FNIHB – Alberta Region - PowerPoint Presentation

1. FNIHB – Alberta RegionSeptember 23, 2020Influenza Program OverviewFor videoconference assistanceCall 1-888-999-3356

2. Reminder: This videoconference will be recorded.September 20202

3. Land AcknowledgementWe would like to begin by acknowledging that we are on the traditional lands, referred to as Treaty 6 Territory and that the participants of this session, and all the people here, are beneficiaries of this peace and friendship treaty.  Treaty 6 encompasses the traditional territories of numerous western Canadian First Nations, including Cree, Dene, Stoney Nakota Sioux, Saulteaux, and Ojibwe. 3

4. AcknowledgementsThe National Advisory Committee on Immunization (NACI), Alberta Health, and Albert Health Services resources have been used in the development of this presentation.September 20204

5. Learning ObjectivesAt the end of the presentation, participants will:Understand what influenza is and its potential impactBe knowledgeable about influenza and Pneumo-P vaccines and related programmingBe able to screen for TBBe able to implement influenza surveillance activitiesUnderstand influenza programming within COVID-19 contextSeptember 20205

6. Background informationSeptember 20206

7. What is Influenza?Commonly known as “the flu”, influenza is a highly contagious infection of the airways caused by the influenza virus.Influenza can happen any time during the year, but in the northern hemisphere it is most common in the winterThe timing and duration of the influenza varies: cases can occur throughout the year, however the “season” is usually considered to be from late September/early October through March, but most often activity peaks in January or laterOutbreaks have been reported as early as October and as late as May.September 20207

8. Symptoms of InfluenzaInfluenza starts suddenly and may include:FeverSore throatRunny nose coughHeadacheMuscle achesPoor appetiteFeeling tiredVomiting and diarrhea can happen but are more common in children.September 20208

9. Influenza VirusesInfluenza A and B viruses cause seasonal epidemics/outbreaks, while type C causes mild respiratory illnessInfluenza A viruses are divided into subtypes based on surface proteins: hemagglutinin (H) and neuraminidase (N).Influenza B viruses are not divided into subtypes, but generally fall in 2 strain families (lineages):Yamagata and Victoria like virusesVaccines only protect against types A and BSeptember 20209

10. Influenza Types – A and BType A(seasonal, avian, swine . . .)Type B(seasonal influenza)Can cause significant diseaseGenerally causes milder disease but may also cause severe diseaseInfects humans and other species (e.g. Birds, pigs)Limited to humansCan cause epidemics and other pandemics (worldwide epidemics)Generally causes milder epidemicsSeptember 202010

11. Influenza Types – A and BSmall changes in influenza viruses occur continually (drift)New strains may not be recognized by the body’s immune system.A person infected with a specific influenza virus strain develops immunity against that specific strain.Strains in seasonal vaccine are updated to align with any changes in circulating strainsUsually, at least one change each seasonAnnual influenza immunization is recommended to protect against infection from changing virusesSeptember 202011

12. Influenza, Common Cold and Gastrointestinal InfectionSymptomsInfluenzaCommon ColdGI – Stomach UpsetFever*Usually highSometimesRarelyChills, aches, painUsually and often severeRarelyCommonHeadacheUsually, can be severeRarelySometimesLoss of appetiteSometimesSometimesFrequentlyCough*UsuallySometimesRarelySore Throat*SometimesSometimesRarelyRunny nose or sneezesSometimesUsuallyRarelyInvolves whole bodyUsuallyNeverStomach/bowel onlySymptoms appear quicklyYesMore gradualYesExtreme tirednessUsuallyRarelySometimesComplicationsPneumonia; can be life threateningSinus infection/ear infectiondehydrationSeptember 2020*Along with SOB/breathing difficulty, these are also COVID-19 symptoms that require isolation12

13. Influenza and COVID-19 ContextCOVID-19 Testing:By CMOH Order 05-2020, individuals with fever, cough, shortness of breath, runny nose or sore throat require 10 day mandatory isolation.Testing is recommended to confirm or rule out a COVID-19 diagnosis for individuals with COVID-19 compatible symptoms.See page 13 Alberta Public Health Disease Management Guidelines – Coronavirus – COVID-19: (August 28, 2020) for full list of COVID-19 associated symptoms and management.September 202013

14. 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 parasites.Influenza is a respiratory disease – not a stomach or intestinal disease.While vomiting, diarrhea and nausea can sometimes occur with influenza (particularly with children), these problems are not the main symptoms of influenza.September 202014

15. How Serious is Influenza?Fortunately, the majority of infected people will recover.However, annually in Canada, influenza causes:12,200 hospitalizations 3,500 deaths annuallyInfluenza is among the top 10 leading causes of death in Canada.September 202015

16. In Alberta during the 2019 – 2020 influenza season:There were a total of 8,470 lab confirmed cases of influenza 4708 Influenza A 3762 Influenza B1,534 persons were admitted to hospital39 deaths were attributed to influenzaHow Serious is Influenza?September 202016Alberta Health Services: Influenza Immunization webpage, Accessed August 2020

17. In Alberta First Nations communities during the 2019 – 2020 influenza season:59 people were admitted to hospital1 death was attributed to influenzaNote: due to way confirmed influenza cases are reported in Alberta, the total number of cases in First Nations communities for the 2019 – 2020 season could not be obtained.How Serious is Influenza?September 202017

18. How is Influenza Spread?Influenza is easily spread when an infected person sneezes, coughs, or even talks.The virus gets into the air and can be breathed in by others.You can also be exposed to the virus when you touch something that has the virus on it (like hands or objects) and then touch your eyes, nose, or mouth.Hard surfaces: virus can survive for 1 – 2 days but is only infectious for about 8 hoursSoft surfaces: virus can survive 8 – 12 hours but is only infectious for a few minutesNote: influenza can be spread even before symptoms startSeptember 202018

