INFLUENZA VACCINE PROGRAM REVIEW. IERHA Immunization Program September 2018

Transcription

1 INFLUENZA VACCINE PROGRAM REVIEW IERHA Immunization Program September 2018

2 Let s talk about Flu..

3 INFLUENZA Viral infection lasts ~ a week - sudden onset of high fever, aching muscles, headache, severe malaise, non-productive cough, sore throat.

4 WHAT S THE BIG DEAL, ANYWAY? Because flu is a contagious respiratory illness (transmitted via droplets), its spread can cause mild to severe illness. Serious outcomes of flu can result in hospitalization or death. The elderly, young children, and people with certain health conditions are at high risk for serious flu complications. In Canada, it is estimated that an average of 12,000 hospitalizations and ~ 3500 deaths are related to influenza. Best way to prevent flu is annual vaccination.

5 INFLUENZA STRAIN REPORTED BY NML SEPT 1, 2017 APRIL 28, 2018 Influenza A (H3N2) was the predominating flu virus last season overall, but influenza B was predominant from February April Significantly more influenza B detections in than any previous flu seasons since Last season, majority of laboratory-confirmed influenza cases & influenza-associated hospitalizations and deaths were among adults 65 years of age and older.

6 SEASONAL INFLUENZA Influenza season typically November April Development of immune response occurs 2 weeks after vaccination; antibodies persist for ~ 6 months Scientists monitor global spread of flu, decide which strains will likely cause most illness during flu season Vaccine strains can change from year to year

7 FLU VACCINE COMPOSITION As per the WHO, all quadrivalent flu vaccines for the in the northern hemisphere contain: A/Michigan/45/2015 (H1N1)pdm09-like virus A/Singapore/INFIMH /2016(H3N2)-like virus B/Colorado/06/2017-like virus B/Phuket/3073/2013-like virus

8 FLU VIRUSES ARE ALWAYS CHANGING When the vaccine matches the circulating flu virus(es), the vaccine can be as high as 85% effective. Effectiveness as age and in people who are immunocompromised. About 22% of Manitoba residents get flu shots. Vaccines generally are safe and effective. Because the flu virus is constantly changing, the challenge is to improve the flu vaccine. Currently, the flu vaccine is still our best defense against getting/transmitting the flu!

9 WHO IS ELIGIBLE? All Manitobans including those highest risk: Seniors 65 years of age All children 6 months of age PCH residents Anyone with chronic health issues Individuals with neurologic and neurodevelopmental conditions* Health care workers and First Responders Pregnant women Morbidly obese people Indigenous people Household contacts of those listed above *new NACI recommendation for at

10 VACCINE CHARACTERISTICS FOR 2018/19: Fluzone Sanofi Pasteur Flulaval Tetra GSK Flumist AstraZeneca Vaccine Preparation QIV QIV LAIV Vaccine Type Inactivated- split unit Inactivated- split virus Live attenuated Route of admin IM IM Intranasal spray Authorized age for use 6 months 6 months 2-17 years of age Adjuvant No No No Format available Multi-dose vial = MDV Pre-filled syringe = PFS 10 dose MDV and PFS - packages of dose MDV pre-filled single use glass sprayer Post puncture shelf life for multi-dose Until expiry date 28 days from puncture N/A Thimerosal Yes MDV No - PFS Yes No Antibiotics None None Gentamycin Contains Latex No No No Okay in Pregnancy Yes Yes No

11 CONTRAINDICATIONS TO FLU VACCINE History of anaphylaxis to a previous flu vaccination History of anaphylaxis to any vaccine component (excluding eggs) History of Guillain-Barre syndrome within 6 weeks of a previous flu vaccination Infants < 6 months of age

12 EGG ALLERGIC INDIVIDUALS & FLU VACCINE NACI has concluded that egg-allergic individuals may be vaccinated against influenza using any appropriate product without prior influenza vaccine skin test and with the full dose, irrespective of a past severe reaction to egg and without any particular consideration, including immunization setting. The waiting period post immunization would be as recommended in the CIG. (NACI Statement ). CIG states vaccine recipients should be kept under observation for at least 15 minutes when there is a specific concern about possible vaccine allergy; 30 minutes is a safer interval since the majority of cases of anaphylaxis will occur within 30 minutes following vaccine administration.

