UPDATEUPDATE

Talking Points Talking Points and and ResourcesResourcesfor Busy Healthcare Professionalsfor Busy Healthcare Professionals

Presenter: Jackie Hartley-Langille, RN, BScN Presenter: Jackie Hartley-Langille, RN, BScN Occupational Health/Travel HealthOccupational Health/Travel Health

At the end of this presentation, participants will be able to:1.Discuss the importance of adult vaccination2.Be aware of immunization updates and resources3.Discuss adult immunization practice 4.Seize opportunities in adult immunization and discussion

Learning ObjectivesLearning Objectives

Impact of Vaccine Preventable Diseases in PeopleImpact of Vaccine Preventable Diseases in People

““WHEN MEDITATING OVER A DISEASE, I WHEN MEDITATING OVER A DISEASE, I NEVER THINK OF FINDING A REMEDY FOR IT, NEVER THINK OF FINDING A REMEDY FOR IT, BUT, INSTEAD, A MEANS OF PREVENTION.” BUT, INSTEAD, A MEANS OF PREVENTION.”

LOUIS PASTEURLOUIS PASTEUR

Diseases for Which Vaccination isDiseases for Which Vaccination isRoutinely RecommendedRoutinely Recommended

Other Diseases for Which Vaccines are Other Diseases for Which Vaccines are Used in Special SituationsUsed in Special Situations

Ten Great Public Health Achievements Ten Great Public Health Achievements 1900 - 19911900 - 1991

MYTH: MYTH: Disease rates have droppedDisease rates have droppeddue to factors other than vaccinationdue to factors other than vaccination• • Better living conditions (less crowded housing, better nutrition, etc.)Better living conditions (less crowded housing, better nutrition, etc.)have had an impact on disease rates. BUT, the only real decrease in ahave had an impact on disease rates. BUT, the only real decrease in aVPD has occurred after the introduction of a vaccine to prevent it.VPD has occurred after the introduction of a vaccine to prevent it.• • This is also true for newer vaccines like Hib (1987) and varicellaThis is also true for newer vaccines like Hib (1987) and varicella(1995), which were introduced during times of modern hygiene.(1995), which were introduced during times of modern hygiene.• • When some developed countries (U.K., Sweden, Japan) stopped usingWhen some developed countries (U.K., Sweden, Japan) stopped usingDTP vaccine, their pertussis rates jumped dramatically.DTP vaccine, their pertussis rates jumped dramatically.• • Several recent outbreaks of measles, pertussis, and varicella in theSeveral recent outbreaks of measles, pertussis, and varicella in theU.S. have been traced to pockets of unvaccinated children in statesU.S. have been traced to pockets of unvaccinated children in statesthat allow personal belief exemptions. When vaccinationthat allow personal belief exemptions. When vaccinationrates go down, disease rates go uprates go down, disease rates go up.

Why Should Adults Vaccinate?Why Should Adults Vaccinate?

Adult Vaccination Adult Vaccination ChallengesChallenges

RESOURCES FOR IMMUNIZERSRESOURCES FOR IMMUNIZERS NACI – National Advisory Committee on Immunizations (Canada) PHAC – Public health Agency of Canada (Canada) CATMAT - Committee to Advise on Tropical Medicine and Travel Canadian Immunization Guide (Canada) Immunize Canada (Canada) IPAC – Infection Prevention and control Canada (Canada) ICID – International Centre for Infectious Diseases (Canada) CRNNS – College of Registered Nurses Nova Scotia (Canada) - Care Directives: Guidelines for Registered Nurses - Immunization Guidelines for Registered Nurses Nova Scotia Communicable Disease Prevention and Control (Canada) Nova Scotia Immunization Manual (Canada) ICPNS – Infection Prevention and Control Nova Scotia (Canada) Canadian Pediatric Society (Canada) CDC – Centre for Disease Control (United States) WHO – World Health Organization (International)

NACI is a national advisory committee of experts in the fields of NACI is a national advisory committee of experts in the fields of pediatrics, infectious diseases, immunology, medical pediatrics, infectious diseases, immunology, medical microbiology, internal medicine and public health. microbiology, internal medicine and public health.

