Preventing Influenza

1. Preventing Influenza “Prevent all the Disease You Can… Then Treat the Rest.” John D. Grabenstein

2. Seasonal Influenza Vaccines • Live Attenuated Influenza Vaccine (LAIV) (Flu Mist) Trivalent Inactivated Influenza Vaccine (TIV) (Fluzone, Fluviron, Fluarix, FluLaval, Afluria) -not all created equal

3. Target groups for Influenza Vaccination: • Children age 6 months through 18 years old • Pregnant women • Caregivers • Healthcare workers • Elderly (>= 50 years old!) (ACIP not me!) • Nursing home patients • People with chronic pulmonary, cardiovascular, renal, hepatic, immuno-supression, neuro-muscular, hematological or metabolic conditions. • Any person who wishes to reduce the likelihood of becoming ill with or transmitting influenza to others.

4. Can the vaccine cause the Flu? • NO! • TIV (the shots) cannot cause influenza because it is an inactivated vaccine. • LAIV (the spray) cannot cause influenza because it cannot replicate in the temperature of the lower respiratory tract and dies at temps >38C. It only lives in the upper respiratory tract and and can cause “Influenza-like Illness”, but not the full blown disease.

5. Flu Mist (Live Attenuated Vaccine) • Intranasal spray • Healthy, non-pregnant patients aged 2-49 years. • Not recommended within 7 days of taking care of severely immunocompromised patients (Not recommended for HCW!) • Dose: Total of 0.2ml (0.1ml in each nostril) for all patients aged 2-49 years

6. Children aged 2-8 years • If child aged 2- 8 years is receiving Influenza vaccine for the first time, they should get a second dose at least 4 weeks after the initial dose within the same flu season. • If child being vaccinated for the first time and receives only one dose-but does not return for the second dose that year, how many doses should that child receive the next year if still < 9 years old?

7. Start all over again! • Administer 2 doses (at least 4 weeks apart) to children age 9 years or younger who are receiving influenza vaccine for the first time or who were vaccinated for the first time during the previous influenza season but only received 1 dose for that year. ACIP (Advisory Committee on Immunization Practices) www.cdc.gov/vaccines/recs/acip

8. Who should NOT get LIVE vaccine? • Allergic to eggs • Children less than 2 years of age • Children aged 2-4 years with asthma or wheezing • Children or adolescents on long-term aspirin therapy • Adults >= 50 years of age • Patients with chronic medical conditions • Pregnant women • Immunosuppressed/Immunodeficiency patient • Close contacts of these patients (some shedding of vaccine virus occurs though transmission to others is rare.) • Previous history of Guillain-Barre syndrome

9. Inactivated Influenza Vaccine • Age 6-35 mon (<3 years) = 0.25ml IM • (2 doses if first time, 1 month apart) • Age 3 to < 9 years = 0.5ml IM • (2 doses if first time, 1 month apart) • >= 9 years – adults = 0.5ml IM

10. Not All IM Vaccines Created Equal! • Only Fluzone approved for all ages (6 months through adult) • Fluvirin only approved for age >= 4 years through adult • Afluria, Fluarix, FluLaval only for age • >=18 years to through adult

11. Who should not get TIV shots? • Allergic to eggs • Younger than 6 months old

12. How do I store my flu shots and Spray? • Refrigerated at 2-8C (35-46F) • Do not Freeze

13. H1N1 Vaccines • Monovalent Vaccine A/Calif/07/2009(H1N1) • Made by the same manufacturers and by same processes as the Trivalent Vaccine for seasonal influenza • 250 million doses purchased by US Govt. • Producing about 20 million doses/week

14. Who gets H1N1 vaccine? • Same indications as for seasonal influenza: (especially children > 6mon-24yrs, care providers to children, pregnant women, healthcare & emergency personnel, high risk conditions age 25-64yrs) • Shots recommended for ages > 6mon • Spray recommended for ages > 2 years

15. H1N1 Quick Facts • 98% of current circulating influenza cases • Only 1% of cases are > 65 years old • 4x risk of miscarriage if pregnant

16. Offering Other Vaccines? • Pneumococcal 23-valent (Pneumovax)? • Streptococcus Pneumoniae • Not just for “pneumonia!” • More efficacious for bacteremia than pneumonia (85-90% of serotypes)

17. Who Gets Pneumococcal Vaccine? • Adults >= 65 years old • Age 19-64 who smoke or have asthma • Age 2-64 years with chronic illnesses: • -Cardiovascular, Pulmonary, Metabolic, Immunosupression, Asplenia, Hepatic, Renal Disease… ACIP recommendations www.cdc.gov/vaccines/pubs/acip-list.htm

18. Dosing of Pneumococcal Vaccine • 0.5ml IM (or SQ if you like the pain!) • For ages >= 65 years – one time dose if 1st time receiving. • For patients who got 1st dose PRIOR to age 65 years, should get a 2nd dose at age 65years or after, once 5 years have passed since 1st dose.