13 FLUZONE QUADRIVALENT (MDV) Quadrivalent Vaccine Prepared in eggs Other ingredients - thimerosal, sucrose, formaldehyde, triton X dose vial Once punctured, good till expiry date Administered IM

14 FLUZONE (PFS) Quadrivalent Vaccine Prepared in eggs Thimerosal free Single dose syringe Other ingredients - formaldehyde, triton X-100, sucrose Administered IM

15 FLULAVAL TETRA QUADRIVALENT Quadrivalent Vaccine Prepared in eggs Other ingredients - sodium deoxycholate, ethanol, formaldehyde, sucrose, -tocopheryl hydrogen succinate, polysorbate 80, thimerosal 10 dose vial Once punctured, good for 28 days Administered IM

16 CONTRAINDICATIONS & SIDE EFFECTS TO QIV Flu vaccine is contraindicated for individuals with allergies to any component of flu vaccine (excluding eggs) Common local side effects include soreness, redness and swelling at the injection-site Common systemic side effects include sore muscles, headache, fatigue, and irritability (in children)

17 DOSAGES Age Group Dosage # of Doses Route 6 months to <9 years 0.5mL 1 or 2 IM 9 years 0.5mL 1 IM ** Two doses administered at least 1 month apart are recommended for children < 9 years of age receiving seasonal influenza vaccine for the first time.

18 FLUMIST Live attenuated Vaccine Prepared in eggs Other ingredients gentamycin, gelatin hydrolysate, sucrose, arginine, monosodium glutamate Not licensed for under 2 years of age and over 60 years of age Indicated for 2 17 year olds but not preferentially Pre-filled glass syringe sprayer - contains 0.2mL dose Administered intranasally - give 0.1mL per nostril

19

20 FLUMIST FOR After careful review of available studies from several past influenza seasons, NACI concludes that the current evidence is consistent with LAIV s providing comparable protection against influenza to that afforded by IIV. Previous studies and clinical experience also indicate LAIV to be a safe vaccine. NACI s recommendations on the use of influenza vaccine in children 2 17 years of age: In children without contraindications to the vaccine, any of the influenza vaccines can be used: quadrivalent live attenuated influenza vaccine (LAIV) and quadrivalent inactivated influenza vaccine (QIV) The current evidence does not support a recommendation for the preferential use of LAIV in children and adolescents 2 17 years of age.

21 CONTRAINDICATIONS TO FLUMIST Allergies to any component of this vaccine (excluding eggs). Allergy to gentamycin (including aminoglycoside antibiotics tobramycin, neomycin, streptomycin, kanamycin, amikacin) Children < 2 years of age Pregnancy Severe asthma = currently on oral or high-dose inhaled glucocorticosteroids or active wheezing, or those with medically attended wheezing in the seven days prior to immunization

22 CONTRAINDICATIONS TO FLUMIST Children 2 to 17 years of age currently receiving aspirin or aspirin-containing therapy (re: the association of Reye s syndrome with aspirin and wild-type influenza infection.) Persons with immune compromising conditions, due to underlying disease and/or therapy Health care workers (working with immunocompromised individuals) History of Guillain Barré Syndrome (GBS) within 6 weeks of receipt of a previous dose of influenza vaccine.

23 A FEW IMPORTANT POINTS WITH FLUMIST PRECAUTION: FluMist recipients should avoid close contact with persons with severe immune compromising conditions (e.g., bone marrow transplant recipients requiring isolation) for at least two weeks following vaccination (r/t the theoretical risk for transmitting vaccine virus causing infection). Received any live vaccines in the past 4 weeks? Based on expert opinion, NACI recommends that intranasal LAIV can be given together with or at any time before or after the administration of any other live attenuated or inactivated vaccine. No interference is expected.

