Update for Mass Flu clinic for PHNs

1. 1
1

2. VIHA Child, Youth and
Family Community Health
2

3. RNs now authorized per HPA: RN/NP
Regulation to HPA - RN/NP Regulation
 diagnose and manage conditions  Reserved Titles
(including prevention), e.g. Anaphylaxis  Defined scope of
practice
 administer certain medications to treat ◦ “Restricted Acts”
conditions or prevent disease/disorders, ◦ With/without an
e.g. immunization for influenza order
 Requirements on
No order, transfer of function or delegation practice
required ◦ “additional
education”
◦ CRNBC Certified
Practice
3
3

4. CRNBC requires RNs to have
“additional education” to
administer influenza* without
an order (as determined by their
employer)
and “strongly recommends”
use of evidence-informed
clinical decision support tools
(“DSTs” or “CDSTs”) to guide
practice, e.g. protocols, clinical
practice guidelines, order sets, etc.
4
4

5.  Educational  Clinical
component ◦ Immunization of
◦ Attend an Influenza clients >5 years
education session or ◦ Observation of 5
review Influenza immunizations
materials ◦ Be observed doing 5
immunizations
◦ Skills Checklist
 Yearly Review
5
5

6. 1. Vaccine Preventable Diseases
◦ The Immune System
◦ Vaccine Development
◦ Types of Immunizing Agents
◦ Vaccine Immune Response
2. Immunization Schedules
◦ Populations Requiring Special Consideration
3. Storage and Handling of Vaccine
4. Client Assessment
◦ Legal and Ethical- Informed Consent
5. Administration
◦ Clinic set up
◦ Injection techniques
◦ Documentation
6. Reactions Following Immunization
7. Common Myths
6
6

7. 7
7

8.  An acute onset of respiratory illness with
fever and cough and one or more of the
following:
-Sore throat -Muscle aches
-Joint pain -Fatigue
 Fever and other symptoms can last 7-10
days, fever may not be present in the
elderly or children under 5 years of age
 Children <5 may have GI symptoms
8
8

9.  Spread:
◦ direct, indirect, droplet
◦ Can survive in environment for
hours (door knobs etc)
 Incubation:
◦ 1-3 days
 Period of communicability
◦ 3-5 days from onset of
symptoms, up to 7 days in
children
9
9

10.  “stomach flu” – influenza does not usually
cause GI symptoms
 Colds – e.g. rhinoviruses
 Similar symptoms to RSV
◦ Sneezing, chills, malaise, teary eyes
10
10

11. Each year:
 5 million Canadians (1 in 6) are infected
 50,000 will be hospitalized
 Estimated up to 7,000 will die from flu and its
complications
 1.5 million work-days will be lost
 In BC about 1,400 people die from the flu and
pneumonia
11
11

12.  Can damage the lining of the respiratory tract
 Secondary infections – viral or bacterial
◦ Strep.pneumococcal
 Hospitalization for complications
12
12

13.  Influenza A causes:
◦ Moderate to severe illness
◦ Epidemics
◦ Pandemics
 Influenza B causes:
◦ Milder epidemics
 Influenza C causes:
◦ No disease in humans
13
13

14.  Overall activity was mild
 Increased activity presented later in the
season
 Influenza A & B detections reported across the
country
 Emergence of H1N1
14
14

15. “Immunization is one of the miracles of this
century. With the exception of safe drinking
water, no other intervention - not even antibiotics
- has had such a major impact on people’s health
and survival” (Plotkin & Plotkin)
15
15

16.  Individual effect:
individual is protected
against disease
 Collective effect:
entire population,
including those not
immunized or not
having illness is
protected against
disease when a critical
number of people are
immune
HERD IMMUNITY
16
16

17.  Annual fall administration
 Reduces influenza incidence, severity, duration and
shedding of virus
◦ Protects against outbreaks
 In elderly and high risk:
- Reduces clinical infection
- Reduce hospitalization/pneumonia
- Reduces mortality
17
17

18. Influenza A / Brisbane / 59 / 2007 / (H1N1)
This is the type The place where the isolate year subtype
(A or B) the virus was first number
code
isolated
18
18

19.  Frequent Hand Hygiene
 Yearly influenza vaccination
 Cough etiquette
 Stay home when ill
 Outbreak control measures in
facilities
◦ Standard precautions
◦ Antivirals etc…

