“Prevent all the Disease You Can… Then Treat the Rest.” Preventing Influenza “Prevent all the Disease You Can… Then Treat the Rest.” John D. Grabenstein

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

Target groups for Influenza Vaccination: Children age 6 months through 18 years old Pregnant women Caregivers Healthcare workers Elderly (>= 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.

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 >38C. It only lives in the upper respiratory tract and and can cause “Influenza-like Illness”, but not the full blown disease.

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

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 < 9 years old?

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

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 >= 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

Inactivated Influenza Vaccine Age 6-35 mon (<3 years) = 0.25ml IM (2 doses if first time, 1 month apart) Age 3 to < 9 years = 0.5ml IM >= 9 years – adults = 0.5ml IM

Not All IM Vaccines Created Equal! Only Fluzone approved for all ages (6 months through adult) Fluvirin only approved for age >= 4 years through adult Afluria, Fluarix, FluLaval only for age >=18 years to through adult

Who should not get TIV shots? Allergic to eggs Younger than 6 months old

How do I store my flu shots and Spray? Refrigerated at 2-8C (35-46F) Do not Freeze

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

Who gets H1N1 vaccine? Same indications as for seasonal influenza: (especially children > 6mon-24yrs, care providers to children, pregnant women, healthcare & emergency personnel, high risk conditions age 25-64yrs) Shots recommended for ages > 6mon Spray recommended for ages > 2 years

H1N1 Quick Facts 98% of current circulating influenza cases Only 1% of cases are > 65 years old 4x risk of miscarriage if pregnant

Offering Other Vaccines? Pneumococcal 23-valent (Pneumovax)? Streptococcus Pneumoniae Not just for “pneumonia!” More efficacious for bacteremia than pneumonia (85-90% of serotypes)

Who Gets Pneumococcal Vaccine? Adults >= 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

Dosing of Pneumococcal Vaccine 0.5ml IM (or SQ if you like the pain!) For ages >= 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.

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

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.

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

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

Credible Vaccine Websites www.cdc.gov/vaccines www.immunize.org www.who.int/immunization_safety_quality/approved_vaccine_safety_websites/en/index.html

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

Let’s “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…)

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

Adverse Events Following Influenza Vaccination TIV shots- Injection Site soreness LAIV spray – mild form of natural disease Syncope Anaphylaxis

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

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

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

Frequency and timing 63% with =< 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

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?

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

Obtain Informed Consent Provides documentation Provides record for patient (must be kept for the patient’s lifetime) Decreases liability/litigation

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

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.

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

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