24 A FEW IMPORTANT POINTS Currently or have received anti-viral medications in the past 2 weeks? LAIV should not be administered to individuals taking antiviral agents (including oseltamivir & zanamivir) r/t interference with immune response to LAIV. Antiviral agents administered 48 hours before, to 2 weeks after receipt of LAIV, revaccinate when antiviral agents have been discontinued for at least 48 hours. Offer QIV. Have received a tuberculosis (TB) skin test in the past 4 weeks? Do TB skin testing on the same day as LAIV immunization, or delay TB skin testing 4 weeks, to avoid false negative TB skin test result.

25 Can FluMist be given to household contacts of someone who is immunocompromised? Yes. LAIV is contraindicated only for those who are contacts of persons who are severely immunocompromised, defined by NACI, as hospitalized and requiring care in a protected environment. All vaccine recipients should be informed that FluMist is a live vaccine that contains a weakened strain of influenza virus and has the potential to be transmitted to another person through contact with respiratory secretions. Vaccine recipients should therefore avoid close contact with severely immunocompromised individuals for two weeks after receiving LAIV. If such contact cannot be avoided, IIV should be used.

26 CONCERNS WITH ADMINISTRATION Sneezing right after OR receiving both half doses in same nostril No need to repeat (binding of virus to epithelial cells occurs rapidly & there are more virus particles in vaccine than needed to establish immunity). Client sprayed in the eye by accident: Flush eye immediately with water. If at least half of the LAIV dose was administered into the nostril the client does not need further vaccine. But if the 1 st half of the vaccine dose went into the eye the 2 nd half of the dose should be offered. If at that time the child or parent does not want to attempt further administration of LAIV, offer QIV. Child refuses second half of dose? Attempt to give, but if unsuccessful there is no need to repeat as each ½ dose of LAIV contains enough viral particles to induce an immune response.

27 COMMON SIDE EFFECTS OF FLUMIST May cause mild influenza symptoms including runny nose, nasal congestion, cough, sore throat, fever Some children may have a headache, decreased appetite or weakness

28 PNEUMOVAX 23 Indications to give: All seniors 65 years of age All residents of PCHs Homeless individuals Illicit drug users All persons 2 years of age with: Alcoholism Anatomic or functional asplenia Cerebrospinal fluid (CSF) leak Diabetes Hemoglobinopathies HIV Infection Kidney, heart, liver or lung disease Malignant neoplasms (incl. leukemia & lymphoma) Solid organ or stem cell transplant Weakened immune system r/t disease or therapy

29 PNEUMOCOCCAL LETTERS Dosage for adult and children 2 years of age: 1 dose 0.5mL IM or SC Routine re-immunization is not recommended. See reference guide for side notes For adults who received Pneumo23 vaccine before age 65, an additional dose of Pneumo23 should be administered at 65 years of age, at least 5 years after any previous dose. MB Health to send reminder letters to individuals who turn 65 years of age this year and have not received a previous dose of the Pneumo 23 vaccine according to Panorama. Pneumo eligibility list available at flu clinics

30 IM TECHNIQUES - GOOD REMINDERS Land marking TARGET ZONE for deltoid IMI is 4 cm below the acromion (for safety of axillary nerve) nurses should know what 4 cm is for them. Depth of injection Deltoid intramuscular injection requires penetration of the needle into the deltoid muscle layer by 5 mm or more to ensure that the injection would be into the muscle mass Chose proper needle length to achieve IMI do not use the one size fits all approach. Important that vaccine is administered as intended to ensure effective immune response.

31 Give in the central, thickest portion of deltoid above level of armpit and ~4 cm below the acromion process. To avoid causing an injury, do not inject too high (near the acromion process) or too low.

32 SIMULTANEOUS ADMINISTRATION Influenza vaccine may given at the same time as other vaccines. The same limb may be used if necessary, but different sites of the limb should be chosen (1 apart). Influenza and pneumococcal vaccines should be given to all eligible persons at the same visit.