20.  Doesn’t work if hands are greasy or visibly dirty. If
hands are visibly soiled, use soap and water, if not
available towelettes may be used first
 Make sure hands are dry. Use enough product to
cover all the surfaces of hands and fingers.
 Rub hands together until the product has evaporated.
20
20

21.  Does not replace annual influenza vaccine
 Used to control influenza outbreaks among
high risk residents in facilities – given to all
residents during an outbreak
 Adjunct to late vaccination of people at high
risk
 For unvaccinated people who provide care
for high risk people during an outbreak
21
21

22. Oseltamivir (Tamiflu®)
◦ Neuraminidase inhibitor (stops virus from releasing
particles)
◦ Effective for both influenza A and B
◦ Some strains of Influenza A are resistant
◦ Lab results important to make decision about which
antiviral to use during an outbreak
22
22

24.  Body wide network of
cells and organs
 Evolved to defend
against foreign
invaders
24
24

25.  ANTIGEN – any molecule that identifies
as foreign to the immune system and
stimulates the immune system to attack
it.
25
25

26.  Protein (Immunoglobulin) produced by
the body in response to stimulation by
an antigen.
 Unique contours in antigen binding
sites allow antibody to recognize
matching antigen (“lock and key”)
26
26

27.  Immunity is the ability of the body to defend
itself, particularly against attack by an infectious
agent
 There are two types of immunity
◦ Acquired (Passive)
◦ Natural (Active)
27
27

28. I.G.
SHORT TERM PROTECTION
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28

29. LONGER TERM PROTECTION
29
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30. 30
30

31.  The goal of vaccines is to stimulate the immune
system to produce an immune response similar
to that caused by disease, without causing the
recipient to experience the disease or its
complications.
31
31

32.  The strains of virus that circulate in the community change
frequently because of Antigenic Drift.
 It is necessary to update the flu vaccines each year with these
new strains.
 This is a killed split virus vaccine
 Vaccines consist of 3 different virus subtypes each year.
Currently this is:
◦ A H1N1 strain
◦ A H3N2 strain
◦ B strain
32
32

33.  Influenza viruses can change in two different ways
 Not different mechanisms just different degrees of
genetic changes
1. Antigenic “drift”
◦ Small changes that occur continuously over time
2. Antigenic “shift”
◦ Abrupt, major change in virus proteins
33
33

34. Flu Vaccine Production Timeline
• Decision on which • Virus multiplies in • 3 vaccine strains
3 strains eggs blended
• Manufacturers • Virus inactivated • Packaging into
purchase hens’ with chemicals syringes /vials
eggs • Egg white removed • Licensure and
• Virus strains sent / virus harvested release
to manufacturers • Vaccine tested for • Shipping
purity & potency Immunization
• Eggs inoculated
begins
with virus
34
Jan Feb May June-July Aug Sep Oct 34

35. 2009-2010 vaccine:
A/Brisbane/59/2007 (H1N1)-like strain: A/Brisbane/59/2007
IVR-148
A/Brisbane/10/2007 (H3N2)-like strain: A/Uruguay/716/2007
NYMC X-175C
B/Brisbane/60/2008-like strain: B/Brisbane/60/2008
(new strain for 2009-2010)
35
35

36. Influenza A / Brisbane / 59 / 2007 / (H1N1)
This is the type The place where the isolate year subtype
(A or B) the virus was first number code
isolated
36
36

37.  Contain killed bacteria or viruses and
cannot replicate
 Usually no interference from circulating
antibodies
 Induces long term memory
 Antibody levels fall over time
37
37

38.  Fluviral®
◦ Used for general public
◦ Use multi dose vial within 28 days
 Vaxigrip®
◦ Use multi dose vial within 7 days
◦ Preferential use for pregnant women
 Influvac®
◦ Thimerosal free – only indicated for >
18 years of age and those who are
anaphylactic to thimerosal
38
38

39.  Both vaccines have minute quantities of thimerosal
(mercury) used as a preservative
 Thimerosal is a safe and effective preservative and
has been used in some vaccines since the 1930s
 The mercury is an organic form called ethylmercury
 The amount of ethylmercury in vaccines does not
cause neurological problems
39
39

40. 40
40

41.  Antibodies develop within 14 days
 Immunity depends on age and
immunocompetence
41
41

42. 42
42

43. AGE GROUP DOSE # OF DOSES
6-35 months 0.25ml IM 1 or 2*
3-8 years 0.5 ml IM 1 or 2*
9 years and older 0.5 ml IM 1
*Previously un-immunized children under 9 years of age require 2
doses of vaccine with an interval of 4 weeks * 2nd dose is not
required if the child has ever received one or more doses of
influenza vaccine from a previous year
43
43

