Guidance for influenza vaccine delivery in the presence of COVID-19

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Preamble

The purpose of this document is to provide guidance for the delivery of seasonal influenza vaccine in fall 2020, when ongoing COVID-19 activity may continue to stress public health capacity and affect clinic operations and attendance. This guidance has been developed by the Public Health Agency of Canada (PHAC) in consultation with the Canadian Immunization Committee and the National Advisory Committee on Immunization (NACI).

Reducing the burden of influenza is particularly important this fall and winter to prevent an increase in health care utilization at the same time as there is a potential resurgence of COVID-19 activity. In its seasonal influenza vaccine statement for 2020-2021, NACI advises that priority should be given to providing influenza vaccine to persons at high risk of influenza complications and those capable of transmitting infection to them.

The seasonal influenza immunization campaign provides an opportunity to develop and practice approaches that may be used for the anticipated COVID-19 immunization program and to ensure consideration of the diverse needs of population groups based on access to services, vulnerability, ethnicity/culture, ability status and other socioeconomic and demographic factors. These approaches may also be useful for the provision and catch-up of routine immunization. Additional advice for the provision of routine immunization programs during the COVID-19 pandemic is available from PHAC and from provinces and territories.

Challenges posed by COVID-19

The COVID-19 pandemic creates a series of challenges for the delivery of the seasonal influenza immunization program, including:

Recommendations for influenza immunization programs

Consider alternate models of influenza vaccine delivery this fall

Provinces and territories use varying systems for their seasonal influenza program, and local factors also play an important role in the planning and delivery of influenza vaccine. This fall, jurisdictions should consider a wide range of strategies to deliver influenza vaccine, with the goal of reducing crowding while maintaining or increasing vaccine uptake. Alternate models include the use of non-traditional settings as permitted by provincial/territorial legislation (for example, for immunization by pharmacists or paramedics). If demand is high, potential vaccine supply limitations may affect the decision to use some alternate delivery models.

Approaches to be considered include:

Adaptations to usual immunization procedures

The text box below highlights the types of adaptations to usual immunization practices that are recommended in the presence of COVID-19 activity. The sections that follow provide additional details.

Adaptations to usual immunization procedures

  • screening for illness/exposure to COVID-19
    • staff
    • volunteers
    • clients
  • physical distancing: may affect the physical layout and number of clients that can be accommodated at any given time
  • infection prevention and control (IPC) requirements, including the need for personal protective equipment (PPE)
  • increased environmental cleaning
  • potential need for longer hours and increased staff
  • use of appointment systems to reduce clinic crowding
  • use of technology and other methods to reduce contact
    • such as
      • on-line registration
      • paperless registration
      • consent and recording processes
  • visible and audible communications explaining COVID-19 adaptations to influenza immunization campaigns in accessible formats

Screening and entry: all venues

All persons attending the venue should be passively screened (through signage) and actively screened before entry, even if they were already pre-screened by telephone when the appointment was made. Staff and volunteers should be screened before each shift. There are various options for active screening, for example:

Signage at the door should advise visitors not to enter if they are ill, to put on their non-medical mask or face covering (depending on jurisdictional advice), use the hand sanitizer provided on entry, practice respiratory etiquette, and maintain physical distancing. If required, masks should be available for those who come without, preferably at no cost to the client.

If any persons are identified with symptoms on arrival at the venue, they should be instructed to perform hand hygiene, put on a medical mask and be redirected for assessment (for example, to a health care provider or COVID-19 assessment site depending on their symptoms).

Provincial and territorial guidance should be consulted for screening language and tools.

Physical distancing

A two-metre physical distance should be maintained as much as possible, using strategies such as:

Infection prevention and control (IPC)

IPC measures are needed to prevent transmission of COVID-19 in the immunization setting. These include:

Considerations for PPE selection

Physical distancing may be difficult to maintain at immunization venues and the immunization procedure requires close physical proximity between the vaccinator and the client. The following recommendations are based on PHAC IPC guidance for ambulatory care settings and apply in geographical areas where there is known or possible community transmission of COVID-19. Readers should refer to local, provincial or territorial guidance and organizational policies for specific recommendations for use of masks, eye protection and other PPE, PPE conservation strategies, and the use of non-medical masks by the public. These may differ over time based on the changing epidemiology of COVID-19.

Staff and volunteers

When immunization is provided during another health care visit (for example, primary care visit, home care or while in hospital), it is anticipated that the health care professional will already be using PPE appropriate for the situation. In addition to the ambulatory care guidance already cited, IPC guidance is available for home care providers.