33 ADMINISTERING TWO VACCINES IN THE SAME LIMB

34 STORAGE OF VACCINE Stored in approved vaccine refrigerator between 2 8 C During transport & at clinics, store vaccine in a cooler Icepacks at immunizing stations not required

35 ORGANIZING YOUR VACCINE STATION Hand sanitizer Syringes Alcohol swabs Cotton balls Band-aids Garbage bag Sharps container

36 FLOW OF FLU CLINICS Clients are greeted by our clerical staff, given flu fact sheet and flu screening form Directed to read fact sheet and complete top portion of screening form Informed that the number at top of their form will be called when it is their turn Immunizing nurses (or clerical if available) will call next client when ready Nurse reviews form with client, completes the health information section, and asks client if ready to proceed with vaccination

37 INFECTION PREVENTION & CONTROL Potential Sequence of Care: 1. The client walks in (while the previous one walks out), sits down on chair. The HCW performs hand hygiene. 2. The client exposes his arm, HCW swabs the injection site with alcohol swab, discards it after use. 3. The HCW picks up the flu vaccine syringe. 4. The HCW performs the injection. 5. The HCW discards the needle into the sharps disposal container. 6. The HCW applies bandaid to the injection site. 7. The HCW documents on consent form. 8. The client gets up and leaves the room (while the next one walks in) 9. The HCW performs hand hygiene*

38 *If the sequence occurs as described with no breaks and under normal conditions, the performance of the hand hygiene action is performed once between patients. Staff in Public Health took part in a Hand Hygiene audit in a sample of regional immunization clinics at past two flu seasons flu clinic audits are TBA. Be prepared. Regional hand hygiene compliance for Public Health ranges from 70% to 84% depending on the moment observed. Only 30% - 40% of HCPs in Canada comply with best practice guidelines regarding when and how to clean their hands. A target of 85% compliance for all HCPs at all indications has been set.

39

40 COMFORTING & SECURING CHILDREN DURING IMMUNIZATION Immunizing infants & toddlers parent embraces babe, holds arms, snuggles Immunizing children parent hugs securely in an upright position, holds arms (& legs prn)

41 NEEDLE ANXIETY?

42 REDUCING PAIN & FEAR WITH VACCINATIONS Many photos on public health websites and brochures show children getting vaccinated looking happy, willing, compliant. These images don t indicate that there is any pain or fear with getting a needle.

43 But in reality, how often do these images match our experience?

44 PAIN WITH VACCINATION In general, there is no acknowledgement of needle pain in society. Yet when you ask clients, parents and immunizers, there are often challenges with receiving and giving needles. In practice, we see crying, screaming, flailing, use of restraint, running away, kicking. We know that FEAR of needles increases PAIN associated with getting a needle. Although we cannot completely remove the pain of an injection, there are strategies we can use to reduce fear and pain.

45 REDUCING PAIN DURING VACCINATIONS Pain at the time of vaccine injection is a common concern and contributes to vaccine hesitancy across the lifespan. Pain mitigation is considered part of good vaccination clinical practice by the World Health Organization WHO has accepted the practical interventions from the research done by the HELPinKids&Adults team in Canada. Evidence-based and feasible interventions are available to mitigate pain and are part of good vaccination clinical practice (Taddio et al)

46 RECOMMENDATIONS FOR INFANTS/CHILDREN < 3YRS No aspiration Most painful last &/or simultaneous injection for 0 1 yrs Breastfeeding before, during & after injection OR Positioning/holding before, during & after injection Sweet-tasting solution (sucrose/glucose) before injection (0 2 yrs) Sucking/pacifier before, during & after injection (0 2 yrs) Distraction with toys DO use neutral words to signal the impending procedure i.e. Here we go DON T use repeated reassurance or suggest it will not hurt Topical anesthetics Education for caregivers