44. 44
44

45. Recommendations for Influenza are published
yearly by the National Advisory Committee on
Immunization (NACI)
45
45

46.  Fall 2009: 65 years and older and residents in
Long Term Care
 Early 2010: All other recommended groups under
the age of 65 years
46
46

47. 47
47

48.  History of anaphylactic reaction to a previous dose of any type
of influenza vaccine
 History of anaphylactic reaction to any component of vaccine
◦ Fluviral- egg protein, formaldehyde, thimerosal, sodium
deoxycholate, sucrose
◦ Vaxigrip- egg protein, neomycin, formaldehyde, thimerosal, sodium
phosphate, sucrose, Triton X -100
 History of anaphylaxis to eggs
 Infants less than 6 months of age
 Hx of Guillain Barre Syndrome (GBS) within 8 weeks of receipt
of a previous dose of influenza vaccine
48
48

49.  First seen in 2000/01 influenza season
 Consist of bilateral red eyes or facial swelling or
respiratory symptoms within 24 hours or vaccination
 Most people do not experience it again
 Approx 5 – 34% experience another episode – usually
milder
 If mild to moderate ORS usually can safely re-vaccinate
 If severe ORS consult physician before vaccinating
49
49

50. Legal
Requirements
50
50

51.  Informed consent is an essential pre-condition
to providing immunization.
 It is the professional and legal responsibility of
the provider to obtain informed consent prior to
immunization
51
51

52. 1. Assess capability to give informed consent
2. Determine authority to provide informed consent
52
52

53. 3. Provide Standard Information:
 Confirm the voluntary nature of immunization
 Advise that consent is obtained for a vaccine series and is valid
until completion of the series or consent is revoked
 Provide the vaccine information as outlined in BC Health Files:
 Benefits of vaccination
 Risk of not getting vaccinated
 Eligibility for the vaccine
 Common and expected adverse events
 Possible serious or severe adverse events and their frequency
 Contraindications
 Disease(s) being prevented
53
53

54. 4. Confirm understanding of Standard Information
5. Provide an opportunity for questions
6. Confirm consent
7. Document consent or refusal
54
54

55. An elderly client presents at a mass clinic with his
daughter. He has never had the Influenza
vaccine before. He is worried that it might make
him sick, but she wants him to be protected
against influenza.
How would you proceed?
55
55

56. A mom brings her 7 year old child in for a flu shot,
and says she is the foster mom.
How would you proceed?
56

57. 57
57

58.  Vaccines must be maintained at the appropriate
temperature between 2 to 8 degrees
 Pack coolers according to BCCDC section 6 of the
Immunization Manual
 Some biological products are
sensitive to light (e.g.:
MMR, epinephrine, PPD)
 Return vaccines to fridge as soon as possible upon
return to the health unit
58
58

59.  Ensure cold chain is maintained at all times
 Each vaccinating nurse will have a separate small cooler
at their work station to store a small amount of vaccine
 Vaccine should be protected from freezing by separating it
from the ice pack with insulating material
 When a dose is drawn up return the vial to the cooler
 Mark the date of opening on all multi dose
 vials
59
59

60.  A minimum/maximum thermometer is recommended
for monitoring temperature:
◦ for large coolers during mass clinics and
◦ for vaccine in all coolers longer than 4 hours
◦ check temperature reading hourly
 Provide a protective barrier of insulating material
such as a flexible insulating blanket between
vaccines and the frozen packs.
 Place frozen packs at the top of the cooler
60
60

61.  Consider local testing of packing configurations to
maintain the temperature between 2-8 degrees C.
 If vaccines are transported to mass clinics in
numerous coolers, use all the vaccines in one cooler
before opening the next cooler.
61
61

62. 62
62

63.  Immunizing station setup includes:
◦ Cooler/ice packs
◦ Sharps container
◦ Easily accessible anaphylaxis kit
◦ Supply of syringes, band aids, alcohol swabs, gauze or cotton
balls, extra needles, alcohol hand sanitizer and a tray or
paper mat
◦ Health Files
◦ Client records, vaccine recording sheets
63
63

64. All used
safety
syringes
should go
directly into a
sharps
container
after
immunizing a
client.
64
64

65. 65
65

66.  Nurses administering vaccine need to follow
7 rights of medication administration:
◦ Right drug
◦ Right client
◦ Right dose
◦ Right time
◦ Right route
◦ Right reason
◦ Right documentation
Nursing BC Oct. 2006
66
66

