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2017-2018 Influenza Immunization

Orientation

October 2017

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Introduction

This 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 October but most often activity peaks in January or

later. Late season outbreaks occurring in April and even May have

also been reported.

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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 diseaseGenerally 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

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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 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

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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 3–4 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 2–3 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.

Alberta Health http://www.health.alberta.ca/health-info/influenza-compare-symptoms.html

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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

• 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 persons

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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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 adolescentsFlannery B, Reynolds SB, Blanton L, et. al. Influenza Vaccine Effectiveness Against Pediatric Deaths. Pediatrics. 2017. DOI:

10.1542/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 4 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

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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

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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.

• Exercise. Drink plenty of water. Eat well and do not

smoke.

• Avoid crowds when influenza season hits your area.

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Influenza prevention hand washing

√ 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 else’s 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 (cont’d)

• There are currently seven 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 2017-2018 influenza immunization program, Alberta will be

using one QIV product and one TIV product. The TIV product will

be used for administration to adults 65 years of age and older living

in Long Term Care or Supportive Living sites only.

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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 with non-

adjuvanted TIV and the 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 45-85% 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.

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Vaccine strains for 2017-2018

The strains that will be included in the 2017-2018 influenza vaccine

for the Northern hemisphere are:

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

• A/Hong Kong/4801/2014 (H3N2)-like virus

• B/Brisbane/60/2008-like virus

• B/Phuket/3073/2013-like virus (QIV only)

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Facts about inactivated influenza vaccine (TIV/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 A

1. Which strains of influenza virus are included in the 2017-2018

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.

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

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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 23, 2017.

• Vaccine may be offered earlier for certain high risk populations (e.g., continuing

care residents, lodge residents, homebound clients, homeless individuals, HCWs,

children 6-59 months in routine immunization clinic) 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%

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Provincially funded influenza vaccines for 2017/2018

Fluzone® (QIV)

(Sanofi Pasteur)Fluad® (TIV – MF59 adjuvanted)

(Seqirus)

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

Pre-filled, single dose syringe

(luer lock needles not included)

Eligibility Individuals who live, work or go to school

in AlbertaIndividuals who live in congregate living facilities,

provided in AHS outreach program and to LTC facilities

Indication 6 months1 and older; pregnant women 65 years of age and older

Ingredients2 Thimerosal-free (single dose formulation

only), formaldehyde, sodium phosphate

buffered isotonic sodium chloride

solution, Triton® X-100

Thimerosal-free, trace amounts of egg proteins,

formaldehyde, kanamycin, neomycin,

cetyltrimethylammonium bromide (CTAB), MF59

adjuvant (squalene, polysorbate 80, sorbitan trioleate,

sodium citrate, citric acid)

Schedule 1 or 2 doses3 1 dose

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 ingredients

3Children 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.

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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

and provide a copy of the form to 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

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Pregnancy and breastfeeding

“NACI 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 2017

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Pregnancy and breastfeeding (cont’d)

• QIV is safe for pregnant women at all

stages of pregnancy

• QIV is safe for breastfeeding mothers

*Fluad® is not recommended for use in

pregnant or breastfeeding women

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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.

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Reactions to TIV/QIV

Rare Reactions

• Immediate, allergic-type responses such as hives, angioedema,

allergic asthma, systemic anaphylaxis

• Guillain-Barré Syndrome (GBS)

• Oculorespiratory Syndrome (ORS)

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Guillain-Barré 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-Barré Syndrome (GBS) (cont’d)

• 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 vaccination 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.

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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) (cont’d)

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

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)

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Reporting of adverse events following immunization (AEFI)

An adverse event following immunization is defined as a serious or unexpected event

temporarily associated with immunization.

The most commonly reported AEFIs in the 2016-2017 influenza immunization season

were allergic reaction (not anaphylaxis), pain/swelling, rash and severe diarrhea and/or

vomiting.

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

OR

reaction requires hospitalization

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AEFI reporting (cont’d)

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 TIV/QIV

TIV/QIV should not be administered to individuals who:

• Are less than 6 calendar months of age

– Fluad® should not be administered to persons under 65 years 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-Barré 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 (TIV/QIV)

• Egg-allergic individuals may be immunized using TIV/QIV without a

prior influenza vaccine skin test and with the full dose of vaccine,

irrespective of a past severe reaction to egg

• Egg-allergic vaccine recipients should be kept under observation

for 30 minutes following the administration of inactivated influenza

vaccine

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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 B

1. 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-Barré 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?

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

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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 or community physician partners, but also in conjunction with the Influenza Immunization Program due to ease of access to target population

• 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 eligibility

I. 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 heart 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 kidney 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 (cont’d)

– Chronic lung 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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Pneumococcal polysaccharide vaccine eligibility (cont’d)

– Illicit injection drug use

– Immunosuppressive therapy including use of long term corticosteroids,

monoclonal antibodies (e.g., eculizumab [Soliris®]),chemotherapy, radiation

therapy, post-organ transplant therapy and certain anti-rheumatic drugs

– Malignant neoplasms including leukemia, Hodgkin’s and non-Hodgkin’s

lymphomas, multiple myeloma and other malignancies

– 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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Pneumococcal polysaccharide vaccine eligibility (cont’d)

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

Pneumococcal polysaccharide vaccine eligibility (cont’d)

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Pneumococcal polysaccharide vaccine

• Provincially funded product - Pneumovax®23 (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

– Hepatic cirrhosis

– HIV infection

– Immunosuppression related to disease or therapy (e.g., lymphoma,

Hodgkin’s disease, multiple myeloma, high-dose systemic steroids)

– Solid organ transplant

• This one-time reinforcing dose should be given:

– 5 years after the initial dose of pneumococcal polysaccharide vaccine

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Reinforcing dose

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.

