Annual Residential Care Update Influenza

Transcription

1 Annual Residential Care Update Influenza VCH Communicable Disease Control 1 Slides will be available by mid-october on the VCH Internet ( 2 1

2 New online course For immunizers who are new to providing flu vaccinations and for those who want in-depth information on the disease and/or vaccines: Foundations of Influenza: Disease & Vaccines using enrolment key bccdcflu1415 2

3 Influenza The disease Outline Influenza prevention and control Vaccine and administration Infection control practices Antivirals and outbreak management 5 Key Points Influenza kills more people than any other vaccine preventable illness Influenza vaccination program launch week of November 3. Vaccine available in community prior to this date Publicly funded vaccines: Fluad -LTCF residents and seniors >65 Fluviral and Agriflu everybody else Eligibility criteria includes children with morbid obesity, women at any stage of pregnancy, and visitors to a health care facility Getting immunized is the best way to protect yourself and your loved ones from getting the flu. 6 3

4 Influenza immunization campaign Vaccine antigens remain unchanged from last season Provincial campaign launch week of November 3rd. VCH will distribute vaccine starting mid October to: Long-term care facilities Health care workers High risk community outreach VCH public health clinics start the last week of October, in full swing in November Seniors are at greatest risk of influenza illness, disability and death Influenza affects 5-10% of population o Infection rate highest in the young (20-30%) o ~ 20,000 hospitalizations per year o ~ deaths (80-90% in seniors) Complications o Secondary bacterial infections o Dehydration o Worsening of chronic medical conditions Viboud C et al PLoS Curr Influenza March 20: RRN

5 Influenza activity in Canada Influenza activity started to increase in Decemberand peaked in January The National Microbiology Laboratory (NML) characterized 2000 isolates: o A/H1N1 58%, B/Massachusetts 34%, A/H3N2/Texas 7% o Excellent match between circulating strains and vaccine for all three strains 9 ILI Surveillance in BC 10 5

6 Respiratory virus detections in BC 11 Influenza Viruses Belong to the Orthomyxoviridae family Types A, B and C (uncommon) all infect humans Type A can also infect 12 6

7 Key concepts Antigenic variation: o Changes to surface proteins: Hemagglutininand Neuraminidase o Antigenic drift vs shift Influenza-like illness (ILI) o Acute onset respiratory illness with fever + cough + one or more of: arthralgia, myalgia, extreme fatigue, weakness, sore throat o Fever not prominent in young kids or seniors Communicability (-1 to +7 days) 13 Influenza Infection 1. Virus enters nose 2. Attaches to respiratory tract 3. Replicates in host 4. Degree of severity Viral factors Underlying host factors Incubation period = exposure to development of symptoms 1-7 days 7

8 The Illness Influenza infection can result in a wide range of illnesses: infection without any symptoms common cold-like illness with or without fever typical flu with sudden onset of fever, headaches, aches and pains, fatigue, sore throat and cough fever, vomiting, abdominal pain and diarrhea, with or without respiratory symptoms, especially in infants and young children 15 Droplet o Person sneezes or coughs onto you: 1 2m Contact o Hands: 5 min o Porous surfaces: 8 12 hr o Hard surfaces: hrs Modes of Transmission 16 8

9 Influenza Prevention and Control Your role as a health care provider: Promote the uptake of influenza and pneumococcal vaccine Develop protocols for annual influenza vaccination of residents and staff Develop protocols for preventing, identifying and controlling influenza outbreaks Prevention and Control = Immunization + Infection Control + Antivirals 18 9

10 BC influenza vaccine program: all immunizers ready to launch November Influenza vaccine is recommended for all Canadians as long as they do not have contraindications Source: NACI

11 Influenza Vaccines 21 Eligibility criteria for publicly-funded vaccine (selected) People at high risk of influenza-related complications or those more likely to require hospitalization People of any age who are residents of nursing homes and other chronic care facilities. People 65 years of age. People capable of transmitting influenza to those at high risk Healthcare and other care providers in facilities and community settings. Household contacts (adults and children) of individuals at high risk of influenza complications, whether or not the individual at high risk has been immunized. Visitors to a health care facility People who provide essential community services 22 11