The Committee reports to the Assistant Deputy Minister of The Committee reports to the Assistant Deputy Minister of Infectious Disease Prevention and Control, and works with staff Infectious Disease Prevention and Control, and works with staff of the Centre for Immunization and Respiratory Infectious of the Centre for Immunization and Respiratory Infectious Diseases of the Public Health Agency of Canada to provide Diseases of the Public Health Agency of Canada to provide ongoing and timely medical, scientific and public health advice.ongoing and timely medical, scientific and public health advice.

NACI makes recommendations for the use of vaccines currently NACI makes recommendations for the use of vaccines currently or newly approved for use in humans in Canada, including the or newly approved for use in humans in Canada, including the identification of groups at risk for vaccine-preventable diseases identification of groups at risk for vaccine-preventable diseases for whom vaccination should be targeted. for whom vaccination should be targeted.

NACI knowledge syntheses, analyses and recommendations on NACI knowledge syntheses, analyses and recommendations on vaccine use in Canada are included in published literature vaccine use in Canada are included in published literature reviews, statements and updates. NACI recommendations are reviews, statements and updates. NACI recommendations are also published in thealso published in the Canadian Immunization Guide.

About NACIAbout NACIhttp://www.phac-aspc.gc.ca/naci-ccni/

Table of Updateshttp://healthycanadians.gc.ca/healthy-living-vie-saine/immunization-immunisation/canadian-immunization-guide-canadien-immunisation/updates-mises-a-jour-eng.php

Hepatitis A vaccine Hepatitis A vaccine New recommendation: Hepatitis A (HA) vaccine may be New recommendation: Hepatitis A (HA) vaccine may be administered to persons six months of age and older. 2016-September administered to persons six months of age and older. 2016-September

Hepatitis A vaccine Hepatitis A vaccine New recommendation: For post-exposure prophylaxis New recommendation: For post-exposure prophylaxis within 14 days of exposure of susceptible adults 60 years of age and older within 14 days of exposure of susceptible adults 60 years of age and older who are household or close contacts of a case, Ig may be provided in who are household or close contacts of a case, Ig may be provided in addition to HA vaccine. 2016-Septemberaddition to HA vaccine. 2016-September

Hepatitis A vaccine Hepatitis A vaccine New recommendation: Immunization with HA vaccine New recommendation: Immunization with HA vaccine may be considered for all individuals receiving repeated replacement of may be considered for all individuals receiving repeated replacement of plasma-derived clotting factors. 2016-September plasma-derived clotting factors. 2016-September

Hepatitis A vaccine Hepatitis A vaccine New recommendation: For post-exposure prophylaxis of New recommendation: For post-exposure prophylaxis of susceptible individuals with chronic liver disease, Ig should be provided susceptible individuals with chronic liver disease, Ig should be provided within 14 days of exposure in addition to HA vaccine. 2016-September within 14 days of exposure in addition to HA vaccine. 2016-September

Influenza Vaccine Updated recommendation: Influenza Vaccine Updated recommendation: The current evidence The current evidence does not support a recommendation for the preferential use of LAIV in does not support a recommendation for the preferential use of LAIV in children and adolescents 2–17 years of age. 2016-September children and adolescents 2–17 years of age. 2016-September

Influenza Vaccine New recommendation: Influenza Vaccine New recommendation: egg allergic individuals may egg allergic individuals may be vaccinated against influenza using the low ovalbumin–containing be vaccinated against influenza using the low ovalbumin–containing live attenuated influenza vaccine (LAIV) licensed for use in Canada.live attenuated influenza vaccine (LAIV) licensed for use in Canada.