19. Influenza IncubationTime period from exposure to the virus to developing symptoms is 1 to 4 days average is 2 days.September 202019

20. Influenza InfectivityMost healthy adults may be infectious from 1 day before symptoms develop through 5 days after becoming ill.Age and health of the person will impact how long they are contagiousYoung children and people with weakened immune systems may be infectious > 1 week.Some people can be infected but have no symptoms – they can still spread the virusBest Practice: all Health Care Workers receive influenza immunizationSeptember 202020

21. Who is at Higher Risk of Developing Complications?Influenza can lead to other health problems, especially for individuals who:Have heart or lung conditions, diabetes, a weak immune system, a lot of extra weight, or other health problemsLive in a care facilityAre under 5 years of ageAre over 65 years of ageAre pregnantAre IndigenousSeptember 202021

22. Complications of InfluenzaComplications of influenza can include: pneumonia (bacterial and viral)ear and sinus infectionsdehydrationworsening of chronic medical conditions such as congestive heart failure, asthma, or diabetes.September 202022

23. Treatment of Influenza Non-complicated cases of influenza are generally managed at home with “self-care”Bed restAnalgesicsFluidsTimeSeptember 202023

24. Influenza Self Care GuidelinesAnnual influenza immunizationCover your coughHand hygieneAvoid touching eyes, nose or mouthClean and disinfect high touch surfacesHealthy lifestyle (exercise, water, diet, avoid smoke)Avoid crowds when influenza is aroundSeptember 202024

25. Influenza Self Care GuidelinesHandwashing:Use regular soap – antibacterial soap not recommendedLather and friction for at least 20 secondsRinse wellDry wellSeptember 202025

26. Influenza Self Care GuidelinesSelf Care at WorkFrequently wipe down keyboard, mouse and phoneIf ill, stay home!Practice hand hygiene frequentlyespecially after contact with high touch surfacesBefore eatingSeptember 202026

27. Antiviral TherapyOf the specimens tested last influenza season:All influenza A strains were resistant to amantadineAll influenza strains (A & B) were susceptible to oseltamivir and zanamivirEach year, antiviral therapy guidelines are prepared by Association of Medical Microbiology and Infectious Disease Canada (AMMI)September 202027FluWatch Report Weeks 30-34 (Government of Canada, Public Health Agency of Canada)

28. Influenza vaccinesSeptember 202028

29. Influenza Vaccine DevelopmentEach February, the WHO recommends which strains should be included in the influenza vaccines for the Northern Hemisphere.A new vaccine is formulated each year based on these recommendationsEach vaccine lot is tested on healthy individuals to ensure the vaccine is safe and effective.September 202029

30. Influenza VaccineThere are 4 components in the quadrivalent vaccine (2 Type A & 2 Type B) and 3 components in trivalent vaccines (2 Type A & 1 Type B)Tailored to match the strains that are projected to be in circulation September 202030

31. Influenza VaccineInactivated (killed) vaccines:The vaccine cannot cause influenza diseaseThe virus is grown in hen eggs, inactivated, broken apart and highly purifiedThe vaccine may contain: Thimerosal (preservative in multi-dose vials)Trace residual amounts of egg proteins, formaldehyde, Triton X-100 (an emulsifier), ethanol, and sucroseCheck the product monograph for a full list because ingredients vary by vaccinesSeptember 202031

32. Influenza VaccineInactivated (killed) vaccines:Both humoral and cell-mediated responses play a role in immunity.Administration of inactivated influenza vaccine results in the production of IgG antibodies to the virus.A cytotoxic T lymphocyte response is also initiatedHumoral 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 and in individuals who are immunocompromised.September 202032

33. Children between 6 months of age up to and including 8 years of age require 2 doses the first year they get a seasonal influenza immunization only require 1 dose in subsequent seasonsEveryone else only needs 1 dose each influenza seasonSeptember 202033Influenza Vaccine

34. Effectiveness of Influenza VaccinesVaccine effectiveness depends on the similarity between strains in the vaccine and the strains in circulation during influenza seasonSeptember 202034

35. Effectiveness of Influenza VaccinesThe body’s immune response from vaccination diminishes within a yearInfluenza viruses change frequently, so the vaccine is updated each year to keep up with these changes.September 202035

36. 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.Effectiveness of Influenza VaccinesSeptember 202036

37. Effectiveness of Influenza VaccinesFluzone™ High Dose (HD) vaccine: there is good evidence that Fluzone™ HD provides better protection compared to Fluzone™ standard dose in adults 65 years of age and older.Rates of seroconversion are about 19% higher for 65 years and older (range: 8 – 39%)Higher rates of seroconversion also noted for those 75 years and older.September 202037

38. 2020 Season Program OverviewSeptember 202038

39. Influenza VaccineTwo quadrivalent inactivated influenza vaccines will be used for the universal influenza program in Alberta:Fluzone®Flulaval®Tetra The Government of Canada has purchased a trivalent product for persons 65 years of age and older that reside in Long Term facilities: Fluzone® High-DoseSeptember 202039Pharmacies will have the following quadrivalent products:Afluria™ Tetra: licensed for 5 years of age and olderInfluvac ™Tetra: licensed for 3 years of age and olderReview current AHSInfluenza Biological Pages

40. 2020 – 2021 components in influenza vaccines used for the universal influenza program are:A/Guangdong-Maonan/SWL 0153/2019 (H1N1) pdm09 - like virusA/Hong Kong/2671/2019(H3N2)-like virusB/Phuket/3073/2013 (B Yamagata lineage)-like virusB/Washington/02/2019 (B/Victoria lineage)-like virusThe only strain carried over from last year’s vaccine is the B/Phuket–like virus.Influenza VaccineSeptember 202040

