VCH Seasonal Influenza Update Immunization Campaign 2020-2021 - Christina Cordova, Regional Immunization CRN Dr. Meena Dawar, MHO - Sneezes + Diseases

VCH Seasonal Influenza
        Update
Immunization Campaign

            2020-2021
Christina Cordova, Regional Immunization CRN
            Dr. Meena Dawar, MHO

Acknowledge the unceded traditional homelands of the
Musqueam, Squamish and Tsleil-Waututh Nations on whose land
we work, live and play with gratitude.

Quick Reminders

Outline
To review epidemiology of Influenza in the 2019-
                 2020 season
To describe the public health Influenza campaign
                and our partners

To review the vaccine products available this fall

 To review best practices recommended for the
      campaign during COVID-19 pandemic

Goals of the Influenza Prevention Program
 • To reduce illness and death associated with
   influenza.
 • To reduce predictable and preventable
   pressures on the health care system incurred
   by influenza illnesses.
 • To reduce the confusion between respiratory
   illness caused by influenza vs COVID-19

ImpactofofInfluenza
    Impact       Influenza
                         in in Canada
                             Canada
   One of the top 10 leading causes of death

• #1 cause of mortality from a Vaccine
  Preventable Disease
• Responsible for an estimated average of
  12,200 hospitalizations and ~ 3,500 deaths per
  year
                           Summary of the NACI Seasonal Influenza Vaccine Statement for 2020-2021.
                           CCDR. Volume 46–5, May 7, 2020: Nosocomial infection surveillance.

ImpactInfluenza
2019-2020  of Influenza in Canada
                    Season  Review

    • Illness in the community
      – Influenza
      – COVID 19
    • Lab data

2019-2020 ILI in the Community

         BC Influenza Surveillance Bulletin. Influenza Season 2019-2020, Number
         11, Week 18. April 26 – May 2, 2020.

2019-2020 Visits to BCCH ED

        BC Influenza Surveillance Bulletin. Influenza Season 2019-2020, Number
        11, Week 18. April 26 – May 2, 2020.

2019-2020 Lab Detections

      BC Influenza Surveillance Bulletin. Influenza Season 2019-2020, Number
      11, Week 18. April 26 – May 2, 2020.

2019-2020 Virus Subtype by Age

        BC Influenza Surveillance Bulletin. Influenza Season 2019-2020, Number
        11, Week 18. April 26 – May 2, 2020.

Global Influenza Activity Summer 2020

                      https://www.who.int/influenza/surveillance_monitoring/updates/
                      2020_08_17_influenza_update_374.png?ua=1

Impacts of COVID-19

            http://www.bccdc.ca/Health-Info-
            Site/Documents/BC_Surveillance_Summary_Sept%2024%202020_final.pdf

VCH Influenza program strategies

     Immunization Campaign
      Infection Control Measures
               Antivirals

2019-2020 Influenza Immunization campaign

• Nearly 450,000 doses of vaccine distributed by
  VCH

• Approximately 40% doses administered by
  pharmacists within VCH geographic area

• Approximately 25-30K doses administered by
  Public Health

Influenza strains in 2020-2021

                2019-2020                                      2020-2021

• A/Brisbane/02/2018 (H1N1) pdm09-like virus      •   New → A/Guangdong Maonan/SWL1536/2019
                                                      (H1N1)pdm09-like virus
• A/Kansas/14/2017(H3N2)-like virus
                                                  •   New → A/Hong Kong/2671/2019(H3N2)-like virus
• B/Colorado/06/2017 like virus(Victoria lineage) •   New → B/Washington/02/2019(B/Victoria
                                                      lineage)-like virus
• B/Phuket/2013 like virus(Yamagata lineage)QIIV •    B/Phuket/3073/2013 like virus (B/Yamagata
                                                      lineage) QIIV

                                                                                              16

Reminder about nomenclature

             Vaccine Components 2020-2021
A/Guangdong Maonan/SWL1536/2019 (H1N1)pdm09-like virus
        A/Hong Kong/2671/2019(H3N2)-like virus
    B/Washington/02/2019(B/Victoria lineage)-like virus
  B/Phuket/3073/2013 like virus (B/Yamagata lineage) QIIV

                                                            17

Reminder about protection
• Immune system is made up of a specialized network of
  organs, cells and tissues to help protect against disease

• Influenza vaccines are made using inactivated virus or
  subunit proteins (exception, live intranasal influenza
  vaccine)

• Once immunized, the immune system responds as it
  would if it was the real virus with the formation of
  memory B and T cells and development of antibodies

• It takes about 2 weeks following immunization to develop
  protection against influenza
                                         Immunize BC. https://immunizebc.ca/how-do-vaccines-work

http://www.bccdc.ca/resource-
gallery/Documents/Statistics%20and%20Research/Publications/Epid/Influenza%20and%20Respiratory/SPSN_VE_By_Ye
ar_Table.pdf

Who should be vaccinated?

