Initial antibody response may be lower in the elderly and immune-compromised.

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Effectiveness of influenza vaccine

Vaccine effectiveness depends on the similarity between vaccine strains and the strains in circulation during influenza season, as well as individual factors Influenza immunization prevents disease in 52-82% of healthy individuals In the elderly vaccine effectiveness is about half of that of healthy adults;

however influenza immunization decreases the incidence of pneumonia, hospital admission and death in the elderly, and reduces exacerbations in persons with chronic obstructive pulmonary disease

Vaccine efficacy of 50% or lower in healthy adults has been identified during select seasons of vaccine mismatch. A vaccine that is not perfectly matched can still offer protection against related viruses making illness milder and preventing complications

PresenterPresentation NotesNACI reviewed current evidence on QLAIV, either LAIV or QIV can be used on children 2-17 years. Current evidence does not support a preferential use of LAIV in children 2-17 years of age.

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Vaccine strains for 2018-2019

The strains that will be included in the 2018-2019 influenza vaccine for the Northern hemisphere are:

A/Michigan/45/2015(H1N1)pdm09-like virus

A/Singapore/INFIMH-16-0019/2016(H3N2)-like virus

B/Colorado/06/2017-like virus

B/Phuket/3073/2013-like virus

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Facts about inactivated influenza vaccine (QIV)

Is an inactivated (killed) vaccine cannot cause influenza disease in the vaccine recipient

The virus is grown in hens eggs, inactivated, broken apart and highly purified

In addition to the antigen, the vaccine may contain:- Thimerosal (preservative in multi-dose vials) - Trace residual amounts of egg proteins, formaldehyde, kanamycin,

neomycin, gentamicin, cetyltrimethylammonium bromide (CTAB), polysorbate 80, sodium deoxycholate and sucrose

Check the product monograph as ingredients vary with specific inactivated influenza vaccines

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Section Two Influenza Vaccine Knowledge Check

Review Questions Section 2: Part A1. Which strains of influenza virus are included in the 2018-2019

influenza vaccine for the northern hemisphere? a) Why are these strains chosen?

2. Why is it necessary to get an influenza immunization each year to be protected?

3. Can you get influenza disease from the influenza vaccine? Explain.


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Universal Influenza Immunization Program

Alberta Health (AH) funds a Universal Influenza Immunization Program.

All people 6 months of age and older who live, work or go to school in Alberta are eligible for vaccine at no charge

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Influenza Immunization Program in Alberta

Alberta Health Services (AHS) coordinates the delivery and administration of the Universal Influenza Immunization Program. The program will begin with a public launch October 15, 2018. Vaccine may be offered earlier for certain high risk populations (e.g., continuing care

residents, lodge residents, homebound clients, homeless individuals, HCWs and individuals with booked immunization appointments) once vaccine is available

As in previous years, immunization partners (e.g. physicians, pharmacists, private health agencies, occupational health services) will play an essential role in achieving the AH immunization targets:- Seniors aged 65 years and older 80%- Children aged 6 months to 23 months 80% - Residents of long-term care facilities 95%- Staff of long-term care facilities 95%- Health Practitioner (HCW) 80%- Immunizers 100%

PresenterPresentation NotesHealth Practitioner refers to hospital employees, physicians, and other staff who work or study in hospitals (e.g., students in health care disciplines, contract workers, volunteers) and other health care personnel (e.g., those working in clinical laboratories, nursing homes, home care agencies and community settings) who are risk of exposure to communicable diseases because of their contact with patients/clients (diagnosed or undiagnosed) or their environment.

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Provincially funded influenza vaccines for 2018/2019Fluzone (QIV)(Sanofi Pasteur)

Flulaval Tetra (QIV)(GlaxoSmithKline)

Dosage/Route 0.5 mL 0.5 mL IM

Packaging Single Dose: Pre-filled, single dose syringe (luer lock needles not included)

Multi-dose: 5 mL vial

Multi-dose: 5 mL vial

Eligibility Individuals who live, work or go to school in Alberta

Individuals who live, work or go to school in Alberta

Indication 6 months1 of age and older 6 months1 of age and older

Ingredients2 Thimerosal-free (single dose formulation only), formaldehyde, sodium phosphate buffered, isotonic sodium chloride solution, Triton X-100

Egg proteins, sodium deoxycholate, ethanol, formaldehyde, sucrose, -tocopheryl hydrogen succinate, polysorbate 80, thimerosal

Schedule 1 or 2 doses3 1 or 2 doses3

1Children must be 6 calendar months of age; do not compress this age by using 28 day months2Refer to vaccine product monograph for a complete listing of the ingredients3Children less than 9 years of age require 2 doses given at a minimum of 4 weeks apart if they have never received seasonal influenza vaccine. This recommendation applies whether or not the child received monovalent pH1N1 vaccine in 2009-2010.

PresenterPresentation Notes*Fluzone and Flulaval are licensed for individuals 6 months of age and older.

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Influenza vaccine dosing for specific ages

6 months up to & including 8 years of age 2 doses* if never previously immunized with seasonal influenza

vaccine (spaced 4 weeks apart minimum interval) 1 dose only if previously immunized with seasonal influenza vaccine

9 years of age and older 1 dose

* This recommendation applies whether or not the child received monovalent pH1N1 vaccine in 2009-2010.

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Return visit for children who need a second dose

Indicate date to return for second dose of vaccine on the NCR form or Aftercare with Immunization Record and provide the form to the parent or guardian of the client

See local protocol for indicating location for second dose of vaccine

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Thimerosal Multi-dose vials of vaccine contain a preservative called thimerosal

(ethylmercury) Ethylmercury is not the same compound as methylmercury

Methylmercury is a known neurotoxin in high concentrations or with prolonged exposure (e.g., ingesting some types of fish)

Ethylmercury is eliminated much more quickly and is less likely to reach toxic levels in the blood than methylmercury

Studies have found there is no association between immunization with thimerosal-containing vaccines and neurodevelopmental outcomes, including autistic-spectrum disorders

Additional information regarding thimerosal is available at http://www.phac-aspc.gc.ca/publicat/ccdr-rmtc/07vol33/acs-06/index-eng.php

PresenterPresentation NotesThere has been no thimerosal in routine childhood vaccines since 2001 (due to public pressure resulting from inaccurate media reports)

http://www.phac-aspc.gc.ca/publicat/ccdr-rmtc/07vol33/acs-06/index-eng.php

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Pregnancy and breastfeedingNACI recommends the inclusion of all pregnant women, at any stage of pregnancy [among high priority recipients

of influenza vaccine] due to: the risk of influenza associated morbidity in pregnant women evidence of adverse neonatal outcomes associated with maternal respiratory hospitalization or influenza during pregnancy

evidence that vaccination of pregnant women protects their newborns from influenza and influenza-related hospitalization, and

evidence that infants born during influenza season to vaccinated women are less likely to be premature, small for gestational age, and low birth weight.

NACI Statement 2018

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Pregnancy and breastfeeding (contd)

QIV is safe for pregnant women at all stages of pregnancy

QIV is safe for breastfeeding mothers

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Reactions to inactivated influenza vaccine

Common Reactions

Injection site redness, swelling, pain Fatigue, headache, myalgia Arthralgia, fever, chills, malaise

The majority of people do not have a reaction to TIV/QIV; however some reactions that may occur are outlined below. These reactions generally start 6 to 12 hours after immunization and can last for 1 to 2 days.

