General Recommendations on Immunization and Medication Dispensing

Learning Objectives At the end of section 1 & 2 the EMT will be able to: List the type of vaccine that will be administered, indications, contraindications and precautions, dosage and side effects. State when an EMT is permitted to administer vaccines List the anatomic sites for intramuscular injections for patients of various ages

Learning Objectives List the appropriate steps for intramuscular injections Demonstrate the safe administration of vaccine Understand the EMT role in an emergency medication dispensing situation NOTE: This course will prepare you specifically for influenza administration. Just in time training will occur should there be a situation of another vaccine preventable disease that emerges.

When is an EMT Permitted to Administer Influenza Vaccinations? Must posses a valid immunization endorsement During a Nevada State Health Division training exercise or public vaccination clinic During a local health authority exercise or public vaccination clinic When there is an actual epidemic or emergency declared by the Governor and the assistance of state agencies is needed to supplement local efforts Under the direct supervision of the local health officer or designee of the jurisdiction in which the immunization is administered or the medication is dispensed or in which the emergency or need exists

Principles of Vaccination General Rules All vaccines can be administered at the same visit as all other vaccines. Vaccine doses must not be administered earlier than the minimum age, e.g., in regards to influenza vaccine, an infant must be at least 6 months of age Vaccine cannot be administered at intervals less than the minimum interval

Spacing of Vaccine Seasonal Influenza Minimum Interval IM Injection Nasal Spray H1N1 Information to follow Minimum Interval 4 weeks

Violation of Minimum Intervals or Minimum Age ACIP recommends that vaccine doses given up to four days before the minimum interval or age be counted as valid Immunization programs and/or school entry requirements may not accept all doses given earlier than the minimum age or interval

Effectiveness of Influenza Vaccine Effective in protecting up to 90% of healthy vaccinees younger than 65 years of age from illness 30%-40% effective in preventing illness among persons 65 years of age and older However, among those 65 years and older, the vaccine is effective in preventing complications and death. Among the elderly the vaccine is 50%-60% effective in preventing hospitalization and 80% effective in preventing death.

Trivalent Inactivated Influenza Vaccine (TIV) Inactivated flu vaccine contains three viruses, two type A and one type B Vaccine is grown in chicken eggs and the final product contains residual egg protein Available in pediatric and adult formulations All adult formulations are delivered in 0.5cc dose; children aged 6 months to 35 months receive 0.25 cc

TIV, Continued Available with thimerosal (a mercury derivative) as a preservative or preservative free Multi-Dose Vials have thimerosal Single-dose syringes do not have preservative Several manufacturers: Read the Label!! Different manufacturers may be licensed for different age groups

Live Attenuated Influenza Vaccine (LAIV) Contains the same viruses as TIV The viruses are cold adapted and replicate in the mucosa of the nasopharynx Grown in chicken eggs and contains residual egg protein Vaccine is provided in a single dose sprayer

LAIV, Continued Provided in a single dose sprayer Half the dose is delivered into each nostril Does not contain thimerosal Approved for use only in healthy, non-pregnant persons aged 2-49 years of age

Considerations for LAIV Cannot be given within 4 weeks of another live vaccine; OK if given the same day TB skin test must be given the same day, or wait 4 weeks Persons must not have: Chronic medical conditions Pregnancy Lung disease Diabetes Immunosuppression

Vaccine Adverse Reactions Adverse reaction (vaccine side effect) Any medical event following vaccination Local, systemic and allergic Local Most frequent, least severe Systemic Generalized events Allergic (rare) Severe

Vaccine Adverse Reactions Local pain, swelling, redness at site of injection common with inactivated vaccines usually mild and self-limited

Vaccine Adverse Reactions Systemic fever, malaise, headache nonspecific may be unrelated to vaccine such as a concurrent viral infection, stress or excessive alcohol consumption Allergic: hives or anaphylactic

Reactions Specific to Live Attenuated Vaccine Runny nose, nasal congestion Sore throat in adults Other Considerations: if a person is taking antivirals, they must wait 48 hours after their last dose to receive LAIV

Vaccine Adverse Event Reporting System (VAERS) www.vaers.hhs.gov

Contraindication A condition in a recipient that greatly increases the chance of a serious adverse reaction

Precaution Similar to a contraindication, a precaution is condition in a recipient that might increase the chance or severity of an adverse reaction With a precaution, is a person is at high risk for the disease, a provider may choose to vaccinate and treat the adverse condition. In our clinic, we obtain a specific doctor’s order to vaccinate with a precaution.