67.  Hand washing/cleansers
 Check vaccine expiry date
 Shake vial well
 Cleanse rubber stopper with alcohol/air dry
 New disposable syringe & safety needle
 Check dose for age
 Draw vaccine into syringe immediately before
giving
67
67

68.  Use a needle length sufficient to reach the
largest part of the muscle
 Infants, toddlers, older children = 7/8” – 1”
 Adolescents and adults = 1 – 11/2”
 The IM site of choice for children > 12 months of
age and for adults
is the deltoid muscle.
68
68

69.  This site is used for IM injections only
69
69

70. 1) Use correct length and size of needle
2) Clean the site with a cotton pad/swab/ball
moistened with 70% isopropyl alcohol
3) Insert needle quickly at a 90o angle into the
muscle
 If client’s muscle mass is small, grasp body of muscle
between thumb and fingers before and during the
injection
70
70

71. 4) Rapidly inject the biological product
5) Remove the needle in one swift motion,
immediately applying pressure to the injection site
with a dry cotton pad/swab/ball. Continue to apply
pressure for 30 seconds.
- Do not massage injection site
71
71

72.  Hold the child on parent’s lap or have the
child stand in front of the seated parent
 Parent’s arms embrace the child during the
process
 Both legs firmly between the parent’s legs
72
72

73. Watch BCCDC’s demonstration of IM
injections in the Deltoid Click here
73

74.  Define this site by dividing the space between the
trochanter major of the femur and the top of the
knee into 3 parts; draw a horizontal median line
along the outer surface of
the thigh.
 The injection site is in the
middle third, just above
the horizontal line.
74
74

75.  Click Here to watch BCCDC's demo IM
Injection Vastus Lateralis
75

76.  Activate safety needle with thumb
 Discard needle & syringe into sharps container
 Observe client briefly - ask to stay in observation
area for 15 minutes
76
76

77.  To view more videos on landmarking for IM
injections go to www.bccdc.ca
 Click on:
◦ Vaccines and Immunization
◦ For Health Professionals
◦ Immunization Competency
77
77

78. 78
78

79.  For each biological product administered, the minimum data to be
recorded is:
◦ Name of biological product
◦ Date
◦ Route of administration
◦ Site
◦ Name of biological product manufacturer
◦ Lot number
◦ Name and title of person administering biological product
◦ Any reactions following immunization
◦ Any recommended biological products that were not given (i.e., declined, deferred or
contraindicated
◦ Informed consent for immunization obtained.
 Vaccine given to children up to 18 years entered into iPHIS
 Provide client with record of immunization
79
79

80. 80
80

81. Local Systemic
 Soreness at the • Fever, malaise,
injection site lasting myalgia
two days • may occur 6-12 hours
 Redness, swelling, following vaccination
itching , warmth, pain and lasting 1-2 days
on contact • especially in
individuals receiving
vaccine for the 1st time
81
81

82.  Acetaminophen for local reactions and fever
 Comfort measures - cool cloth on injection site
 Fluids
82
82

83.  An untoward event temporally associated
with immunization that may or may not
have been caused by the vaccine or the
immunization process.
83
83

84.  Carefully review history of anaphylaxis to any
antigens or components in the vaccine
 Instruct client to remain under observation for 15
minutes
 Take precautions for those with previous allergies to
the biological product
84
84

85.  Know what to do in the event of anaphylaxis
 Know address and location of where you are
 Ensure anaphylaxis kits are up to date
 Protect epinephrine from light and open vial only when ready to
use
85

86.  Based on clinical presentation, exposure history
 Cutaneous, respiratory symptoms most common
 Some cases may be difficult to differentiate
◦ Vasovagal (fainting)
◦ Anxiety
86
86

87. • Immediate systemic allergic reaction
• Affects body as a whole
• Multiple organ systems may be
involved
• Onset generally acute
• Manifestations vary from mild to fatal
• Incidence: 0.4 to 1.8 reports per
1,000,000 vaccine doses distributed
in Canada
87
87

88. Fainting (vasovagal episode)
 Lack of hives, slow steady pulse rate and cool pale skin
 Sometimes accompanied by brief clonic seizure activity.
 If unconsciousness persists more than 2 to 3 minutes,
call 911 and proceed with anaphylaxis treatment
Anxiety:
 sudden onset.
 Pale, cold clammy skin, hyperventilation, rapid pulse
 fearful.
88
88