PresenterPresentation NotesSoreness at the injection site may occur after administration of inactivated vaccines and is more common with adjuvanted or intradermal vaccines.

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Reactions to inactivated influenza vaccine

Rare Reactions

Immediate, allergic-type responses such as hives, angioedema, allergic asthma, systemic anaphylaxis

Guillain-Barr Syndrome (GBS)

Oculorespiratory Syndrome (ORS)

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Guillain-Barr Syndrome (GBS)

GBS is an illness that affects the nervous system It is rare; general risk is about 2 cases per 100,000 person years It is characterized by loss of reflexes and symmetric paralysis

usually beginning in the legs It results in complete or near complete recovery in most cases

It is thought that GBS may be triggered by an infection The infection that most commonly precedes GBS is caused by

Campylobacter jejuni bacteria Other respiratory or intestinal illnesses and other triggers may also

precede an episode of GBS, including Cytomegalovirus, Epstein-Barr virus and Mycoplasma pneumoniae

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Guillain-Barr Syndrome (GBS) (contd)

In 1976, the swine flu vaccine was associated with an increased risk of GBS this has not been found with influenza vaccines administered after the swine influenza vaccine program according to the US Institute of Medicine

Absolute risk of GBS after immunization is about 1 excess case per 1 million vaccinees above background rate of 10 - 20 cases/million

Risk of GBS associated with influenza infection is much greater than that associated with immunization

It is recommended that you DO NOT provide influenza immunization to people who have been diagnosed with GBS within 6 weeks of previous influenza immunization.

PresenterPresentation Notes17 GBS cases per million in persons diagnosed with influenza disease vs 1 per million cases of GBS following influenza immunization

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Oculorespiratory Syndrome (ORS)

In 2000-2001, Health Canada received increased reports of unusual symptoms following influenza immunization. These symptoms were subsequently described as Oculorespiratory Syndrome (ORS).

Case definition of ORS (onset within 24 hours of immunization) bilateral red eyes

and one or more of the following respiratory symptoms (cough,

wheeze, chest tightness, difficulty breathing, difficulty swallowing, hoarseness, sore throat) with or without facial swelling

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Oculorespiratory Syndrome (ORS) (contd)

Immunization recommendations following client report of ORS are based on: risk/benefit assessment,

and severity of symptoms as perceived by the individual who experienced

the symptoms

For immunization recommendations following client report of ORS:

Refer to Decision Making Algorithm: Influenza Vaccine for Persons with Previous ORS Symptoms

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ORS Decision Flowchart

How severe were the ORS symptoms?

Mild (easily tolerated, present but not problematic)

Moderate (bothersome, interferes with activities of daily living, requires activity change & possible medication)

Severe (prevents activities of daily living, unable to work or sleep)

May receive the influenza vaccine


Lower respiratory symptoms (wheeze, chest tightness, difficulty breathing) and/or difficulty swallowing (within 24 hrs of immunization)

May receive the influenza vaccine Case should be reviewed by

MOH before receiving subsequent influenza vaccine

Non-lower respiratory symptoms (bilateral red eyes, cough, hoarseness, sore throat, facial swelling)

How severe were the ORS symptoms?

Severe

(prevents activities of daily living, unable to work or sleep)

Moderate

(bothersome, interferes with activities of daily living, requires activity change & possible medication)

Mild

(easily tolerated, present but not problematic)



Lower respiratory symptoms (wheeze, chest tightness, difficulty breathing) and/or difficulty swallowing (within 24 hrs of immunization)

Non-lower respiratory symptoms

(bilateral red eyes, cough, hoarseness, sore throat, facial swelling)


Case should be reviewed by MOH before receiving subsequent influenza vaccine

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Reporting of adverse events following immunization (AEFI)

An adverse event following immunization is defined as a serious or unexpected event temporally associated with immunization.

The most commonly reported AEFIs in the 2017-2018 influenza immunization season were allergic reaction (not anaphylaxis), pain/swelling, cellulitis and rash.

Local reactions are the most commonly reported event following immunization. A local reaction of pain and/or swelling is ONLY reportable if:

1.the onset of swelling is within 48 hours following immunization;

AND 2.swelling extends past the nearest joint

OR severe pain that interferes with the normal use of the limb lasting greater than 4 days

ORreaction requires hospitalization

PresenterPresentation NotesThe most commonly reported AEFIs in the 2017-2018 season were allergic reaction (60% of reports) and pain/swelling (60%) followed by Cellulitis (32%) and Rash (23%).

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AEFI reporting (contd)Any of the following are also reportable adverse events: GBS ORS Anaphylaxis Other allergic reactions Any reaction outside of what is expected Consult with AHS local Public Health as soon as possible for any case where

there is uncertainty as to whether a symptom following immunization is related to the immunization.

Report AEFIs or unusual incidents that may occur as per local protocols. Severe reactions should be reported within 24 hours and all other reactions within one week to your zone contact. Reportable AEFIs are reported to Alberta Health, and in turn to the National Surveillance Program.

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Contraindications to QIVInactivated influenza vaccine should not be administered to

individuals who: Are less than 6 calendar months of age Have had an anaphylactic reaction to a previous dose of influenza vaccine Have a known hypersensitivity to any component of the vaccine with the

exception of egg

Have been diagnosed with Guillain-Barr Syndrome within 6 weeks of a previous dose of influenza vaccine

Have experienced severe Oculorespiratory Syndrome (ORS) within 24 hrs of receiving influenza immunization these individuals should be assessed further prior to immunizing

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Egg-allergic individuals Egg allergy is no longer considered a contraindication for influenza

vaccine

Egg-allergic individuals may be immunized without a prior influenza vaccine skin test and with the full dose of vaccine, irrespective of a past severe reaction to egg

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Vaccine deferral

Vaccine may be deferred until later in the following situations: Those with serious acute febrile illness usually should not be

immunized until symptoms have abated

Vaccine does not require deferral and can safely be given to the following individuals: Those with mild acute illness, with or without fever Individuals who are recovering from illness or are taking antibiotics

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Section Two Influenza Vaccine Knowledge Check

Review Questions Section 2: Part B1. In Alberta this year, who is eligible for the influenza vaccine at no

charge?2. Is thimerosal in vaccines a threat to health? Explain.3. Who should not be immunized with influenza vaccine?4. What is the recommendation for people who have been diagnosed

with Guillain-Barr syndrome within 6 weeks of a previous influenza immunization?

5. What is the recommendation for clients who have experienced a mild case of ORS in the past?


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Section 3 Pneumococcal Immunization

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Section 3: Pneumococcal Immunization Learning Objectives

The immunizer will be able to: describe the pneumococcal immunization program within Alberta administer pneumococcal polysaccharide vaccine in accordance with

local protocols.

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What is pneumococcal polysaccharide vaccine?

Pneumococcal vaccines are used to prevent serious illnesses caused by the Streptococcus pneumoniae bacteria the vaccine protects against 23 serotypes of this bacteria

The vaccine is sometimes referred to as the pneumonia shot The immunization program was implemented nationally in 1998 The vaccine is provided throughout the year by Public Health,

community physician partners and effective January 1, 2019 by community pharmacists (to healthy adults 65 years of age and older)

Pneumococcal polysaccharide vaccine is available for eligible people age 24 months and older

Onset of immunity is about 10 to 15 days after immunization

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Why is pneumococcal polysaccharide vaccine important?

