National guidelines for immunization practices: Canadian Immunization Guide

Updated: February 2016

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To define optimal practices that address the ongoing challenges of immunization in Canada, the National Advisory Committee on Immunization (NACI) developed the National Guidelines for Immunization Practices. The Guidelines below, are recommended for use by all health professionals who administer vaccines or manage immunization services to plan, to conduct, to review, and to evaluate immunization practices. The order in which the guidelines are presented does not reflect priorities. The competencies contained in the Public Health Agency of Canada's Immunization Competencies for Health Professionals additionally support the practical application of these guidelines.

Guideline 1

Immunization services should be readily available.

Immunization services should be responsive to the needs of vaccine recipients. When feasible, vaccine providers should schedule immunization appointments in conjunction with appointments for other health services. Newborn infants should have the first immunization appointment arranged as soon as possible after birth. Immunization services should be available during regular business hours as well as during hours that are convenient for working vaccine recipients and parents (for example, weekends, evenings, early mornings or lunch hours).

Guideline 2

Vaccine providers should facilitate timely receipt of vaccine and eliminate unnecessary prerequisites to the receipt of vaccines.

While appointment systems facilitate clinic planning and avoid long wait times, appointment-only systems may act as barriers to the receipt of vaccines. People who present for vaccination without an appointment, particularly those in hard-to-reach populations, should be accommodated whenever possible.

The administration of vaccine in a clinic setting should not depend on written orders for specific individuals or on a referral from a primary health care provider.

Guideline 3

Vaccine providers should use all clinical opportunities to screen for needed vaccines and to administer all vaccine doses for which a vaccine recipient is eligible at the time of each visit.

Each encounter with a health care provider, including hospitalization, a visit to an outpatient clinic, or a visit to the emergency department, is an opportunity to review the immunization status and to offer vaccination to persons of all ages. Health care providers should review the immunization status at every visit and either offer immunization service as a part of routine care, or encourage attendance at an immunization clinic. At each hospital admission, the vaccination record should be reviewed and needed vaccines should be administered before discharge. The vaccine recipient's regular vaccine provider should be informed about the vaccines administered in hospital. Refer to Immunization of Patients in Health Care Institutions in Part 3 for additional information.

Home care and public health nurses should use home visits as an opportunity to immunize adults and children who are homebound and therefore unable to attend immunization services in the community.

Most routine vaccines can be safely and effectively administered at the same visit. Refer to Timing of Vaccine Administration and Vaccine Administration Practices in Part 1 for information about concomitant administration of vaccines and administration of multiple injections.

Guideline 4

Vaccine providers should communicate current knowledge about immunization using an evidence based approach.

Vaccine providers should educate people, in a culturally sensitive way, about the:

  • importance of vaccination
  • diseases that vaccines prevent
  • recommended immunization schedules
  • need to receive vaccines at recommended ages
  • importance of bringing the immunization record to every health care visit

Vaccine providers should answer the vaccine recipient's or parent's questions and provide educational materials at suitable reading levels, preferably in the vaccine recipient's or parent's own language. Refer to Benefits of Immunization, Communicating Effectively about Immunization and Vaccine Administration Practices in Part 1 for additional information about pre-vaccination and post-vaccination counselling.

Parents and adult vaccine recipients should be encouraged to take responsibility for ensuring completion of the vaccine series. Refer to Recommended Immunization Schedules in Part 1 for information about immunization schedules.

Guideline 5

Vaccine providers should inform vaccine recipients and parents in specific terms about the risks and benefits of vaccines that they or their children are to receive.

Information pamphlets about routine vaccines are available from health authorities in many jurisdictions and from the Canadian Paediatric Society. Information pamphlets facilitate informed consent and are helpful in answering questions that vaccine recipients or parents may have about immunization. Vaccine providers should document in the medical record that they have asked the vaccine recipient or parent if they have any questions and should ensure that satisfactory answers to questions were given. Refer to Benefits of Immunization, Communicating Effectively about Immunization and Immunization Records in Part 1 for additional information.