41. The trivalent Fluzone HD product contains:A/Guangdong-Maonan A/Hong Kong, B/WashingtonHas four times the amount of antigen than the regular dose productSeptember 202041Influenza Vaccine

42. ImmunizationThe Universal Program is for anyone 6 months of age and older who lives, works or studies in Alberta. Includes those on extended visits from other provincesCan provide influenza immunization to individuals working in the community even if they don’t live thereThere is a focus on increasing uptake for:People at high risk of influenza-related complications or hospitalization (identified on slide following)People capable of transmitting influenza to those at risk (identified on slide following)September 202042

43. People at high risk of influenza-related complications or hospitalization: All pregnant womenPeople of any age who are residents of nursing homes and other chronic care facilitiesAdults 65 years of age and olderAll children 6–59 months of ageIndigenous peoplesAdults and children with the following chronic health conditions:cardiac or pulmonary disorders (includes bronchopulmonary dysplasia, cystic fibrosis, and asthma)diabetes mellitus and other metabolic diseasescancer, immune compromising conditions (due to underlying disease, therapy or both)renal diseaseanemia or hemoglobinopathyneurologic or neurodevelopmental conditions morbid obesity (body mass index of 40 and over)children 6 months to 18 years of age undergoing treatment for long periods with acetylsalicylic acidSource: 2020 NACI Statement: List 1, page 10September 202043

44. People capable of transmitting influenza to those at risk:Health care and other care providers in facilities and community setting household contacts of individuals at high riskhousehold contacts of infants less than six months of age, as these infants are at high risk but cannot receive influenza vaccinemembers of a household expecting a newborn during the influenza seasonthose providing regular child care to children 6–59 months of age, whether in or out of the homethose who provide services within closed or relatively closed settings to people at high risk (e.g. crew on a ship)Source: 2020 NACI Statement: List 1 page 10September 202044Note: these people should be immunized even if the person at risk has been immunized.

45. Others:People who provide essential community servicesPeople who are in direct contact with poultry infected with avian influenza during culling operationsSource: 2020 NACI Statement: List 1 page 10September 202045

46. Influenza VaccineFluzone® (QIV)(Sanofi Pasteur)Flulaval Tetra™ (QIV)(GlaxoSmithKline)Strains includedA/Guangdong-Maonan/SWL 0153/2019 (H1N1) pdm09 - like virusA/Hong Kong/2671/2019(H3N2)-like virusB/Phuket/3073/2013 (B Yamagata lineage)-like virusB/Washington/02/2019 (B/Victoria lineage)-like virusLicensed for6 months of age and older6 months of age and olderPackagingSingle dose: pre-filled syringeMulti-dose: 5 mL vialMulti-dose: 5 mL vialIngredientsFormaldehyde Triton X-100 (prevents aggregation and precipitation)Multidose vials also contain: Thimerosol See monograph for complete listMultidose vials contain:Thimerosol Trace amounts of formaldehyde, egg proteins, ethanolPolysorbate 80See monograph for complete listSeptember 202046

47. Long Term Care Residents 65 years of age and olderNew for 2020 flu program:High Dose trivalent influenza vaccine for residents in Long Term CareThere are 5 FN communities who receive funding for LTC bedsFluzone™ High Dose will be provided for this populationSeptember 202047

48. Influenza VaccineFluzone ™HD (TIV) Sanofi PasteurStrains includedA/Guangdong-Maonan/SWL 0153/2019 (H1N1) pdm09 - like virusA/Hong Kong/2671/2019(H3N2)-like virusB/Washington/02/2019 (B/Victoria lineage)-like virusLicensed for65 years of age and olderProgram useLTC residentsPackagingSingle Dose: Pre-filled syringeIngredients60 μg hemagglutinin (HA)4 times more than in standard dose vaccineFormaldehyde Egg proteinTriton X-100See monograph for complete listSeptember 202048

49. Influenza Vaccine AdministrationAgeQIV# of DosesInfants under the age of 6 monthsNot eligibleNot eligibleIndividuals 6 months up to and including 8 years of age who HAVE NOT received influenza vaccine in a previous season:0.5 mL IM2 doses, 4 weeks apart *Individuals 6 months up to and including 8 years of age who HAVE received influenza vaccine in a previous season:0.5 mL IM1 dose**Individuals 9 years of age and older: 0.5 mL IM1 dose** *To be recorded as 1 of 2, 2 of 2 **To be recorded as annualUse an immunization appointment/reminder process relating to 2nd dose if required.September 202049

50. Influenza VaccineMulti dose vials and prefilled syringes must be shaken well before each dose: will be clear to slightly off white suspension.Multi-dose vials: discard 28 days after first puncture into the vial.Do not freeze. Protect from light.MDV = Multi-Dose Vial; PFS = Pre-filled SyringeSeptember 202050

51. Influenza Vaccine ReactionsSide effects from the vaccine tend to be mild and go away in a few days. They include: September 202051Redness, swelling, bruising, or feeling sore at the injection siteCrying, feeling tired, or getting upsetHeadacheFever or chillsBody aches or sore jointsLoss of appetiteNausea, stomach pain, vomiting, loose stoolSore throat, cough, or runny nose

52. Influenza Vaccine ReactionsUncommon:Lymphadenopathy, dizziness, cough, rash, upper respiratory tract infection, injection site pruritus. Rare:Anaphylaxis, allergic reaction, Guillain Barré Syndrome (GBS), oculorespiratory syndrome (ORS). As with any immunization, unexpected or unusual side effects can occur. Refer to product monograph for more detailed information.September 202052

53. Influenza Vaccine ReactionsFluzone™ HD:Injection site and systemic reactions are more frequent with high dose vaccinesHigher rates of malaise, myalgia and moderate to severe feverMost systemic reactions are mild and resolve within 3 days.Severe adverse events are rare and similar to standard dose vaccinesHD = high doseSeptember 202053