This vaccine can prevent serious infections, such as bacteremia and meningitis caused by the Streptococcus pneumoniae bacteria

Certain populations are more at risk of serious illness caused by this bacteria, so the vaccine is offered to them to provide protection

This bacteria is becoming resistant to some of the antibiotics used to treat it

Vaccine effectiveness is dependent on the age and immune competency of the vaccine recipient The immunity conferred is serotype specific The vaccine is 56% - 81% effective in preventing invasive

pneumococcal disease

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Pneumococcal polysaccharide vaccine eligibilityI. Routine Recommended Immunization

Individuals 65 years of age and older

II. Medically at Risk Individuals 24 months up to and including 64 years of age with the following: Alcoholism; includes individuals with any history of alcohol abuse Anatomic or functional asplenia, splenic dysfunction Chronic cardiac disease; includes congestive heart failure, myocardial infarction

and individuals taking heart medications or being followed by a cardiac specialist

Chronic cerebrospinal fluid (CSF) leak Chronic renal disease; includes nephrotic syndrome and renal dialysis Chronic liver disease; includes chronic hepatitis B, hepatitis C and cirrhosis due

to any cause

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Pneumococcal polysaccharide vaccine eligibility (contd)

Chronic pulmonary disease (including asthma requiring medical treatment within the last 12 months regardless of whether they are on high dose steroids)

Chronic neurologic conditions that may impair clearing of oral secretions Cochlear implant (candidates and recipients) Congenital immune deficiencies involving any part of the immune system,

including B-lymphocyte (humoral) immunity; T-lymphocyte (cell) mediated immunity; complement system (properdin or factor D deficiencies); or phagocytic functions.

Diabetes mellitus; includes both insulin and non insulin dependent (controlled by oral medication or diet)

HIV infection

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Illicit injection drug use Immunosuppressive therapy including:

use of long term corticosteroids, chemotherapy, radiation therapy, post-organ transplant therapy

biologic and non-biologic immunosuppressive therapies for:o Inflammatory arthropathies, e.g., systemic lupus erythematous (SLE),

rheumatoid or juvenile arthritiso Inflammatory dermatological conditions, e.g., psoriasis, severe atopic

dermatitis and eczemao Inflammatory bowel disease, e.g., Crohns disease, ulcerative colitis

- Malignant hematologic disorders including leukemia, Hodgkins and non-Hodgkins lymphomas, multiple myeloma and other malignancies

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- Malignant solid organ tumors either currently or within the past 5 years- Sickle cell disease and other hemoglobinopathies- Solid Organ Transplant (SOT) candidates and recipients and

Hematopoietic stem cell (HSCT) recipients 24 months of age and older See Standard for Immunization of Transplant Candidates and Recipients #08.304

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III. High Risk Setting Individuals 24 months up to and including 64 years of age who are

homeless or living in chronic disadvantaged situations Includes those with no fixed address or living in shelters

Individuals 24 months up to and including 64 years of age who are residents of Long Term Care or Continuing Care facilities

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Yes NOMyocardial infarction Repeated pneumonia

Chronic liver disease includes cirrhosis, Hepatitis B and Hepatitis C

Fibromyalgia

Chronic Fatigue Syndrome

Hypertension


PresenterPresentation NotesClients with MS and Cystic Fibrosis may be eligible due to difficulty clearing secretions or if on immunosuppressive drugs. Client with Lupus may eligible if on immunosuppressive drugs.

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Pneumococcal polysaccharide vaccine Provincially funded product - Pneumovax23 (Merck)

Dosage is 0.5 mL (comes in a single dose vial)

Intramuscular injection given in the deltoid use 3 cc syringe needle size dependent on muscle mass

Eligible person can receive pneumococcal vaccine with influenza vaccine on the same visit but it must be given in a separate injection, in a different immunization site (e.g., one vaccine in left deltoid, one in the right)

The vaccine should be given at least 14 days prior to initiation of immunosuppressive therapies (e.g., chemotherapy)

Check your local protocol for clients who are unsure of past pneumococcal polysaccharide immunization history

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Schedule and reinforcing dose One primary dose is sufficient for most individuals

Two doses are required for HSCT recipients

A one-time reinforcing dose is recommended ONLY for individuals with: Functional or anatomic asplenia, splenic dysfunction or sickle cell disease Chronic renal failure or nephrotic syndrome Chronic liver disease including hepatic cirrhosis Congenital immunodeficiencies involving any part of the immune system HIV infection Immunosuppression related to therapy

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Schedule and reinforcing dose (contd)

Immunosuppression related to therapy: use of long term corticosteroids, chemotherapy, radiation therapy,

post-organ transplant therapy biologic and non-biologic immunosuppressive therapies for:

o Inflammatory arthropathies, e.g., systemic lupus erythematosus (SLE), rheumatoid or juvenile arthritis

o Inflammatory dermatological conditions, e.g., psoriasis, severe atopic dermatitis and eczema

o Inflammatory bowel disease, e.g., Crohns disease, ulcerative colitis

- Malignant hematologic disorders including leukemia, Hodgkins and non-Hodgkins lymphomas, multiple myeloma and other malignancies

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Schedule and reinforcing dose (contd)

Sickle cell disease

Solid organ transplant

This one-time reinforcing dose should be given: 5 years after the initial dose of pneumococcal polysaccharide vaccine

Exception: Individuals will be eligible for a dose of pneumococcal polysaccharide

vaccine at 65 years of age and older (as long as 5 years have passed since a previous dose of this vaccine), regardless of the number of doses received prior to 65 years of age.

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Pneumococcal polysaccharide vaccine side effects

Common side effects: small amount of swelling and soreness at the injection site

Less common side effects: mild fever, feeling tired, headache and/or muscle pain

Some individuals have more serious side effects such as a large amount of swelling and pain People who have a reaction that concerns them or is an unusual reaction should contact Health Link at 811 for direction

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Contraindications

Pneumococcal polysaccharide vaccine is contraindicated for the following people:

People who have experienced anaphylaxis to a previous dose of pneumococcal polysaccharide vaccine

People who have a known severe hypersensitivity to any component of the vaccine

Children under 24 months of age

Special consideration needs to be given to clients undergoing splenectomies, transplants or immunosuppressive therapy. Refer these individuals to Public Health (in some zones to the Communicable Disease Unit) for assessment.

PresenterPresentation NotesSpecial considerations for those clients undergoing splenectomies, transplants or immunosuppressive therapy are related to the assessment of eligibility for pneumococcal conjugate vaccine and timing of immunization.

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Section Three Pneumococcal Immunization Knowledge Check

Review Questions Section 3

1. Are people with asthma eligible for the pneumococcal polysaccharide vaccine?

Note: Answers can be found the end of the PowerPoint.

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Section 4 Vaccine Administration

Client Interview (Fit to Immunize Assessment) Informed Consent Vaccine Administration Process

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Section 4 Vaccine Administration Learning Objectives

The immunizer will be able to: explain the best practices in influenza and pneumococcal

polysaccharide vaccine management and administration discuss the vaccines, their use and potential adverse events following

immunization administer influenza and pneumococcal polysaccharide vaccine in

accordance with national guidelines and local protocols

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Fit to immunize assessment

The immunizer will: Assess the need for immunization Confirm the client has not received a dose of influenza vaccine in the

2018-2019 influenza season Complete a fit to immunize assessment

health status today history of allergies previous reactions chronic illness/medications pregnancy

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Informed consent Clients must give informed consent before immunization Prior to immunizing the immunizer must:

Determine that the client is eligible (lives, works or goes to school in Alberta)

Review the disease(s)* being prevented Review antigen(s)* Discuss:

risks and benefits of getting the vaccine(s)* and not getting the vaccine(s)*

side effects and after care how the vaccine(s) is given

Provide the opportunity to ask questions Affirm verbal consent

* You will review two vaccines if you are also administering pneumococcal polysaccharide vaccine.

