FLU VACCINE ADMINISTRATION 2019-2020 *

Seasonal vs  Pandemic *

What is Influenza? Influenza is a highly contagious respiratory viral illness Caused by various types of influenza viral strains Rates of infection are highest among children Rates of serious illness and death are highest among persons aged >65 years, children aged <2 years, and persons of any age who have medical conditions that place them at increased risk for complications *

Human Influenza Viruses 4 antigenic types – A, B, C and D Epidemics caused by types A and B C is never in Vaccine and D is primarily affect cattle *

Influenza Antigenic Changes Influenza A viruses subtyped by 2 surface antigens, hemagglutinin (H1,H2,H3) and neuraminidase (N1,N2) Antigenic drift: Slight change-frequent small mutations in the H and N antigens Antigenic shift: Major change-marked change in the H or N antigen due to replacement with a different one from another virus, or introduction of new virus strain. Diarrhea & vomiting are more common in children. Many illnesses, including the common cold, can have similar symptoms. * 5

CDC Naming Flu Virus The antigenic type (e.g., A, B, C) The host of origin (e.g., swine, equine, chicken, etc. For human-origin viruses, no host of origin designation is given.) Geographical origin (e.g., Denver, Taiwan, etc.) Strain number (e.g., 15, 7, etc.) Year of isolation (e.g., 57, 2009, etc.) For influenza A viruses, the hemagglutinin and neuraminidase antigen description in parentheses (e.g., (H1N1), (H5N1) *

2019-2020 Quadrivalent A/Brisbane/02/2018 (H1N1)pdm09-like virus (updated) A/Kansas/14/2017 (H3N2)-like virus (updated) B/Colorado/06/2017-like (Victoria lineage) virus B/Phuket/3073/2013-like (Yamagata lineage) virus Phuket Thailand

Influenza Type A (Pandemics) Year Subtype Severity 1889 H3N2 Moderate 1918 (Spanish) H1N1 Severe 1957 (Asian) H2N2 1968 (Hong Kong) 1977 Mild 2009

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Epidemiology Flu related hospitalizations in US: 2010-2011 to 2015-2016 140,000-710,000 2015-2016 310,000 PEAK INCIDENCE: Winter outbreaks lasting 5 to 6 weeks PREDOMINANT SEX: none PREDOMINANT AGE: Infection rates are higher among children than adults, although children are less prone to develop pulmonary complications *

Peak Month of Flu Activity 1982-1983 through 2017-2018 https://www.cdc.gov/flu/about/season/flu-season.htm *

Is it the flu or the common cold? “Common cold” and “flu” are syndromes of familiar symptoms caused by viral infection of the upper respiratory tract. The best predictors for influenza are cough and fever. *

Influenza Respiratory transmission Viral shedding in respiratory secretions for 5- 10 days. Shedding begins BEFORE onset of symptoms Incubation period 1-3 days Abrupt onset of fever, myalgia (muscle pain), sore throat, nonproductive cough, headache *

Transmission of Influenza Primarily droplet (spread by coughing, sneezing, etc.) Can survive on hard, non-porous surfaces for 24-48 hours (such as door knobs) Survive on cloth paper and tissue for 8-12 hours Survives on hands for 5 minutes *

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Symptoms: Sudden Onset Fever Sore Throat Headache Rhinitis (runny nose) Myalgia (muscle pain) Diarrhea & Vomiting Non-productive Cough Otitis media (infection or inflammation of the middle ear) and nausea are also commonly reported among children *

Treatment for Influenza Rest Adequate fluid intake Antipyretics and analgesics (fever and pain reducers) *

Possible Complications of Viral Influenza: Pneumonia Ear infections Sinus infections Dehydration Worsening of chronic medical conditions, such as congestive heart failure, asthma, diabetes *

Yearly vaccination is most important! Primary Prevention Yearly vaccination is most important! -Cover your nose and mouth when you cough or sneeze -Wash your hands often with soap and water (Alcohol- based hand cleaners are also effective) -Avoid close contact with sick people -If you are sick, stay home and limit contact with others -Avoid touching your eyes, nose, or mouth -Take anti-virals – if recommended by healthcare provider. *

Injectable Quadrivalent inactivated influenza vaccine (QIV) >6 months Dead virus IM 0.5ml pre-filled syringes *

Latex….. None of the tip caps and plungers of the prefilled syringes, or the vial stoppers are made with natural latex 22

People at Increased Risk of Influenza Complications Children ages 6 months through 5 years Adults 65 years of age and older Pregnant women ( and up to 2 weeks post partum) Residents in nursing homes and other long-term care facilities American Indians and Alaska Natives People who have medical conditions *

At Risk continued Adults and children who are immunosuppressed Chronic health conditions Residents of nursing homes/chronic-care facilities *