54. Influenza Vaccine ContraindicationsInfants under 6 months of ageAnaphylactic or allergic reaction to a previous dose of influenza vaccine or to any constituent of the vaccineKnown hypersensitivity to any component of the vaccine -excluding eggs.Known history of severe oculorespiratory syndrome (ORS) that included lower respiratory symptoms within 24 hours of receiving influenza vaccine (contact CDC Team to have MOH review)Individuals who developed Guillain Barré Syndrome (GBS) within 6 weeks of previous influenza immunization.September 202054

55. Influenza Vaccine PrecautionsNACI states:Egg allergy is NOT a contraindication for influenza immunization. Individuals severely allergic to eggs should be monitored for 30 minutes following immunization. Egg-allergic individuals may be vaccinated against influenza using any appropriate product without prior influenza vaccine skin test and without any particular consideration, including immunization setting.2020 NACI Statement: page 12September 202055

56. Vaccine DeferralVaccine should be deferred for individuals presenting with acute febrile illnessRecommendation to be immunized when symptoms have resolved.Vaccine can be safely given to:Individual with mild acute illness, with or without feverIndividuals recovering from illness or who are taking antibioticsSeptember 202056

57. GBS, ORS and AEFI REportingSeptember 202057

58. Guillain Barré Syndrome (GBS)GBS illness affects the nervous systemRare: general risk is about 2 cases/100,000 person yearsCharacterized by loss of reflexes and symmetric paralysis, usually beginning in the legsComplete or near complete recovery in most casesGBS is thought to be triggered by an infectionCampylobacter jejuni infection most commonly precedes GBSOther respiratory or intestinal illness have preceded GBS (i.e. Cytomegalovirus, Epstein-Barr Virus, Mycoplasma pneumoniae)September 202058

59. Guillain Barré Syndrome (GBS)In 1976, the “swine flu” vaccine was associated with increased risk of GBS: not found with any other vaccines sinceAbsolute risk of GBS after influenza vaccine is about 1 excess case per 1,000,000 vaccines above background rate of 10 – 20 cases/millionRisk of GBS associated with influenza infection is much greater than that associated with the immunizationIt is recommended the you DO NOT provide influenza immunization to people who have been diagnosed with GBS within 6 weeks of previous influenza immunization.September 202059

60. Oculorespiratory Syndrome (ORS)ORS Case Definition: (onset within 24 hours of immunization)bilateral red eyes and one or more respiratory symptoms (cough, wheeze, chest tightness, difficulty breathing, difficulty swallowing, hoarseness or sore throat) with or without facial swelling Immunization recommendations following client reported ORS are based on:Risk/benefitSeverity of symptoms as perceived by the individual who experienced the symptomsContact the CDC Team to have MOH review.September 202060

61. Adverse Event Following Immunization ReportingLocal reactions are reportable if they have:Onset within 48 hours following immunization andSwelling that extends past the nearest joint orSevere pain that interferes with the normal use of the limb lasting > 4 days orReaction requires hospitalizationSeptember 202061

62. Adverse Event Following Immunization ReportingAny of the following are also reportable adverse reactions:GBSORSAnaphylaxis – report immediately after treatingOther allergic reactionsAny unexpected reactionSeptember 202062

63. Adverse Reaction ReportingUse Alberta Health Report of Adverse Reaction following Immunization (AEFI) formonly available on-lineSevere reactions are reportable within 24 hours. All other reactions within one week.September 202063

64. Post influenza immunization after care guidance during COVID-19Most reactions to influenza immunizations are mild, develop within 24 hours, and could last 24 – 48 hours.Many of the reactions that can occur after the vaccine are similar to the symptoms of COVID-19.Individuals with COVID-19-like symptoms should stay homeSeptember 202064

65. Post influenza immunization after care guidance during COVID-19 (con’t)If the symptoms following influenza immunization resolve within 48 hours after onset, the individual can return to normal activities, unless they have been instructed to quarantine or isolate for other reasons.September 202065

66. Post influenza immunization after care guidance during COVID-19 (con’t)If the symptoms persist longer than 48 hours and are not related to a pre-existing illness or health condition, individuals must continue to stay home and arrange for COVID-19 testing.September 202066

67. Post influenza immunization after care guidance during COVID-19 (con’t)If testing is not done:By law, individuals with fever, cough, runny nose, sore throat, or shortness of breath need to remain at home for 10 days or until symptoms resolve, whichever is longer.Individuals with any other symptoms on the COVID-19 symptom list should remain home until symptoms resolveSeptember 202067

68. Pneumococcal Disease and vaccinesSeptember 202068

69. Why is Pneumo-Polysaccharide (Pneumo-P) Important?Protects against 23 common types of Streptococcus pneumoniae and can cause bacterial pneumonia and other serious infections like bacteremia and meningitisVaccine offered to certain groups of individuals who are more at risk of serious illnessBacteria becoming resistant to some antibioticsVaccine effectiveness related to age and immune competency of individual immunizedOnly protects against serotypes included in vaccineVaccine is 56 – 81% effective in preventing invasive pneumococcal disease (IPD)September 202069

70. Recommended Pneumo-P RecipientsRoutine: Those 65 years of age and older, regardless of previous Pneumo-P (minimum spacing: 5 years)Medically at Risk:Individuals 24 months up to and including 64 years of age with chronic conditions.Individuals 24 months up to and including 64 years of age in high risk settings:Homeless/sheltersLong term care settingsReview current AHSPneumo-P Biological PageSeptember 202070

