Concern over vaccines — Trump, Ben Carson, Carly Fiorina, Rand Paul, and others

From this morning’s Financial Post:

http://business.financialpost.com/fp-comment/lawrence-solomon-how-vaccine-safety-turned-into-one-of-trumps-first-presidential-priorities

Lawrence Solomon | January 11, 2017 4:48 PM ET

With repealing Obamacare, building a wall, cutting corporate taxes and keeping jobs at home all high on Donald Trump’s agenda, the announcement Tuesday that he asked Robert F. Kennedy Jr. to consider chairing a commission into vaccine safety and scientific integrity took many by surprise.

It shouldn’t have. Vaccines and his belief that they can cause autism are personal to Trump, who held multiple meetings with vaccine skeptics in the late stages of the presidential campaign and into the packed transition period prior to assuming the presidency. Moreover, although vaccine skeptics are often associated with far-left Birkenstock elites, many Republicans — including top Republicans close to Trump — have expressed doubts about the uncritical acceptance of vaccines.

Aside from a small minority, neither Trump nor any of the so-called vaccine skeptics are ideologically opposed to all vaccines, or even consider themselves anti-vaccine in any way. They’re more likely to think vaccines are over-hyped and overused, and want them to be used in ways they consider more judicious and more consistent with personal freedom.

Dr. Ben Carson, the pediatric neurosurgeon who is Trump’s choice to be the new Secretary of Housing and Urban Development, represents a common conservative viewpoint on vaccines. As he told Jake Tapper in a nationally televised debate for the Republican nomination for president,  “Vaccines are very important — certain ones, ones that would prevent death or crippling.  There are others — there’s a multitude of vaccines that probably don’t fit into that category, and there should be some discretion in those cases. But you know, a lot of this is pushed by big government.”

Other past Republican contenders for president who dissent from the official government position on vaccines included Carly Fiorina, the former CEO of Hewlett-Packard, Chris Christie, the governor of New Jersey and Dr. Rand Paul, a physician and senator from Kentucky who is also a member of the American Association of Physicians and Surgeons (AAPS), a free-market alternative to the more mainstream American Medical Association. AAPS, which was founded in 1943 to “fight socialized medicine and to fight the government takeover of medicine,” is known for its opposition to mandatory vaccinations; many of its members, including Paul, believe children have suffered “profound mental disorders” after being vaccinated.

But another member of AAPS looms especially large: Dr. Tom Price — who is outspoken on the need for patients to have autonomy over the treatment they and their children receive — is Trump’s pick to serve in his cabinet as the new secretary of Health and Human Services.

Other skeptics close to Trump include Rick Perry, his energy secretary, who has said he regrets having proposed the mandatory vaccination of teens with the HPV vaccine when he was governor of Texas, and Mike Pence, Trump’s vice president, who as governor of Indiana lobbied against legislation that would have required teenagers to be vaccinated with the HPV vaccine.

The opinion that counts most, of course, is Trump’s, and on vaccines he’s long been adamant. “Autism is an epidemic,” he stated in a September TV debate, referring to statistics from the Centers for Disease Control showing the dramatic yet unexplained rise of autism over time, now afflicting one child in 68 and over two per cent of boys. That contrasts with “25 years ago, 35 years ago, you look at the statistics, not even close,” Trump says. “I am totally in favour of vaccines but I want smaller doses over a longer period of time.”

In the September debate and on numerous earlier occasions, Trump has referred to his personal experiences with those he’s known. “I’ve seen people where they have a perfectly healthy child, and they go for the vaccinations, and a month later the child is no longer healthy,” he told Fox News in 2012. “It happened to somebody that worked for me recently. I mean, they had this beautiful child, not a problem in the world. And all of a sudden, they go in, they get this monster (sized) shot. You ever see the size of it? It’s like they’re pumping in — you know, it’s terrible, the amount. And they pump this into this little body. And then all of the sudden, the child is different a month later.”

Others very important to Trump — his voters — also help explain Trump’s enthusiasm for a commission into vaccine safety. According to an Economist/YouGov poll taken in December, 31 per cent of Trump voters believe that vaccines can cause autism and only 21 per cent reject that view outright. Other voters doubtless worried about vaccines for reasons other than autism. Many of those vaccine-issue voters would have been highly motivated, since the health of their children was at stake.

Trump believes his presidency places him at the head of an historic movement, “a beautiful movement. We are going to make America safe and great again.” Making America safe doesn’t just involve building a wall to keep out criminals and terrorists, he believes. To Trump, it also includes making sure that there’s safety in America’s vaccines.

 LawrenceSolomon@nextcity.com

Over the past year, I have engaged with the BC Government people on the question of injecting a possible ‘preventative’ against a sexually-transmitted disease into little kids,…… little nine year old girls, and now with the urging of the BC Cancer Society, adding little boys to the lucrative business of injecting the Merck company’s Gardasil into little children.

I think this is horrific, stupid and immoral.  Not that I believe all vaccinations are unnecessary.  But THIS ONE IS!!!

The message to our precious children is, ‘You are nothing more than an animal.  You have no control over your own body, or emotions.  There is nothing high or lofty to reach for.  As soon as you reach puberty you will be roiling in sex.  You have no self-control.  Just do it.  Just let all the leeches out there at you.  And kid,…..there is no God who loves you and wants you to live on a higher plane.  Oh, and if all that sex results in a new life forming, believe us,…..that’s just a fetus,…..not a baby, and we’ll soon dispose of that.’

I think neither Merck, nor anyone in the government will be there, for hapless victims of ill thought out injections, as they journey through life.  Nor do I think anyone at Merck or the BC government will ever be held accountable, if in the future these totally unnecessary invasions of a child’s healthy cells, creates unforeseen health complications.

Below are MANY pages, in response to my Freedom of Information requests.  I’m sincerely thankful to live in a democracy where citizens can freely ask questions, raise doubts, and sometimes even get answers from their government.

I’m hoping someone, far more equipped than I am, will peruse these pages and be motivated to investigate further.  – Gerda

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Number of students who have been given Gardasil® in BC schools to date

Prepared on November 24, 2016

The number of BC female students who have ever received a dose of Gardasil® is not routinely assessed at the BC Centre for Disease Control (BCCDC).

A rough approximation can be obtained using BCCDC’s reports of annual Grade 6 and 9 immunization coverage rates, which include HPV. The public reports are available here:

  • –  Grade 6 (see Definitions on page 1-3 and HPV coverage rates on page 13-
    14): http://www.bccdc.ca/resource- gallery/Documents/Statistics%20and%20Research/Statistics%20and%20Reports/Immunization/ Coverage/Grade6 Coverage Results.pdf
  • –  Grade 9 (see Definitions on page 1 and HPV coverage rates on page 9-
    11): http://www.bccdc.ca/resource- gallery/Documents/Statistics%20and%20Research/Statistics%20and%20Reports/Immunization/ Coverage/Grade9 Coverage Results.pdfThe HPV immunization coverage statistics in these reports are calculated based on the number of female students enrolled in Grade 6 and 9 who are assessed as up-to-date for HPV immunization (the numerator) divided by the number of female students enrolled in Grade 6 and 9 (the denominator) in a given school year. Up-to-date for HPV immunization is defined as 3 doses of HPV vaccine before the 2010/11 school year and 2 doses from 2010/11 onwards. For more information,
    see http://www.bccdc.ca/health-info/immunization-vaccines/immunization-coverage

    To obtain an estimate of the number of female students who were up-to-date for HPV immunization, the denominator can be approximated using BC population estimates. The majority of Grade 6 students would be expected to be 11 years old in a given school year, and grade 9 students are expected to be 14 years old. Note that immunization coverage reporting is assessed at the end of the school year, for example, the majority of Grade 6 students are 11 years old in 2008 for the 2008/09 school year, and the coverage statistics are assessed and reported out in 2009.

