Influenza Immunization Competency Training: Protecting Health Care Professionals and Communities

1. The Flu Stops With You 2011 Education for Influenza Immunizers

2. Contributors • Issy Aguiar (Promotion & Prevention) • Nicki Gill (Infection Prevention & Control) • Rhodina Hobbs (Workplace Health &Safety) • Dixie Ross (Workplace Health & Safety) • Joanne Smrek (Promotion & Prevention) • Heather Way (Promotion & Prevention) Past contributors: Marina Calangis-Jones (WH&S)

3. Presentation Outline Promotion & Prevention slides 4-58 Workplace Health & Safety slides 59-67 Infection Prevention & Controlslides 68-85 Conclusion: slides 86-88

4. Immunization Competency • Legislated scope of practice for all health care professionals (HPAct) • Standards of practice (Colleges/Associations) • BCCDC Immunization Competencies • Decision Support Tools (BC Centre for Disease Control (BCCDC) Communicable Disease Control Manual, Chapter II-Immunization Program / IH developed resource tools)

5. Learning Objectives Learners will be able to demonstrate the following skills per immunization competency as they relate to influenza & pneumococcal disease and vaccine: • Demonstrates an understanding of the rationale and benefit of influenza & pneumococcal immunization • Applies the knowledge of the component and properties of influenza & pneumococcal vaccines as needed for safe and effective practice • Explains how vaccine works using basic knowledge of the immune system • Demonstrates an understanding of the influenza & pneumococcal immunization schedule

6. Learning Objectives • Implements provincial guidelines when storing, handling or transporting influenza & pneumococcal vaccines • Prepares and administers influenza & pneumococcal vaccine correctly • Anticipates, identifies and manages reactions following immunization • Documents information in accordance with provincial/jurisdictional guidelines and processes • Acts in accordance with legal and ethical standards including the process for obtaining informed consent

7. Learning Objectives • Recognizes and responds to the unique immunization needs of certain populations groups • Applies relevant principles of population health for improving immunization rates • Communicates effectively about influenza & pneumococcal immunization • Demonstrates an understanding of respiratory outbreak management • Explains the role of the flu champ/clinic nurse in the IH employee flu campaign • Prevents and manages needle stick & repetitive strain injuries

8. Promotion & PreventionInfluenza Disease & Immunization

9. Each Year During Influenza Season…. In Canada, an estimated: • 10-25% could have influenza each year • 4,000 to 8,000 (mostly seniors) die every year from pneumonia related to flu http://www.hc-sc.gc.ca/iyh-vsv/diseases-maladies/flu-grippe_e.htmlalth-Influenza (the 'flu')Health Canada, 2009

10. What is Influenza Disease? • AKA “The Flu” • Respiratory infection caused by influenza virus • Can cause severe illness & death • Main cause of vaccine preventable deaths

11. How Is Influenza Spread? Droplet Contact (the most common route of transmission)

12. The Influenza Virus Can Survive… • On unwashed hands for FIVE minutes • On tissues for 8-10 hours • On hard surfaces such as door handles and telephones for up to 48 hours

13. How To Prevent Influenza Disease • Immunize! • Wash your hands! • Cover your cough/sneeze • Eat well, exercise and get enough sleep!

14. What Is Influenza Vaccine?

15. Seasonal Influenza Vaccine • Recommended yearly • Duration of Protection: 6mon – 1yr • Efficacy: 70-90% in healthy children & adults

16. Seasonal Influenza Vaccine • Made from 3 types of influenza virus most likely to show up each winter • A/California/7/2009 (H1N1)-like • A/Perth/16/2009 (H3N2)-like • B/Brisbane/60/2008-like

17. Influenza Vaccine Products Fluviral® • approximately 74% supply • all eligible groups • approximately 26% supply • pregnant women • children 6-23 month Agriflu®

18. Influenza Vaccines Fluviral® • from GSK • multi-dose vials . Must be discarded 28 days after first entry • from Novartis • single dose syringes • no needle supplied Agriflu®

19. Vaccine Components Fluviral® • inactivated split-virionvaccine • egg protein, formaldehyde, thimerosal, sodium deoxycholate, • sucrose • subunit, non-adjuvanted vaccine • thimerosal-free • egg protein, ovalbumen, formaldehyde, polysorbate80 or cetyltrimethylammonium bromide (CTAB), neomycin, kanamycin, barium, citrates Agriflu®

20. Nasal Influenza Vaccine • FluMist (AstraZeneca) live, intranasal vaccine • Will not be provincially funded • Approved in Canada for use in clients 2-59 yrs • For use in healthy people only