71. Recommended Pneumo-P RecipientsA one-time reinforcing dose of Pneumo-P is recommended ONLY for individuals at highest risk of invasive pneumococcal disease.See current pneumococcal biological pages for detailsThis one time dose is given 5 years after initial doseIndividuals 65 years and older should receive one dose of Pneumo-P regardless of # of previous dosesEnsure any dose is at least 5 years after any previous doseSeptember 202071

72. Polysaccharide Pneumococcal VaccineProduct used: Pneumovax 23®, produced by MerckPneumo-P can be administered either SC or IM, but it is recommended to use IM in deltoid.FLU and Pneumo-P can be administered during the same visit, using separate syringes at different sites.September 202072

73. Pneumo-P ReactionsVery common:Injection site soreness, redness and swellingCommon:Fever > 38.5Headache, malaise, chillsRare:Large amount of swelling and painNausea and vomitingGeneral rashSeptember 202073

74. Pneumo-P ContraindicationsChildren less than 24 months of ageKnown sensitivity to any vaccine componentHistory of anaphylactic reaction to any previous dose of vaccineSpecial considerations needs to be given to clients undergoing splenectomies, transplants or immunosuppressive therapy. Discuss with CDC team.September 202074

75. Vaccine managementSeptember 202075

76. Vaccine ManagementCommunicate with your vaccine depot regarding influenza vaccine ordering and delivery schedules.# of doses shipped are based on doses administered last yearAdd influenza vaccine doses into AVI inventory as soon as receivedSeptember 202076

77. Vaccine ManagementAll multidose vials must be dated upon opening.Check expiry date of all products being administeredCommunicate the need to use nearly expired vials to other staff membersVaccine should be withdrawn from the vial by the immunizer administering the vaccineDo not mix vaccine from vials with different lot numbersDo not pre-draw vaccineSeptember 202077

78. Program InformationSeptember 202078

79. Program InformationGeneral resources will be emailed out and then posted on the Influenza section on OneHealth.***Not updated yet***September 202079

80. ImmunizationSeptember 202080

81. ImmunizationOctober 13, 2020: Soft roll outCan begin immunizing individuals at greatest risk.Can include influenza vaccine as part of routine childhood immunization clinics, include child and anyone who accompanies them.Health care workersOctober 19, 2020: Advertised influenza vaccine clinics can begin.Pneumo-P is offered throughout the year and can be given at same time as influenza vaccine.September 202081

82. Who Can ImmunizeIn order to be part of the influenza immunization team, all nurses, LPNs and paramedics must participate in or view the recording of this in-service and review. Influenza Program resources Anaphylaxis – Canadian Immunization GuideBest Practices: Vaccine ManagementSeptember 202082

83. Following this presentation, RNs (public health and home care) and NPs who hold a current* FNIHB Immunization Provider Certificate:can provide influenza and/or Pneumo-P immunizations for all ages if they have the knowledge, skills, and competence to administer the vaccine*Not sure if current? Contact Regional Nursing Education teamWho Can ImmunizeSeptember 202083

84. Following this presentation, RNs (public health and home care) and NPs who do NOT hold a current FNIHB Immunization Provider Certificate:can provide influenza and/or Pneumo-P immunizations for eligible clients older than 5 years of age if they have the knowledge, skills, and competence to administer the vaccineWho Can ImmunizeSeptember 202084

85. Who Can ImmunizeFollowing this presentation, all LPNs (who hold or do NOT hold a current FNIHB Immunization Provider Certificate) can provide influenza and/or Pneumo-P immunizations for eligible clients older than 5 years of age if they have the knowledge, skills and competence to administer the vaccine. (see next slides)September 202085

86. Who Can ImmunizeLPNs and Immunization:The Council of the College of Licensed Practical Nurses of Alberta (CLPNA) updated their policy “Practice and Education Requirements for Restricted Activities and Advanced Practice” effective February 1, 2020. Immunization no longer requires Registrar authorization and authorization will not be noted on the practice permit.Any LPN who graduates in Alberta after June 2022 will have education on administering immunizations as part of their diploma program.September 202086

87. Who Can ImmunizeGuidance for current LPNs:LPNs who have “Immunization Specialty” on their practice permit:May continue to administer vaccines without need for further education/training.LPNs who do NOT have “Immunization Specialty” on their practice permit:Must take additional training/education prior to administering immunizationsCLPNA website has a module on administering immunizations: available to members at no cost.Note: Contact CLPNA if more information or guidance is neededSeptember 202087

88. Who Can ImmunizeLPNs and Immunization:LPNs who want to provide routine immunizations in addition to influenza and Pneumo-P should contact the FNIHB Nursing Education Team to review the process and requirements.September 202088

89. Who Can ImmunizeParamedics and ImmunizationThere are different levels of emergency responders:EMR: emergency medical responderPCP: primary care paramedicACP: advanced care paramedicAdministering vaccines falls within authorized restricted activities for PCP and ACP.Province of Alberta, Health Professions Act: Paramedics Profession Regulation. Alberta Regulation 1151-2016September 202089

90. Who Can ImmunizeCurrently, the Nursing Education team is updating the Mandatory Inoculist Certification and Re-certification Program policy and guidelines to include the scope and practice of immunization for primary care and advanced care paramedics. Attending or viewing the Annual Influenza Program Overview will be part of the requirementSeptember 202090

91. Fit to immunize:The immunizer will:Assess the need for immunizationConfirm the client has not received a dose of influenza vaccine in the 2020-2021 seasonComplete a fit to immunize assessmentHealth status todayHistory of allergiesPrevious reactionsContraindicationsChronic illness/medicationsPregnancy Immunization ProcessResource: “Influenza Vaccine Pre-Screening” toolSeptember 202091