1) Obtain the denominator

The population estimates for this age cohort can be obtained at BC Stats Population
Estimates: http://www.bcstats.gov.bc.ca/statisticsbysubject/Demography/PopulationEstimates.aspx

To obtain the population estimate of 11- and 14-year old girls, select the following:

  • –  Select regions(s): 0 – British Columbia
  • –  Select years(s): 2008 to 2014

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  • –  Select sex(es): Females
  • –  Select age group: Custom Age Groups: => From 11 To 11, From 14 To 14Click “Generate output”. Click on the CSV icon to export this output into an Excel file (see image below)

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2) Calculate the numerator

Multiply the numerator with the HPV immunization coverage rate for the appropriate school year and grade. For example, the number of Grade 6 female students who were up-to-date for HPV immunization is calculated by:

23,733 [11 years olds in 2008] x 61.8% [proportion of female students up-to-date for HPV immunization in the 2008/09 school year] = 14,667 female students

Limitations

This method of back-calculating the numerator is imprecise and produces a very rough approximation at best. Note the following limitations in interpreting the results:

  • –  The HPV coverage statistics are not broken down by type of HPV vaccine (ie. Gardasil® or Cervarix®). However Gardasil® is the vaccine used in the routine immunization schedule, therefore it can be assumed that only a very small number, if any, of the school-based immunizations are not using Gardasil®.
  • –  The HPV coverage statistics assess for female students who are up-to-date for HPV vaccination (i.e., 2 or 3 doses of HPV, depending on the school year). The number of students who ever received a dose of Gardasil® is expected to be higher.
  • –  HPV coverage statistics in the BCCDC reports are calculated based on students enrolled in BC schools, therefore using population estimates as the denominator may overestimate the actual number of enrolled students in schools.
  • –  Immunization coverage statistics are assessed annually based on the number of students enrolled in a given school year, and therefore the numerator calculated by the approach described above would provide the number of students who are up-to-date for HPV immunization in a given school year and not over their lifetime. Students who are assessed in both Grade 6 and 9 over the time period between 2008 and 2015 may be double counted.
  • –  Note that the BCCDC immunization coverage statistics are based on immunizations given through the publicly-funded immunization program. Students who obtained their vaccinations through private pay (such as male students) are not assessed by BCCDC.

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#3-A record which includes an estimate of future uptake for the Quadrivalent HPV Vaccine Program.

Future uptake of Quadrivalant HPV Vaccine: At present, Gardasil 9 is being administered, BC’s vaccine coverage rate target is 90%. Given an average school cohort size of 45,000, and that half of the average school cohort size is female, should this target rate be achieved in future, this would equate to 20,250 female students vaccinated annually.

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What is HPV and who can get it?

HPV is one of the most common sexually transmitted infections (STIs) and 3 out of 4 sexually active people will get HPV at some time. Anyone who has any kind of sexual activity with another person involving oral, genital or anal contact can get HPV. Sexual intercourse is not necessary to get infected.

Every year in B.C. approximately:

  •   175 women will get cervical cancer and 50 will diefrom the disease.
  •   6,000 women will develop high risk changes to the cervix which are precancerous.
  •   Over 500,000 women will undergo Pap tests and over 20,000 will need further follow-up which may include additional Pap tests and other procedures to stop cancer of the cervix from developing.People are best protected when they get the HPV vaccine before they become sexually active. The vaccine prevents almost 100% of cases of cancer of the cervix and genital warts caused by the 9 HPV types covered by the vaccine.

    What are the possible reactions after these vaccines?

    Common reactions may include soreness, redness and swelling in the arm where the vaccine was given. Headache and mild fever may also occur. A rash which looks like chickenpox but with fewer spots can occur about 2 weeks after getting the chickenpox vaccine. The rash is usually 2 to 3 small blisters in the skin near where the needle was given but may sometimes appear on other parts of the body. Very rarely, an immunized person who develops a rash after vaccination can spread the virus from the chickenpox vaccine to others. To prevent spreading the virus to others the rash should be covered until the blisters have dried and crusted over.

    It is important to stay in the clinic for 15 minutes after getting any vaccine because there is an extremely rare possibility, less than 1 in a million, of a life-threatening allergic reaction called anaphylaxis. This may include hives, difficulty breathing, or swelling of the throat, tongue or lips. Should this reaction occur, your health care provider is prepared to treat it. Emergency treatment includes administration of epinephrine (adrenaline) and transfer by ambulance to the nearest emergency department. If symptoms develop after you leave the clinic, call 9-1-1 or the local emergency number.

    It is important to always report all serious or unexpected reactions to your health care provider.

*Ibuprofen should not be given to children under 6 months of age without first speaking to your health care provider.

For more information on Reye Syndrome, see

HealthLinkBC File #84 Reye Syndrome.

Who should not get a vaccine?

A vaccine is not recommended for:

  •   People who have had a life-threatening allergic reaction to a previous dose of vaccine, or to any component of the vaccine including yeast (in the hepatitis B and HPV vaccines), latex (in some hepatitis B vaccines), neomycin and gelatin (in some chickenpox vaccines).
  •   Some people who have an immune system weakened by disease or medical treatment should not receive chickenpox vaccine.
  •   People who have had a blood transfusion or received other blood products may need to wait up to 11 months before receiving the chickenpox vaccine, depending on which blood product they received.
  •   People with active untreated tuberculosis should not get the chickenpox vaccine.
  •   Women who are pregnant should not receive the chickenpox or HPV vaccines.There is no need to delay getting immunized because of a cold or other mild illness. However, if you have concerns, speak with your health care provider.

    Mature Minor Consent

    It is recommended that parents or guardians and their children discuss consent for immunization. Children under the age of 19, who are able to understand the benefits and possible reactions for each vaccine and the risk of not getting immunized, can legally consent to or refuse immunizations. For more information on mature minor consent see HealthLinkBC File # 119 The Infants Act, Mature Minor Consent and Immunization.

Acetaminophen (e.g. Tylenol®) or ibuprofen* (e.g. Advil®) can be given for fever or soreness. ASA (e.g. Aspirin®) should not be given to anyone under 18 years of age due to the risk of Reye Syndrome.

For more HealthLinkBC File topics, visit http://www.HealthLinkBC.ca/healthfiles or your local public health unit. For non-

emergency health information and advice in B.C. visit http://www.HealthLinkBC.ca or call 8-1-1 (toll-free). For deaf and

hearing-impaired assistance, call 7-1-1. Translation services are available in more than 130 languages on request. PHSA 0042-16 Page 13

BACKGROUNDER

2008HEALTH0053-000699 Ministry of Health May 5, 2008

HUMAN PAPILLOMAVIRUS AND THE HPV VACCINE

Human Papillomavirus (HPV) is a common, yet preventable, infection that can lead to cancer of the cervix, and is associated with other types of cancer in both women and men.

There are more than 100 types of HPV, including a number of strains linked to cervical cancer. Most HPV infections will clear on their own but for some women the HPV will not go away and cells infected with the virus can develop into cancer.

