Vaccination Training for Health Care Providers

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

12. Health Care Workers: Protect Yourself, Protect Your Clients Individuals are contagious for 1 to 4 days before the onset of symptoms and about5 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, thecause of 36,000 deaths eachyear in the U.S. Immunizations are first lineof 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 SeasonalFlu 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) allergyto 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 strain”—would 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 1930’s • 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 reactions1 • 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 attached—various 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 Practice—Part 2Measuring & administering doses Draw up0.5 ml dose of sterile water into a 3 cc safety syringe Show the 0.5 ml dose Administer 0.5 ml doseinto an orange Activate the syringe’s 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. Deltoid • The deltoid site may be used on a child that is one year old and walking, depending on the child’s 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

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 Practice—Part 3Locating 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 Practice—Part 4FluMist 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 nurse’s 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 syringe’s 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 parent’s lap • One of child’s arms embraces parent’s back and is held under parent’s arm • Other arm controlled by parent’s arm and hand--for infants, parents can control both arms with one hand • Both legs anchored with the child’s feet held firmly between parent’s thighs, and controlled by parent’s other arm.

50. Comforting Restraint for Kindergarten & Older Kids • Hold the child on parent’s lap or have the child stand in front of the seated parent • Parent’s arms embrace the child • Both legs are firmly between parent’s legs