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Vaccine management All multi-dose vials must be dated upon opening*

Multi-dose Fluzone and Flulaval Tetra must be discarded 28 days after first puncture

Check expiry date of all products being administered

Communicate use of near expiry vials to other staff members, so the vaccine can be used before it expires

Vaccine should be withdrawn from the vial by the immunizer administering the vaccine

Do not mix vaccine from vials with different lot numbers

Do not pre-draw vaccine* Refer to local protocol for dating vials

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Preparing the vaccine

Determine the appropriate vaccine and route of administration

Provide appropriate information to client

Detach self from conversation

Visually inspect the vaccine. Do not use if: it is discolored you notice extraneous particulate matter present the multi-dose vial/prefilled syringe is defective

PresenterPresentation NotesFlulaval appears as a opalescent translucent to off-white suspension that may sediment slightly.Fluzone clear to slightly opalescent suspension; shake well to uniformly distribute the suspension.

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Preparing the vaccine (contd) Determine the site of injection For multi-dose vials select appropriate syringe and needle

it is not necessary to change needles after drawing up vaccine, unless the needle is damaged or contaminated

For prefilled syringes select appropriate needle to attach to syringe

Select and read the label on the multi-dose vial or prefilled syringe

Check the vaccine expiry date if applicable, check the date the multi-dose vial was opened

For prefilled syringes, ensure the lot number on the syringe matches the lot number on the box (syringe is discarded after administering vaccine and lot number is recorded from the box)

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Preparing the vaccine (contd)

For multi-dose vials agitate the vial before drawing up each dose swab the top of the vial and allow it to dry withdraw the appropriate dose of the vaccine

For prefilled syringes agitate the prefilled syringe before administration

Recheck the vaccine label

Check the record to verify you have the correct vaccine for each client (e.g., Fluzone, Flulaval Tetra or pneumococcal polysaccharide vaccine)

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Administering QIV Expose and position the clients limb for injection Swab the site of injection Allow the site to dry for 10 - 15 seconds Secure the injection site using the appropriate stabilization technique Insert the needle at a 90 angle Administer the vaccine with controlled pressure Activate the safety engineered device Discard the needle and syringe, and empty vaccine vials into an

appropriate sharps container Use a cotton ball and apply pressure to the injection site Reinforce the 15 min wait period with the client or parent/guardian

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Intramuscular injections

Children less than 12 months old 3 mL syringe 25G 1 needle insert at 90 degree angle vastus lateralis - middle third of

anterior thigh and slightly lateral to the midline

Note: This site can be used for children older than 12 months of age with inadequate deltoid muscle mass. Check with a Public Health Nurse if you are unsure

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Intramuscular injections

Children 12 months and older 3 mL syringe 25G - 5/8 to 1 needle depending

on muscle mass insert at 90 degree angle mid portion of deltoidAdults 3 mL syringe 25G - 1 to 1 needle depending on

muscle mass and adipose tissue insert at 90 degree angle mid portion of deltoid

PresenterPresentation NotesReference the dark circle drawn mid deltoid as the correct location for administration for a single injection into the deltoid

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Immunizing mastectomy clients

Single Mastectomy Influenza Vaccine Only:

Give IM in arm opposite to mastectomy Influenza and Pneumococcal Vaccine:

Give both vaccines IM in arm opposite to mastectomy (space injections minimum of 1 apart)

Double Mastectomy Influenza Vaccine Only:

Give IM in Vastus Lateralis Influenza and Pneumococcal Vaccine:

Give both vaccines IM in Vastus Lateralis (space injections minimum of 1 apart)

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Position & stabilization techniques for vastus lateralis site (infants less than 12 months)

For injection in the vastus lateralis

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Position & stabilization techniques for deltoid site

Infants 12 months and older Infants 18 months old and older (The pretzel hold)

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Distraction Tools Not Supported for use in AHS Immunization Clinics Providing safe, effective immunizations is the responsibility of and priority for public

health nurses. Devices that may interfere with injection land marking, stabilization of the limb and

infection control measures are not recommended. The use of a product that a registered nurse is not familiar with and that may interfere with usual practice could result in patient or nurse injury and/or improper injection technique.

There is insufficient evidence to recommend for or against the use of the Shot Blocker or Buzzy device.

The AHS Immunization Program Standard Manual: Standard for Administration of Immunizations # 06.100 provides guidance to public health nurses, and resources for PHNs and parents/guardians to reduce the discomfort caused by immunizations.

https://www.albertahealthservices.ca/assets/info/hp/cdc/if-hp-cdc-ipsm-standard-administration-immunization-06-100.pdf

https://www.albertahealthservices.ca/assets/info/hp/cdc/if-hp-cdc-ipsm-standard-administration-immunization-06-100.pdf

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Section 4 Vaccine Administration Knowledge Check

Review Questions Section 41. Is it important to agitate Flulaval Tetra and Fluzone before drawing

up each dose?2. After opening a multi-dose vial, it is important to date it. What is the

time frame for expiry for multi-dose influenza vaccine?


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Section 5 Anaphylaxis and SyncopeAnaphylaxis Anaphylaxis is a potentially life-threatening allergic reaction Very rare (about 1 per 1,000,000 doses) but even so, it should be

anticipated with every client Pre-immunization screening can prevent episodes ask questions about

possible allergy to the vaccine or any vaccine component Every immunizer should be familiar with the symptoms of anaphylaxis and

be ready to initiate appropriate interventions Most instances begin within 15 minutes after immunizationAll clients are encouraged to wait for 15 minutes after immunization. For clients with any known anaphylactic allergies, extend this

recommended wait period to 30 minutes Have clients remain within a short distance and return immediately for

assessment if they feel unwell

PresenterPresentation NotesPrecautions are the same as with administering any vaccine.Advise client to wait/ observe client for 15 minutes administration of a vaccine.

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Anaphylaxis recognition & treatment

The immunizer must: be able to identify allergic reactions and

anaphylaxis, and know how to respond appropriately

be able to distinguish between fainting, breath-holding spells, anxiety, and anaphylaxis

always have an up-to-date anaphylaxis kit readily available when immunizing

PresenterPresentation NotesThe vaccine provider must be able to identify allergic reactions and anaphylaxis, and to know how to respond appropriately.Refer to your facilitys protocols for such an event.

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Histamines do what??

They cause: Capillary permeability and therefore the escape of plasma into the

tissues

Widespread dilatation of arterioles and capillaries (vasodilation)

Smooth muscle contraction

Over secretion by mucous glands

PresenterPresentation NotesHistamines are mediators of hypersensitivity reactions including anaphylaxis.

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which is why we see these symptoms

Respiratory: dyspnea - wheezing - sneezing choking - drooling cyanosis angioedema - tightness

in throat/chest

Dermatologic (skin): urticaria - erythema - pruritus flushing - pale/grey - facial swelling tingling of mouth or face followed by a feeling of warmth

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... and these symptoms...