In the fall of 2008, British Columbia will begin offering the vaccine Gardasil, which is almost 100 per cent effective in preventing cancerous changes in the cervix due to two strains (types 16 and 18) of HPV. These two types of HPV are responsible for 70 per cent of all cases of cervical cancer in B.C.

Clinical trials involving approximately 20,000 girls and women aged 16 to 26 have shown that Gardasil is safe, and rarely causes allergic reactions. There is no evidence that it causes auto-immune diseases. Surveillance and research underway will determine its effectiveness over the long term, including any need for booster shots to maintain protection.

Gardasil has been approved by Health Canada which regulates and approves vaccines for use, and recommended by the National Advisory Committee on Immunization, which reviews evidence of safety and effectiveness. The Committee has recommended immunizations for girls ages 9-13, before the likelihood of sexual activity and HPV infection.

A second product, Cervarix, has been widely used in Europe, and is currently being reviewed for use in Canada. Both products have been extensively tested, and are highly effective against HPV types 16 and 18.

Frequently Asked Questions

How common is HPV?

HPV is one of the most common sexually transmitted infections in Canada. It can result from any oral or genital contact – intercourse is not necessary – and at least 50 per cent of sexually active women will get HPV at some time in their lives. In B.C., over 30 per cent of girls are sexually active by the time they are 16. In studies on young women who became sexually active, almost 50 per cent became infected with at least one type of HPV within three years of initiation of sexual activity. Other studies have shown that over 90 per cent of those cervical HPV infections will clear on their own. Only a small percentage will lead to changes in the cells of the cervix.

-more-

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-2-

Will my daughter be required to get the vaccine?

Immunization is not mandatory in B.C. However, eligible candidates are strongly encouraged to take advantage of this new vaccine. Vaccines save lives. They also prevent many harmful effects caused by disease.

Why give the HPV vaccine to girls at such a young age?

It’s always better to prevent disease than treat it. The vaccine is most effective when girls/women are immunized before their first sexual contact. However, even after sexual activity has begun, women may still benefit from the vaccine if they have not been infected with the strains contained in the vaccine.

Will girls/women be protected against HPV and related diseases, even if they don’t get all three doses?
Studies are underway to determine whether fewer doses of the vaccine offer the same level of protection. Until we know the results, it is important to get all three doses of the vaccine.

Can HPV infection be treated?

There is no cure for HPV, but there are treatments for the health problems that HPV can cause, such as genital warts, cervical cell changes, and cancers caused by HPV.

Are there additional ways girls and women can reduce their risk of HPV infection and cervical cancer?
The risk of HPV infection increases with the number of sexual partners and unprotected sex. Therefore, abstinence, reducing the number of sexual partners and using condoms during sex can all reduce the risk of HPV infection. Girls and women can also lower their risk of cervical cancer by not smoking. Most important, however, are regular Pap tests – as recommended by physicians – to detect any cervical changes before cancer develops.

Media Michelle Stewart
contact: Communications Director

Ministry of Health
250 812-5571 (cell)
250 952-1887 (media line)

-30-

For more information on government services or to subscribe to the Province’s news feeds using RSS, visit the Province’s website at http://www.gov.bc.ca.

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B.C. ROUTINE IMMUNIZATION SCHEDULE SCHOOL AGE

VACCINE

Grade 6

HealthLinkBC File # 50f

Grade 9

HealthLinkBC File # 50g

Hepatitis B

1. HealthLinkBC File # 25a 2. Product Monograph Recombivax HB / Engerix-B

2 doses
(if 3 doses not received in infancy)

2nd dose 6 months after 1st dose

HPV (girls only)

(human papillomavirus)

1. HealthLinkBC File # 101b
2. Product Monograph Gardasil 9

2 doses
2nd dose 6 months after 1st dose

Varicella ‡

(chickenpox)

1. HealthLinkBC File # 44b 2. Product Monograph

Varilrix / Varivax III

1 or 2 doses ‡
2nd dose at least 3 months after 1st dose

Meningococcal Quadrivalent Conjugate

1. HealthLinkBC File # 23b 2. Product Monograph Menveo / Menactra

1 dose

Tdap

(tetanus, diphtheria, pertussis)

1. HealthLinkBC File # 18c 2. Product Monograph

Adacel / Boostrix

1 dose

‡ Children who had chickenpox or shingles disease, diagnosed by a health care provider, at 1 year of age or older do not need the chickenpox vaccine. Children who received a single dose of chickenpox vaccine at a younger age only need 1 dose in grade 6. Children who have never received the chickenpox vaccine need 2 doses.

Access the BC Immunization Manual

Sep 6, 2016

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#7b-A record which details the number and the timing of shots received by each student.

The HPV program for school aged girls has been as follows. These schedules all use Gardasil® (4 valent HPV vaccine) :

September 2008 – 3 dose series for girls in grades 6 and 9 (grade 9 program was a 3 year catch up)

September 2010 – extended 3 dose schedule for girls in grade 6 (2 doses in grade 6 + 3rd dose in grade 11)

September 2013 – 3rd dose of the extended schedule moved to grade 9
October 2014 – 2 dose schedule for grade 6 girls (3rd dose in grade 9 no longer given) September 2016 – Gardasil® 9 (9 valent HPV vaccine) replaces Gardasil® for grade 6 girls

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1.0 2.0

Communicable Disease Control Immunization Program Section IV– Administration of Biological Products January 2016

TABLE OF CONTENTS DEFINITIONS………………………………………………………………………………………………….. 1

PREPARATION FOR ADMINISTRATION OF BIOLOGICAL PRODUCTS……………….. 1 2.1 Product Preparation…………………………………………………………………………………. 1 2.2 Informed Consent ……………………………………………………………………………………. 2 2.3 Client Assessment …………………………………………………………………………………… 2

4.0 5.0 6.0 7.0 8.0

9.0

10.0 11.0

12.0 13.0

DRAWING UP MULTIPLE DOSES OF A BIOLOGICAL PRODUCT ……………………….. 4 DRAWING UP BIOLOGICAL PRODUCTS IN VIAL PRESENTATION …………………….. 5 DRAWING UP BIOLOGICAL PRODUCTS IN AMPULE PRESENTATION ………………. 6 STANDARD PRECAUTIONS…………………………………………………………………………….. 7 INJECTION SITES, NEEDLE SIZE AND POSITIONING ……………………………………….. 7

8.1 Needle size and site for subcutaneous (SC) injection…………………………………. 8 8.2 Needle size and sites for intramuscular (IM) injection ………………………………… 9 8.2.1 Vastus lateralis (anterolateral thigh) site …………………………………………………. 10 8.2.2 Deltoid site ……………………………………………………………………………………………. 11 8.2.3 Ventrogluteal site …………………………………………………………………………………… 12 8.2.4 Dorsogluteal site ……………………………………………………………………………………. 13 8.3 Site and needle size for intradermal injection…………………………………………… 14

INJECTION ROUTES……………………………………………………………………………………… 14 9.1 Injection Routes for Biological Products …………………………………………………. 15 9.2 Subcutaneous (SC) injection route………………………………………………………….. 16 9.3 Intramuscular (IM) injection route……………………………………………………………. 17 9.4 Intradermal (ID) injection route ……………………………………………………………….. 18

CLIENT OBSERVATION FOLLOWING IMMUNIZATION …………………………………….. 19

MANAGEMENT OF FEVER AND PAIN FOLLOWING IMMUNIZATION ………………… 20 11. 1 Fever Management…………………………………………………………………………………. 21 DOCUMENTATION………………………………………………………………………………………… 22 REFERENCES ………………………………………………………………………………………………. 23