66

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.

67

Section 4 – Vaccine Administration

• Client Interview (Fit to Immunize Assessment)

• Informed Consent

• Vaccine Administration Process

68

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

69

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

2017-2018 influenza season

• Complete a “fit to immunize” assessment

– health status today

– history of allergies

– previous reactions

– chronic illness/medications

– pregnancy

70

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)*

– 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 administering pneumococcal polysaccharide vaccine.

71

Vaccine management

• All multi-dose vials must be dated upon opening*

– Multi-dose Fluzone® 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

72

Preparing the vaccine

• Determine the appropriate vaccine and route of administration

• Provide appropriate information to client

• Detach self from conversation

• For TIV/QIV, 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

73

Preparing the vaccine (cont’d)

For TIV/QIV

• 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)

74

Preparing the vaccine (cont’d)

• 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®, Fluad® or pneumococcal polysaccharide

vaccine)

75

Administering TIV/QIV

• Expose and position the client’s 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 90º 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

76

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

77

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 deltoid

Adults

– 3 mL syringe

– 25G - 1” to 1½” needle depending on muscle mass and adipose tissue

– insert at 90 degree angle

– mid portion of deltoid

78

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)

79

Position & stabilization techniques for vastus lateralis

site (infants less than 12 months)

For injection in the vastus lateralis

80

Position & stabilization techniques for deltoid site

Infants 12 months and older Infants 18 months old and older

(“The pretzel hold”)

81

Section 4 – Vaccine Administration Knowledge Check

Review Questions Section 4

1. Is it important to agitate Fluad® 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 Fluzone® vaccine?

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

82

Section 5 – Anaphylaxis and Syncope

Anaphylaxis

• 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 - 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 immunization

All 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

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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 when immunizing

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Histamine/mediators – 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

85

… 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

86

... 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

87

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

88

What would you do?

Would you give this child

epinephrine? Why or why not?

89

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!

90

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

91

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

92

Signs and symptoms of syncope

Musculoskeletal

• muscles relaxed

• weakness

• incontinence (rare)

• clonic jerks of limbs and face

Respiratory

• normal or yawning

Dermatologic

• pallor/grey color - sweating

93

Signs and symptoms of syncope (cont’d)

Gastrointestinal

• vomiting - nausea

Cardiovascular

• hypotension, slow weak pulse

• ringing in ears

Neurological

• light headedness, dizziness

• spots before the eyes

• dazed

• unconsciousness

94

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% 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!

95

Tips to prevent syncope

• Administer vaccine while client is seated

• Maintain a calm and confident demeanor

• Observe anxious client while seated until anxiety has resolved after

immunization

• Have clients with a history of fainting lie down prior to administering

vaccine

• Client with pre-syncopal symptoms (such as dizziness, anxiety,

pallor, perspiration, trembling, or cool, clammy skin) should sit or lie

down until symptoms resolve

96

Assisting clients after syncope

• Assist the client to lay down with feet elevated

• Ensure the client’s 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 client’s 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

97

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

98

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

99

Section 5 - Anaphylaxis and Syncope Knowledge Check

Review Questions Section 5

1. 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 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 Procedure

http://www.albertahealthservices.ca/info/Page14956.aspxs

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3

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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4

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

– 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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5

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 on the NCR, do not put the NCR on the small

drape

– Available space on the large drape can be used or the small drape

folded in half before placing the NCR or other paperwork on top.

This ensures the inner surface remains clean

• 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

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6

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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7

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 1:9 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 recording

Information 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

• Immunizer’s first initial and last name, designation & signature

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Influenza/pneumococcal vaccine recording (cont’d)

• Immunizer’s full name to be recorded on back of white copy (first

page)

• Public Health 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 Influenza/Pneumococcal

Vaccine Record (NCR) for recording purposes. A 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 the 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 List

When 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

Calgary Zone Public Health will be offering Prevnar® 13 at large public immunization clinics.

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Employee Data Collection

AHS Workplace Health and Safety (WHS) and Covenant Health

Occupational Health and Safety (OHS) require notification of

employee immunization for the following reasons:

• In the event of an outbreak, influenza immunization status of

employees is required to manage the outbreak

• AHS WHS/Covenant Health OHS are required to provide overall

organizational rates of influenza immunization each year – doses

provided by Public Health are included in the rates.

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Employee Data Collection (cont’d)

When an AHS or Covenant Health employee presents at a

Public Health Clinic for influenza immunization you will need to:

1. Determine if the employee works for AHS or Covenant

Health

2. Have the employee complete the bottom section of the

NCR form

3. The NCR will be sent to AHS WHS or Covenant Health

OHS for data entry; follow Zone processes.