Chapter(s) revised to reflect this change: Contraindications, Chapter(s) revised to reflect this change: Contraindications, Precautions Precautions

and Concerns and Anaphylactic Hypersensitivity to Egg and Eggand Concerns and Anaphylactic Hypersensitivity to Egg and Egg Related Antigens. 2016-September Related Antigens. 2016-September Influenza Vaccine New productInfluenza Vaccine New product: : Fluzone® High-Dose influenza vaccine Fluzone® High-Dose influenza vaccine

has been approved for use in Canada in adults ≥65 years of age. 2016-has been approved for use in Canada in adults ≥65 years of age. 2016-May May

Influenza Vaccine New recommendation: Influenza Vaccine New recommendation: NACI now includes adults NACI now includes adults with neurologic or neurodevelopment conditions among the groups for with neurologic or neurodevelopment conditions among the groups for whom influenza vaccination is particularly recommended. 2016 - Maywhom influenza vaccination is particularly recommended. 2016 - May

 Human papillomavirus vaccine New recommendation: Human papillomavirus vaccine New recommendation: Gardasil®9 (HPV9 Gardasil®9 (HPV9 vaccine) has recently been authorized for use in Canada for the prevention vaccine) has recently been authorized for use in Canada for the prevention of HPV types 6, 11, 16, 18, 31, 33, 45, 52, and 58 -related cancers and of HPV types 6, 11, 16, 18, 31, 33, 45, 52, and 58 -related cancers and anogenital warts 2016-July anogenital warts 2016-July

Human papillomavirus vaccine New recommendation: Human papillomavirus vaccine New recommendation: Any of the currently Any of the currently authorized HPV vaccines in Canada can be used according to the authorized HPV vaccines in Canada can be used according to the recommended HPV immunization schedules. 2016-Julyrecommended HPV immunization schedules. 2016-July

Pneumococcal vaccine New recommendation: Pneumococcal vaccine New recommendation: On an individual basis, On an individual basis, PNEU-C-13 vaccine may be recommended to immunocompetent adults PNEU-C-13 vaccine may be recommended to immunocompetent adults aged 65 years and older not previously immunized against pneumococcal aged 65 years and older not previously immunized against pneumococcal disease, for the prevention of community acquired pneumonia and disease, for the prevention of community acquired pneumonia and invasive pneumococcal disease caused by the 13 pneumococcal serotypes invasive pneumococcal disease caused by the 13 pneumococcal serotypes included in the conjugate vaccine. When it is given, it should precede included in the conjugate vaccine. When it is given, it should precede PNEU-P-23 vaccine. 2016-October PNEU-P-23 vaccine. 2016-October

Pneumococcal vaccine New recommendation: If both PCV13 and PPSV23 are indicated, these vaccines should not be given at the same visit. For adults age 19–64 who are receiving both vaccines due to a high risk condition, the PCV13 should be given first followed by PPSV23 ‐at least 8 weeks later. If PPSV23 has already been given, wait 8 weeks (for a child) or 1 year (for an adult age 19 years or older) before giving PCV13 to avoid interference between the 2 vaccines. For adults age 65 and older who are receiving both PCV13 andPPSV23 as part of the routine recommendation, PCV13 should be givenfirst and PPSV23 at least 8 weeks after . ** In Nova Scotia currently only the PPSV23 vaccine is publically funded.

Varicella vaccine A clarification Varicella vaccine A clarification on the minimum interval between two on the minimum interval between two varicella-containing vaccines has been made in accordance with the varicella-containing vaccines has been made in accordance with the information available in the Health Canada approved product monographs. information available in the Health Canada approved product monographs. NACI considers the minimum interval of 4 weeks to be acceptable in NACI considers the minimum interval of 4 weeks to be acceptable in exceptional circumstances. If the second dose of varicella-containing vaccine is exceptional circumstances. If the second dose of varicella-containing vaccine is administered at an interval of less than 4 weeks, it should be repeated. NACI administered at an interval of less than 4 weeks, it should be repeated. NACI continues to recommend an interval between two varicella-containing continues to recommend an interval between two varicella-containing vaccines of at least 3 months for children less than 13 years of age and 6 weeks vaccines of at least 3 months for children less than 13 years of age and 6 weeks for individuals 13 years of age and older. 2016-September for individuals 13 years of age and older. 2016-September