CONSIDERATIONS FOR THE SCHEDULING AND ADMINISTRATION OF MULTIPLE

3.0 INJECTIONS……………………………………………………………………………………………………………… 3

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Communicable Disease Control Immunization Program Section IV – Administration of Biological Products December 2015 Page 1

1.0 DEFINITIONS

Infant
T oddler
Preschooler Subcutaneous injection

Intramuscular injection Intradermal injection

Birth up to the age of 12 months

Age 12 months up to the age of 3 years

Age 3 years to the age of 5 years

Injection of a biological product into the layer of fatty tissue between the skin and muscle

Injection of a biological product into muscular tissue

Injection of a minimal quantity (0.01 ml to 0.1 ml) of a biological product just under the dermis

  1. 2.0  PREPARATION FOR ADMINISTRATION OF BIOLOGICAL PRODUCTS
  2. 2.1  Product Preparation

For the administration of particular products, review guidelines in the Communicable Disease Control Manual, Chapter 2, Section VII: Biological Products

Prepare necessary materials (e.g. sterile syringe/needle, 70% isopropyl alcohol, sharps container, supplies for the management of anaphylaxis).

When administering any biological product, consider the 7 “Rights” of medication administration (i.e. right product, right client, right dose, right time, right route, right reason, and right documentation).

Check the characteristics of the product to be administered:

  • Correct product, form of presentation and expiry date. Check three times that it isthe correct product: when removing from fridge/biological cooler, when drawing

    up/reconstituting, and prior to administration.

  • Expected appearance: are there any irregularities (e.g., particulate matter, damage)?
  • Expiry date. If only the month and year are provided for the expiry date, thebiological product can be used to the end of that month.
  • If a previously opened multi-dose vial, check the date that the vial was opened (asrecorded on the label). Multi-dose vials must be used within 30 days of opening, unless the manufacturer specifies a shorter period.

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Communicable Disease Control Immunization Program Section IV– Administration of Biological Products December 2015 Page 2

2.2 Informed Consent

Informed consent is an essential pre-condition to providing immunization. It is the professional and legal responsibility of the provider to obtain informed consent prior to immunization.

Refer to the Communicable Disease Control Manual, Chapter 2, Section IB: Informed Consent.

Also refer to the informed consent policy specific to your worksite and the

College of Registered Nurses of British Columbia Standard of Practice, Consent available at https://www.crnbc.ca/Standards/PracticeStandards/Lists/GeneralResources/359Consen

tPracStd.pdf

Note the following are elements of informed consent:

2.3

• • • • • • • •

specific to immunization service client-centered
voluntary
obtained without fraud or misrepresentation assesses client’s capability

provides standard information
provides client time to ask questions and receive answers gives client the right to refuse or revoke consent

Client Assessment

Review client’s record to determine which biological products client is eligible for at this visit.

Ask client or parent / guardian about all relevant contraindications and precautions to receiving the biological product, including history of anaphylaxis and history of fainting. Note that the only contraindications to all vaccines approved in Canada are: anaphylaxis to a component of the vaccine; significant immunosuppression (live vaccines only); and pregnancy (live vaccines only). Review precautions for each biological product in the Communicable Disease Control Manual, Chapter 2, Section VII: Biological Products.

To reduce the likelihood of fainting (and the possibility of injuries), consider the following measures to lower stress in those awaiting immunization:

• Seat every client prior to immunization
• Maintain a comfortably cool room temperature and if possible, plenty of fresh air • Avoid long line ups in mass immunization clinics
• Prepare biological product(s) out of view of recipients
• Provide privacy during immunization
• If client is anxious and pale, have them lie down with legs elevated
• Apply cold wet cloth to face.

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Communicable Disease Control Immunization Program Section IV – Administration of Biological Products January 2010 Page 3

3.0 CONSIDERATIONS FOR THE SCHEDULING AND ADMINISTRATION OF MULTIPLE INJECTIONS

“Administer all vaccine doses for which a recipient is eligible at the time of each visit.” This is Guideline 7 of the National Guidelines for Immunization Practices (Canadian Immunization Guide, 2006). Adherence to this standard of practice will avoid a missed opportunity for immunization and the inherent possibility of the individual contracting a vaccine preventable disease in the intervening period of time. Individuals should be fully immunized at the appropriate age. The practice also results in fewer periods of discomfort for the client and fewer office visits with decreased time and cost factors for both clients and health care providers.

There are no contraindications to giving multiple injections of vaccines at the same clinic visit. There is no increase in side effects, reduced vaccine effectiveness, or reduced parental compliance.

When two or more biological products are to be administered, it is preferable, but not necessary, to use different limbs. Use of different limbs assists in differentiation of local adverse events following immunization.

If multiple injections are to be given, and two health care providers are available, ask client if they would like to have the biological products administered simultaneously in different limbs. The premise is that this procedure allows the client more control in the immunization experience and may decrease anxiety from anticipation of next injection(s).

Give biological products that are known to cause more stinging and/or pain last (e.g., give INFANRIX hexaTM first, followed by Prevnar). Give MMRII last. Published pain- related data are not available for other vaccines.

When administering two or more biological products in the same limb, separate the injections by as much distance as possible. A separation of 2.5 cm (1”) is preferable so that local reactions are unlikely to overlap.

When administering multiple vaccines intramuscularly, the vastus lateralis or deltoid muscle may be used.

  • For infants less than 12 months of age, the thigh (vastus lateralis) is the preferred site for more than one IM injection because of its greater muscle mass. The thigh may also be used at any other age.
  • For infants ≥ 12 months, older children and adults, the deltoid is the preferred site for more than one IM injection, providing there is adequate muscle mass.

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Communicable Disease Control Immunization Program Section IV – Administration of Biological Products November 2010 Page 4

The literature contains varying recommendations regarding the maximum number of injections and maximum total volume of all the injections to be given into one IM injection site (i.e., the vastus lateralis or the deltoid). The decision regarding number of injections and maximum volume to be administered should be based on the age and assessed muscle mass of the individual. In general:

4.0

• •

Vastus lateralis: 1.0 ml in infants; 2 ml in children ≥ 12 months to 5 years; 3 ml in children 5 years to 18 years, 5.0 ml in adults
Deltoid: 1.0 ml in children ≥12 months to 18 years; 2.0 ml in adults

DRAWING UP MULTIPLE DOSES OF A BIOLOGICAL PRODUCT

A biological product should be withdrawn from the vial by the provider administering the product. The College of Registered Nurses of British Columbia Practice Standard Medications states “Nurses only administer medications they themselves or a pharmacist have prepared, except in an emergency.” The Practice Standard is available at: https://www.crnbc.ca/Standards/Pages/Default.aspx

Pre-loading syringes with a biological product is discouraged because of the uncertainty of product stability in syringes, risk of contamination, increased potential for administration errors, and biological product wastage.

