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VIHA Child, Youth and

Family Community Health

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Reserved Titles

Defined scope of practice◦ “Restricted Acts”

◦ With/without an order

Requirements on practice ◦ “additional

education”

◦ CRNBC Certified Practice

RNs now authorized per HPA: RN/NP Regulation to

diagnose and manage conditions (including prevention), e.g. Anaphylaxis

administer certain medications to treat conditions or prevent disease/disorders, e.g. immunization for influenza

No order, transfer of function or delegation required

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HPA - RN/NP Regulation

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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.

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Educational

component ◦ Attend an Influenza

education session or

review Influenza

materials

Clinical ◦ Immunization of

clients >5 years

◦ Observation of 5

immunizations

◦ Be observed doing 5

immunizations

◦ Skills Checklist

Yearly Review

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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

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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

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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

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“stomach flu” – influenza does not usually

cause GI symptoms

Colds – e.g. rhinoviruses

Similar symptoms to RSV

◦ Sneezing, chills, malaise, teary eyes

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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

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Can damage the lining of the respiratory tract

Secondary infections – viral or bacterial◦ Strep.pneumococcal

Hospitalization for complications

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Influenza A causes:◦ Moderate to severe illness

◦ Epidemics

◦ Pandemics

Influenza B causes:◦ Milder epidemics

Influenza C causes:◦ No disease in humans

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Overall activity was mild

Increased activity presented later in the

season

Influenza A & B detections reported across the

country

Emergence of H1N1

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“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)

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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

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HERD IMMUNITY

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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

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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

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Frequent Hand Hygiene

Yearly influenza vaccination

Cough etiquette

Stay home when ill

Outbreak control measures in

facilities◦ Standard precautions

◦ Antivirals etc…

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.

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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

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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

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Body wide network of

cells and organs

Evolved to defend

against foreign

invaders

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ANTIGEN – any molecule that identifies

as foreign to the immune system and

stimulates the immune system to attack it.

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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”)

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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)

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I.G.SHORT TERM PROTECTION

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LONGER TERM PROTECTION

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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.

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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

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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

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Flu Vaccine Production Timeline

• Decision on which

3 strains

• Manufacturers

purchase hens’

eggs

• Virus strains sent

to manufacturers

• Eggs inoculated

with virus

• Virus multiplies in

eggs

• Virus inactivated

with chemicals

• Egg white removed

/ virus harvested

• Vaccine tested for

purity & potency

• 3 vaccine strains

blended

• Packaging into

syringes /vials

• Licensure and

release

• ShippingImmunization

begins

Jan Feb May June-July Aug Sep Oct

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)

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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

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Contain killed bacteria or viruses and

cannot replicate

Usually no interference from circulating

antibodies

Induces long term memory

Antibody levels fall over time

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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

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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

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Antibodies develop within 14 days

Immunity depends on age and

immunocompetence

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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

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*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

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Recommendations for Influenza are published

yearly by the National Advisory Committee on

Immunization (NACI)

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Fall 2009: 65 years and older and residents in

Long Term Care

Early 2010: All other recommended groups under

the age of 65 years

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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

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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

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Legal Requirements

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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

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1. Assess capability to give informed consent

2. Determine authority to provide informed consent

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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

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4. Confirm understanding of Standard Information

5. Provide an opportunity for questions

6. Confirm consent

7. Document consent or refusal

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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?

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A mom brings her 7 year old child in for a flu shot,

and says she is the foster mom.

How would you proceed?

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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

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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

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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

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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.

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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

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All used

safety

syringes

should go

directly into a

sharps

container

after

immunizing a

client.

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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

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Nursing BC Oct. 2006

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

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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.

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This site is used for IM injections only

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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

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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

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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

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Watch BCCDC’s demonstration of IM

injections in the Deltoid Click here

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.

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

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Activate safety needle with thumb

Discard needle & syringe into sharps container

Observe client briefly - ask to stay in observation area for 15 minutes

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To view more videos on landmarking for IM

injections go to www.bccdc.ca

Click on:◦ Vaccines and Immunization

◦ For Health Professionals

◦ Immunization Competency

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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

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Local

Soreness at the injection site lasting two days

Redness, swelling, itching , warmth, pain on contact

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Systemic

• Fever, malaise,

myalgia

• may occur 6-12 hours

following vaccination

and lasting 1-2 days

• especially in

individuals receiving

vaccine for the 1st time

Acetaminophen for local reactions and fever

Comfort measures - cool cloth on injection site

Fluids

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An untoward event temporally associated

with immunization that may or may not

have been caused by the vaccine or the

immunization process.

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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

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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

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Based on clinical presentation, exposure history

Cutaneous, respiratory symptoms most common

Some cases may be difficult to differentiate

◦ Vasovagal (fainting)

◦ Anxiety

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• 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

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.

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• 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

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• 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

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• Uniphasic

• Biphasic

• Recurrence up to 8 to 12 hours later

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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

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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

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Dose: 0.01 ml/kg to maximum of 0.5 ml

OR:

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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

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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.

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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

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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.

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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

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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.

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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?

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NACI statement on Influenza Vaccination

BCCDC Immunization Program Manual

Canadian Immunization Guide

Vancouver Coastal Health

Fraser Health Authority

Claire Coombs

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