Contraindications and Precautions Permanent contraindications to vaccination: Severe allergic reaction to a vaccine component or following a prior dose Encephalopathy not due to another identifiable cause occurring within 7 days of pertussis vaccination

Vaccination of Pregnant Women Live vaccines should not be administered to women known to be pregnant In general, inactivated vaccines may be administered to pregnant women for whom they are indicated

Immunosuppression Corticosteroids 20 mg or more per day of prednisone* 2 mg/kg or more per day of prednisone* NOT aerosols, alternate day, short courses, topical *for 14 days or longer

Vaccination of Immunosuppressed Persons Live vaccines should not be administered to severely immunosuppressed persons Inactivated vaccines are safe to use in immunosuppressed persons but the response to the vaccine may be decreased

Invalid Contraindications to Vaccination Allergy to products not present in vaccine or allergy that is not anaphylactic Antimicrobial therapy Breastfeeding Disease exposure or convalescence Family history of adverse events

Invalid Contraindications to Vaccination Mild illness Multiple vaccines Pregnant or immunosuppressed person in the household Preterm birth Tuberculin skin testing

Screening Questions Is the child (or are you) sick today? Does the child have an allergy to any medications, food, or any vaccine? Has the child had a serious reaction to a vaccine in the past? Has the child had a seizure, brain or nerve problem? Does the child have cancer, leukemia, AIDS, or any other immune system problem?

INFLUENZA VACCINE SCREENING QUESTIONNAIRE PLEASE PRINT Name ______________________________________________________________ Gender o F o M Address ______________________________________________________________ Medicaid _________ City/State/Zip Code ____________________________________________________ Phone ( ) Birthdate________________ Age Today ____ mm/dd/yyyy) Is the person to be vaccinated sick today? o Yes o No Has the person to be vaccinated had an allergy or reaction to a vaccine or vaccine component in the past? o Yes o No Is the person to be vaccinated allergic to eggs? o Yes o No Is the person to be vaccinated allergic to thimerosol? o Yes o No Does the person to be vaccinated have Guillain-Barré syndrome? o Yes o No Does the person to be vaccinated have long-term health problems with heart disease, lung disease, asthma, kidney disease, metabolic, disease (e.g. diabetes), anemia or other blood disorders? oYes o No Does the person to be vaccinated have an immunodeficiency disease (such as HIV/AIDS) or have a weakened immune system (immunosuppressed)? o Yes o No Has the person to be vaccinated been vaccinated against influenza in the past? o Yes o No Is the person to be vaccinated pregnant? o Yes o No I have read and truthfully answered the questions above. I have also received a copy of the Influenza Vaccine Information Statement. My signature indicates my permission for Influenza Vaccine to be given to me or my child. Signature ________________________________________________________________ Date _______________ PLEASE DO NOT WRITE BELOW

Documentation, Continued Screened By: _____________________________    Administered By:__________________________ ***Highlight Vaccine Type***        Vaccine Manufacturer Lot# Exp. Date Site Fluzone 6-35 months Sanofi-Pasteur   90655 IM       Fluzone 36 months + Sanofi-Pasteur   90658 IM       Fluarix 18yrs + GSK  90658 IM  FluMist Intranasal 2-49 yrs MedImmune  90660 Nasal  MedImmune Nasal: Persons who should not be vaccinated with FluMist: • persons aged less than 2 years or those over 49 years • children aged 2 - 4 years with asthma or chronic wheezing • persons with an allergy to eggs• children or adolescents receiving aspirin or other salicylates • persons with these underlying medical conditions: −pregnant women  −heart disease −anemia or other blood disorders −lung disease −immunodeficiency diseases (HIV/AIDS)    −kidney disease −immunosuppressed states   −metabolic diseases (e.g., diabetes)   