89. • Skin: Hives at injection site, generalized
urticaria (hives), flushing, pruritus
(itchiness) , angioedema (welts)
• Upper respiratory: Congestion, rhinorrhea
• Lower respiratory: Bronchospasm, throat
or chest tightness, hoarseness, wheezing,
shortness of breath, cough
89
89

90. • Cardiovascular system:
• Tachycardia, bradycardia,
hypotension/shock, arrhythmias, ischemia,
chest pain
• Gastrointestinal tract:
• Oral pruritus (itchiness)
• Cramps, nausea, vomiting, diarrhea
• Other symptoms:
• Headache, uneasiness, restlessness,
agitation
90
90

91. 91
91

92. • Uniphasic
• Biphasic
• Recurrence up to 8 to 12 hours later
92
92

93.  CALL 911
 Administer Epinephrine IMMEDIATELY.
There is no contraindication to
epinephrine in anaphylaxis
 Give epinephrine (1:1000) IM into an
unimmunized thigh.
 If both thighs were used for immunization:
- Give epinephrine IM into deltoid if client is > 12
months old
- Give epinephrine SC into upper outer triceps
area of the arm(s) if client is < 12 months old
93
93

94.  Repeat epinephrine twice at 5 minute
intervals as needed to a maximum of 3
doses.
- Alternate right and left thigh (or arm)
sites for repeat doses of epinephrine.
 Injection can be made through clothing if
necessary
94
94

95. Dose: 0.01 ml/kg to maximum of 0.5 ml
OR:
AGE Epinephrine
2 – 6 months 0.07 ml
7 – 12 months 0.10 ml
13 months – 4 years 0.15 ml
5 years 0.20 ml
6 – 9 years 0.30 ml
10 – 13 years 0.40 ml
> 14 years 0.50 ml
Section V, June 2009
95
95

96. What about Benadryl?
 can be used as an adjunct if client not
responding well to epinephrine; OR
 to maintain symptom control when client can’t be
transferred to acute care within 30 minutes.
 Administer 1 dose of Benadryl IM preferably in a
different site in which epinephrine was given.
Can be given in same muscle mass as vaccine.
 Can be given either after the initial or repeat
doses of epinephrine.
96
96

97. AGE Diphenydramine
hydrochloride
< 2 years 0.25 ml
2 – 4 years 0.50 ml
5 – 11 years 0.50 – 1.0 ml
> 12 1.0 ml
Section V, June 2009
97
97

98.  Position client recumbent position and elevate legs
as tolerated symptomatically.
 Monitor respiratory effort, pulse and level of
consciousness.
 If experiencing respiratory difficulty, elevate head and
chest slightly.
 If airway is impaired, use head tilt, chin lift or jaw
thrust.
 If vomiting is likely, turn person to side lying position.
 Arrange for rapid transport by emergency vehicle to
an emergency department.
98
98

99. Suggested epinephrine kit contents:
 BCCDC guidelines for the management of anaphylaxis: Sections 2.3,
10.0 and 11.0
 3 - 1 cc syringes and needles (25 – 27 gauge, 1" needle)
 1 - 1cc syringe and needle (25 – 27 gauge, 1 ½" needle)
 2 - 3 cc syringes and needles (25 – 27 gauge, 1” and 1 ½" needles)
 2 – 1cc syringes and needles (25 – 27 gauge, 5/8”) for SC route
 extra needles
 4 ampules of epinephrine 1:1,000 (within expiration time frame)
 2 vials of diphenhydramine hydrochloride 50mg/ml (within expiration
time frame)
 alcohol swabs
 pens/paper Section V, June 2009
99
99

100.  Use the “Worksheet for Emergency
Treatment of Anaphylaxis”.
 Complete iPHIS Adverse Event form.
 Document in the client’s immunization
record/consent card
 Recommendation will be made by the
MHO.
100 10
0

101. Mr. Smith is 65 years old and comes into your flu clinic for
his flu immunization. Mr. Smith is nervous about getting
his shot as he has never had a flu immunization before.
After administering his flu immunization, you notice that
Mr. Smith’s face becomes flushed and his breathing
becomes wheezy, and states that his mouth feels
“tingly”.
 What is happening?
 Why do you think this?
 What do you do?
101 10
1

102.  NACI statement on Influenza Vaccination
 BCCDC Immunization Program Manual
 Canadian Immunization Guide
 Vancouver Coastal Health
 Fraser Health Authority
 Claire Coombs
102 10
2