• Everybody
• Provided free to:
 1. Those at high risk of influenza
    complications
 2. Those in contact with people at high risk
 3. Essential community service providers

Risk factors for influenza-related complications

      • Persons with underlying health conditions
      • Residents of nursing homes and other
        chronic care facilities
      • Adults > 65 years of age
      • Children 6 months to 5 years of age
      • Indigenous Peoples
      • Pregnant women

Pregnancy
Women at all stages of pregnancy are
recommended to receive influenza vaccine in order
to protect themselves and their babies
Benefits include:
  • Decreased hospitalization rates for pregnant moms
    and babies
  • Decreased rate of premature births
  • Decreased rate of low birth weight in babies
  • Vaccine is safe and should be offered in all stages of
    pregnancy

Key Messages for the Public
Influenza vaccine is:
• Safe and well-tolerated

• Cannot cause influenza illness

• Annual vaccination is recommended

Development of annual vaccine

• Virus strains change frequently, important to get immunized
  each season

• Based on surveillance, research and expert opinion, the
  influenza vaccine is made to protect against the influenza
  viruses that will likely be most common during the season as
  recommended by the WHO Global Influenza Surveillance
  Network

• Steps of development: Strain selection, production of vaccine
  to include strains, annual license approval, distribution of
  vaccine, and administration

              WHO report for approving Influenza vaccine virus selection. Retrieved from http://dx.doi.org/10.1016/j.vaccine.2015.06.090

VACCINE PRODUCTS

Increased vaccine quantity purchased
          across the country

• BC purchased approximately 30% greater
  amount of vaccine this year in anticipation of
  increased demand
• VCH will receive more vaccine as well

Product selection

Product choices for kids
                     6 months to 17 years
Quadrivalent vaccines preferentially offered to
children for the extra influenza B protection

       Alternate products: Agriflu ® or Fluviral® > 6 months of age

Product choice 18 years and older

    Alternate products: Flulaval Tetra ® > 6 months of age

Product choice: Age 65+
• Fluad: adjuvanted influenza vaccine
   – Adjuvant: MF59
   – Preferred option for community dwelling seniors
   – If unavailable, offer Fluviral or Agriflu

• Fluzone HD® is recommended by NACI for seniors, only
  publicly funded for BC residents residing in LTCFs
   – Trivalent Inactivated Influenza vaccine with fourfold dose
     of antigen compared to standard dose influenza vaccines
   – Provides better protection for this age group
   – Seniors interested in private purchase: availability and cost
     may vary at local pharmacies and medical clinics

Vaccine components: addressing
                  concerns
• Thimerosal is a preservative in multi-dose influenza vaccines – easily
  excreted from the body and does not cause neurological symptoms
• Egg protein – contain low levels of residual egg protein, does not
  trigger allergic reaction
• Antibiotics such as neomycin and kanamycin – used to prevent
  contamination during cell culture
• Vaccine components are used in very small amounts and most of
  these are removed during the manufacturing process, minute amounts
  may remain in final product
• For more information see Immunize BC’s ‘Quick Reference
  Immunization Communication tool for Immunizers’

                                             Immunize BC. Quick Reference Immunization communication tool.

Pneumococcal vaccine –
  please continue to offer during the campaign
• Pneumococcal Polysaccharide vaccine (PPV23) is recommended for
  individuals at high risk of getting ill from pneumococcal infections:
    • Seniors 65 years of age and older
    • Residents of long-term care facilities and assisted living facilities
    • Those living with certain medical conditions
• In addition, a once-only booster 5 years after initial dose for certain
  medical conditions

• Pneumococcal conjugate vaccine (PCV13) is recommended by NACI
  for adults with certain medical conditions but not provided free
• For complete list of indications, see BCCDC Immunization manual
  Part 4: Biological Products page Pneumococcal vaccines

Bottom line
             Do not defer
Use the best product choice available

          Practice principles
 • Offer vaccine to all who present/request
    o Be lenient
    o Clients without Care Card are welcome
 • Product Choice
    o Be flexible

Campaign Launch
• The VCH launch dates:
  • LTCFs, Acute Care sites beginning of October
  • CVPs: vaccine distribution starting week of October
    5th
  • Public Health Units: Soft launch starting week of
    October 13
  • Health care workers: Starting week of October 13
  *Please start offering influenza vaccine within CHCs as
  soon as you have vaccine available

Best Practices
•   Immunizing during COVID-19 pandemic
•   Administration
•   Anaphylaxis management
•   Managing cold chain
•   Documentation
•   Reporting
•   VCH policy