Clients and their accompanying persons

Depending on jurisdictional advice, clients and their accompanying persons should be asked to wear a non-medical mask or face covering. This recommendation may be waived for young children for whom mask use is problematic. In addition, non-medical masks or face coverings should not be placed on children under the age of two years, anyone who has trouble breathing, or is unable to remove the mask without assistance.

Clinic set up and immunization process

Priority clinic modifications for COVID-19 have already been identified in this document (screening for illness, physical distancing, and IPC measures). The following are additional suggestions for modifying the clinic set up and immunization process:

Vaccine information can be provided in ways that minimize the use of paper, for example:

Additional considerations for other settings

School-based clinics

School-based clinics are used to deliver routine immunizations to children and teens, including influenza vaccine in some jurisdictions. These clinics may be affected by the jurisdiction's plans for return to school in fall 2020 (for example, partial or staggered attendance) and public health resource availability.

Considerations for delivery of vaccines at school include:

Outreach and mobile clinics

Outreach clinics are an effective way to reach underserved and vulnerable populations and persons unable to attend conventional immunization sites.Footnote 3Footnote 4Footnote 5 It is important to choose the location carefully. The best options are places that are most frequented by the vulnerable population(s) being targeted, for example, food banks, shelters for persons experiencing homelessness, centres providing free meals, centres for immigrants and refugees. Partnering with trusted community leaders is also recommended along with advance clinic promotion to encourage attendance.

Additional information can be found in the references provided above and a CDC resource: Checklist of best practices for vaccination clinics held at satellite, temporary or off-site locations.

Outdoor venues, including drive-through clinics

Drive-through and parking lot clinics (also called drive-in clinics) have been used successfully in some jurisdictions in past seasons for the seasonal influenza vaccine, and are particularly useful for people with reduced mobility or those who are apprehensive about a clinic setting. In the COVID-19 situation, they provide a way to maintain physical distancing by avoiding waiting rooms and lineups.

Potential issues for program planners include inclement weather, availability of suitable locales, and occupational health concerns for vaccinators (for example, exposure to auto exhaust or ergonomic issues if they are trying to reach far into a car). There is also potential for shoulder injury in the recipient if the arm is not adequately visualized while they are in the car, resulting in incorrect landmarking of the injection site.Footnote 6

Parking lot clinics: Providing immunization in the parking lot may be a viable option for some primary care practitioners, pharmacies and public health departments. Detailed advice for mounting a parking lot clinic (also called a drive-in clinic) can be found in an Australian resource: NSW guidance for drive-in immunization clinics.

Drive-through clinics: These clinics are larger-scale operations that may be mounted in fixed or rotating locations. Potential venues should offer shelter for the immunization team and sufficient parking for the required post-immunization observation period. Possibilities include community buildings with a marquee, car washes, warehouses, insurance inspection stations, arena parking lots or drive-through tents erected for the occasion.

Planning logistics have been described, including the development of a traffic flow pattern with traffic lanes for the consent and immunization processes and adequate parking spaces for post-immunization monitoring.Footnote 7Footnote 8Footnote 9Footnote 10

Clients should be instructed to wear a non-medical mask and loose-fitting clothes to allow easy access to the deltoid area. Clients should be seated to allow window or door access for the vaccinator, who should not enter the car. Parents may hold their child on their lap for the child's immunization. The entire upper arm (or upper outer thigh in infants) should be exposed to find the correct injection site.

Remote and isolated communities

Remote and isolated communities have many years of experience with influenza immunization campaigns. In these settings, many of the adaptations outlined earlier in this document will be applicable; however, additional considerations may be needed. Suggestions include:

Note that lack of connectivity in many remote and isolated communities may prevent the use of electronic systems for appointments, registration or recording.

Additional resources

Canada

Public Health Agency of Canada. Infection prevention and control for COVID-19: Interim guidance for outpatient and ambulatory care settings. May 23, 2020. Available from: https://www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection/guidance-documents/interim-guidance-outpatient-ambulatory-care-settings.html

Public Health Agency of Canada. Infection prevention and control for COVID-19: Interim guidance for home care settings. 2020-05-01. Available from: https://www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection/health-professionals/infection-prevention-control-covid-19-interim-guidance-home-care-settings.html

National Advisory Committee on Immunization. Interim guidance on continuity of immunization programs during the COVID-19 pandemic. May 13, 2020. Available from: https://www.canada.ca/en/public-health/services/immunization/national-advisory-committee-on-immunization-naci/interim-guidance-immunization-programs-during-covid-19-pandemic.html

Public Health Agency of Canada. Vaccine annex: Canadian Pandemic Influenza Preparedness: Planning Guidance for the Health Sector. Appendix B - Planning Guidance for Mass Immunization Clinics. Available from: https://www.canada.ca/en/public-health/services/flu-influenza/canadian-pandemic-influenza-preparedness-planning-guidance-health-sector/vaccine-annex.html#appb

