Preventing Influenza

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Preventing Influenza

• Prevent all the Disease You Can Then Treat the
  Rest.
• John D. Grabenstein

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Seasonal Influenza Vaccines

• Live Attenuated Influenza Vaccine (LAIV)
• (Flu Mist)
• Trivalent Inactivated Influenza Vaccine (TIV)
• (Fluzone, Fluviron, Fluarix, FluLaval, Afluria)
• -not all created equal

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Target groups for Influenza Vaccination

• Children age 6 months through 18 years old
• Pregnant women
• Caregivers
• Healthcare workers
• Elderly (gt 50 years old!) (ACIP not me!)
• Nursing home patients
• People with chronic pulmonary, cardiovascular,
  renal, hepatic, immuno-supression,
  neuro-muscular, hematological or metabolic
  conditions.
• Any person who wishes to reduce the likelihood of
  becoming ill with or transmitting influenza to
  others.

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Can the vaccine cause the Flu?

• NO!
• TIV (the shots) cannot cause influenza because it
  is an inactivated vaccine.
• LAIV (the spray) cannot cause influenza because
  it cannot replicate in the temperature of the
  lower respiratory tract and dies at temps gt38C.
  It only lives in the upper respiratory tract and
  and can cause Influenza-like Illness, but not
  the full blown disease.

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Flu Mist (Live Attenuated Vaccine)

• Intranasal spray
• Healthy, non-pregnant patients aged 2-49 years.
• Not recommended within 7 days of taking care of
  severely immunocompromised patients (Not
  recommended for HCW!)
• Dose Total of 0.2ml (0.1ml in each nostril) for
  all patients aged 2-49 years

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Children aged 2-8 years

• If child aged 2- 8 years is receiving Influenza
  vaccine for the first time, they should get a
  second dose at least 4 weeks after the initial
  dose within the same flu season.
• If child being vaccinated for the first time and
  receives only one dose-but does not return for
  the second dose that year, how many doses should
  that child receive the next year if still lt 9
  years old?

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Start all over again!

• Administer 2 doses (at least 4 weeks apart) to
  children age 9 years or younger who are receiving
  influenza vaccine for the first time or who were
  vaccinated for the first time during the previous
  influenza season but only received 1 dose for
  that year.
• ACIP (Advisory Committee on Immunization
  Practices) www.cdc.gov/vaccines/recs/acip

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Who should NOT get LIVE vaccine?

• Allergic to eggs
• Children less than 2 years of age
• Children aged 2-4 years with asthma or wheezing
• Children or adolescents on long-term aspirin
  therapy
• Adults gt 50 years of age
• Patients with chronic medical conditions
• Pregnant women
• Immunosuppressed/Immunodeficiency patient
• Close contacts of these patients (some shedding
  of vaccine virus occurs though transmission to
  others is rare.)
• Previous history of Guillain-Barre syndrome

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Inactivated Influenza Vaccine

• Age 6-35 mon (lt3 years) 0.25ml IM
• (2 doses if first time, 1 month apart)
• Age 3 to lt 9 years 0.5ml IM
• (2 doses if first time, 1 month apart)
• gt 9 years adults 0.5ml IM

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Not All IM Vaccines Created Equal!

• Only Fluzone approved for all ages (6
  months through adult)
• Fluvirin only approved for age gt 4 years
  through adult
• Afluria, Fluarix, FluLaval only for age
• gt18 years to through adult

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Who should not get TIV shots?

• Allergic to eggs
• Younger than 6 months old

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How do I store my flu shots and Spray?

• Refrigerated at 2-8C (35-46F)
• Do not Freeze

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H1N1 Vaccines

• Monovalent Vaccine
• A/Calif/07/2009(H1N1)
• Made by the same manufacturers and by same
  processes as the Trivalent Vaccine for seasonal
  influenza
• 250 million doses purchased by US Govt.
• Producing about 20 million doses/week

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Who gets H1N1 vaccine?

• Same indications as for seasonal influenza
  
  (especially children gt 6mon-24yrs, care providers
  to children, pregnant women, healthcare
  emergency personnel, high risk conditions age
  25-64yrs)
• Shots recommended for ages gt 6mon
• Spray recommended for ages gt 2 years

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H1N1 Quick Facts

• 98 of current circulating influenza cases
• Only 1 of cases are gt 65 years old
• 4x risk of miscarriage if pregnant

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Offering Other Vaccines?

• Pneumococcal 23-valent (Pneumovax)?
• Streptococcus Pneumoniae
• Not just for pneumonia!
• More efficacious for bacteremia than pneumonia
  (85-90 of serotypes)

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Who Gets Pneumococcal Vaccine?

• Adults gt 65 years old
• Age 19-64 who smoke or have asthma
• Age 2-64 years with chronic illnesses
• -Cardiovascular, Pulmonary, Metabolic,
  Immunosupression, Asplenia, Hepatic, Renal
  Disease
• ACIP recommendations
• www.cdc.gov/vaccines/pubs/acip-list.htm

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Dosing of Pneumococcal Vaccine

• 0.5ml IM (or SQ if you like the pain!)
• For ages gt 65 years one time dose if 1st time
  receiving.
• For patients who got 1st dose PRIOR to age 65
  years, should get a 2nd dose at age 65years or
  after, once 5 years have passed since 1st dose.