Vascular Collapse (cardiovascular) rapidly falling blood pressure sweating rapid, thready pulse a feeling of uneasiness, restlessness or anxiety weakness or dizziness throbbing in the ears or a headache

Gastrointestinal: nausea, vomiting diarrhea abdominal cramps

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Anaphylactic shock intervention

The Initial Response

Call for help

Lie the client on his/her back with feet elevated, if possible

Loosen restrictive clothing around the neck

Establish an adequate airway

Note the time

PresenterPresentation NotesInitial Call for Help is to get assistance with the management and assessment of the client.

Loosen restrictive clothing around neck - assists in establishing an adequate airway

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What would you do?

Would you give this child epinephrine? Why or why not?

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Prompt administration of epinephrine is essential

Refer to your local Anaphylaxis Management Guideline and information in your anaphylaxis kit for direction on how to proceed with administration of epiNEPHrine and diphenhydramine hydrochloride (e.g., Benadryl)

Remember:Failure to administer epiNEPHrine promptly is more dangerous than administering it in a situation where anaphylaxis is not truly present!

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Syncope post immunization

Fainting is also known as syncope or vasovagal syncope

Vasovagal syncope is triggered by a stimulus (anxiety) that causes an exaggerated response in the part of the nervous system that regulates involuntary body functions (like heart rate and blood flow)

When a stimulus triggers an exaggerated response, both heart rate and blood pressure drop, quickly reducing blood flow to the brain and leading to loss of consciousness

PresenterPresentation NotesHaving someone faint after immunization can be distressing for the provider. It is important that the provider be able to distinguish between a faint and an anaphylactic responseif in doubt offer epinephrine! The symptoms of someone who faints may be similar to individual anaphylactic responses but do not progress to shock.Symptoms of faint include: sudden pale skin, loss of consciousness, collapse, and possible brief clonic seizure activity.Faint is usually not accompanied by the rapid, weak pulse and cold, clammy skin characteristic of shock.

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Syncope post immunization

In about 25% of cases, reduced blood flow can result in jerking movements that resemble seizures

These movements are more common when fainting occurs soon after immunization, and disappear when consciousness is regained

Clients fainting due to vasovagal syncope recover quickly, usually within seconds or a few minutes

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Signs and symptoms of syncopeMusculoskeletal muscles relaxed weakness incontinence (rare) clonic jerks of limbs and face

Respiratory normal or yawning

Dermatologic pallor/grey color - sweating

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Signs and symptoms of syncope (contd)Gastrointestinal vomiting - nausea

Cardiovascular hypotension, slow weak pulse ringing in ears

Neurological light headedness, dizziness spots before the eyes dazed unconsciousness

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Facts about syncope

There is a clear incidence peak in age 10 to 19 years, with a smaller peak at age 4-6 years After the age of 20 years, the incidence decreases with age

57.5% of syncopal episodes occur in females The incidence of fainting is under-reported Most cases occur within 5 minutes of

immunization Fainting can result in head trauma if a client falls

The goal is to prevent falls!

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Tips to prevent syncope

Administer vaccine while client is seated Maintain a calm and confident demeanor Observe anxious client until anxiety has resolved after immunization Have clients with a history of fainting lie down prior to administering

vaccine Clients with pre-syncopal symptoms (such as dizziness, anxiety,

pallor, perspiration, trembling, or cool, clammy skin) should sit or lie down until symptoms resolve

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Assisting clients after syncope

Assist the client to lay down with feet elevated Ensure the clients airway is open (ABCs) Monitor for signs of allergic reaction Call for assistance if needed Cover the client with a blanket for warmth if available Wipe the clients forehead with a damp cool cloth May offer fluids Have the client resume a standing position in stages (sit, stand, walk) Observe the client until the symptoms have resolved

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Anxiety spells

Signs and Symptoms Fearful Pale Diaphoretic Complains of light headedness, dizziness, numbness, and tingling

of face and extremities Hyperventilation

Treatment Reassurance Instruct to relax and breathe slowly

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Breath holding

Occurs in young children when upset

Signs and symptoms: Suddenly become quiet but still very agitated Facial flushing & perioral cyanosis Often ends with resumption of crying, or a brief period of

unconsciousness during which time breathing resumes

Treatment Reassurance

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Section 5 - Anaphylaxis and Syncope Knowledge Check

Review Questions Section 51. What is the incidence of anaphylaxis after immunization?2. Should you withhold epiNEPHrine if you are not completely sure

whether the client is experiencing anaphylaxis?3. What is the percentage of people who experience jerking movements

that resemble seizures after fainting?

Note: Answers can be found at the end of the power point.

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Section 6- Infection Prevention & Control (IPC)

Hand hygiene is the single most important action that decreases the spread of infection

Hand hygiene is done with:

Alcohol-based hand rub (ABHR)

Regular liquid soap, water and disposable hand towels

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Hand hygiene Alcohol-based hand rub (ABHR)

Approved AHS product Use sufficient ABHR to rub all surfaces of hands (2-3 pumps)

including between fingers and the base of the thumbs for a minimum of 15 seconds

Regular liquid soap, water and disposable hand towels Wet hands, apply soap, rub all surfaces for minimum 15 seconds Rinse with clear, running water Recommended if hands are visibly soiled

Apply AHS approved hand creams to maintain skin integrity Glove use is not a substitute for hand hygiene

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Four Moments of Hand Hygiene

Before each client contact or contact with their environment Before clean/aseptic procedures (such as immunization) After blood and body fluid exposure risk (such as after immunization) After contact with the client or their environment

AHS Hand Hygiene Policy and Procedurehttps://extranet.ahsnet.ca/teams/policydocuments/1/clp-hand-hygiene-ps-02-policy.pdfhttps://extranet.ahsnet.ca/teams/policydocuments/1/clp-hand-hygiene-ps-02-01-procedure.pdf

PresenterPresentation NotesPolicy states staff and medical staff wearing casts, dressings or splints that hinder Hand Hygiene can not provide direct client carePolicy states that artificial nails, nail enhancements, and chipped nail polish should not be worn. Natural nails should be clean, healthy and not to exceed 6 mm or 0.25 inches.Rings limited to plain bands.

https://extranet.ahsnet.ca/teams/policydocuments/1/clp-hand-hygiene-ps-02-policy.pdfhttps://extranet.ahsnet.ca/teams/policydocuments/1/clp-hand-hygiene-ps-02-01-procedure.pdf

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Hand hygiene at large immunization sites

Examples only, not limited to these occasions:

Start and end of shift

Before and after contact with the client

Before handling immunization supplies (entering vaccine bags), including the set up of immunizing stations

After vaccine administered and before handling other equipment, such as papers and pens

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IPC for vaccine administration Clean and disinfect clinic table/ work surface with appropriate low-

level disinfectant (e.g., accelerated hydrogen peroxide, quaternary ammonium compounds)

This is a two step procedure - clean first, and then disinfect

Always start the disinfection stage with a clean cloth

Cover table/work station with a large clean drape

Use a small drape in front of immunizing staff as a clean work area avoid placing papers/pens on this area

Place appropriate puncture resistant biohazard container for use at point of contact to dispose of sharps immediately after use

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Preparing for immunization in large public clinic sites Maintain small drape as the clean surface for the immunization station

(needles, syringes, swabs, etc) When documenting ensure the clean surface is not contaminated by

either paperwork or computer. When station not in use:

Drape with a clean drape (e.g., coffee times, meal times) Drapes used to cover the immunization stations can be reused for the

day Ensure they are folded so the inside portion maintains a clean field

PresenterPresentation NotesThe rationale for covering when not in use is optics (so it does not look like the spot is active but no one is there), keeping the area clean in the event clients may rest items on the table or someone may cough or sneeze on the station.