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Employee Data Collection (cont’d)

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Employee Data Collection (cont’d)

Please remember the following:

• Identify the employee:

03 Health care worker □ AHS/Covenant Employee

• Have the employee complete the bottom portion of the NCR form

– Ensure all fields have been completed including their employee number

– Ensure staff are aware that not completing the section may lead to work

restrictions or reassignment during an influenza outbreak until confirmation of

influenza immunization is provided

• White copy to be kept by Public Health

• Yellow copy to be given to the AHS or Covenant Health employee

• Employee copy has aftercare information on back

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Data collection (cont’d)

• 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 False

2. The influenza virus is spread only through droplets in the air. True or False

3. Influenza is contagious only after symptoms appear. True or False

4. In general, higher rates of influenza occur during which time of the year in North

America?

a. Year round

b. September through December

c. December through March

d. 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 Test

6. 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. 45-85%

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 TIV/QIV for an 18-month-old child is:

a. 0.25 mL

b. 0.5 mL

c. 0.75 mL

d. 1 mL

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Influenza/Pneumococcal Self Learning Test

9. For an 8-year-old boy who has never received influenza vaccine, how many

doses will he need to receive this season?

a. One

b. Two

10. The most common side effects after inactivated influenza immunization are:

a. Flu like symptoms

b. Redness, soreness and swelling at the injection site

c. Guillain-Barré syndrome

d. Systemic symptoms of headache, fever, runny nose

11. Which vaccines would you offer to a 65-year-old man who has chronic lung

disease?

a. Influenza

b. Pneumococcal Polysaccharide 23

c. Both Influenza and Pneumococcal Polysaccharide 23

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Influenza/Pneumococcal Self Learning Test

12. 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 Test

16. Signs of an anaphylactic reaction include:

a. Swelling of the mouth and throat

b. Hives

c. Difficulty breathing

d. Hypotension

e. 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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6

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 at

high 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 weren’t?

• 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 year’s 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

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References

1. Alberta Health: Government of Alberta. (2017, July). Alberta’s Influenza Immunization Program Policy

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

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

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

5. 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.

6. Immunize Canada. Influenza. Retrieved August 21, 2014 from http://www.immunize.cpha.ca/en/diseases-vaccines/influenza.aspx

7. 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

8. Merck Canada Inc. (July 27, 2016). PNEUMOVAX®23 (pneumococcal vaccine, polyvalent, MSD Std.). Product monograph.

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References

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

10. 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

11. National Advisory Committee on Immunization (2017). Canadian Immunization Guide Chapter on Influenza and Statement on Seasonal Influenza Vaccine for 2017-2018. Ottawa, ON: Public Health Agency of Canada.

12. Seqirus UK Limited. (2017). FLUAD® (Influenza Vaccine, Surface Antigen, Inactivated, Adjuvanted with MF59C.1). Product Monograph.

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 from http://www.phac-aspc.gc.ca/influenza/index-eng.php

15. Sanofi Pasteur Inc. (April 2017). FLUZONE® Quadrivalent (Influenza Virus Vaccine Quadrivalent Types A and B (Spit Virion). Product Monograph.

16. Alberta Health, Health System Accountability and Performance Division, Alberta Immunization Policy (2017, June 15). Influenza Vaccine: FLUAD®

17. Alberta Health, Health System Accountability and Performance Division, Alberta Immunization Policy (2017, June 15). Influenza Vaccine: Fluzone®

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Answer Keys

Section One- Influenza Disease Knowledge Check Answers

1. 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 Keys

Section Two Part A - Influenza Vaccine Knowledge Check Answers

1. Which strains of influenza virus are included in the 2017-2018 influenza

vaccine for the northern hemisphere?

• Strains included in the 2017-2018 vaccine include:

• A/Michigan/45/2015 (H1N1)pdm09–like virus

• A/Hong Kong/4801/2014 (H3N2)-like virus

• B/Brisbane/60/2008-like virus

• B/Phuket/3073/2013-like virus (QIV only)

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. TIV/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 Key

Section Two Part B- Influenza Vaccine Knowledge Check Answers

1. 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 Key

3. Who should not be immunized with influenza vaccine?

• TIV/QIV should not be administered to:

– children less than 6 calendar months of age

• Fluad® should not be administered to persons under 65 years of age or

women who are pregnant or breastfeeding

– 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-Barré 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-Barré 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 Fluad® 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 Fluzone® vaccine?

• Yes. Open vials of multi-dose Fluzone® must be discarded 28 days after the

first puncture.

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Answer Key

Section Five- Anaphylaxis & Syncope Knowledge Check Answers

1. 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. True

2. False

3. False

4. December through March

5. False

6. 45-85%

7. False

8. 0.5 mL

9. Two

10.Redness, soreness and swelling at the injection site

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Self Test Answer Key

11. Both Influenza and Pneumococcal Polysaccharide 23

12. False

13. True

14. True

15. True

16. All of the above

17. False

18. True

19. False

20. False