Varicella vaccine Updated recommendation: Varicella vaccine Updated recommendation: Susceptibility and Immunity Susceptibility and Immunity section updated to provide further information about individuals who require section updated to provide further information about individuals who require immunization with varicella vaccine 2016-September immunization with varicella vaccine 2016-September

Varicella vaccine Updated recommendation: Varicella vaccine Updated recommendation: Varicella immune globulin Varicella immune globulin recommendations updated to allow for product administration up to 10 days recommendations updated to allow for product administration up to 10 days since last exposure for the purpose of disease attenuation 2016-September since last exposure for the purpose of disease attenuation 2016-September

Canadian Immunization GuideCanadian Immunization Guide

http://healthycanadians.gc.ca/healthy-living-vie-saine/immunization-immunisation/canadian-immunization-guide-canadien-immunisation/index-eng.php

The Canadian Immunization Guide is a comprehensive resource on The Canadian Immunization Guide is a comprehensive resource on immunization. It was developed based on recommendations and immunization. It was developed based on recommendations and statements of expert advisory committees, including the:statements of expert advisory committees, including the:••National Advisory Committee on Immunization (NACI)National Advisory Committee on Immunization (NACI)••Committee to Advise on Tropical Medicine and Travel (CATMAT)Committee to Advise on Tropical Medicine and Travel (CATMAT)

Care Directives: Guidelines for Care Directives: Guidelines for Registered NursesRegistered Nurses

http://crnns.ca/publication/care-directives-guidelines-for-registered-nurses/

http://crnns.ca/publication/immunization-guidelines-for-registered-nurses/

Immunization Guidelines for Registered Nurseses 

Care Directive:    Influenza Vaccine   Indication: For immunization against infection caused by influenza viruses for patients meeting the criteria per the Canadian Immunization Guidelines.   Adults: Administer Influenza vaccine 0.5 ml I.M per product monograph.  Children: Administer Influenza vaccine 0.5 ml I.M. per NACI recommendations. Schedule: 6 months to 8yrs. Initial vaccine: 2 doses 0.5ml - 4 weeks apart                                                    Prior vaccine:  1 dose 0.5ml   Administer to patients who meet the criteria as per The Canadian Immunization Guide Evergreen Edition section, Part 4 Active Vaccines: http://www.phac-aspc.gc.ca/publicat/cig-gci/p04-eng.php   Note: Epinepherine HCl 1:1000 must be available for immediate use in case of anaphylaxis or hypersensitivity reaction. (See Epinepherine Care Directive)      _______________________ ________________________________ Date Physician Signature     _______________________ ________________________________ Date Clinic Manager Review

Care Directives 

Care Directive:   Epinephrine HCl – Adrenalin 1:1000  Indication: For the relief of respiratory distress due to bronchospasm to provide rapid relief of hypersensitivity reaction to vaccines, drugs and other allergens per the Canadian Immunization Guidelines.  For Adults: Administer Epinephrine 0.01mg/kg (maximum 0.5ml) I.M. for anaphylaxis.  For post vaccination anaphylaxis administer in mid-anterolateral aspect of the thigh, not the deltoid. Dosing can be repeated twice at 5 - 15 minute intervals to a maximum of 3 doses if symptoms persist.  All vaccine recipients receiving emergency epinephrine must be transported to hospital immediately, via ambulance, for evaluation and observation. Ensure patient remains in a recumbent position following receipt of epinephrine injection and is monitored closely. For Children: Administer dose: Epinephrine 1:1000, 1 mg/ml solution, by age or weight.  