Vaccination During Acute Illness No evidence that acute illness reduces vaccine efficacy or increases vaccine adverse reactions Vaccines should be delayed until the illness has improved Mild illness, such as otitis media or an upper respiratory infection, is NOT a contraindication to vaccination

National Immunization Program Contact Information Telephone 800.CDC.INFO Email nipinfo@cdc.gov Website www.cdc.gov/nip

Reference List Atkinson, W., Wolfe, C., Humiston, S., Nelson, R. (Eds). (2004). Epidemiology and Prevention of Vaccine-Preventable Diseases. Washington, DC: U.S. Department of Health and Human Services. Center for Disease Control. (2003). Guide to Contraindications to Vaccinations. Washington, DC: U.S. Department of Health and Human Services. Center for Disease Control. (2002). Parents Guide to Childhood Immunizations. Washington, DC: U.S. Department of Health and Human Services. World Health Organization. (2005, January 7). Weekly epidemiological record. Switzerland. (ISSN 0049-8114). www.cdc.gov www.cdc.gov/mmwr/preview www.immunize.org

Immunization Record Fill in the following information: Date Manufacturer’s name Lot numbers VIS sheet Date Site of immunization Your signature and title

Demonstration Documentation: Clinic record and patient record VAERS forms Screening tool Where to find vaccine lot# and expiration date Where documents are stored

Dispensing Prophylaxis Medications The Strategic National Stockpile (SNS) of the Centers for Disease Control (CDC) is a federally owned and managed national repository of antibiotics, antivirals, chemical antidotes, antitoxins, life support pharmaceuticals, vaccines, PPE and other life support materials. The mission of the SNS is to rapidly provide these items in a safe manner to supplement and resupply any community in Nevada in the event that local capacities are exceeded or are about to be exceeded due to a weapon of mass destruction or a major natural or technological disaster.

Medications The most likely medications to be dispensed using a POD (point of distribution) include: Ciprofloxacin (antimicrobial) Doxycycline (antimicrobial) Oseltamivir (Tamiflu®; antiviral) Zanamivir (Relenza®; antiviral) Information on these drugs included in class hand-out

POD Leadership The POD staff follow a command structure led by the POD Manager. Medication dispensing falls under the Medical Branch Director, who oversees: Screening Medication dispensing Vaccination operations Staff

Medical Branch Operations Role of Screeners Thoroughly read the medication fact sheets and dispensing algorithm prior to starting your shift; pay special attention to pediatric dosing instructions within the dispensing algorithm; review the completed client screening form and clearly circle the recommended medication and dose; direct the client to the dispensing area Role of Express Medication Dispensers Hand client a bottle of medication for all household members and one medication information sheet. Do not write the client’s name on the medication bottles

Medical Branch Operations Role of Medication Dispensers Review the client’s completed screening form Write the client’s name on the recommended medication bottle and hand the medication to the client. Client receives an information sheet for each type of medication dispensed Screeners and Medication Dispensers Purpose if to dispense medication to as many people as possible, as quickly as possible. The POD is a dispensing site only, not a clinic Instruct clients to contact their personal medical provider or City telephone call-line or visit the City website if they have any questions after leaving the POD

Medical Branch Operations Role of Screener Unit Leader and Medication Dispensing Unit Leader Supervise screeners/medication dispensers and answer their questions

Just in Time Training This course gave a rough overview. Just in time training will take place just prior to opening a medication POD to go over forms, exact medication dispensed and frequently asked questions.

Medication Demonstration Will Cover Informed consent Screening forms Patient teaching What to do if there is a severe reaction