If the decision is made to draw up multiple doses of a biological product for programmatic reasons, such as a mass influenza or disease outbreak immunization clinic, follow these guidelines:

  • Check product insert. Some biological products should not be pre-drawn as they mustbe used immediately (e.g., varicella vaccine).
  • Keep pre-drawn biological product in an insulated biological cooler at a temperature of2° – 8° C. Avoid direct contact between the syringes and the ice pack.
  • Securely attach needle caps over the needles, when possible.
  • If the needle cap becomes loose or dislodged, discard the needle and biological product-containing syringe.
  • To ensure there is no tampering with pre-drawn biological product do not leave biological coolers unattended at any time.
  • Unless otherwise specified by the biological product manufacturer, or Epidemiology Services, BCCDC, discard unused pre-drawn biological products at the end of the clinic.Clearly record the date of opening on the labels of any leftover, opened multi-dose vaccine vials

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5.0 DRAWING UP BIOLOGICAL PRODUCTS IN VIAL PRESENTATION

Wash hands or cleanse with a sanitizer. Remove the plastic cap covering the vial.

Cleanse the surface of the rubber stopper using a cotton pad/swab moistened with 70% isopropyl alcohol. Allow to air dry.

Gently swirl the vial immediately before removing each dose to ensure that the contents are fully dispersed.

For a product in a “ready to go” liquid presentation, draw into the syringe a volume of air equal to the quantity of biological product to be removed.

For lyophilized, or freeze-dried products (e.g., MMR) having to be reconstituted, the diluent acts as the air in the syringe so there is no need to draw air into the diluent syringe.

Hold/place the vial right side up and insert the needle through the centre of the rubber stopper.

Slowly inject the air or diluent from the syringe.

If the biological product was reconstituted, gently swirl the vial to ensure the contents are fully dispersed.

Hold the vial upside down and withdraw the required quantity of biological product into the syringe.

Remove the needle from the vial and expel the air bubble(s).

It is not necessary to change needles between drawing up the biological product into the syringe and immunizing the client. Change the needle only if it is damaged, or becomes contaminated.

If it is the first entry into a multi-dose vial, record the date (include day, month and year) on the label of the vial.

Immediately return multi-dose vials to the refrigerator/biological cooler.

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6.0 DRAWING UP BIOLOGICAL PRODUCTS IN AMPULE PRESENTATION

Gently swirl the ampule immediately before removing the contents to ensure that the contents are fully dispersed.

Tap the ampule lightly to ensure that the contents are in the lower part of the ampule.

Using a swab moistened with isopropyl alcohol, wipe the neck area of the ampule prior to opening to prevent bacterial contamination of ampule contents.

Break the neck of the ampule using the alcohol swab, a clean cotton ball or a clean cotton gauze. If you cut yourself in breaking the ampule, discard the ampule, since the product may be contaminated. Wash your hands and cover the cut before continuing.

Withdraw the contents of the ampule using a sterile syringe and 25-gauge needle. It is not necessary to change needles between drawing up the biological product into the syringe and administering it to the client.

Discard the ampule into a hard sided, labeled sharps container. Expel the air bubble(s) from the syringe.

The literature suggests there is a potential for introduction of microscopic glass shards into the contents of an ampule when it is opened. The clinical significance of intramuscular or subcutaneous administration of glass shards is not clear. There is a theoretical association between the injection of glass shards and transient local reactions. Filter needles are recommended in the literature when a medication in ampule presentation is delivered intravenously, and when a patient is receiving ongoing IM injections of a medication from an ampule.

Filter needles are not indicated for the routine administration of biological products or epinephrine. The reasons are as follows:

  • There are fewer glass shards introduced to ampule contents on opening of a smaller ampule (e.g., Varilrix® diluent), compared to a larger size ampule.
  • Fewer shards will potentially be drawn into an unfiltered needle when the needle bore is smaller (i.e., higher gauge needles used for vaccination).
  • The practice standard of using a cotton pad when opening the ampule will reduce the risk of glass shards entering the ampule contents.
  • Filter needles could potentially filter out particulate matter such as adjuvants or other active ingredients, making a vaccine less effective.

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7.0 STANDARD PRECAUTIONS

Communicable Disease Control Immunization Program Section IV – Administration of Biological Products October 2008 Page 7

Gloves are not required when administering biological products unless the vaccinator has open hand lesions or will come into contact with potentially infectious body fluids.

Wash hands well or use a sanitizer between clients.
To prevent accidental needle stick injury, do not recap standard needles.

When safety needles are used, engage safety mechanism immediately following administration of the biological product.

Immediately discard needle and attached syringe in hard sided, labeled sharps container. Place sharps container so as to avoid reaching or having to reach in front of the client. Caution should also be taken so that the sharps container cannot be reached by children in the clinic setting.

Do not empty used needles and syringes from one sharps container to another.

Report percutaneous (needle stick) injuries immediately to supervisor for consideration of possible post-exposure immunoprophylaxis. Follow worksite health and safety protocol. All immunization providers should have completed a full series of hepatitis B vaccine.

8.0 INJECTION SITES, NEEDLE SIZE AND POSITIONING

Use clinical judgment to select appropriate injection site and needle size. This assessment is based upon:

• client’s age
• volume of biological product to be administered
• viscosity of biological product
• adequacy of muscle mass
• recommended route of administration for the biological • number of products to be administered.

After selecting the appropriate injection site, inspect the skin’s surface over the site for bruises, scars, or inflammation. Palpate site for masses, edema, or tenderness. If any of these are found at the injection site, do not use the site, as there might be interference with absorption of the biological.

Correct positioning of the client is a critical step in ensuring the biological product is administered in the correct site. Instruct the parent /guardian to hold the child such that the immunization site is clearly visible to the immunizer and the child is sufficiently restrained to prevent as much movement as possible during the immunization. See the following website for photos of “comforting restraint” of infants, toddlers and older children. http://www.immunize.org/news.d/comfrten.pdf

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Examples of positioning for injection in the vastus lateralis:

Examples of positioning for injection in the deltoid:

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8.2 Needle size and sites for intramuscular (IM) injection

Use a needle length sufficient to reach the largest part of the muscle. This is to prevent the biological being deposited in subcutaneous tissue and to decrease or prevent abscess formation. The use of longer needles has also been associated with less redness and swelling at the immunization site than occurs with shorter needles.

For infants, toddlers, and older children a 7/8”- 1”needle is recommended, depending on the muscle size and the amount of subcutaneous tissue.

For adolescents and adults, a 1 – 11/2 “needle is usually used.

Use a 22 to 25 gauge needle depending on the viscosity of the biological product. A larger bore needle (e.g., 22 gauge) may be required when administering viscous products such as immune globulin preparations.

The IM site of choice for infants less than 12 months of age is the vastus lateralis (anterolateral thigh). It should also be considered for older children with a small deltoid muscle mass. For children ≥12 months of age and for adults, the preferred site is the deltoid muscle. When the deltoid muscle is used for children ≥12 months of age, first assess the adequacy of the muscle mass.

Assess the depth of the muscle mass to determine the needle length to be used. One way of doing this is as follows: before injecting the deltoid muscle or vastus lateralis, grasp the muscle between thumb and index finger. One half the distance between thumb and index finger will be the approximate length of the needle required to penetrate that muscle.

Assessing the ventrogluteal muscle or dorsogluteal muscle requires more calculation because the muscle mass cannot be easily grasped. However, the amount of subcutaneous fat at the site can be assessed. Using thumb and index finger pick up the layer of fat and skin above the muscle. This layer of tissue moves easily over the underlying muscle. One half of the distance between thumb and index finger will be the approximate length of the needle required to reach the muscle. The client’s overall size will need to be assessed in order to decide on the length to add in order to penetrate the muscle mass. For example, frail adults may need a needle length of 1 inch; well- developed, muscular adults or obese adults will need a longer needle length.