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Preparing for immunization at large public clinic sites During the clinic:

Immunization station and tables are cleaned and disinfected at the start of the clinic and at the end of the clinic, not at the beginning and end of staff shifts

Cleaning and disinfection of the station during the shift needs to be done only if the area becomes dirty/contaminated/wet At that time, the area would be cleaned, disinfected and set up

At the end of the day, for sites that are only there for the day: Clean and disinfect station per IPC Guidelines but not set up for the

next day For sites where the campaign is ongoing & stations used next day:

Area cleaned, disinfected & set up with fresh supplies and draped in preparation for the next day.

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Cleaning of blood and body fluids Appropriate Personal Protective Equipment (PPE) must be worn

Gloves must be worn and if there is the possibility of splashing, further PPE (gown, mask and eye protection) may be required

Clean area by blotting blood/body fluids with disposable towels, discarding in a regular plastic-lined waste container in addition, for non porous surfaces, clean area with soap & water once clean-up is completed, tie garbage bag and place in regular

garbage

After initial cleaning, disinfect with a fresh solution of bleach (1 part bleach:9 parts water) or use a low level disinfectant

Thoroughly clean equipment (e.g. mop &handle, pail) before re-use

Wash hands with soap and running water

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Section 7 Recording & Data Collection

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Influenza/pneumococcal vaccine recordingInformation required to be recorded on all clients includes: Client demographic information

full name, personal health number, date of birth, gender, address including postal code

Reason code for immunization Dose number Vaccine name & lot number Dosage administered Site of injection Route of administration Date of immunization Immunizers first initial and last name, designation & signature

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Influenza/pneumococcal vaccine recording (contd) North, Edmonton, Central and South Zones will be doing direct data entry into

the Meditech system The Care After Immunization/Client Immunization Record document is available

for public health and community providers to provide to clients after immunization

Public Health in Calgary Zone will utilize the Influenza/Pneumococcal Vaccine Record for recording purposes Vaccine record is in a duplicate format - no carbon record (NCR) White copy to be kept by AHS Client receives yellow copy as their record of immunization Client copy has aftercare information on the back

Community providers may utilize the AHS Influenza/Pneumococcal Vaccine Record for recording purposes. This PDF fillable form is available or a record of their own choosing can be used.

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Influenza/Pneumococcal Vaccine Record (NCR)

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Choosing the reason for immunization code from the Priority List

When completing documentation, include the immunization reason code. Start at the top of the priority list, and choose the first code that applies (e.g. If the client is a health care worker, is pregnant, and has asthma, choose code #03 Health care worker because it is higher on the list).

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Influenza Vaccine Priority ListWhen determining which code to pick, start at the top of the list and choose the first code that applies

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Pneumococcal Vaccine Priority List

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Care After Immunization

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Data collection

All immunization providers are required to account for vaccine doses administered, vaccine doses wasted and vaccine doses on hand. The rationale for requiring data collection is as follows:

To determine influenza immunization rates

To be accountable for doses administered and meet requirements of government auditing processes

To monitor vaccine safety

For planning and operational decisions for subsequent seasonal programs

Refer to local protocols for data collection instructions

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Influenza/Pneumococcal Self Learning Test

1. Influenza vaccine can be a live or inactivated vaccine. True or False2. The influenza virus is spread only through droplets in the air. True or False3. Influenza is contagious only after symptoms appear. True or False4. In general, higher rates of influenza occur during which time of the year in North

America? a. Year roundb. September through Decemberc. December through Marchd. April through September

5. Influenza vaccines are most effective at preventing influenza infection in persons 65 years of age and older. True or False

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Influenza/Pneumococcal Self Learning Test6. How effective is influenza vaccine in preventing the disease when it is given to

healthy individuals when strains in the vaccine are similar to the strains circulating during that influenza season?a. 40-50%b. 60-70%c. 52-82%d. 70-90%

7. Influenza vaccine should not be offered until after influenza disease is common in the community. True or False

8. The correct dose of QIV for an 18-month-old child is:a. 0.25 mLb. 0.5 mLc. 0.75 mLd. 1 mL

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Influenza/Pneumococcal Self Learning Test9. For an 8-year-old boy who has never received influenza vaccine, how many doses

will he need to receive this season?a. Oneb. Two

10. The most common side effects after inactivated influenza immunization are:a. Flu like symptomsb. Redness, soreness and swelling at the injection sitec. Guillain-Barr syndromed. Systemic symptoms of headache, fever, runny nose

11. Which vaccines would a 65-year-old man who has chronic pulmonary disease be eligibile for? a. Influenzab. Pneumococcal Polysaccharide 23c. Both Influenza and Pneumococcal Polysaccharide 23

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Influenza/Pneumococcal Self Learning Test12. A 4-year-old-girl has a severe kidney infection with high fever. She should receive

the influenza vaccine today.True or False

13. While screening a 60-year-old man you find out that he has a history of difficulty breathing after eating eggs. He required a visit to the emergency room to resolve the situation. He should receive influenza vaccine today.True or False

14. A 72-year-old woman is taking antibiotics for a minor wound infection. She should receive influenza vaccine today.True or False

15. A 28-year-old man is HIV positive. He should receive influenza vaccine today and be assessed for history of pneumococcal vaccine.True or False

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Influenza/Pneumococcal Self Learning Test16. Signs of an anaphylactic reaction include:

a. Swelling of the mouth and throat b. Hivesc. Difficulty breathingd. Hypotensione. All of the above

17. The ventral gluteal site is an appropriate site for inactivated influenza vaccine administration, with the exception of a client who has had a double mastectomy with lymph node removal.True or False

18. A client states she had red eyes a few years ago following immunization with influenza vaccine. She did not have any other symptoms. She should be immunized today.True or False

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Influenza/Pneumococcal Self Learning Test

19. The immune system can easily be overloaded by more than one immunization.True or False

20. It is important to change the needle after drawing up each dose of vaccine.True or False

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Questions

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Can too many vaccines weaken the immune system?

Vaccines do not weaken the immune system. Rather, they harness and train it to defend, rapidly, against vaccine-preventable diseases before illness can occur. Getting an annual influenza vaccine is a good way to keep both yourself and your immune system healthy.

Our immune systems are bombarded with constant challenges from bacteria in food to the dust we breathe. Compared to what the immune system typically encounters and manages each day, vaccines are literally a drop in the ocean. At present, infants receiving recommended vaccines starting at two months of age come into contact with only 34 antigens just 34 antigens among the millions handled every day by our immune systems.

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Should I get the influenza vaccine if I am healthy?

You may not be in a group that is athigh risk for influenza related complications,but your patients/residents/clients may be,and members of your family may be as well.

If you get influenza, you put people around you at high risk for serious illness. You can help ensure that they stay healthy this winter by protecting yourself.

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If residents/patients get immunized, why should I?

Can you be sure that all those you care for were immunized? What if they werent?

Health care providers who have direct patient contact should consider it their responsibility to provide the highest standard of care which includes annual influenza immunization.

Getting immunized will add an extra level of certainty that you will not get influenza, and will not pass it on to others.

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Can the influenza vaccine give me influenza? Immunization with inactivated vaccine cannot

cause influenza disease because the vaccine does not contain live viruses.

The vaccine takes about two weeks to become completely effective, so you could still get influenza during these two weeks. If you get influenza after this period, you may experience milder symptoms than if you had not had the immunization.

Many people confuse influenza with a cold or other respiratory infections, which the vaccine will not protect you against.