Guideline 6

Vaccine providers should recommend deferral or withholding of vaccines for true contraindications only.

There are very few true contraindications to vaccination. Vaccine providers must be aware of the true contraindications to vaccination and should not defer administration of indicated vaccines because of conditions or circumstances that are not true contraindications. Withholding vaccines for conditions that are not true contraindications often results in the needless deferral of indicated vaccines. Screening procedures for precautions and contraindications include, at a minimum, asking questions to elicit a history of possible adverse events following prior vaccinations and determining any existing precautions or contraindications. Refer to Contraindications, Precautions and Concerns in Part 2 and Vaccine Administrations Practice in Part 1 for additional information about pre-immunization screening for contraindications and precautions.

Guideline 7

Vaccine providers should ensure that all vaccinations are accurately and completely recorded.

Vaccine care providers must maintain a record of all vaccines administered and must ensure that information is accurately and completely recorded in their files. All vaccine providers should encourage vaccine recipients or parents to keep their personal immunization records and to present them at each health care visit so that they can be updated. If the personal immunization record is not available at the time of vaccination, the vaccine provider should ensure that adequate information is given so that the vaccine recipients or their parents can update the personal immunization record. Refer to Immunization Records in Part 1 for additional information.

Comprehensive national, provincial and territorial immunization registries enable timely and efficient evaluation and planning of immunization programs by ensuring the availability of accurate and readily accessible information on immunization. Refer to Immunization Records in Part 1 for additional information about immunization registries.

Guideline 8

Vaccine providers should maintain easily retrievable summaries of immunization records to facilitate age-appropriate vaccination.

Vaccine providers should maintain easily retrievable summaries of vaccination records to permit regular checking and updating of the individual's immunization status, as well as the identification and recall of vaccine recipients, especially children, who are delayed in the recommended immunization schedule. Electronic immunization records enable more efficient storage and retrieval of information, including the generation of notices (for example, recall reminders). Refer to Immunization Records in Part 1 for additional information.

Guideline 9

Vaccine providers should report clinically significant adverse events following immunization (AEFI) promptly, accurately and completely.

All vaccine recipients or their parents should receive instructions for post-immunization care.

Prompt reporting of AEFI is essential to ensure vaccine safety, to allow timely corrective action when needed, and to update information regarding vaccine risk-benefit ratios and contraindications. Vaccine providers should instruct vaccine recipients or their parents to inform them or another health care provider promptly of AEFI. In addition, at each immunization visit, vaccine providers should ask vaccine recipients or their parents about clinically significant adverse events that may have occurred following previous vaccinations. Vaccine providers should fully document all clinically significant adverse events in the medical record as soon they become aware as of such an event. Vaccine providers should report, without delay, all serious or unexpected AEFI to the appropriate public health authority.

Refer to Adverse Events Following Immunization in Part 2 for additional information about AEFI reporting. Refer to Vaccine Administration Practices in Part 1 for information about pre-immunization and post-immunization counselling.

Guideline 10

Vaccine providers should report all cases of vaccine preventable diseases as required under provincial or territorial legislation.

Vaccine providers should comply with provincial or territorial requirements for communicable disease reporting. Reporting of vaccine preventable diseases is essential for public health management of the disease to limit transmission, ongoing evaluation of the effectiveness of immunization programs, as well as public health and medical investigation of vaccine failures.

Guideline 11

Vaccine providers should adhere to appropriate procedures for the storage and handling of immunizing agents.

Immunizing agents must be handled and stored as recommended in manufacturers' product monographs or leaflets, and jurisdictional or national guidelines. The temperatures at which immunizing agents are transported and stored should be monitored according to jurisdictional or national guidelines. Immunizing agents must not be administered after their expiry date, and products that have been exposed to environmental conditions outside those recommended for the product should not be used without appropriate consultation with experts, such as local public health officials or the vaccine supplier. Vaccine providers should report product usage, wastage, loss and inventory as required by the appropriate jurisdictional authority.