92. Immunization ProcessMust obtain “informed consent”Risks and benefits of influenza and Pneumo-P vaccines should be discussed prior to vaccination, as well as the risks of not getting immunizedDo not need signature if the individual presents at a “flu clinic” and bares injection siteChildren presenting without a parent/guardian will need a signed consent form or verbal consent from the parent/guardian.Follow residential facility consent process when providing immunization in care faciltiesSeptember 202092

93. Intramuscular InjectionsChildren < 12 months old3 mL syringe25G 1” needleinsert at 90 degree anglevastus lateralis - middle third of anterior thigh and slightly lateral to the midlineNote: This site can be used for children older than 12 months of age with inadequate deltoid muscle mass. September 202093

94. Intramuscular InjectionsChildren ≥ 12 months old3 mL syringe25G 1” needleinsert at 90 degree angle mid portion of deltoidAdults3 mL syringe25G - 1” to 1½” needle depending on muscle mass and adipose tissueinsert at 90 degree anglemid portion of deltoidSeptember 202094

95. Importance of Accurate Land-markingShoulder Injury Related to Vaccine Administration:Sequelae of immune response to direct intracapsular injectionTypical symptoms:Rapid onset of painLimited range of motionPersists weeks/monthsEnsure correct needle length is used, correct depthEnsure site of injection avoids the top 1/3 of deltoidApplied Radiology, 2014;43(12):30 – 31 “Shoulder Injury Related to Vaccine Administration.”http://www.medscape.com/viewarticle/837089 September 202095

96. Intramuscular InjectionsWomen with history of mastectomy, lumpectomy or other breast surgery:Single Mastectomy:One vaccine: give in arm opposite to mastectomy. Two vaccines: give both in arm opposite mastectomy with a minimum of 1” apart.Double mastectomy:One vaccine: give in Vastus Lateralis.Two vaccines: give both in Vastus Lateralis with a minimum spacing of 1” apart.September 202096

97. Discard all influenza vaccine and influenza resources from previous years.September 202097

98. Anaphylaxis, Fainting, Anxiety, and Breath holdingResource: Anaphylaxis Module Everyone involved in immunization should review module and ensure appropriate measures are in place to manage any potential situation.September 202098

99. AnaphylaxisPotentially life threatening allergic reactionVery rare (about 1 per 1,000,000 doses) but should be anticipated with every clientPre-immunization screening can prevent episodesEvery immunizer should be familiar with the symptoms of anaphylaxis and be ready to initiate appropriate interventionsMost reactions begin within 15 minutes of immunizationAll clients should be encouraged to wait 15 minutes after immunization.Clients with known anaphylactic allergies, and clients with severe egg allergies should be monitored for 30 minutes after immunizationSeptember 202099

100. Canadian Immunization Guide - AnaphylaxisAll immunizers must review the current anaphylaxis guidelines in the Canadian Immunization Guide. The Canadian Immunization Guide is available online. Canadian Immunization guidePart 2 – Vaccine SafetyEarly vaccine reactions including anaphylaxisSeptember 2020100

101. Anaphylaxis ManagementImmunization related anaphylaxis protocol has NOT Changed.Reminder that oral Benadryl is only to be used in High Alert situations.The epinephrine auto-injectors provided to the health centre (pediatric and adult versions) are for use for the management of non-immunization anaphylaxis only.September 2020101

102. Quick Anaphylaxis ReviewA quick & excessive release of Histamine causes:Plasma to leave capillaries and enter tissues ++ swelling, trouble breathingVasodilation of capillaries and arterioles low blood pressureSmooth muscle contraction trouble breathing, GI problemsIncreased mucous productiontrouble breathingSeptember 2020102

103. Respiratory:dyspnea - wheezing - sneezingchoking - drooling cyanosis – angioedema - tightness in throat/chestDermatologic (skin):urticaria (hives), erythema (redness of the skin), pruritus (itchy)flushing - pale/grey - facial swellingtingling of mouth or face followed by a feeling of warmthQuick Anaphylaxis ReviewSeptember 2020103

104. Vascular Collapse (cardiovascular) rapidly falling blood pressuresweatingrapid, thready pulsea feeling of uneasiness, restlessness or anxietyweakness or dizzinessthrobbing in the ears or a headacheGastrointestinal:nausea, vomitingdiarrheaabdominal crampsQuick Anaphylaxis ReviewSeptember 2020104

105. Anaphylactic shock interventionThe Initial Response …Call for helpLie the client on his/her back with feet elevated, if possibleLoosen restrictive clothing around the neckEstablish an adequate airwayNote the timeInitiate anaphylaxis protocolSeptember 2020105

106. What would you do?If in doubt, give!Would you give this child epinephrine? Why or why not?Failure to administer epinephrine promptly is more dangerous than administering it in a situation where anaphylaxis is not truly present.September 2020106

107. Fainting after ImmunizationAlso known as syncope or vasovagal syncopeTriggered by a stimulus (anxiety) that causes an exaggerated response in the part of the nervous system that regulates involuntary body functions (heart rate, 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 consciousnessSeptember 2020107

108. Fainting after ImmunizationIn about 25% of cases, reduced blood flow can result in jerking movements that resemble seizuresMore common when fainting occurs soon after immunization and disappears when consciousness is regainedClients fainting due to vasovagal syncope recover quickly, usually within seconds or a few minutesSeptember 2020108

109. Symptoms of FaintingMusculoskeletal:Muscles relaxedWeaknessIncontinence (rare)Clonic jerks of limbs and face RespiratoryNormal or yawningDermatologicPallor/grey colour – sweatingGastrointestinalVomiting, nauseaCardiovascularHypotension, slow weak pulseRinging in earsNeurologicalLight headedness, dizzinessSpots before the eyesdazedUnconsciousnessSeptember 2020109