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Should I get an influenza vaccine every year?

YES Strains of the influenza virus change every

year, and new vaccines are produced to counter them as soon as they are identified

The immunization you had last year will likely not be effective against this years virus

Even if you have avoided getting influenza so far, it does not mean that you will not get sick this year

By not getting the influenza immunization, you are increasing your chances of becoming ill

PresenterPresentation NotesEvery year, different dominant flu strains can emerge. For the vaccine to be protective, it must be reformulated every year according to the dominant flu strains.

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References

1. Alberta Health, Public Health and Compliance. (2018, June). Albertas Influenza Immunization Program Policy

2. Alberta Health, Health System Accountability and Performance Division, Alberta Vaccine Cold Chain policy (2017, April).

3. Alberta Health Services. Population Public and Indigenous Health, Infection Prevention and Control and Workplace Health and Safety. (July 2018). Guidelines for Outbreak Prevention, Control and Management in Acute Care and Facility Living Sites.

4. Do Bugs Need Drugs (September 2011). Healthy Hands at Work: Being sick at work is everyones business, Employer Handbook. http://www.dobugsneeddrugs.org/wp-content/uploads/employer-handbook.pdf

5. Do Bugs Need Drugs (August 2014). Healthy Hands at Work: Being sick at work is everyones business, Worker Handbook. http://www.dobugsneeddrugs.org/wp-content/uploads/worker-handbook.pdf

6. Centers for Disease Control and Prevention. Epidemiology and Prevention of Vaccine-Preventable Diseases. Hamborsky J, Kroger A, Wolfe S, eds. 13th ed. Washington D.C. Public Health Foundation 2015.

7. GlaxoSmithKline Inc. (April 13, 2018.) FLULAVAL TETRA Quadrivalent Influenza Vaccine (Split Virion, Inactivated). Product Monograph.

8. Health Canada. Health Products and Food Branch Inspectorate. (April 28, 2011) Guidelines for Temperature Control of Drug Products during Storage and Transportation (GUI-0069). http://www.hc-sc.gc.ca/dhp-mps/compli-conform/gmp-bpf/docs/gui-0069-eng.php

9. Merck Canada Inc. (July 27, 2016). PNEUMOVAX23 (pneumococcal vaccine, polyvalent, MSD Std.). Product monograph.

http://www.dobugsneeddrugs.org/wp-content/uploads/employer-handbook.pdfhttp://www.dobugsneeddrugs.org/wp-content/uploads/worker-handbook.pdfhttp://www.hc-sc.gc.ca/dhp-mps/compli-conform/gmp-bpf/docs/gui-0069-eng.php

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References

10. Merck Canada Inc. (July 25, 2014). ZOSTAVAX (zoster vaccine live, attenuated [Oka/Merck]). Product monograph.

11. National Advisory Committee on Immunization. Canadian immunization guide (Evergreen Edition). Ottawa, ON: Public Health Agency of Canada. http://www.phac-aspc.gc.ca/publicat/cig-gci/index-eng.php

12. National Advisory Committee on Immunization (2018). Canadian Immunization Guide Chapter on Influenza and Statement on Seasonal Influenza Vaccine for 2018-2019. Ottawa, ON: Public Health Agency of Canada.

13. Public Health Agency of Canada (PHAC). National vaccine storage and handling guidelines for immunization providers 2015. Retrieved August 15, 2017 from https://www.canada.ca/en/public-health/services/publications/healthy-living/national-vaccine-storage-handling-guidelines-immunization-providers-2015.html

14. Public Health Agency of Canada (PHAC). Influenza. Retrieved August 15, 2017 fromhttp://www.phac-aspc.gc.ca/influenza/index-eng.php

15. Sanofi Pasteur Inc. (May 1, 2018). FLUZONE Quadrivalent Influenza Virus Vaccine Quadrivalent Types A and B (Spit Virion). Product Monograph.

16. Alberta Health, Public Health and Compliance, Alberta Immunization Policy (2018, June 13). Influenza Vaccine: Quadrivalent Inactivated (2018-2019).

http://www.phac-aspc.gc.ca/publicat/cig-gci/index-eng.phphttps://www.canada.ca/en/public-health/services/publications/healthy-living/national-vaccine-storage-handling-guidelines-immunization-providers-2015.htmlhttp://www.phac-aspc.gc.ca/influenza/index-eng.php

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Answer KeysSection One- Influenza Disease Knowledge Check Answers1. During which time period are individuals who have been infected with

influenza contagious? Individuals with influenza are infectious 1 day before symptoms develop and up

to 5 days after becoming ill. The period when an infected person is contagious depends on the age and health of the person. Young children and people with weakened immune systems may be contagious for longer than a week.

2. Which individuals are at highest risk of developing complications from influenza? Children 6 to 59 months of age, pregnant women, those 65 years of age and

over, individuals with chronic health conditions, aboriginal people and those who are morbidly obese are at higher risk of developing complications from influenza illness. Complications can include pneumonia (bacterial and viral), ear and sinus infections, dehydration, and worsening of chronic medical conditions, such as congestive heart failure, asthma or diabetes.

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Answer KeysSection Two Part A - Influenza Vaccine Knowledge Check Answers1. Which strains of influenza virus are included in the 2018-2019 influenza

vaccine for the northern hemisphere? Strains included in the 2018-2019 vaccine include:

A/Michigan/45/2015(H1N1)pdm09-like virus A/Singapore/INFIMH-16-0019/2016(H3N2)-like virus B/Colorado/06/2017-like virus B/Phuket/3073/2013-like virus

2. Why are these strains chosen? Each February, the World Health Organization (WHO) makes a recommendation

on the strains to be included in the influenza vaccine for the northern hemisphere. Two influenza A viruses and one (for trivalent vaccines) or two (for quadrivalent vaccines) influenza B virus are selected based on the characteristics of the current circulating and new influenza virus strains).

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Answer Key

3. Why is it necessary to get an influenza immunization each year to be protected?

A new vaccine is reformulated each year to protect against new infections. Each vaccine lot is tested on healthy individuals to ensure the vaccine is safe and effective.

4. Can you get influenza disease from the influenza vaccine? Explain. No. QIV is an inactivated (killed) vaccine and therefore you cannot get influenza

disease from the vaccine. QLAIV is a live vaccine which does not cause influenza disease in the vaccine recipient because the vaccine virus is attenuated or weakened.

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Answer KeySection Two Part B- Influenza Vaccine Knowledge Check Answers1. In Alberta this year, who is eligible for the influenza vaccine at no charge?

Alberta Health (AH) funds a Universal Influenza Immunization Program, where all people 6 months of age and older who live, work or go to school in Alberta are eligible for vaccine at no charge.

2. Is Thimerosal in vaccines a threat to health? Explain. No. Thimerosal (ethylmercury) is a preservative used in multi-dose vials of

vaccine it is not the same compound as methylmercury, which is a known neurotoxin in high concentrations, or with prolonged exposure (e.g., ingesting some types of fish). Ethylmercury is excreted from the body much faster and is less likely to reach toxic levels in the blood than methylmercury. Multi-dose vials of vaccine contain very small amounts of thimerosal. Studies have demonstrated that there is no association between immunization with thimerosal-containing vaccines and neurodevelopmental outcomes, including autistic-spectrum disorders.

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Answer Key3. Who should not be immunized with influenza vaccine?

