1. Vaccination Training for Health Care Providers Betsy Hubbard, RN, MN Immunization Clinical Practice Supervisor Colleen Woolsey PhD, ARNP, MSN H1N1 Flu Training Coordinator

2. Agenda--1 Overview & Introductions Flu Disease & Flu Vaccine Intramuscular Injection Immunization Techniques Video Skills practice 1: Drawing up vaccines & using safety syringes Locating IM injection landmarks Skills Practice 2: Locating IM injection sites

3. Agenda--2 Skills Practice 3: FluMist administration Giving Vaccines in a Medication Center Adverse Reactions Skills Practice 4: Positioning & comforting restraint Skills Practice 5: Locating IM injection sites on adult and child arm and leg Skills Practice 6: Use of Triage Algorithm Q&A and Evaluation

4. What is the flu? Highly infectious viral illness Characterized by abrupt onset of fever, dry cough, muscle aches and malaise Cough and malaise may persist up to two weeks Transmitted by respiratory droplets Seasonal flu season typically occurs late fall through spring

5. Flu can complicate underlying medical conditions, causing…. Bacterial infections Pneumonia Sinus and ear infections in children Increased risk of stroke, MI, and heart failure Increased blood sugar in diabetics Death

6. How is influenza transmitted? Large-particle respiratory droplets (infected person coughs or sneezes near a susceptible person) Requires close contact (<6 feet) Novel A H1N1 probably spread in ways similar to other flu viruses

7. Transmission of Influenza Other possible sources of transmission: Contact with contaminated surfaces Via droplet nuclei--also called airborne transmission (particles stay suspended in the air) All respiratory secretions and bodily fluids (diarrheal stool) of novel influenza A (H1N1) cases should be considered potentially infectious

8. Distribution by Age Group of Cases Hospitalized with Pandemic H1N1 July 2009 *April 12–June 30

12. Health Care Workers: Protect Yourself, Protect Your Clients Individuals are contagious for 1 to 4 days before the onset of symptoms and about 5 days after the first symptom About 50% of infected people do not have any symptoms but are still contagious Health care workers are frequently the source of influenza transmission in health care settings

13. Influenza Vaccine

14. Why immunize? Flu is a serious illness, the cause of 36,000 deaths each year in the U.S. Immunizations are first line of defense: 70-90% effective in <65 yrs; 30-40% in frail elderly Immunizations prevent serious illness, hospitalization and death

15. Groups at Increased Risk for Seasonal Flu Complications Children less than 5 years old Persons aged 65 years or older People age <18 years who are on long-term aspirin therapy (risk of Reye syndrome) Pregnant women Adults and children with chronic medical conditions Adults and children who have immunosuppression (caused by medications or by HIV) Residents of nursing homes and other chronic-care facilities

16. H1N1 vaccine Target groups for vaccination All pregnant women People who live with or care for children age < 6 months Healthcare and emergency services personnel All people ages 6 months through 24 years Persons ages 25 through 64 years with chronic medical conditions

17. Who Should Not Be Immunized? Anyone with: Severe (anaphylactic) allergy to eggs, gentamycin or a previous dose of influenza vaccine. Moderate to severe illness, with or without fever History of *GBS within 6 weeks after a previous flu shot.

18. Flu Vaccine Formulations Seasonal flu vaccine Trivalent inactivated influenza vaccine (TIV) Ten-dose vial Prefilled syringe 0.25 ml and 0.5 ml Live attenuated influenza vaccine (LAIV) Novel H1N1 –monovalent versions of the same formulations Age range for vaccines and formulations differs by manufacturer

19. Flu Vaccine Strains Seasonal flu vaccine components usually change every year 2009-10 vaccine has: A/Brisbane (H1N1), A/Brisbane (H3N2), and B/Brisbane Novel H1N1 vaccine (A/California) licensed as change of strainwould have been in seasonal flu vaccine if outbreak had started earlier in the spring

20. Flu Vaccine Dosage TIV and Novel H1N1 0.5 ml--Children 3 years through adult 0.25 ml--Infants/toddlers age 6-35 months LAIV (seasonal and novel H1N1) 0.2 ml (intranasal) Two doses of vaccine 4 weeks apart are needed the first year they get it for: children under age 9 years for seasonal flu children under age 10 years for novel H1N1