Table 1: Dose of epinephrine (1:1000, 1 mg/mL solution), by age or weight 

Age WeightTable 1 - Footnote 1 Dose by injection Dose by autoinjector

0 – 6 months  Up to 9 kg (20 pounds)  0.01 mg/kg body weight  Not applicable 

7 - 36 months   9 - 14.5 kg (20 - 32 lb)  0.1 - 0.2 mg   Not applicable 

37 - 59 months   15 - 17.5 kg (33 – 39 lb)  0.15 -  0.3 mgTable 1 - Footnote 2  Junior dose of 0.15 mg 

5 - 7 years   18 - 25.5 kg (40 – 56 lb)  0.2 - 0.3 mgTable 1 - Footnote 2  Junior dose of 0.15 mg 

8 - 12 years   26 - 45 kg (57 – 99 lb)  0.3 mgTable 1 - Footnote 2  - If , less than 30 kg (66 lbs) give Junior dose - If 30 kg or more: Give standard dose 

13 years and older  46 + kg (100 + lb)  0.5 mgTable 1 - Footnote 3   Give standard dose of 0.3mg 

Adapted from Immunization Action Coalition. Medical Management of Vaccine Reactions in Children and Teens (PDF document) . Accessed June 2012.  Table 1 - Footnote 1

Rounded weight at the 50th percentile for each age range 

Table 1 - Footnote 2 Maximum dose for children 12 years of age and younger 

Table 1 - Footnote 3 Maximum dose for adolescents 

  Administer to patients who meet the criteria described in the Anaphylaxis policy and as per The Canadian Immunization Guide Evergreen Edition section: Anaphylaxis: Initial Management in Non-Hospital Settings. http://www.phac-aspc.gc.ca/publicat/cig-gci/

      

Care Directive:   Benadryl® (Diphenhydramine hydrochloride) Administration   Indication: As an optional adjunct to epinephrine per the Canadian Immunization Guidelines.  Administer  Benedryl® 50mg P.O. or I/M per product monograph.  May be given as an adjunct to epinephrine to relieve itching, flushing, uticaria, and nasal and eye symptoms. Not recommended for infants under 12 months of age. When given to children, dosage should be determined by weight (1 mg/kg) Refer to dosing guidelines in Table 2:  

Table 2: Dose of diphenhydramine hydrochloride, by age 

Age Weight (pounds) Dose of diphenhydramine hydrochloride

12-23 monthsTable 2 - Footnote 1  7-12 kg (15-25 lbs)  6.25 - 12.5 mg 

2 to 4 years   12-25 kg (25-55 lbs)  12.5 - 25 mg 

5 to 11 years   25-45 kg (55-99 lbs)  25 - 50 mg 

12 years and older  45 kg + (99 lbs or more)  50 mg 

1 Use with caution in children 12 - 23 months due to risk of sedation or paradoxical excitement.  

 

 Administer to patients who meet the criteria described per The Canadian Immunization Guide Evergreen Edition section: Anaphylaxis: Initial Management in Non-Hospital Settings. http://www.phac-aspc.gc.ca/publicat/cig-gci/   _______________________ ________________________________ Date Physician Signature     _______________________ ________________________________ Date Clinic Manager Review

IMPORTANT RULE:IMPORTANT RULE:

Vaccine doses should not beVaccine doses should not be

administered at intervals less than theadministered at intervals less than the

recommended minimal intervals orrecommended minimal intervals or

earlier than the minimal ages.earlier than the minimal ages.

But there is no maximum But there is no maximum interval!interval!And the classic error :And the classic error :Re‐starting a vaccine seriesRe‐starting a vaccine seriesbecause of a longer‐than recommendedbecause of a longer‐than recommendedinterval.interval.

Required information to Required information to documentdocument

• • Type of vaccine (e.g., MMR or Hib)Type of vaccine (e.g., MMR or Hib)

• • Vaccine name and lot numberVaccine name and lot number

• • Date the vaccination was givenDate the vaccination was given

• • Name, office address, and title of the healthcareName, office address, and title of the healthcare

provider administering the vaccineprovider administering the vaccine

SummarySummary