12 WHO recommendations Influenza vaccines in the influenza season (northern hemisphere) contain: o A/California/7/2009 (H1N1) pdm09-like virus o A/Texas/50/2012 (H3N2) virus o B/Massachusetts/2/2012-like virus (Yamagata lineage) Quadrivalentvaccines also contain: B/Brisbane/60/2008-like virus (Victoria lineage) Annual vaccination is recommendedfor optimal protection 23 Non-publicly funded influenza vaccines Trivalent Inactivated Influenza Vaccines (TIIV) Vaxigrip Influvac Intanza Fluzone Quadrivalent Inactivated Influenza Vaccines (QIIV) Flulaval Tetra Fluzone Quadrivalent 24 12

13 Publicly funded influenza vaccines in BC Product FLUVIRAL (GSK) AGRIFLU (Novartis) FLUAD (Novartis) Program indications >6 months of age 6 mos of age >65 years of age Comments Split virus vaccine Multi-dose vial Subunit vaccine Thimerosal-free, single dose pre-filled syringe Indicated for those with history of allergic reaction to thimerosal Subunit, adjuvanted vaccine Packaged pre-mixed with adjuvant in a single-dose pre-filled syringe; needle not included Preferential recommendation for use in seniors 25 Key Vaccine components & packaging FLUVIRAL FLUAD AGRIFLU Multi-dose Single dose* Single dose Thimerosal (50 μg) Squalene Polysorbate 80 Cetyltrimethylammonium bromide (CTAB) Polysorbate 80 Kanamycin Neomycin Kanamycin Neomycin 3 influenza strains inactivated split virion Formaldehyde Egg protein 26 13

14 Thimerosal in vaccines Multidose dose vials require a preservative to prevent contamination Thimerosal content of vaccines is safe for all age groups and pregnancy Fluviral contains 50 µg of thimerosal Agriflu available for individuals allergic to thimerosal 27 Thimerosal in vaccines Thimerosal is a mercury based preservative that is metabolized into ethyl mercury and thiosalicylate. Ethyl mercury is rapidly excreted by the body and thus does not cause harm. Methyl mercury, a different compound, is a known neurotoxin in high concentrations and can be commonly found in fish. A large body of epidemiological evidence has been reviewed and thimerosal-containing vaccines do not cause autism, or other neurological disorders

15 FLUAD >65 years of age 29 Adjuvanted vaccine for the elderly 90% of influenza mortality is in elderly Immunosenescence with age impairs protection from vaccine Protection poorest against drifted strains MF 59 oil-in-water adjuvant Studies indicate better immune response Licensed in vaccine since 1997 > 50 Million doses distributed Established safety profile 30 15

16 Protection from Fluad Higher antibody response on initial and repeat vaccination Vaccine effectiveness 23% (5-36%) against acute respiratory infection (ARI) NACI has not made a preferential recommendation 31 Pneumococcal polysaccharide vaccine (PPV23) Each year 1400 people die from influenza and pneumonia Pneumococcal vaccination can prevent secondary pneumonia Vaccine available year round Dose 0.5 ml IM or SC 32 16

17 Pneumococcal vaccine eligibility All those 65 years of age All residents of extended or intermediate care facilities Adults and children 2 years with many of same health issues as those who qualify for flu vaccine Homelessness and/or illicit drug use Given once only to most people A once-only revaccination should be offered to Asplenia, sickle cell disease, immunosuppression, chronic kidney or liver disease Interval between administration of conjugate & polysaccharide pneumococcal vaccines is 8 weeks 33 VCH Health Care Worker Influenza Control Program Vaccine or mask for the duration of the influenza season: Dec 1-Mar

18 Goals of the HCW influenza policy Protect influenza transmission from HCWs to vulnerable patients Reduce influenza morbidity and mortality Additional goal for HCW program Reduce worker absenteeism 35 Reasons why HCWs should get the flu shot Vaccination is the single most effective intervention in preventing transmission of influenza Esp to vulnerable patients who are both poor responders and at high risk of complications and death Every code of ethics adopted by physicians, nurses, nurses aides, social workers, pharmacists and other health-care professionals states very clearly, succinctly, and loftily that the interests of the patients must come ahead of anyone else s. Vaccinating HCWs protects patients from influenza and death 100% HCW vaccination will decrease risk of influenza by 43% among hospitalized patients and 60% among nursing home patients Studies also show that HCWs may have mild or subclinical influenza In a British study, 59% of HCWs with serologic evidence of influenza did not recall symptoms but were still contagious* Vaccinating HCWs protects us from getting ill 36 18