21. Thimerosal Free Influenza Vaccine--1 Thimerosal is a preservative containing ethyl mercury used in vaccines since 1930s No conclusive scientific evidence of harm from exposure to thimerosal Studies of risk were of methyl mercury In 1999, USPHS recommended eliminating thimerosal in vaccines for infants, as a precaution and to retain trust in vaccine supply

22. Thimerosal Free Influenza Vaccine--2 Influenza vaccine in multi-dose vial contains 25mcg/dose Manufacturers make a limited amount of thimerosal-free (<1mcg /dose) flu vaccine Benefits of flu vaccine outweigh any theoretical risk from thimerosal Washington law requires that children <3 years and pregnant women be given thimerosal-free vaccine, as of 7/1/2007

23. Thimerosal Free Influenza Vaccine--3 Emergency suspension of thimerosal law for H1N1 vaccine only, as of 9/24/09 Can give thimerosal-containing vaccine to children <3 years and pregnant women, BUT must give notice of the suspension to: Everyone < 18 years Pregnant and breastfeeding women

24. 10 minute break Break out Health Educators

25. Use the correct needle length for IM injections 1 minimum needle recommended 1½ to 2 needle for larger arm Longer needles: Hurt less Cause fewer local reactions 1 Assures proper route and a valid dose of vaccine Diggle L, Deeks J. BMJ 2000;321(7266):931-33.

26. Needle gauge Determine appropriate needle gauge IM: 22 - 25 gauge Lower gauge number = bigger needle Use for more viscous medications Usual needle length/gauge for IM vaccines is 25 G 1

27. Syringes Use 3 cc syringes for vaccine Vanish Point safety syringes have needle attachedvarious sizes and gauges Manufacturer-prefilled syringes need to attach a separate needle

28. Intramuscular (IM) injection Insert the needle at a 90º angle to the skin IM injection sites Deltoid (arm) Vastus Lateralis (thigh)

29. Intramuscular (IM) injection

30. Vaccine Administration Video Clip from Immunization Techniques Safe, Effective, Caring

31. Skills PracticePart 2 Measuring & administering doses Draw up 0.5 ml dose of sterile water into a 3 cc safety syringe Show the 0.5 ml dose Administer 0.5 ml dose into an orange Activate the syringes safety device Repeat with the Smith syringe

32. Locating injection landmarks

33. Landmarks: 2-3 finger widths down from the acromion process; bottom edge is at an imaginary line drawn from the axilla. Deltoid

34. The deltoid site may be used on a child that is one year old and walking, depending on the childs muscle mass Assess the deltoid muscle of the child to determine if it has sufficient mass for the injection Bunching of the muscle may be needed with smaller muscle mass Deltoid

35. Vastus Lateralis Landmarks: Place one hand below the greater trochanter and one hand above the lateral femoral condyle, mid- lateral thigh

36. The muscle of choice for IM injections in a child less than 12 months of age Vastus Lateralis in Infants

37. Injection Site Assessment Do not use a site with any of the following: Muscle atrophy Inflammation Edema Scarring, tattoo, mole, or lesion IV port/ access Surgery in the limb/lymph node problems

38. Skills PracticePart 3 Locating Injection Sites Locate the appropriate site for a deltoid injection on your partner.

39. Intranasal Vaccine (LAIV) www.flumist.com/professional/media/flumist_nurse.mpg

40. Skills PracticePart 4 FluMist Administration Dispense the first half of the FluMist dose into the air (NOT INTO YOUR NOSE!) Remove the dose-divider clip Dispense the second half of the FluMist dose

41. Getting ready to give vaccines in a Medication Center Assessment and client education is done by others in Step 1: Registration/Consent form Risk vs. benefit of vaccine (Vaccine Information Statement) Thimerosol Information Sheet After care instructions Emergency Situations call 911 and use PH CHS Emergency Response Procedures ( see Handouts for Vaso-vagul and Emergency Response )

42. Getting Ready--2 Identify antigen/formulation to be administered Patient documentation Wash/sanitize hands Draw up/prepare the vaccine Have bandage and supplies ready

43. Giving the injection Ensure client is seated Gloves are not required, unless there is a break in the skin on the nurses hand(s) Clean the injection site with alcohol and let it dry before injecting Suggest client take slow deep breath, relax arm muscle during injection Aspiration not necessary

44. After the immunization--1 Engage syringes safety device Have the patient hold the cotton on their injection site No need to massage the injection site Used needles and syringes go into sharps container Place empty vials into biohazard bags