21. Vaccine Storage • Must be kept at a temperature of 2 to 8º C at all times • Preferable to use a purpose-built fridge • Do not store in the door of a fridge • Maintain cold chain during transport • Report cold chain breaks to local Health Centre See BCCDC Communicable Disease Control Manual, Chapter II, Immunization Program, Section VI Management of Biologicals

22. Vaccine Handling • Insulated coolers 2 to 8º C • ice packs, insulating materials • record the date of opening on multi-dose vials • Pre-loading discouraged • Best practice –temperature monitoring device in cooler See BCCDC Communicable Disease Control Manual, Chapter II, Immunization Program, Section VI Management of Biologicals

23. Vaccine Administration Routine Practice Technique See BCCDC Communicable Disease Control Manual, Chapter Il, Immunization Program, Section IV, Administration of Biological Products

24. Influenza Vaccine Administration Intramuscular injection at 90º angle • Deltoid >12 months of age • Vastuslateralis infants 6-12 months Needle size (25g) • Infants/toddlers/older children: 7/8”-1” • Adolescents/Adults: 1”-1 ½” See BCCDC Communicable Disease Control Manual, Chapter Il, Immunization Program, Section IV, Administration of Biological Products

25. Deltoid Site Define the site by drawing a triangle with its base at the lower edge of the acromion and its peak above the insertion of the deltoid muscle. The injection site is in the centre of the triangle See BCCDC Communicable Disease Control Manual, Chapter Il, Immunization Program, Section IV, Administration of Biological Products

26. VastusLateralis Site Define the site by dividing the space between the trochanter major of the femur and the top of the knee into three parts; draw a horizontal median line along the outer surface of the thigh. The injection site is in the middle third, just above the horizontal line. See BCCDC Communicable Disease Control Manual, Chapter Il, Immunization Program, Section IV, Administration of Biological Products

27. Positioning When immunizing an infant, have the parent/caregiver hold the infant in a “cuddle” or semi-recumbent position on their lap. See BCCDC Communicable Disease Control Manual, Chapter Il, Immunization Program, Section IV, Administration of Biological Products

28. Dosage *Previously unimmunized children under 9 yrs of age require 2 doses given 4 weeks apart. **New information this year: small excess risk of febrile seizures if receiving both Trivalent Influenza Vaccine (TIV)and Pneumococcal Conjugated vaccine (PCV13) at the same time. See BCCDC Communicable Disease Control Manual, Chapter Il, Immunization Program, Section Vll, Biological Products (Fluviral & Agriflu p32-33)

29. Side Effects • May start 6-12 hours post immunization and last 1-2 days: • Fever, headache, flu like symptoms (malaise and myalgia) • Soreness, swelling at the injection site • Rare: Guillain-Barre Syndrome (GBS) and oculorespiratory syndrome (ORS) See BCCDC Communicable Disease Control Manual, Chapter Il, Immunization Program, Section Vll, Biological Products (Fluviral & Agriflu p32-33)

30. Anaphylaxis • A potentially life-threatening allergic reaction • Rare but need immediate attention • Report Adverse Events & Anaphylaxis to Public Health for evaluation/documentation See BCCDC Communicable Disease Control Manual, Chapter Il, Immunization Program, Section V Management of Anaphylaxis in a Non-Hospital Setting

31. Signs and Symptoms of Anaphylaxis Early/Mild: swelling/hives at injection site, sneezing, nasal congestion, tearing, coughing, facial flushing, urticaria (hives), angioedema (welts) Moderate/Severe: obstructive swelling of upper airway, hypotension, bronchospasm * All symptoms not necessarily present but it is a multi-system event BCCDC Communicable Disease Control Manual, Chapter Il, Immunization Program, Section V Management of Anaphylaxis in a Non-Hospital Setting

35. Emergency Treatment 1. Call 9-1-1 for ambulance (mass public clinics/residential care) * Acute care calls a “code” 2. Give Epinephrine! a) 0.5ml EPINEPHRINE (1:1,000) IM into an unimmunized thigh b) DO NOT inject epinephrine into the same muscle mass as vaccine was administered. c) If both thighs were used for immunization, give IM in deltoid if client is >12 months of age or SC in upper outer triceps if <12 months d) Refer to table for infant/child doses 3. Position person recumbent with legs elevated 4. Monitor respiratory effort, pulse and level of consciousness See BCCDC Communicable Disease Control Manual, Chapter II, Immunization Program, Section V-Management of Anaphylaxis in a Non-Hospital Setting

