1. “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

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

3. 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.

4. 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.

5. 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

6. 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?

7. 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)

8. 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

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

10. 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

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

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

13. 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

14. 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

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

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

17. Who Gets Pneumococcal Vaccine?
Adults >= 65 years old
Age who smoke or have asthma
Age 2-64 years with chronic illnesses:
-Cardiovascular, Pulmonary, Metabolic, Immunosupression, Asplenia, Hepatic, Renal Disease…
ACIP recommendations

18. 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.

19. 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)

20. 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.

21. 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

22.
Look at executive summaries for information on each

23. Credible Vaccine Websites

24. 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

25. 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…)

26. 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

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

28. 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

29. 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

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

31. Frequency and timing 63% with =< 5 minutes post-vaccination
8% within 15 minutes of vaccination
35% reported in patients age years
71% reported in women
14% of episodes result in hospitalization
(from injuries.)
Observe patient for suitable time after vaccination. ACIP guidelines = 15 minutes

32. 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?

33. 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

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

35. 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

36. 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.

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

38. VAERS Vaccine Adverse Events Reporting System
Alerts manufacturers and CDC of adverse events Or