Health Care Providers: Transmission Sources Health Care Providers: People who provide home care to persons in groups at high risk People working in health-care settings include physicians, nurses, and other workers in hospitals, long term care facilities, assisted living and outpatient-care settings Medical emergency response workers Students in these professions who will have contact with patients *

Influenza Vaccine Clinic in the School or Mass Setting Influenza viruses undergo frequent antigenic change (i.e., antigenic drift) and vaccine is updated annually. Persons recommended for vaccination must receive an annual vaccination against the influenInza viruses forecasted to be in circulation. If vaccine supply is limited, priority for vaccination is typically assigned to persons in specific groups and of specific ages who are, or are contacts of, persons at higher risk for influenza complications * 28

Everyone greater than 6 months old Recommendations Everyone greater than 6 months old 29

Injectable Vaccine Fast Facts Antibodies develop approximately 2 weeks after vaccine Common reactions (Injectable) Soreness/erythema/induration at site lasting 1-2 days (15-20%) Fever/chills/malaise/myalgias lasting 1-2 days (<1%) Rare: Immediate hypersensitivity allergic reactions (hives/angioedema/allergic asthma/systemic anaphylaxis) 30

Contraindications for all Influenza Vaccine People who had a severe (anaphylactic) reaction to chicken eggs People who had a severe reaction to a flu vaccination in the past Children <6mo of age People who developed Guillain-Barre' syndrome following influenza vaccination (requires a consultation with patient’s physician) *

Vaccine Administration Sites: Infants (birth to 11 months old): vastus lateralis (anterolateral thigh) Young children over the age of 12 months-anterolateral aspect of the thigh may be used if the deltoid is underdeveloped Adults and older children: deltoid (upper arm) *

Injection Technique “Nursing 101” * 33

Injection Technique “Nursing 101” Determine appropriate injection site *

2. Prep site with alcohol wipe/cotton ball 3. Using circular motion/wipe from center out/allow to dry *

4. Spread skin taut between thumb and forefinger OR grasp tissue and “bunch up” muscle. (acceptable for pediatric and geriatric patients) 5. Insert needle fully into muscle at 90 degree angle and inject vaccine quickly. The most frequent complication of influenza is pneumonia, most commonly bacterial pneumonia (like Staph and Strep pneumonia) Complications of flu can include bacterial pneumonia, ear infections, sinus infections, and worsening of chronic medical conditions, such as congestive heart failure, asthma, or diabetes. Other possible serious complications triggered by flu can include inflammation of the heart (myocarditis), brain (encephalitis) or muscle (myositis, rhabdomyolysis) tissues, and multi-organ failure (for example, respiratory and kidney failure). Flu virus infection of the respiratory tract can trigger an extreme inflammatory response in the body and can lead to sepsis, the body’s life-threatening response to infection. Flu also can make chronic medical problems worse. For example, people with asthma may experience asthma attacks while they have the flu, and people with chronic heart disease may experience a worsening of this condition triggered by flu. *

Aspiration Aspiration is the process of pulling back on the plunger of the syringe prior to injection to ensure that the medication is not injected into a blood vessel. Although this practice is advocated by some experts, the procedure is not required with immunizations because no large blood vessels exist at the recommended injection sites. ADH Policy and Procedures require aspiration with giving injections…..except Immunizations.  Note:  Effective 08/01/2008 Policy – “When giving immunizations, aspiration is at the nurse’s discretion”.  Patient Care & Laboratory Services Volume 2 –   PATIENT CARE SERVICES – Page PRO-24a, #13.   *

2-3 finger breaths below top of shoulder *

Muscle Tissue • Intramuscular (IM) injections are administered into muscle tissue below the dermis and subcutaneous tissue. Needle Gauge & Length - 1 inch - 23- to 25-gauge needle Muscle Tissue Fatty (Subcutaneous) Tissue Dermis 90° Angle 39

Needle Safety ADH utilizes prefilled syringes with safety needles If safety needles are not available or the cover fails or malfunctions…. Dispose of the entire unit in biohazard container- never recap, remove or break used needles If a needle stick injury occurs-report IMMEDIATELY to the nursing coordinator 40

“Nursing 101” Withdraw needle and apply light pressure to site for several seconds with dry cotton ball or gauze Dispose of needle in sharps container. It is recommended each nurse have a sharps container (not shared). Take your time……Needle sticks require source testing as well as vaccinator * 41

Positioning & Comforting Restraints For a child, the parent/guardian should be encouraged to hold the child during administration. If the parent is uncomfortable, another person may assist or the patient may be positioned safely on a table or lap. 42

Comforting Restraints For infants and toddlers: This method involves the parent in embracing the child and controlling all four limbs. It avoids “holding down” or overpowering the child, but it helps you steady and control the limb of the injection site. 43