110. Facts about FaintingClear incidence peak in age 10 to 19 years of age, with smaller peak at 4 to 6 yearsAfter the age of 20 years, the incidence decreases with age57.5% occur in femalesIncidence of fainting is under-reportedMost cases occur within 5 minutes of immunizationFainting can result in head trauma if a client fallsThe goal is to prevent fallsSeptember 2020110

111. Tips to Prevent FaintingAdminister vaccine while client is seatedMaintain a calm and confident mannerObserve anxious clients while seated until anxiety has resolved after immunizationHave clients with a history of fainting lie down prior to administering the vaccineClients with pre-syncopal symptoms (such as dizziness, anxiety, pallor, perspiration, trembling, or cool clammy skin) should sit or lie down until symptoms resolveSeptember 2020111

112. Assisting Clients after FaintingAssist the client to lay down with feet elevatedEnsure the client’s airway is open (ABCs)Monitor for signs of allergic reactionCall for assistance if neededCover client with blanket for warmth if availableWipe client’s forehead with cool damp clothCan offer fluids once alertHave the client resume a standing position in stages (sit, stand, walk)Observe the client until the symptoms have resolvedSeptember 2020112

113. Anxiety SpellsSymptoms:Fearful, pale, diaphoreticComplains of light headedness, dizziness, numbness, and tingling of face and extremitiesHyperventilationTreatmentReassuranceInstruct to relax and breathe slowlySeptember 2020113

114. Breath HoldingOccurs in young children when upsetSuddenly become quiet but still very agitatedFacial flushing and perioral cyanosis (blue around the mouth)Often ends with resumption of crying, or a brief period of unconsciousness during which time breathing resumesTreatment:reassuranceSeptember 2020114

115. Infection prevention and controlSeptember 2020115

116. Infection Prevention and ControlHand hygiene is criticalMust be done between each clientWaterless hand gelHand creams to maintain skin integrityGloves are not recommended during immunizations“Respiratory Etiquette” protocol.September 2020116

117. Infection Prevention and ControlVaccine AdministrationEnsure a clean workspaceClean surface at start and end of dayEstablish clean work area (blue pad, professional towel, etc.) Avoid placing papers, pens in this areaSharps managementUse safety syringes and needlesSharps disposal at point of contactSeptember 2020117

118. COVID-19 Context GuidelinesKey changes for immunization clinics in COVID-19 context. PHAC documentFNIHB documentAlberta Health document (included as an attachment)September 2020118

119. COVID-19 Context GuidelinesKey Components:Screening: self-screen for all staffProcess to screen clients (appointments, prior to entry)Physical Distancing:Scheduled appointments, mass immunization clinic not recommendedLimit number of clients at any one time (including 15 minute post immunization wait time)Ensure seating in any waiting area complies with 2 metre spacingEnsure minimum of 2 metre spacing between each immunization stationOne way traffic flow, i.e: entry→ waiting area→ immunization station → post immunization waiting area → exit.September 2020119

120. COVID-19 Context GuidelinesInfection Prevention and Control:Masks must be worn by all staff and all clientsException: children younger than two, individuals with respiratory conditions, and those requiring assistance to don/doff masksHand hygiene: clients must perform hand hygiene upon entry to siteEnvironmental cleaning: cleaning of high touch areas at least twice daily, or when dirty.September 2020120

121. COVID-19 Context GuidelinesPPE guidance for Staff:Completion of a point of care risk assessment should be done prior to the immunization event in order to assess the risk of COVID-19 exposure.Other than a mask, additional PPE is not typically requiredIf a patient/client cannot wear a non-medical mask (due to age or capacity) during the immunization, the HCP should wear eye protectionAppropriate PPE should be immediately available to all personnel who need to provide first aid or respond to an emergency.September 2020121

122. COVID-19 Context GuidelinesOther recommendations:Minimize large groupsi.e. one immunizer : one personMaintain a list of staff and clients attending each clinicSignage to help with instructionsConsider various clinic formats in accordance with available resources/community context, e.g.:Drive through immunization clinicsImmunize during home visitsOutreach/mobile clinicsPHAC 2020: “Guidance for Influenza Vaccine Delivery in the presence of COVID-19”.September 2020122

123. COVID-19 Context GuidelinesThe FNIHB August 21, 2020 guidance document includes recommendations for:Immunization clinics in Community Health Centres/Nursing StationsImmunizations during Home Care Visits or Door-to-Door campaignsParking lot or drive through clinicsOutreach or mobile clinicsSchool-based clinicsSeptember 2020123

124. Recording & Data CollectionSeptember 2020124

125. Overall ObjectivesImmunization Coverage:80% of all persons > 65 years of age95% residents of LTC facilities80% of high risk persons 80% of children 6 to 59 months of age100% assessment for Pneumo-P eligibility with all individuals presenting for influenza vaccine100% TB assessment for chronically ill adultsSee TB screening algorithmsSeptember 2020125

126. FLU Reporting RequirementsAlberta Health has set the following reason codes for influenza immunization documentation in order of priority:Pregnant womenThose 65 years and olderChildren 6 months to 59 months of ageIndividuals 5 through 64 years of age with chronic health condition/high risk populationHousehold or close contacts of any of the groups aboveIndividuals 5 through 64 years that do not fit in any of the groups aboveWhen determining which code to pick, start at the top of the list and choose the first code that appliesNote: Health care workers are no longer reported separatelySeptember 2020126Every vaccine administered MUST have a code attached.