Immunizing during COVID-19
            Safety Approaches
• Stay home when sick – applies to staff and clients
   • Pre-screening (at booking)
   • passive screening (signage at clinic, no entry if ill)
• Hand hygiene of staff and clients
   • Staff: before and after each client
   • Clients: upon entry and exit of clinical space
• Clinic set up and traffic flow
   • Larger community spaces for clinics
   • Physical distancing
   • Appointment vs drop-in
   • Signage & set up directing flow

Immunizing during COVID-19
         Safety Approaches
• Enhanced cleaning & disinfecting
   • High touch surfaces bid
   • Procedure/exam spaces (eg. Chairs, tables,
     floors) cleaned at least 2x/day
   • Coolers/ice packs – after each use
   • Lamination/posting of health files
• PPE use by staff
   • Masks & eye protection
   • Gloves only with flumist

Immunizing during COVID-19
    Planning considerations
• Greater demand, potentially less availability at family
  doctors, thus larger clinics
• More staff: public health nurses, student nurses
• Stronger partnerships with community immunizers
• Municipal and Post-secondary support for larger
  spaces across the region
• Technology platforms to assist with bookings
• Communication through signage, posters, floor prints
• Onsite cleaning and security

Reminder: Administration
• When administering any biological product consider 7
  “Rights” of medication administration

• Professional and legal responsibility of the provider to
  obtain informed consent prior to administration

• Refer to BCCDC Immunization Manual
   • Appendix A: Informed consent
   • Appendix B: Administration of Biological Products
   • Appendix D: Reducing immunization injection pain

Common side effects
• Local: pain, swelling, redness.
• Systemic: fatigue, headache, myalgia, red
  eyes, sore throat, cough, arthralgia, fever,
  chills, malaise, chest tightness.
• Fewer than 1 in 20 people may develop oculo-
  respiratory syndrome (ORS) – red eyes, cough,
  and/or sore throat, hoarseness

Contraindications
• Anaphylactic reaction to a previous dose of any type of
  influenza vaccine or component of specific vaccine to be
  administered (i.e. Fluviral®)
• Guillain-Barré syndrome (GBS) within 8 weeks of receipt of
  a previous dose of influenza vaccine without another cause
  being identified.
• Receipt of a CTLA-4 inhibitor (e.g., ipilimumab) alone or in
  combination with other checkpoint inhibitors for the
  treatment of cancer. Flu vaccine should be given 8 weeks
  before starting treatment or 8 weeks after the last dose.

Additional contraindications for
                Flumist
• Severe asthma or active wheezing
   • high dose inhaled or oral steroids or medically attended
      wheezing in the 7 days prior to vaccination
• Adults and children with immunocompromising conditions
   • Exception: HIV and HSCT recipients > 12 months post treatment
• HCWs working with immunocompromised individuals
• Pregnancy
• Individuals 2-17 years of age receiving aspirin-containing therapy
  because of the association of Reye syndrome with aspirin and wild-
  type influenza infection

Landmarking

Anaphylaxis in Non-hospital Setting
• Preparation:
  – Guidelines Part 3: Management of Anaphylaxis in
    a non hospital setting
  – Keep anaphylaxis kits up to date
     • Suggested contents is listed in Part 3: under (9.) for
       Maintenance of Epinephrine Vials and other
       Emergency Supplies

Anaphylaxis in Non-hospital Setting
• Action:
Part 3:
Management of
Anaphylaxis in a
non-hospital
setting
• AEFI
  reporting

Is it anaphylaxis, anxiety or fainting?
             ANAPHYLAXIS                     FAINTING                   ANXIETY
DEFINITION   An acute systemic and           A temporary                A protective physiological
             potentially fatal allergic      unconsciousness caused     state recognized as fear,
             reaction to a foreign           by diminished blood        apprehension, or worry.
             substance.                      supply to the brain.
             Usually slower, most            Sudden, occurs before,     Sudden, occurs before,
             instances begin within 30       during, or shortly after   during, or shortly after
ONSET        minutes                         immunization; recovery     immunization; recovery
                                             quick                      usually quick
SKIN         - flushed, red blotchy areas    - pale                     - pale
             - itchy, hives                  - excessive perspiration   - excessive perspiration
             - tingling sensation            - cold, clammy             - cold, clammy
             - angioedema
BREATHING    -sneezing, coughing,            - normal or shallow,       - rapid and shallow
             wheezing,                       irregular, labored         (hyperventilation)
             -hoarseness and/or difficulty
             swallowing)
PULSE        - rapid, weak                   - slow, steady             - rapid
BLOOD        - decreased systolic and        - decreased systolic and   - normal or elevated systolic
PRESSURE     diastolic                       diastolic