QIV should not be administered to: children less than 6 calendar months of age people with a known hypersensitivity to any component of the vaccine those with a previous anaphylactic reaction to influenza vaccine people who have been diagnosed with Guillain-Barr syndrome within 6 weeks of a

previous influenza immunization people who have had severe Oculorespiratory Syndrome (ORS) after influenza

immunization - these individuals should be assessed further prior to immunizing.

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Answer Key

4. What is the recommendation for people who have been diagnosed with Guillain-Barr syndrome within 6 weeks of a previous influenza immunization? It is recommended that you do not provide influenza immunization to people who

have been diagnosed with GBS within 6 weeks of previous influenza immunization.

5. What is the recommendation for clients who have experienced a mild case of ORS in the past? They may receive the vaccine. Utilize the ORS Decision Flowchart to guide

immunization decision.

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Answer Key

Section Three- Pneumococcal Immunization Knowledge Check Answers

1. Are people with asthma eligible for the pneumococcal polysaccharide vaccine? Yes if they have required medical attention in the last 12 months.

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Answer Key

Section Four- Vaccine Administration Knowledge Check Answers

1. Is it important to agitate Flulaval Tetra and Fluzone before drawing up or administering each dose? Yes. Agitate the vial or prefilled syringe before drawing up each dose.

2. After opening a multi-dose vial, it is important to date it. What is the time frame for expiry for multi-dose influenza vaccine? Yes. Open vials of multi-dose influenza vaccine must be discarded 28 days after

the first puncture.

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Answer KeySection Five- Anaphylaxis & Syncope Knowledge Check Answers1. What is the incidence of anaphylaxis after immunization?

Although anaphylaxis is very rare with an incidence of about 1 per 1,000,000 doses, it should be anticipated with every client.

2. Should you withhold epinephrine if you are not completely sure whether the client is experiencing anaphylaxis, but you are pretty certain? No. Prompt administration of epinephrine is essential. Refer to your local Anaphylaxis Guideline and information in your anaphylaxis kit for

direction on how to proceed with administration of epinephrine and diphenhydramine hydrochloride (e.g., Benadryl).

Failure to administer epinephrine promptly is more dangerous than administering it in a situation where anaphylaxis is not truly present!

3. What is the percentage of people who experience jerking movements that resemble seizures after fainting? In about 25% of cases, reduced blood flow can result in jerking movements that

resemble seizures. These movements are more common when fainting occurs soon after immunization and disappear when consciousness is regained.

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Self Test Answer Key

1. True2. False3. False4. December through March5. False6. 45-85%7. False8. 0.5 mL9. Two10.Redness, soreness and swelling at the injection site

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Self Test Answer Key

11. Both Influenza and Pneumococcal Polysaccharide 2312. False13. True14. True15. True16. All of the above17. False18. True19. False20. False

2018-2019 Influenza Immunization OrientationIntroductionSlide Number 3What is influenza?A, B and C influenza virusesInfluenza Types A and BHow strains change each yearSigns and symptoms of influenzaInfluenza, the Common Cold and Gastrointestinal InfectionThe myth of the stomach fluHow serious is influenza?How serious is influenza?How is influenza spread?Influenza incubationInfluenza infectivityHealth Care WorkersTreatment of influenzaSlide Number 18Influenza prevention hand washingSlide Number 20Slide Number 21Slide Number 22Slide Number 23Influenza vaccine developmentInfluenza vaccine development (contd)How does inactivated influenza vaccine work?Effectiveness of influenza vaccineVaccine strains for 2018-2019Facts about inactivated influenza vaccine (QIV)Section Two Influenza Vaccine Knowledge CheckUniversal Influenza Immunization ProgramInfluenza Immunization Program in AlbertaProvincially funded influenza vaccines for 2018/2019Influenza vaccine dosing for specific agesReturn visit for children who need a second dose ThimerosalPregnancy and breastfeedingPregnancy and breastfeeding (contd)Reactions to inactivated influenza vaccineReactions to inactivated influenza vaccineGuillain-Barr Syndrome (GBS)Guillain-Barr Syndrome (GBS) (contd)Oculorespiratory Syndrome (ORS)Oculorespiratory Syndrome (ORS) (contd)ORS Decision Flowchart Reporting of adverse events following immunization (AEFI)AEFI reporting (contd)Contraindications to QIVEgg-allergic individualsVaccine deferralSection Two Influenza Vaccine Knowledge CheckSlide Number 52Section 3: Pneumococcal Immunization Learning ObjectivesWhat is pneumococcal polysaccharide vaccine?Why is pneumococcal polysaccharide vaccine important?Pneumococcal polysaccharide vaccine eligibilityPneumococcal polysaccharide vaccine eligibility (contd)Pneumococcal polysaccharide vaccine eligibility (contd) Pneumococcal polysaccharide vaccine eligibility (contd)Pneumococcal polysaccharide vaccine eligibility (contd)Pneumococcal polysaccharide vaccine eligibility (contd)Pneumococcal polysaccharide vaccineSchedule and reinforcing dose Schedule and reinforcing dose (contd) Schedule and reinforcing dose (contd)Pneumococcal polysaccharide vaccine side effects ContraindicationsSection Three Pneumococcal Immunization Knowledge CheckSection 4 Vaccine AdministrationSection 4 Vaccine Administration Learning ObjectivesFit to immunize assessmentInformed consentVaccine managementPreparing the vaccinePreparing the vaccine (contd)Preparing the vaccine (contd)Administering QIVIntramuscular injectionsIntramuscular injectionsImmunizing mastectomy clientsPosition & stabilization techniques for vastus lateralis site (infants less than 12 months)Position & stabilization techniques for deltoid site Distraction Tools Not Supported for use in AHS Immunization ClinicsSection 4 Vaccine Administration Knowledge CheckSection 5 Anaphylaxis and SyncopeAnaphylaxis recognition & treatmentHistamines do what?? which is why we see these symptoms... and these symptoms...Anaphylactic shock interventionSlide Number 91Slide Number 92Syncope post immunizationSyncope post immunizationSigns and symptoms of syncopeSigns and symptoms of syncope (contd)Facts about syncopeTips to prevent syncopeAssisting clients after syncopeAnxiety spellsBreath holdingSection 5 - Anaphylaxis and Syncope Knowledge CheckSection 6- Infection Prevention & Control (IPC)Hand hygieneFour Moments of Hand HygieneHand hygiene at large immunization sitesIPC for vaccine administrationPreparing for immunization in large public clinic sitesPreparing for immunization at large public clinic sitesCleaning of blood and body fluidsSlide Number 111Influenza/pneumococcal vaccine recordingInfluenza/pneumococcal vaccine recording (contd)Influenza/Pneumococcal Vaccine Record (NCR)Choosing the reason for immunization code from the Priority ListInfluenza Vaccine Priority ListPneumococcal Vaccine Priority List Care After ImmunizationData collection Influenza/Pneumococcal Self Learning TestInfluenza/Pneumococcal Self Learning TestInfluenza/Pneumococcal Self Learning TestInfluenza/Pneumococcal Self Learning TestInfluenza/Pneumococcal Self Learning TestInfluenza/Pneumococcal Self Learning TestQuestionsCan too many vaccines weaken the immune system? Should I get the influenza vaccine if I am healthy? If residents/patients get immunized, why should I? Can the influenza vaccine give me influenza? Should I get an influenza vaccine every year?References References Answer KeysAnswer KeysAnswer KeyAnswer KeyAnswer KeyAnswer KeyAnswer KeyAnswer KeyAnswer KeySelf Test Answer KeySelf Test Answer Key

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