36. Emergency Treatment 5. If person’s breathing becomes more labouredor consciousness decreases, repeat EPINEPHRINE at 5 minute intervals to a maximum of 3 doses. Alternate right and left thigh or arm sites for repeat doses 6. If not responding well to EPINEPHRINE or if needing to maintain symptom control, give one dose BENADRYL IM (1.0ml adult) at a different site to that in which epinephrine was given * refer to table for infant/child doses 7. Client must go to ER! See BCCDC Communicable Disease Control Manual, Chapter II, Immunization Program, Section V-Management of Anaphylaxis in a Non-Hospital Setting

37. Who Should Get the Influenza Vaccine?

38. People At High Risk People > 65 years of age People of any age who are residents of long-term care facilities Adults (including pregnant women) & children with the following chronic health conditions: • Cardiac or pulmonary disorders • Diabetes & other metabolic diseases • Cancer; immunodeficiency (including HIV infection); immunosuppression due to underlying disease or therapy • Chronic kidney & liver disease • Anemia & hemoglobinopathy • Conditions that compromise the management of respiratory secretions and are associated with an increased risk of aspiration See BCCDC Communicable Disease Control Manual, Chapter II, Immunization Program, Section Vll-Biological Products p31

39. People At High Risk…. • Children and adolescents( 6 months-18 yrs) with conditions treated for long periods with acetylsalicylic acid • Adults who are morbidly obese (BMI >40) • Aboriginal people • Healthy children 6-23 months • Pregnant women who will be in their 3rd trimester during flu season and their contacts • Inmates and staff of provincial correctional institutions • People working with live poultry and/or swine See BCCDC Communicable Disease Control Manual, Chapter II, Immunization Program, Section Vll-Biological Products p31

40. Those Capable Of Transmitting Influenza To Those At High Risk…. • Health Care Workers (HCW) and other personnel who have significant contact with people in high risk groups • Household contacts (including children) of people at high risk • Those who provide care or service in potential outbreak settings housing high risk persons (e.g.. crew on ships) • Household contacts of children age 0-23 months • Those providing regular child care to children age 0-23 months See BCCDC Communicable Disease Control Manual, Chapter II, Immunization Program, Section Vll-Biological Products p31

41. Essential Community Service Providers: First Responders Corrections Officers See BCCDC Communicable Disease Control Manual, Chapter II, Immunization Program, Section Vll-Biological Products p31

42. Contraindications Those with a history of: • anaphylactic reaction to a previous dose of any type of influenza vaccine • anaphylactic reaction to any component of the vaccine • Guillain-Barre Syndrome (GBS) within 8 weeks of a previous influenza vaccine and infants less than 6 months of age See BCCDC Communicable Disease Control Manual, Chapter II, product pages See BCCDC Communicable Disease Control Manual, Chapter II, Immunization Program, Section Vll-Biological Products p32-33 (Fluviral & Agriflu)

43. Precautions • Severe oculo-respiratory syndrome (ORS) after a previous dose of influenza vaccine • Egg-allergic individuals who experience only hives following egg ingestion See BCCDC Communicable Disease Control Manual, Chapter II, Immunization Program, Section Vll-Biological Products p32-33 (Fluviral & Agriflu)

44. Egg Allergic Individuals See BCCDC Communicable Disease Control Manual, Chapter II, Immunization Program, Section Vll-Biological Products p31a

45. Informed Consent • Essential • Professional and legal responsibility • Standard of Practice See BCCDC Communicable Disease Control Manual, Chapter I1, Section 1B Informed Consent

46. Elements Of Informed Consent (IC) • Specific to the immunization service • Client-centered • Voluntary • Obtained without fraud/misrepresentation • Assesses capability of person • Provides standard information • Provides time to ask questions and receive answers • Gives person providing consent the right to refuse or revoke consent See BCCDC Communicable Disease Control Manual, Chapter I1, Section 1B Informed Consent

47. IC Process Step 1 Determine authority Step 2 Assess capability Step 3 Provide Standard Information Step 4 Confirm understanding of standard information Step 5 Provide opportunity for questions Step 6 Confirm consent Step 7 Document See BCCDC Communicable Disease Control Manual, Chapter I1, Section 1B Informed Consent

48. Documentation • Name of vaccine • Lot number • Site of injection • Provider signature/initial See BCCDC Communicable Disease Control Manual, Chapter I1, Section 1B Informed Consent

49. Pneumococcal Vaccine

50. Pneumococcal Disease 2 types of infection • Local: respiratory • Invasive: bloodstream to organs & tissues Transmission • Coughing, sneezing, close face-to-face and saliva