Reminder: Documentation

• Clinic signature records
• VCH workplace health one-write or Public
  Health Mass Setting one-writes
• PARIS documentation
  • For children < 8 years who require 2 doses
    (influenza vaccine naïve children)
  • All pneumococcal immunizations

Documentation: Public Health mass clinics

Managing the cold chain

Reporting a cold chain incident
• Call VCH CDC immediately if your fridge temperature falls
  out of range (+2 to +8) to determine if vaccine is safe
   – Note temperature and time when out of range
   – If in doubt re: whether cold chain incident or not, call
      VCH CDC
• Quarantine the affected vaccine in a working refrigerator,
  label “Do not use”
   – Important to keep vaccine refrigerated until otherwise
      advised (Do not throw away)
• In consultation with VCH CDC and BCCDC,
  recommendations will be made

General reminders

• Sign the Influenza Clinic Signatures Record
• No pre-drawing of vaccines
• Hand-washing in between clients
  •   Additional considerations related COVID-19
• Obtain informed consent
• Review resources & communication updates
• Manage the cold chain

VCH Influenza Prevention Policy
• All staff, medical staff, contractors, trainees, volunteers and
  visitors need to be immunized against influenza or wear a
  mask when providing patient care or working in patient care
  areas
   – Policy application period: usually Dec 1 – March 31
   – Dates may be altered based on illness activity
• Please report your influenza coverage or mask wearing option
  at the following:
   – Staff and medical residents: https://influenzareporting.org
   – Medical staff: email medicalstaffhealth@vch.ca or call 604-875-4111
      ext.69597
   – Contractors/volunteers: to their manager

Finding other Flu Clinics
• Find flu clinics in your area:
  Immunizebc.ca/clinics/flu
   • Public Health Units
   • Pharmacies
   • Other vaccine providers (MDs, NPs)

Resources
• Flu lead at each health office (CoC)
• Regional CD Team 604-675-3900
  • Immunization Lead: Emily Malnis
  • Immunization CRN: Christina Cordova
  • Regional Vaccine Coordinator/Administrator:
    Wendy DiPalma
  • CD on call nurse

Additional resources
•   BCCDC CD Manual – Chapter 2 - Immunization Manual
     • Part 2: Immunization of Special Populations
     • Part 3: Management of Anaphylaxis in a non-hospital setting
     • Part 4: Biological Products (Influenza Vaccines, Pneumococcal Vaccine pages)
     • Part 5: Adverse Events Following Immunizations (AEFIs)
     • Appendix A: Informed consent
     • Appendix B: Administration of Biological Products
     • Appendix D: Reducing immunization injection pain
     • Appendix E: Management of Bio

•   BCCDC Influenza online courses:
     • Foundations of Influenza – Disease & Vaccines (Modules 1 to 4)
     • Influenza Disease – Seasonal Update (Modules 1 to 5)

Additional resources
• ImmunizeBC.ca
• HealthlinkBC health files
  •   Inactivated flu vaccine
  •   Influenza (flu) season
  •   Facts about Influenza (the flu)
  •   Why seniors should get the Inactivated Influenza
      (flu) vaccine
• VCH Microsite for flu and CD materials
• NACI statement (Government of Canada)

Additional resources
• COVID-19 related resources:
  – BCCDC CD Manual: Public Health Management of
    cases and contacts associated with novel
    coronavirus (COVID-19) in the community
• BCCDC Immunization Manual:
  – Guidance for Influenza Vaccine Delivery in the
    Presence of COVID-19
• VCH IPAC COVID-19:
  – Community Toolkit resources

Summary

• Influenza is the Number #1 cause of mortality
  from a Vaccine Preventable Disease
• Do not defer immunization
     - multiple product options for children and adults

https://goo.gl/forms/fi79o0jxBfmkm9Hg1

References
•   BC Influenza Surveillance Reports: http://www.bccdc.ca/health-professionals/data-
    reports/communicable-diseases/influenza-surveillance-reports

•   WHO report for approving Influenza vaccine virus selection:
    https://www.sciencedirect.com/science/article/pii/S0264410X15009056?via%3Dihub

•   NACI Influenza Update 2019: https://www.canada.ca/en/public-
    health/services/publications/vaccines-immunization/canadian-immunization-guide-
    statement-seasonal-influenza-vaccine-2019-2020.html

•   BCCDC CD Manual: http://www.bccdc.ca/health-professionals/clinical-
    resources/communicable-disease-control-manual/immunization

•   Quick Reference Immunization Communication Tool for Immunizers:
    http://www.bccdc.ca/health-professionals/clinical-resources/communicable-disease-control-
    manual/immunization