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Can vaccines cause Guillain-Barre Syndrome?

• Immune Dysfunction where system attacks itself
  causing nerve damage.
• Can cause permanent nerve damage, paralysis or
  death.
• Rare but can happen with any infection.
• Finding with some vaccines
• BUT NOT at a higher rate in people being
  vaccinated (no causual data found)
• www.iom.edu

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Statistically ?

• 1976-increased risk by 1 in 100,000 people who
  received swine flu vaccine
• (reason undetermined.)
• Recently 1 in 1,000,000 vaccinated for seasonal
  flu may be at risk.

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Institute of Medicine Safety Review

• Vaccines and autism
• Thimerosal-containing vaccines and
  neurodevelopmental disorders
• Vaccines and Sudden Infant Death
• Multiple vaccines and immune dysfunction
• Influenza and neurological complications

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• www.iom.edu/CMS/2955.aspx
• Look at executive summaries for information on
  each

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Credible Vaccine Websites

• www.cdc.gov/vaccines
• www.immunize.org
• www.who.int/immunization_safety_quality/approved_v
  accine_safety_websites/en/index.html

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Anti-Vaccine Groups

• National Vaccine Information Center
• Alliance for Informed Choice in Vaccination
• Healthy Alternatives
• People Advocating Vaccine Education
• Vaccine Information Resource Center
• Natural Immunity Information Network

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Lets Go Vaccinate!

• Patients make vaccine decisions based on
• Perceived susceptibility to the disease
• Perceived seriousness of the disease
• Perceived vaccine benefits
• Perceived barriers (adverse reactions, access,
  cost, time)
• Social Influence (friends, family, healthcare
  workers)

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Misconceptions About Vaccines

• Diseases were disappearing before vaccines
• No need to continue vaccinating
• Vaccines cause harmful effects
• People with disease were vaccinated
• Hot lots of vaccine exist
• Multiple vaccinations cause system overload
• www.who.int/immunization_safety/aefi/immunization_
  misconceptions

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Adverse Events Following Influenza Vaccination

• TIV shots- Injection Site soreness
• LAIV spray mild form of natural disease
• Syncope
• Anaphylaxis

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Treating Serious Adverse Events

• Allow for fainting without injury, plus access to
  hard surface if need CPR
• Epinephrine 0.01mg/kg up to 0.5mg repeat every
  5-10min
• Train staff and practice emergency plan
• 911 (EMS) epinephrine CPR/BLS

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True vs. False Allergy

• True Immediate hypersensitivity (typically
  within minutes)
• -itching, erythema, hives, urticaria symptoms
  progressing toward anaphylaxis
• (shock, angioedema, severe bronchospasm,
  cardiovascular collapse)
• False allergy
• Fever, GI upset, neurologic events

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Vasovagal Syncope

• Loss of consciousness
• Extreme paleness
• Sweating
• Coldness of hands and feet
• Nausea
• Light-headedness
• Dizziness
• Visual disturbances

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Frequency and timing

• 63 with lt 5 minutes post-vaccination
• 8 within 15 minutes of vaccination
• 35 reported in patients age 10-18 years
• 71 reported in women
• 14 of episodes result in hospitalization
• (from injuries.)
• Observe patient for suitable time after
  vaccination. ACIP guidelines 15 minutes

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Screening and Consulting

• Have you ever reacted to a vaccine?
• Do you have allergies to food, medications
  vaccines? (Especially EGGS for influenza)
• Do you have any medical conditions?
• Do you or anyone in your care or household have
  cancer, HIV, take prednisone?
• Hare you sick today?

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Vaccine Information Statement

• Provide to each patient/caregiver
• -updated annually
• -provides an overview of benefits and risks of
  vaccination
• -required by law to provide patients with most up
  to date version
• www.cdc.gov/vis
• www.immunize.org

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Obtain Informed Consent

• Provides documentation
• Provides record for patient (must be kept for the
  patients lifetime)
• Decreases liability/litigation

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Documentation Requirements

• Name of patient
• Date vaccine administered
• Vaccine Manufacturer
• Vaccine Lot Number
• Name, address, title of person administering the
  vaccine
• Date printed on VIS
• Date the VIS given to patient or representative

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National Vaccine Injury Compensation Program

• Act passed in 1986
• Excise tax levied each dose of vaccine sold in
  the United States.
• No fault insurance fund to cover vaccine-related
  injuries.
• If patient experiences an event listed, the
  patient can be awarded damages through the VICP
  fund.
• Must file a claim with the VICP, satisfy
  eligibility requirements to receive compensation.

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• The reward for work well done is the opportunity
  to do more.
• -Jonas Salk

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VAERS

• Vaccine Adverse Events Reporting System
• Alerts manufacturers and CDC of adverse events
• www.vaers.hhs.gov
• Or www.cdc.gov/vaccinesafety