45. After the immunizaton--2 Partial vials and unused manufacturer pre-filled syringes go back into the cooler or refrigerator (35-46° F) If you attach a needle to a manufacturer pre-filled syringe, you must use it in the same clinic day or discard it

46. Immediate Adverse Reactions: Be Prepared! Monitor, if possible, for 15-20 minutes Anaphylaxis rare but may be life-threatening Symptoms: Dyspnea, rapid breathing, wheezing Flushed face, perspiration, anxiety Hives, itching, swelling at injection site Itchy/puffy eyes, swelling of mouth or throat Hypotension, cold/clammy skin, syncope Summon help from paramedics!

47. Additional Considerations Bloodborne Pathogen Exposure Vaccine Adverse Event Reporting System (VAERS) http://vaers.hhs.gov/

48. Positioning the Patient Adults and adolescents should sit down! Parents should use comforting restraint technique Parent embraces the child and controls all four limbs Avoids holding down or overpowering the child, but helps you steady and control the limb of the injection site

49. Comforting Restraint for Infants & Toddlers Hold the child on parents lap 1. One of childs arms embraces parents back and is held under parents arm 2. Other arm controlled by parents arm and hand--for infants, parents can control both arms with one hand 3. Both legs anchored with the childs feet held firmly between parents thighs, and controlled by parents other arm.

50. Comforting Restraint for Kindergarten & Older Kids Hold the child on parents lap or have the child stand in front of the seated parent 1. Parents arms embrace the child 2. Both legs are firmly between parents legs

51. Immunization Resources Public Health-Seattle & King County Immunization Program: www.kingcounty.gov/health/immunization 206-296-4774 CDC National Immunization Program: www.cdc.gov/vaccines Immunization Action Coalition: www.immunize.org

52. Skills PracticePart 5 Positioning an infant and child to receive vaccine

53. Skills Practice Locating landmarks and giving IM injections Locate IM injection sites on adult arm Locate IM injection sites on baby leg Practice giving IM injections

54. Triage Why? Assure safe disposition of patients Present patient information consistently Expansion of skill set for potential public health response

55. Triage: A piece of the pie Screening clients assists in: determining those who may need vaccination prophylaxis or urgent medical attention

56. Triage How? Using the algorithms Pediatric Algorithm Adult Algorithm Home Care Instructions Triage Note

57. Pediatric Triage Algorithm

58. Adult Triage Algorithm

59. Home Care Home Care Recommendations for ILI Keep away from others as much as possible. This is to keep from making others sick. Get plenty of rest. Drink clear fluids (such as water, broth, sports drinks, and electrolyte beverages for infants) to keep from being dehydrated. You will probably be sick for several days with fever, cough and stuffy nose. Cover your cough and sneezes. Frequent hand washing. Dont share drinking glasses or eating utensils. Dishes can be done in dishwasher or with hot soapy water. Throw away tissues and other disposable items used by the sick person in the trash. Wash your hands after touching used tissues and similar waste. Have everyone in the household wash hands often with soap and water, especially after coughing or sneezing. Alcohol-based hand cleansers are also effective. Avoid touching your eyes, nose and mouth. Take medications for symptom relief as needed for fever and pain such as acetaminophen (Tylenol®) and ibuprofen (Advil®, Motrin®, Nuprin®) and cough medicine. These medicines do not need to be taken regularly if your symptoms improve. Stay home for at least 24 hours after your fever is gone except to get medical care or for other necessities. (Your fever should be gone without the use of fever-reducing medicine.) Do not give aspirin (acetylsalicylic acid) or products that contain aspirin (e.g. bismuth subsalicylate – Pepto Bismol) to children or teenagers 18 years old or younger. Children younger than 4 years of age should not be given over-the-counter cold medications without first speaking with a health care provider. If you develop any of the following, seek medical care immediately: o Difficulty breathing o Purple or blue discoloration of lips o vomiting or unable to keep liquids down o Dizziness, no urination, lack of tears in infants (signs of dehydration) o Seizures, uncontrolled convulsions o Confusion, less responsive than normal

60. Triage Note

61. Skills Practice- Part 6 Using the tools Use pediatric and adult algorithms Demonstrate when to advise home care vs. office visit Preview triage note and use in conjunction with the home care sheet

62. Questions?