Vaccine providers should be familiar with national and jurisdictional guidelines for immunizing agent's storage and handling and must ensure that staff members designated to handle products are also familiar with the guidelines. Refer to Storage and Handling of Immunizing Agents in Part 1 for additional information.

Guideline 12

Vaccine providers should maintain up-to-date, easily retrievable immunization protocols at all locations where vaccines are administered.

Vaccine providers should maintain protocols that, at a minimum, outline: appropriate vaccine dosage; vaccine contraindications; recommended injection sites and techniques of vaccine administration; and possible adverse events and their emergency management. The Canadian Immunization Guide and updates, along with product monographs and product leaflets, can serve as references for the development of protocols. Adverse event management protocols should specify the emergency equipment, drugs and dosages, and personnel needed to manage any medical emergencies arising after administration of an immunizing agent safely and effectively. All vaccine providers should be familiar with the location and content of these protocols, and how to follow them.

Refer to Anaphylaxis and other Acute Reactions following Vaccination in Part 2 for additional information about possible AEFI and their emergency management. Refer to Vaccine Administration Practices in Part 1 for information about sites and techniques for vaccine administration. Refer to vaccine-specific chapters in Part 4 for vaccine dosages and contraindications.

Guideline 13

Vaccine providers should be properly trained and maintain ongoing education regarding current immunization recommendations.

Vaccines must be administered only by trained persons who are recognized as qualified to administer vaccines in their jurisdiction. Training and ongoing education should be based on current professional guidelines; NACI and provincial or territorial health authority recommendations; and the National Guidelines for Immunization Practices. Vaccine providers should be familiar with immunization information provided by public health officials and other appropriate sources such as the Immunization Competencies for Health Professionals.

Guideline 14

Immunization errors and immunization related incidents should be reported by vaccine providers to their local jurisdiction.

Immunization errors and immunization related incidents should be monitored as patient safety issues and reported by the vaccine provider in accordance with provincial or territorial regulation or for advice, if needed.

Common immunization errors include errors in vaccine type, dose, site, route, person, time or schedule. Immunization related incidents include a range of events, such as a needle injury caused by failed positioning of a child, immunization without consent, or fainting with a fall resulting in injury. Methods to detect immunization errors or incidents may include vaccine provider self-reporting, direct observation or record audits.

Decreasing immunization errors requires an accurate system of error reporting in an open environment that focuses on improvement in practice, rather than punitive action. Activities to prevent immunization error in an organization are a better barometer of quality than the error rate alone. Publishing or sharing information about immunization errors is a first step towards an immunization quality improvement program that strives to reduce the incidence of errors. Immunization errors can be effectively reduced by systematically identifying, eliminating or minimizing both human and system related factors.

Refer to Vaccine Safety in Part 2 for additional information about immunization error related AEFI.

Guideline 15

Vaccine providers should operate an immunization tracking system.

A tracking system should generate reminders of upcoming vaccinations as well as recalls for individuals who are overdue for their vaccinations. A system may be manual or automated, and may include electronic (for example, email or text message), mailed or telephone messages. All vaccine providers should identify, for additional intensive tracking efforts, vaccine recipients considered at high risk of failing to complete the immunization series on schedule (for example, infants who start their vaccine series late or children who fall behind in their immunization schedule). Refer to Immunization Records in Part 1 for additional information about health care provider records.

Guideline 16

Audits should be conducted in all immunization services to assess the quality of immunization records and the degree of immunization coverage.

An audit of immunization services should include assessment of all, or a random sample of, immunization records to assess the quality of documentation and to determine the immunization coverage level (for example, the percentage of 2 year old children with up-to-date immunization). The results of the audit should be discussed by vaccine providers as part of ongoing quality assurance reviews, and used to develop solutions to the problems identified.

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