Centers for Disease Control and Prevention (CDC)

Centers for Disease Control and Prevention. Interim guidance for immunization services during the COVID-19 pandemic. Available from: https://www.cdc.gov/vaccines/pandemic-guidance/

Centers for Disease Control and Prevention. Guidance for pharmacists. May 28, 2020. Available from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/pharmacies.html

Centers for Disease Control and Prevention. Guidelines for Large-scale influenza vaccination clinic planning. 2015 Dec 16. Available from: https://www.cdc.gov/flu/professionals/vaccination/vax_clinic.htm

Centers for Disease Control and Prevention. Checklist of best practices for vaccination clinics held at satellite, temporary or off-site locations. Available from: https://www.izsummitpartners.org/content/uploads/2019/02/off-site-vaccination-clinic-checklist.pdf

Australia

NSW Health. Guidance for drive-in immunization clinics. Advice for Providers During COVID-19. 4 May 2020. Available from: https://www.cesphn.org.au/preview/population-health/immunisation-1/3157-drive-in-flu-vaccination-clinics/file

World Health Organization (WHO)

World Health Organization. Framework for decision-making: implementation of mass vaccination campaigns in the context of COVID-19. 22 May 2020. Available from: https://apps.who.int/iris/handle/10665/332159

World Health Organization. Guiding principles for immunization activities during the COVID-19 pandemic. Interim guidance 26 March 2020. Available from: https://www.who.int/publications/i/item/guiding-principles-for-immunization-activities-during-the-covid-19-pandemic-interim-guidance

World Health Organization. Immunization in the context of COVID-19 pandemic. Frequently Asked Questions (FAQ). 16 April 2020. Available from: https://apps.who.int/iris/handle/10665/331818

Footnotes

Footnote 1

Centres for Disease Control and Prevention. Interim guidance for immunization services during the COVID-19 pandemic. Available from: https://www.cdc.gov/vaccines/pandemic-guidance/

Return to footnote 1 referrer

Footnote 2

National Advisory Committee on Immunization. Canadian Immunization Guide: Part 2 - Vaccine Safety. Early vaccine reactions including anaphylaxis. June 2013. Available from: https://www.canada.ca/en/public-health/services/publications/healthy-living/canadian-immunization-guide-part-2-vaccine-safety/page-4-early-vaccine-reactions-including-anaphylaxis.html

Return to footnote 2 referrer

Footnote 3

Weatherill SA, Buxton JA, Daly PC. Immunization programs in non-traditional settings. Can J Public Health 2004;95(2):133-7.

Return to footnote 3 referrer

Footnote 4

Kong KL, Chu S, Giles ML. Factors influencing the uptake of influenza vaccine vary among different groups in the hard-to-reach population. Aust NZ Public Health 2020;44:163-8. Doi:10.1111/1753-6405.12964.

Return to footnote 4 referrer

Footnote 5

Thomsen R, Smyth W, Gardner a, et al. Centrelink; an innovative urban intervention for improving adult Aboriginal and Torres Strait Islander access to vaccination. Healthcare Infection 2012;17;136-41. Doi: 10.1071/HI12035

Return to footnote 5 referrer

Footnote 6

Imran M, Hayley D. Injection-induced axillary nerve injury after a drive-through flu shot. Clinical Geriatrics 2013;21(12). Available from: https://www.consultant360.com/index.php/taxonomy/term/7226

Return to footnote 6 referrer

Footnote 7

Le N, Charney RL, Gerard J. Feasibility of a Novel Combination of Influenza Vaccinations and Child Passenger Safety Seat Fittings in a Drive-through Clinic Setting. Disaster Med Public Health Prep 2017;11(6):647-651. doi: 10.1017/dmp.2017.3. Epub 2017 May 2

Return to footnote 7 referrer

Footnote 8

Banks LL, Crandall C, Esquibel L. Throughput times for adults and children during two drive-through influenza vaccination clinics. Disaster Med Public Health Prep 2013;7(2):175-81. doi: 10.1017/dmp.2013.3.

Return to footnote 8 referrer

Footnote 9

Gupta A, Evans GW, Heragu SS. Simulation and Optimization Modeling for Drive-Through Mass Vaccination - A Generalized Approach. Simulation Modelling Practice and Theory 2013;37(September). Available from https://commons.erau.edu/ww-management-science/1

Return to footnote 9 referrer

Footnote 10

Zenwekh T, McKnight J, Hupert N, et al. Mass medication modelling in response to public health emergencies: outcomes of a drive-through exercise. J Public Health Management Practice 2007;13(1);7-15.

Return to footnote 10 referrer

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