47 RECOMMENDATIONS FOR CHILDREN 3 12 YEARS OLD No aspiration Sitting upright Most painful last/simultaneous injections Distraction with toys pinwheel, blowing bubbles DO use neutral words to signal the impending procedure i.e. Here we go DON T use repeated reassurance or suggest it will not hurt Topical anesthetics Education for caregivers

48 RECOMMENDATIONS FOR ADOLESCENTS YEARS Sitting upright No aspiration Most painful injection last Simultaneous injections let client choose DO use neutral words to signal the impending procedure i.e. Here we go DON T use repeated reassurance or suggest it will not hurt Education for clients, caregivers Muscle tension (if history of fainting)

49 INTERVENTIONS NOT RECOMMENDED The following interventions are not supported by evidence and therefore not recommended: Oral analgesics (acetaminophen, ibuprogen) Manual tactile stimulation (rubbing injection site prior to injection) Warming the vaccine Vapocoolants skin refrigerants (children)

50 MUSCLE TENSION TO WARD OFF FAINTING FOR INDIVIDUALS > 7 YEARS OF AGE A simple technique called muscle tension can raise blood pressure & help reduce fainting. Ask client to recline or lie down & tighten his/her leg & stomach muscles (not the arm where the needle is going to be given). Tensing should continue for about 20 seconds until the client is feeling flush in the face. Stop tensing for five seconds (without fully relaxing) before tensing again.

51 CONCLUSION If not addressed, pain can lead to: pre-needle anxiety in the future needle fears health care avoidance behaviours, including nonadherence with vaccination schedules. It is estimated that up to 25% of adults have a fear of needles, with most fears developing in childhood. ~10% of the population avoids vaccination and other needle procedures because of needle fears. Minimizing pain during childhood vaccination can help to prevent distress, development of needle fears and subsequent health care avoidance behaviours,

52 Big gains can be made at the point of care It is our responsibility to educate ourselves, educate parents and clients, with interventions to reduce pain and fear with vaccinations. Our clients anticipate that we will do our best to make the immunization experience as positive as possible More positive experiences during vaccine injections ultimately maintains and promotes trust in health care providers.

53 POST IMMUNIZATION QUICK REVIEW OF NOTICE OF IMMUNIZATION

54 DOCUMENTATION When receiving verbal consent for a client from another person, ensure the name of the person giving consent (i.e. parent for child) is legible (this info gets entered into the electronic record). At end of clinic, or when you have downtime, please review your consent screening forms to ensure your documentation is complete and your provider name is legible. First initial, last name is acceptable.

55 INFLUENZA VACCINE SCREENING FORM

56 REVISED RESOURCES FOR 2018 Flu and Pneumo Vaccine Reference Guide IERHA Flu Q & A IERHA Flu clinic stats sheet MB Health FluMist HCP Q & A MB Health Seasonal Flu Q & A (for the public) MB Health Seasonal Flu Fact Sheet

57 LIMIT CELL PHONE USE WHILE WORKING

58 RESOURCES TO ACCESS IERHA website under Immunizations you can find the online Immunization competencies, Product Monographs, Vaccine Reference Guide. To proceed straight to link: Manitoba Health Website NACI Influenza statement for Q and A

59 REFERENCES Davidson, K. M. & Rourke, L. Teaching bestevidence: Deltoid intramuscular injection technique. Journal of Nursing Education & Practice, 2013; 3(7) Horn MI, McCarthy AM. Children's responses to sequential versus simultaneous immunization injections. J Pediatr Health Care. 1999;13:18-23 Manitoba Health Communicable Disease Control Public Health Agency of Canada. Canadian Immunization Guide. Chapter on Influenza and Statement on Seasonal Influenza Vaccine for

60 REFERENCES Schechter N, Zempsky W, Lindsey L., Cohen L, McGrath P, McMurtry M, Bright N. Pain reduction during pediatric immunizations: Evidence-based review and recommendations. Pediatrics. 2007;119;e1184 Taddio, A, McMurty, M, et al. Reducing pain during vaccine injections: clinical practice guideline. CMAJ DOI: /cmaj Vaccine product monographs

61

62 QUESTIONS?