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8.2.1 Vastus lateralis (anterolateral thigh) site

This site is used for both IM and SC injections.

When immunizing an older child or adult, position client in a supine, side lying, or seated position.

When immunizing an infant, have the parent/caregiver hold the infant in a “cuddle” or semi-recumbent position on their lap.

  • Define the site by dividing the space between the trochanter major of the femur and the top of the knee into three parts; draw a horizontal median line along the outer surface of the thigh.
  • The injection site is in the middle third, just above the horizontal line.

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8.2.2 Deltoid site

This site is used for IM injections only.

Have the child sit sideways on the lap of the parent/caregiver. The injection arm should be held close to the infant’s body while the other arm is tucked behind the parent’s/caregiver’s back.

To help in relaxing the muscle during the injection, the older client may be seated with their elbow bent and their forearm resting on the arm of a chair and internally rotated.

Define the site by drawing a triangle with its base at the lower edge of the acromion and its peak above the insertion of the deltoid muscle. The injection site is in the center of the triangle.

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8.2.3 Ventrogluteal site
Do not use this site for vaccine administration.

The ventrogluteal site is the preferred site for the IM injection of large volumes of immune globulin preparations (e.g. Ig, HBIg, TIg, RabIg).

This site can be used in those over 7 months of age.
This muscle is accessible in the supine, prone, and side lying position.

The right hand is used for locating the site on the left hip; the left hand is used for locating the site on the right hip.

Place heel of the hand over the greater trochanter of the client’s hip with wrist almost perpendicular to the femur. Point the thumb toward the client’s groin and the fingers toward the client’s head. Point index finger to the anterior superior iliac spine, and extend the middle finger back along the iliac crest toward the buttock. The index finger, the middle finger, and the iliac crest form a V-shaped triangle. The injection site is the center of the triangle.

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8.2.4 Dorsogluteal site
Do not use this site for vaccine administration, as it is less immunogenic for a number

of vaccines, including hepatitis B and rabies vaccines.

The dorsogluteal site is only to be used for the IM injection of large volumes of immune globulin preparations when the ventrogluteal and vastus lateralis sites have had maximum volumes of an immune globulin preparation injected and an additional volume still needs to be administered. This is due to the possibility of sciatic nerve injuries when the injection is done in the dorsogluteal site.

This site should only be used in individuals over five years of age. Place client in a prone, side lying, or standing position.

Encourage a posture that will provide muscular relaxation and reduce discomfort (i.e. turning toes inward when prone, flexing the upper leg at hip and knee when lying on the side, flexing knees and leaning upper body against a support when standing).

Define the site by dividing the buttock into 4 quadrants. The injection site is the centre of the upper outer quadrant.

Direct the needle anteriorly (i.e., if the client is lying prone, direct the needle perpendicular to the table’s surface, not perpendicular to the skin plane).

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8.3 Site and needle size for intradermal injection

Use a 1 ml TB syringe and 27 gauge needle of 1/2” length.

The usual site for intradermal injections is the flexor (anterior) surface of the forearm.

Have client rest their arm on a firm surface, forearm turned up.

Because of the decreased antigenic mass administered with ID injections, attention to technique is essential to ensure that the material is not injected subcutaneously.

9.0 INJECTION ROUTES

Routes of administration of each biological product are recommended by the manufacturer. Deviation from the recommended route of administration may reduce vaccine efficacy or increase local adverse events. Report any administration of a biological by a route other than that recommended by the manufacturer to the appropriate person in your health care setting.

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9.2 Subcutaneous (SC) injection route

PROCEDURE

IMPORTANT POINTS

  • Use correct length and size of needle. Grasp a skin fold of fatty tissue at site with thumb and forefinger. Measure skin fold from top to bottom; be sure needle is approximately one half this length.
  • Clean the site with a cotton pad/swab/ball moistened with 70% isopropyl alcohol.
  • Pinching skin elevates SC tissue and ensures that needle will be injected into SC tissue.
  • Allow the skin to air dry prior to injection to avoid a burning sensation on insertion of the needle.
  • Insert the needle quickly and firmly, with the bevel facing upwards, at a constant angle of 45°.
  • For an obese client, use a longer needle and inject at a 90° angle to reach SC tissue.

• Quick, firm insertion minimizes discomfort.

• Release the skin.

• Injecting into compressed tissue irritates nerve fibers.

• Rapidly inject the biological product. 

• Rapid injection reduces pain.

  • Remove the needle in one swift motion, immediately applying pressure to the injection site with a dry cotton pad/swab/ball.
  • Do not massage the injection site.
  • Minimizes discomfort during needle withdrawal. Alcohol on a cotton pad/swab can irritate non-intact skin.
  • Massage can damage underlying tissue.

NOTE: Aspiration is not recommended as there are no data to document its necessity prior to the SC injection of biological products.

 Rapid injection is recommended for all vaccines injected subcutaneously or intramuscularly. It is not recommended for more viscous biological products such as immune globulin preparations or those for which the manufacturer recommends a slower administration.

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9.3 Intramuscular (IM) injection route

PROCEDURE

IMPORTANT POINTS

  • Use correct length and size of needle.
  • Clean the site with a cotton pad/swab/ball moistened with 70% isopropyl alcohol.

• Allow skin to air dry to avoid a burning sensation on insertion of the needle.

• Insert needle quickly at a 90° angle into muscle.

• If client’s muscle mass is small, grasp body of muscle between thumb and fingers before and during the injection.

• Ensures that biological product reaches the muscle mass.

• Rapidly inject the biological product 

• Rapid injection reduces pain.

  • Remove the needle in one swift motion, immediately applying pressure to the injection site with a dry cotton pad/swab/ball.
  • Continue to apply pressure for 30 seconds.
  • Do not massage injection site.
  • Minimizes discomfort during needle withdrawal. Alcohol on a cotton pad/swab can irritate non- intact skin.
  • Minimize bruising.
  • Massage can damage underlying tissue.

NOTE: Aspiration is not recommended as there are no data to document its necessity prior to IM injection of biological products. There are no large blood vessels at the recommended immunization sites. Aspiration may increase the time it takes to immunize and is more painful for the client. To view video clips of slow (including aspiration) immunization techniques and rapid immunization techniques see: http://www.msss.gouv.qc.ca/sujets/santepub/vaccination/index.php?professionnels de la sante Scroll down page to section titled Aspirer ou non avant d’injecter un vaccin? There are 5 videos demonstrating immunization technique.

 Rapid injection is recommended for all vaccines injected subcutaneously or intramuscularly. It is not recommended for more viscous biological products such as immune globulin preparations or those for which the manufacturer recommends a slower administration.

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9.4 Intradermal (ID) injection route

PROCEDURE:

IMPORTANT POINTS:

  • Use correct length and size of needle.
  • Clean the site with a cotton pad/swab moistened with 70% isopropyl alcohol.

• Allow skin to air dry to avoid a burning sensation on insertion of the needle.

• Gently stretch the skin in the selected region between the thumb and index finger.

• Insert the needle with the bevel facing upwards, at a constant angle of 15° until the bevel disappears.

• The needle should be clearly visible beneath the skin.