19 Influenza immunization among LTCF HCWs 2008/9 2013/14 Influenza immunization among LTCF Residents 2008/9 2013/14 19

20 Health care worker influenza control policy: Influenza vaccine is strongly recommended for ALLhealthcare workers, in order to protect patients/clients Policy applies to all HCWs who have patient care duties or work in patient care areas Additional measures apply during an influenza outbreak Policy also applies to visitors 39 If there is an influenza outbreak in a HCW facility: Immunized personnel, volunteers, physicians can work at different work sites and facilities as long as it has been more than two weeks since vaccination no restrictions All symptomatic staff (i.e. fever and cough) should notbe at work Stay home until symptoms resolve Unvaccinated HCWs will need to take antiviral prophylaxis for the duration of the outbreak (or excluded without pay) o Include all staff who work face to face or who will be in close proximity to those people receiving health services Unimmunized HCWs should have an anti-viral (e.g. Tamiflu ) prescription on hold at a 24-hour pharmacy for immediate access if an outbreak declared 40 20

21 Questions Q: What about staff who have true contraindication to influenza vaccination? A: History of previous adverse reaction to be reviewed by VCH MHO Mask, from Dec March inclusive Take antiviral for duration of outbreak or be excluded Agriflu available for those with hypersensitivity to thimerosal 41 Questions Q: Does the policy apply to pregnant and breastfeeding staff? A: Yes, influenza vaccine is safe and recommended in pregnancy and while breast feeding 42 21

22 Vaccine administration Choose the site Tips for Adult IM Injections Deltoid is recommended 2. Clean the site 3. Use the correct needle size 4. Injection technique can reduce pain Rapidly inject at a 90 angle; do not aspirate Withdraw quickly Immediately apply pressure Do not massage may damage tissue Gloves are NOT needed when providing immunizations. Clean/wash your hands between each client

23 Subcutaneous Injections Lateral aspect of the upper arm and the fatty area of the anterolateral thigh 45 angle gauge 5/8 7/8 needle Contraindications to influenza vaccine Do not give a flu shot to the following: o Infants less than 6 months of age o History of anaphylactic reaction to Previous flu shot any component of a flu vaccine, except eggs o History of Guillain-Barré Syndrome (GBS) within 8 weeks of receipt of a previous dose of flu vaccine History of severe reaction/anaphylaxis to eggs: can receive full dose vaccine in one step 46 23

24 Contraindications & precautions to pneumococcal vaccine Do not give pneumococcal vaccine to anyone with a history of anaphylactic reaction to a previous dose or any components Clients with Hodgkin s disease: Do not administer less than 10 days prior to or during immunosuppressive therapy (as the client will not derive protection from the vaccine) Consult with client s medical specialist to determine best time to administer Concern that clients may not receive adequate protection 47 Very Common Side Effects Pain, redness, & swelling at the injection site Common Myalgia, fatigue, headache Do not report expected side effects Doreport febrile seizures or other rare and serious events as adverse events following immunization 48 24

25 Anaphylaxis after vaccination Extremely rare reaction slower onset, usually within minutes, timing unknown Sense of impending doom Different from simple allergic reactions An acute, potentially lethal, multisystem syndrome Cardiovascular system Loss of intravascular volume (50% loss in less than 10 minutes) Impaired breathing: wheezing 49 Preparation Anaphylaxis in non-hospital setting Know the guidelines well BCCDC immunization manual Section 5 Keep anaphylaxis kits up to date Suggested contents -listed in Section 5 page 11 Action Call 911 first Administer Epinephrine 25

26 Adverse Event Reporting Complete and submit your adverse event following immunization (AEFI) forms to your local health unit Available at Managing the cold chain Cold chain quick reference: HANDOUT 26