127. Immunization Reporting RequirementsWeekly clinic summary of influenza doses administeredTo be submitted by Monday, noon, for the previous week’s activity if not submitting through CHIP.Influenza Annual Summary and Denominators:Influenza Target Group Summary: Due Dec 31, 2020.Annual summary of Pneumo-P and TB High Risk screeningdue April 30, 2021. Adverse Reactions:Submit reportable reactions to Regional CDC as they occurReminder to monitor for unexpected adverse events.September 2020127

128. Immunization Documentation RequirementsInformation to include on all clients includes:Client demographic informationFull name, PHN, DOB, gender, full addressVaccine name, lot numberDosage administered, dose numberSite of injection, route of administrationImmunizer name, designation and signatureDate of immunizationSeptember 2020128

129. Alberta Health Services does not print NCRs any moreAn electronic form is available:It can be filled by typing information in, then printingIt can be printed then filled in manually by writing the information on itIt does not specifically include Pneumo-P use “other” section on record and then transfer the information to the client’s immunization recordThe client does not receive a copy of this formThe Care After Immunization: Influenza sheet has a place to document the individual’s influenza immunization on it for themInfluenza Immunization RecordSeptember 2020129

130. September 2020130

131. Influenza Immunization RecordHow long do influenza immunization records need to be kept?If entering the full information into CHIP or onto hard copy immunization record, NCR is considered to be a transitory document and can be shredded once entered.Full information: name, DOB, PHN, full vaccine details (product, lot number, dose, site), immunizerIf only entering partial information, or not entering into CHIP or onto hard chart record:Children: keep 30 yearsAdults (18+): keep 11 yearsSeptember 2020131

132. Data collectionAll 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:To determine immunization ratesTo be accountable for doses received/administeredTo monitor vaccine safetyFor planning and operational decisions for subsequent seasonal programsSeptember 2020132

133. Immunization/Reporting ToolsWeekly Influenza Clinic SummaryDoesn’t need to be done if all vaccines are entered into CHIP and if Okaki received community permission to share with us.Can also use CHIP clinic summary report to gather information for this formSeptember 2020133

134. Immunization/Reporting ToolsInfluenza Target Group Summary ReportUsed to determine coverage rates for community health protection reports.Due December 31, 2020September 2020134

135. Immunization/Reporting ToolsOptional resource – do not submit to FNIHB AB RegionSeptember 2020135

136. Immunization/Reporting ToolsExcel Resource: Fast flow clinic worksheetOptional resource – do not submit to FNIHB RegionSeptember 2020136

137. Immunization Reporting ToolsPneumococcal and Tuberculosis High Risk Medical Condition Screen Coverage ReportDue: April 30, 2021September 2020137

138. SurveillanceSeptember 2020138

139. SurveillancePart of international process to monitor influenza activity around the worldMonitor circulating strains Nasopharyngeal swabs, ILI surveillanceAssess effectiveness of current vaccinesContribute toward Pandemic Influenza preparednessSeptember 2020139

140. ILI DefinitionInfluenza Like Illness definition:Acute onset of respiratory illness with fever and cough and with one or more of:Sore throatJoint PainTenderness or pain in the musclesGeneral exhaustionLaboratory ConfirmationSeptember 2020140

141. SurveillanceComponents of Surveillance:ILI activity (no activity, sporadic, widespread)NP swabsWeekly surveillance reportsPlease call Christina/Brent if you hear of anyone admitted to hospital with influenza.We need to submit a specific report for all cases hospitalized with influenza.Will need history of influenza and pneumococcal immunizations for current and previous seasons.September 2020141

142. SurveillanceNACI Statement:“Studies suggest that when influenza is circulating in a community, patients with ILI who have both cough and fever within 48 hours of symptom onset are likely to have influenza. The presence of sore throat is suggestive of a diagnosis other than influenza.” (2009 NACI Statement)September 2020142

143. SurveillanceWeekly Surveillance ReportDue Monday noon for the previous week ILI activity:September 2020143

144. SurveillanceBegins October 5, 2020 until Spring 2021 Each community to designate an individual as key contact and a back-up contact for weekly surveillanceDoes not need to be a nurseSeptember 2020144

145. SchoolsAccording to the Alberta Public Health Disease management Guidelines: Influenza – Seasonal document:School closure as a measure to mitigate the spread of influenza is not currently recommended. Consideration for school closure will require consultation between the CMOH, local MOH and the affected school authority.September 2020145

146. See COVID-19 requisition guidance document to ensure information on requisition is complete. Do not use COVID-19 requisition to order FLU or RPP tests.UTM transport mediaDon’t use if past expiry date, is cloudy or has changed colourLabel specimen with 2 unique identifiersName, PHN/ULI, specimen siteTransport ASAP and keep coolNasopharyngeal SwabsSeptember 2020146

147. Nasopharyngeal SwabsUse NP flock swabsLabel with patient’s name, PHN and specimen siteBreak off point:September 2020147

148. Nasopharyngeal Swabshttp://www.provlab.ab.ca/education.htmSeptember 2020148

149. Ordering NPSSwabs can be ordered through Provincial Lab:Edmonton (PLPH-M)(780) 407-8971Calgary (PLPH-M)(403) 944-2583September 2020149

150. Tuberculosis ProgramSeptember 2020150

151. TB Screening During Influenza Vaccination ClinicsGoal of Pre-screen Tool:Identify those with signs or symptoms of TB Identify those with At Risk Medical Conditions so they can be further screened for TB risk. Use of pre-screening tool for most clients does not constitute a completed screen. A completed screen is a completed algorithm.Pre-screening ToolSeptember 2020151

152. Identify those with at risk medical conditionsScreen and follow-up for TB using appropriate “At Risk TB Screening Algorithm”Continue to monitor those with at risk medical conditions and TB infectionTB Screening for those with At Risk Medical ConditionsSeptember 2020152

153. TB QueriesIf you have any specific queries relating to TB screening, please contact:Andrea Warman (780) 495-5407Deana Nahachewsky (780) 495-6071September 2020153

154. Thanks to everyone who is involved in the whole influenza program!You are making a difference in the health of the people in the community where you are!September 2020154

155. Questions and roll callSeptember 2020155