19. Can vaccines cause Guillain-Barre Syndrome? • Immune Dysfunction where system attacks itself causing nerve damage. • Can cause permanent nerve damage, paralysis or death. • Rare but can happen with any infection. • Finding with some vaccines • BUT NOT at a higher rate in people being vaccinated (no causual data found) • www.iom.edu

20. Statistically ? • 1976-increased risk by 1 in 100,000 people who received swine flu vaccine • (reason undetermined.) • Recently: 1 in 1,000,000 vaccinated for seasonal flu may be at risk.

21. Institute of Medicine Safety Review • Vaccines and autism • Thimerosal-containing vaccines and neurodevelopmental disorders • Vaccines and Sudden Infant Death • Multiple vaccines and immune dysfunction • Influenza and neurological complications

22. www.iom.edu/CMS/2955.aspx Look at executive summaries for information on each

23. Credible Vaccine Websites • www.cdc.gov/vaccines www.immunize.org • www.who.int/immunization_safety_quality/approved_vaccine_safety_websites/en/index.html

24. Anti-Vaccine Groups • National Vaccine Information Center • Alliance for Informed Choice in Vaccination • Healthy Alternatives • People Advocating Vaccine Education • Vaccine Information Resource Center • Natural Immunity Information Network

25. Let’s “Go Vaccinate!” • Patients make vaccine decisions based on: • Perceived susceptibility to the disease • Perceived seriousness of the disease • Perceived vaccine benefits • Perceived barriers (adverse reactions, access, cost, time…) • Social Influence (friends, family, healthcare workers…)

26. Misconceptions About Vaccines • Diseases were disappearing before vaccines • No need to continue vaccinating • Vaccines cause harmful effects • People with disease were vaccinated • Hot lots of vaccine exist • Multiple vaccinations cause system overload • www.who.int/immunization_safety/aefi/immunization_misconceptions

27. Adverse Events Following Influenza Vaccination • TIV shots- Injection Site soreness • LAIV spray – mild form of natural disease • Syncope • Anaphylaxis

28. Treating Serious Adverse Events • Allow for fainting without injury, plus access to hard surface if need CPR • Epinephrine: 0.01mg/kg up to 0.5mg repeat every 5-10min • Train staff and practice emergency plan • 911 (EMS) + epinephrine + CPR/BLS

29. True vs. False Allergy • True Immediate hypersensitivity (typically within minutes) • -itching, erythema, hives, urticaria: symptoms progressing toward anaphylaxis • (shock, angioedema, severe bronchospasm, cardiovascular collapse) • False allergy: • Fever, GI upset, neurologic events

30. Vasovagal Syncope • Loss of consciousness • Extreme paleness • Sweating • Coldness of hands and feet • Nausea • Light-headedness • Dizziness • Visual disturbances

31. Frequency and timing • 63% with =< 5 minutes post-vaccination • 8% within 15 minutes of vaccination • 35% reported in patients age 10-18 years • 71% reported in women • 14% of episodes result in hospitalization • (from injuries.) • Observe patient for suitable time after vaccination. ACIP guidelines = 15 minutes

32. Screening and Consulting • Have you ever reacted to a vaccine? • Do you have allergies to food, medications vaccines? (Especially EGGS for influenza) • Do you have any medical conditions? • Do you or anyone in your care or household have cancer, HIV, take prednisone? • Hare you sick today?

33. Vaccine Information Statement • Provide to each patient/caregiver • -updated annually • -provides an overview of benefits and risks of vaccination • -required by law to provide patients with most up to date version • www.cdc.gov/vis • www.immunize.org

34. Obtain Informed Consent • Provides documentation • Provides record for patient (must be kept for the patient’s lifetime) • Decreases liability/litigation

35. Documentation Requirements • Name of patient • Date vaccine administered • Vaccine Manufacturer • Vaccine Lot Number • Name, address, title of person administering the vaccine • Date printed on VIS • Date the VIS given to patient or representative

36. National Vaccine Injury Compensation Program • Act passed in 1986 • Excise tax levied each dose of vaccine sold in the United States. • No fault insurance fund to cover vaccine-related injuries. • If patient experiences an event listed, the patient can be awarded damages through the VICP fund. • Must file a claim with the VICP, satisfy eligibility requirements to receive compensation.

37. The reward for work well done is the opportunity to do more. • -Jonas Salk

38. VAERS • Vaccine Adverse Events Reporting System • Alerts manufacturers and CDC of adverse events • www.vaers.hhs.gov • Or www.cdc.gov/vaccinesafety