Comforting Restraints Cont… Have parent hold the child on their lap. 1. One of the child's arms embraces the parent’s back and is held under the parent's arm. 2. The other arm is controlled by the parent's arm and hand. For infants, the parent can control both arms with one hand. 3. Both legs are anchored with the child's feet held firmly between the parent's thighs, and controlled by the parent's other arm. 44

Comforting Restraints Cont… For kindergarten and older children: Hold child on parent’s lap or have the child stand in front of the seated parent. 1. Parent's arms firmly embrace the child during the process. 2. Both of child’s legs are firmly held between parents legs. 45

Mild problems Some children and adolescents 2-17 years of age have reported: Some adults 18-49 years of age have reported: Runny nose, nasal congestion or cough Fever Headache and muscle aches Wheezing Abdominal pain or occasional vomiting or diarrhea Runny nose or nasal congestion Sore throat Cough, chills, tiredness/weakness Headache

Severe problems Life-threatening allergic reactions to vaccines are very rare. If they do occur, it is usually within a few minutes to a few hours after the vaccination.

Live Attenuated Influenza Vaccine [LAIV] (The Nasal Spray Flu Vaccine) The nasal spray is approved for use in non-pregnant individuals, 2 years through 49 years of age. People with some medical conditions should not receive the nasal spray flu vaccine Do not use aspirin in children because of possible complications with certain viral infections 48

Administration of LAIV *

Step 1-Remove Rubber Protector Tip *

Step 4-Pinch and remove dose-divider clip from plunger. *

Step 2-With the patient in an upright position, head tilted slightly back, place the tip just inside the nostril to ensure FluMist is delivered in the nose. *

Step 3-With a single motion, depress plunger as rapidly as possible until the dose-divider prevents you from going further. *

Step 4-Pinch and remove dose-divider clip from plunger. *

Step 5-Place the tip just inside the other nostril and with a single motion, depress plunger as rapidly as possible to deliver remaining vaccine. *

Step 6-Dispose of plunger by placing into the sharp’s container. *

Nursing Non ADH and ADH Non-Clinical Non-ADH nurses Attend orientation Provide current Arkansas Nursing License Picture ID (Driver’s License) Sign Volunteer Indemnity form Sign HIPPA form *

Preparation/Screening Each nurse should always be aware of their role when administering vaccines, and the patient’s role when receiving vaccines All patients should be screened for contraindications and precautions Parents/guardians and patients should be encouraged to take an active role before, during, and after the administration of vaccines 58

Inspecting Vaccine Each vaccine vial/syringe should be carefully inspected for damages or contaminates prior to use. The expiration date printed on the vial box should be checked before use. Vaccine can be used through the last day of the month indicated by the expiration date unless otherwise stated on the package labeling. Expired vaccine should never be used. Frozen vaccine should never be used. 59

Review Flu Form

Anaphylaxis (a life-threatening acute allergic reaction) – Each facility that administers vaccines has protocol, procedures and equipment to provide initial care for suspected anaphylaxis. Facility staff should be prepared to recognize and respond appropriately to this type of emergency situation. All staff should maintain current CPR certification. Emergency protocols, procedures and equipment/supplies should be reviewed periodically. Although both fainting and allergic reactions are rare, vaccine providers should strongly consider observing patients for 15 minutes after they are vaccinated. 68

Infection Control Healthcare providers should follow “Standard Precautions” to minimize the risks of spreading disease during vaccine administration. Hand washing - The single, most effective disease prevention activity is good hand washing. Hands should be washed thoroughly with soap and water or cleansed with an alcohol-based waterless antiseptic between patients, before vaccine preparation, or any time hands become soiled. Gloving - Gloves are not required to be worn when administering vaccines unless the person administering the vaccine is likely to come into contact with potentially infectious body fluids or has open lesions on their hands. Remember gloves cannot prevent needle stick injuries. 69

Infection Control Needle stick Injuries - should be reported immediately to the site supervisor, with appropriate care and follow-up given as directed by state/local guidelines. Safety needles or needle-free injection devices should be used if available to reduce the risk of injury. Equipment Disposal - All used syringe/needle devices should be placed in puncture proof containers to prevent accidents or reuse. 70

Remember… If you need more vaccine, supplies, etc., be sure to let your instructor know and he/she will report to an ADH staff person. Any needle sticks must be reported immediately. Any wasted vaccine must be reported. Add needle to syringe when patient presents to your table. *

Flu Clinic Day Dress appropriately -Mass clinic is outside An ADH nursing coordinator will be at each clinic site for your assistance Locate emergency kit at each site Adjust your work area to accommodate you-place your sharps container readily accessible Review each form for consent and contraindications All questions should be answered Complete and sign form Wear your ID 72

THANK YOU! You have now been a part of our Flu initiative You have helped make Arkansas a healthier state We appreciate you being a part of our team and welcome feedback on how to improve 73