  • Inject the biological product slowly with controlled pressure.
  • A white elevated wheal (bleb) 6-8 mm in size should appear.
  • If an elevated wheal does not appear, repeat the procedure, (use the other arm).
  • Remove the needle quickly and sponge the injection point with a dry cotton pad/swab/ball.
  • Do not apply a Band-Aid after a TB skin test.
  • Injection of the solution in the dermis may cause a burning and prickling sensation.
  • This indicates the product was not administered intradermally.
  • Use of dry cotton pad/swab will minimize discomfort associated with alcohol on non-intact skin.
  • A Band-Aid can mark the skin and confuse skin test readings.

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10.0 CLIENT OBSERVATION FOLLOWING IMMUNIZATION

Advise recipients of any biological product (i.e., vaccine, immune globulin, TB skin test) to remain under supervision for at least 15 minutes after immunization; regardless of whether or not they have had the particular product previously. Thirty (30) minutes is a safer duration when the person has had a prior allergic reaction to the biological product or a component of the biological product. If an individual has such an allergic history, immunization should occur in an emergency room setting. See Communicable Disease Control Manual, Chapter 2, Section IX: Adverse Events Following Immunization. The risk of fainting is the more common reason to keep biological product recipients under observation.

In a school-based or mass immunization setting, the clinic site would be the ideal location for client observation. However, it can be problematic in terms of flow of people. Directly observe any client with symptoms such as pallor or sweating (possibly pre- syncope) in the clinic setting. Enable these clients to sit or lie down until symptoms resolve.

Where recipients of a biological product choose not to remain under supervision after immunization, inform them (or their parent/guardian) of the signs and symptoms of anaphylaxis and instruct them to obtain immediate medical attention should symptoms occur.

If a band-aid is applied to an infant or toddler, advise its removal before leaving the clinic. This is to avoid the risk of the child choking on the band-aid.

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11.0 MANAGEMENT OF FEVER AND PAIN FOLLOWING IMMUNIZATION

Inform the client (or parent/guardian) about common and expected reactions to each biological product administered.

Advise parents/guardians that the child may experience fever, injection site pain and cry or be fussy following immunization. For the alleviation of fever and pain, suggest parents:
• Apply a clean, cool wet washcloth for 15 to 20 minutes over the immunization site(s). • Give acetaminophen (see 11.1 Fever Management for appropriate dosages).

Alternatively, ibuprofen can be given, however it should not be given to children less

than 6 months of age without first speaking to their health care provider.
• Refer to Communicable Disease Control Manual, Chapter 2, Section IVB-Reducing

Immunization Injection Pain for more information regarding strategies to increase child comfort before and during the administration of a biological product.

Instruct the client (or parent/guardian) to contact their health care provider if concerned about a reaction or about any adverse event that occurs following receipt of the biological product. See Communicable Disease Control Manual, Chapter 2, Section IX: Adverse Events Following Immunization for more information regarding adverse events.

Local and systemic reactions may follow use of biological products. Common reactions to biological products are usually mild, self-limited, and without permanent sequelae. They are intrinsic to the immunizing antigen or some component of the biological product. These reactions can safely be managed with symptomatic treatment.

Local reactions include pain, redness and swelling at the injection site. These reactions tend to occur within a few hours of the injection, and are common with inactivated vaccines that contain adjuvants (e.g., DTaP-IPV-Hib). Crying and irritability in infants and young children are likely responses to pain at the site of injection.

The body’s response to injected proteins can also affect heat regulation and produce fever within a few hours of vaccination.

Systemic reactions are more generalized events and include fever, rash, malaise, myalgia, and headache. These reactions are more common following the administration of live attenuated vaccines (e.g., measles, mumps and rubella vaccines) that must replicate in order to produce immunity. The systemic reactions represent symptoms produced from that replication, and are similar to a mild form of the natural disease.

When the immunizing agent is a live attenuated vaccine, inform parents that systemic adverse events tend to occur later than those following the administration of inactivated vaccines. For example, for a measles-mumps-rubella-containing vaccine, fever may occur 5 – 30 days after vaccination, most commonly within 7 –14 days. With a varicella vaccine, fever may occur within 0 – 42 days, most commonly between 14 and 27 days after immunization.

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11. 1

Fever Management

When fever is suspected, it is preferable to use a thermometer to measure temperature accurately.

Recommend acetaminophen for use in managing fever and pain. Acetaminophen may be given at a dosage of 10 – 15 mg/kg, four to five times daily, not to exceed five doses or 65 mg/kg in 24 hours. Advise parents not to continue use beyond 48 hours unless specified to do so by a physician.

Alternatively, ibuprofen may be given, however it should not be given to children under 6 months of age without first speaking to a health care provider. Instruct the client (or parent/guardian) to follow the directions and dosage recommendations on the package. Ibuprofen can be given every 6-8 hours, up to four times in a 24-hour period, and should only be given if the child is well hydrated to reduce the risk of renal adverse events.

Acetylsalicylic acid (ASA) is not recommended for anyone under 18 years of age due to the risk of Reye syndrome.

There are no supporting clinical studies for the prophylactic use of acetaminophen in children prone to febrile seizures. In fact, prophylaxis in high risk children has been shown to be ineffective. Advise parents to initiate this dosage regimen when there are symptoms of fever and/or pain shortly after immunization that are not well tolerated by the child.

The dosage guidelines in the following tables for acetaminophen and ibuprofen will provide an effective but non-toxic serum concentration level based on the child’s weight. Advise parents to follow the instructions on the label of the product they are using and to be aware of the concentration of medication.

Acetaminophen Dosage Guidelines A

Kilograms (kg) Weight Pounds (lb)

Single Dose Acetaminophen

2.7 – 5.4 kg

6 – 11 lb

40 mg

5.5 – 7.9 kg

12 – 17 lb

80 mg

8 – 10.9 kg

18 – 23 lb

120 mg

11 – 15.9 kg

24 – 35 lb

160 mg

16 – 21.9 kg

36 – 48 lb

240 mg

22 – 26.9 kg

49 – 60 lb

320 mg

27 – 31.9 kg

60 – 71 lb

400 mg

32.0 – 43.9 kg

72 – 95 lb

480 mg

Source: Acetaminophen Labelling Standard [Health Canada, 2016] A Do not exceed 5 doses in a 24 hour period.

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Source: American Academy of Pediatrics

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Ibuprofen Dosage Guidelines A, B

Kilograms (kg) Weight Pounds (lb)

Dose in milligrams (mg)

less than 6 kg

Less than 12 lb

Ask a doctor

5.5 – 7.9 kg

12 – 17 lb

50 mg

8 – 10.9 kg

18 – 23 lb

75 mg

11 – 15.9 kg

24 – 35 lb

100 mg

16 – 21.9 kg

36 – 47 lb

150 mg

22 – 26.9 kg

48 – 59 lb

200 mg

27 – 31.9 kg

60 – 71 lb

250 mg

32 – 43.9 kg

72 – 95 lb

300 mg

44 kg and above

96 lb and above

Adult dose

A Ibuprofen should not be given to children under 6 months of age without first speaking B to a health care provider.

Do not exceed 4 doses in a 24 hour period.

12.0 DOCUMENTATION

Promptly record the administration of all biological products using the documentation system in place at your worksite. For each biological product administered the minimum data to be recorded in the client’s record should include:

• name of the biological product • date
• route of administration
• anatomical site

• name of the biological product manufacturer
• lot number
• name and title of the person administering the biological product
• any reactions following immunization
• any recommended biological products that were not given (i.e., declined,

deferred, or contraindicated)
• informed consent for immunization obtained (see BC Communicable Disease

Control Manual, Chapter 2, Section IB)

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13.0 REFERENCES

Communicable Disease Control Immunization Program Section IV– Administration of Biological Products December 2015 Page 23

Alberta Health and Wellness. (2004). Multiple injections workbook. Edmonton, AB: Author.