27 Prevention and Control = Immunization + Infection Control + Antivirals 53 Key messages about influenza prevention 1. Get the flu shot 2. Wash hands with soap and waterwhenever you can 3. Keep an alcohol based hand sanitizer handy 4. Cover mouth and nose with a tissue to cough or sneeze. Throw the tissue out. Cough into the upper sleeve if a tissue isn t available. 5. Stay home when sick. People are most infectious in the first few days of illness. 6. Keep common surfaces and items clean. Surgical masks only No role of N95 in prevention of community or hospital transmission

28 Basic assumptions Routine Practices Blood and body fluids (BBF) contain pathogens Any person can harbor these pathogens Some people will be symptomatic, some will not Applies to: allbody substances, secretions, excretions, mucous membranes and non-intact skin regardless of the diagnosis all patients, clients, residents all the time, regardless of the diagnosis Hand hygiene Routine Practices Personal protective equipment Risk assessment Waste disposal -sharps, regular and biomedical Cleaning and disinfecting of the environment and equipment Education of health care workers, clients, their families and visitors For staff stay home when sick 28

29 Hand Hygiene Hand hygiene can be done with soap and water or with an alcohol-based hand sanitizer Hand washing soap, warm water, friction & time. Wash for at least seconds Additional Precautions Airborne:N95 mask, negative pressure/private room e.g. tuberculosis Contact: gown and gloves for direct care e.g. uncontrolled diarrhea, scabies, shingles Droplet: regular procedure mask e.g. whooping cough, mumps 29

30 Personal Protective Equipment Personal Protective Equipment Gloves Masks/goggles Aprons Surgical masks only No role of N95 in prevention of community or hospital transmission If it s moist and not yours, protect yourself Risk Assessment Should be done at the first point of contact Use appropriate infection control measures Reduce the risk of exposures Based on Resident s symptoms (diarrhea, cough, rash) Type of care or task you are performing What type of setting you are doing it in Factors influencing it Your skill level? Your coworker s skill level? Cooperation/susceptibility of resident 30

31 Influenza Outbreak Definition of an influenza-like illness (ILI): Acute onset of respiratory illness with fever and cough with one or moreof the following: Sore joints/muscles (arthralgia, myalgia) Extreme fatigue/weakness Sore throat Note: in children <5 years and people >65 years, fever may not be prominent Influenza Outbreak Definition Influenza-like illness in two or more residents and/or staff members in a 7-day periodat your facility, with at least one case identified as a resident 31

32 Outbreak Suspicion of an Outbreak Begin a line listing of all residents with symptoms of ILI and all staff who are off ill. Notify Medical Health Officer and continue to monitor residents for symptoms of ILI. Contact ; Fax Fax ILI line lists as requested MHO will declare outbreak Outbreak reporting For VCH owned and operated facilities: Report as per your usual route; i.e. infection control practitioner For private or contracted facilities: Report to VCH CDC Contact ; Fax

33 Line Listing Specimen Collection Please ensure your facility has a specimen kit available to facilitate timely collection of influenza specimens Take viral specimens for lab testing as soon as possible Nasopharyngeal swab is recommended; nasal swabs are also acceptable. Do not send throat swabs Results for testing may be available on the same day specimens received at BCCDC 33

34 For residents: Outbreak Control Measures Cohorting residents Consider cancelling appointments that do not risk the health/well-being of the resident Cancel group outings and group activities One-on-one activities with resident Outbreak Control Measures An annual serum creatinine clearance level is recommended for all residents Use of antivirals as directed by MHO and as ordered by the residents physician as treatment or prevention Must be started within hours of illness onset Shorten duration of fever and respiratory symptoms by ~50% Reduce amount of virus in respiratory secretions Shorten duration of contagiousness 34

35 Outbreak Control Measures Restriction of admissions/transfers Screening of visitors (even in absence of an outbreak) Outbreak signage Housekeeping Notify other service providers Conclusion of Outbreak Control measures to be continued until MHO declares outbreak over; 6 days after last case identified Antiviral medication can be discontinued Order additional viral specimen kits from BCCDC fax request to Completion of Outbreak Report form 35

36 Outbreak Report Form Influenza Binder Coming Soon! 36

37 Resources VCH internet for public Immunization Manual Influenza and Pneumococcal Health Files Acknowledgements Dr. Réka Gustafson, Medical Health Officer Dr. Meena Dawar, Medical Health Officer Tamsin Morgana, Immunization Leader 37

38 The End! Thank you! 38