American Academy of Pediatrics. (2006). Red Book: Report of the committee on infectious diseases. (27th ed.). Elk Grove Village, IL: Author.

Advisory Committee on Immunization Practices. Morbidity and Mortality Weekly Report. Dec 1, 2006/55 (RR15); 1 – 48. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5515a1.htm

Beyea, S.C. & Nicoll, L.H. (1995) Administration of medications via the intramuscular route: An integrative review of the literature and research-based protocol for the procedure. Applied Nursing Research, 8 (1): 23 – 33.

Canadian Paediatric Society. (1998). Acetaminophen and ibuprofen in the management of fever and mild to moderate pain in children. Paediatrics & Child Health, 3(4): 246-250. Also available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2851344/

California Department of Public Health (2007). Comfort measures for infants. Retrieved September 9, 2008 from: http://www.cdph.ca.gov/programs/immunize/Pages/ComfortMeasuresforInfants.aspx

Centers for Disease Control and Prevention. Epidemiology and Prevention of Vaccine- Preventable Diseases. Atkinson W, Hamborsky J, McIntyre L, Wolfe S, eds. 10th ed. Washington DC: Public Health Foundation, 2007.

Chiodini, J. (2001). Best practice in vaccine administration. Nursing Standard, 16(7): 35 – 38.

College of Registered Nurses of British Columbia (2005, December). Consent. Practice Standard for Registered Nurses and Nurse Practitioners. Retrieved September 9, 2008 from: https://www.crnbc.ca/Standards/Pages/Default.aspx

College of Registered Nurses of British Columbia (2007, June). Medications. Practice Standard for Registered Nurses and Nurse Practitioners. Retrieved September 9, 2008 from: https://www.crnbc.ca/Standards/Pages/Default.aspx

Comforting Restraint for Immunizations. (2001). Retrieved September 9, 2008 from:

http://www.immunize.org/news.d/comfrten.pdf

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Cook I, & Murtagh J. (2005). Optimal technique for intramuscular injection of infants and toddlers: a randomized trial. MJA; 183 (2):60-63.

Diggle, L., Deeks, J., & Pollard, A. (2006). Effect of needle size on immunogenicity and reactogenicity of vaccines in infants: randomized controlled trial. BMJ, 333(7568): 571.

Groswasser J., Kahn A., Bouche B., et al. (1997) Needle length and injection technique for efficient intramuscular vaccine delivery in infants and children evaluated through an ultrasonographic determination of subcutaneous and muscle layer thickness. Pediatrics, 100: 400-403.

Health and Welfare Canada. (2006). Canadian Immunization Guide. (7th ed.). Ottawa, On: Health and Welfare Canada. Available at: http://www.phac-aspc.gc.ca/naci- ccni/index-eng.php and http://www.phac-aspc.gc.ca/naci-ccni/index-eng.php. Guide Errata and Clarifications, March 2008.

Heiss-Harris, G. & Verklan, M.T. (2005). Maximizing patient safety: filter needle use with glass ampoules. Journal of Perinatal & Neonatal Nursing, 19(1): 74-81.

Immunization Action Coalition (2008, August 13). Improving immunization practices. Retrieved September 9, 2008 from: http://www.immunize.org/clinic/

Immunization Action Coalition (2009). Administering Vaccines: Dose, Route, Site and Needle Size. Retrieved November 30, 2009 from http://www.immunize.org/catg.d/p3085.pdf

Lenz. C. L. (1983). Make your needle selection right to the point. Nursing, 13(2): 50 – 51.

Nicoll, L. H. & Hesby, A. (2002). Intramuscular injection: An integrative research review and guideline for evidence-based practice. Applied Nursing Research, 16(2):
149 – 162.

Preston, S. & Hegadoren, K. (2004). Glass contamination in parenterally administered medication. Journal of Advanced Nursing. 48(3): 266-270.

Quebec Ministry of Health. (2008) Aspirer ou non avant d’injecter un vaccin? Retrieved September 3, 2008 from: http://www.msss.gouv.qc.ca/sujets/santepub/vaccination/ index.php?professionnels de la sante

Repchinsky. C. (ed). (2004). Compendium of Pharmaceuticals and Specialties. Rodger, M. A. & King, L. (2000). Drawing up and administering intramuscular injections:

A review of the literature. Journal of Advanced Nursing, 31(3): 574 – 582.
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Schnaiderman D., Lahat E., Sheefer T., Aladjem M. (1993). Antipyretic effectiveness of acetaminophen in febrile seizures: ongoing prophylaxis versus sporadic usage. Eur J Pediatr, 152:747-9.

Stein, H. (2006). Glass ampoules and filter needles: an example of implementing the sixth ‘r’ in medication administration. MEDSURG Nursing, 15(5):290-294.

Winnipeg Regional Health Authority. (2008). Injection Site Volume and Equipment Guidelines. WRHA Immunization Manual, Appendix H.

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August 2015

Re: Expanded Eligibility for Human Papillomavirus (HPV) Vaccination

Dear Health Care Provider,

On September 1st 2015, BC will launch a publicly funded, targeted HPV vaccine program using quadrivalent HPV vaccine (GARDASIL®) for boys and young men who are at a higher risk of contracting the virus. The program aims to provide protection to those who are most vulnerable to HPV infection and related disease and who are unlikely to be protected through indirect protection (female vaccination). Those eligible for free HPV vaccine through this program expansion include the following:

 Males 9 to 26 years of age at the time of series commencement (inclusive) who are:
o Men who have sex with men (MSM) including those who may not yet be sexually active and

are questioning their sexual orientation o Street involved
o HIV positive

  •   Males 9 to 18 years of age (inclusive) in the care of the Ministry of Children and Family Development (MCFD)
  •   Males 12 to 17 years of age (inclusive) in youth custody services centresThis program complements BC’s publicly funded HPV vaccine program for Grade 6 girls and a publicly funded time-limited catch up program for young women up to age 26. Targeted male vaccination is likely to be cost effective based on published analyses. In contrast, analyses of routine male vaccination suggest that it is not cost effective when female vaccination rates are over 50% as immunization of girls and young women provides indirect protection to heterosexual males. About 66% of Grade 6 BC girls completed the HPV vaccine series in 2014 and efforts at improving uptake are ongoing.

    The success of this program depends on providers like you promoting and administering the vaccine to eligible males. Your recommendation to vaccinate is a strong predictor of vaccine uptake.

    For questions about the rollout of the new HPV program for males at higher risk of infection, please contact your local public health unit within your respective health authority.

    For more information please refer to the following resources: BC Ministry of Health’s press release:

    https://news.gov.bc.ca/stories/hpv-immunization-program-expanded-to-vulnerable-boys

    BCCDC’s Q&A for HCPs: Expanded Eligibility for Human Papillomavirus (HPV) Vaccination for Select Male Populations:
    http://www.bccdc.ca/NR/rdonlyres/4D3B906F-067C-43DE-B856-
    EDE3080E7D9C/0/HPV QA FINAL Aug19.pdf

    The BC Immunization Manual:

    http://www.bccdc.ca/dis-cond/comm-manual/CDManualChap2.htm

    Section VII, Product Page for GARDASIL®, will be updated shortly to reflect the expanded eligibility.

PHSA 0042-16 Page 45

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