Immunity refers to the body’s ability to prevent the invasion of pathogens. Pathogens are foreign disease-causing substances, such as bacteria and viruses, and people are exposed to them every day. Antigens are attached to the surface of pathogens and stimulate an immune response in the body. An immune response is the body’s defense system to fight against antigens and protect the body.

There are several types of immunity, including innate immunity, passive immunity, and acquired/active immunity. Image 1.1 is a visual showing active immunity as a process of exposing the body to an antigen to produce an adaptive immune response, while passive immunity “borrows” antibodies from another person.

1. Innate immunity is general protection that a person is born with, including physical barriers (skin, body hair), defense mechanisms (saliva, gastric acid), and general immune responses (inflammation). This type of immunity is considered non-specific (Khan Academy, n.d). Although the immune system does not know exactly what kind of antigen is invading the body, it can respond quickly to defend against any pathogen.
2. Passive immunity is the body’s capacity to resist pathogens by “borrowing” antibodies. For example, antibodies can be transferred to a baby from a mother’s breast milk, or through blood products containing antibodies such as immunoglobulin that can be transfused from one person to another. The most common form of passive immunity is that which an infant receives from its mother. Antibodies are transported across the placenta during the last one to two months of pregnancy. As a result, a full-term infant will have the same antibodies as its mother. These antibodies will protect the infant from certain diseases for up to a year, and act to defend against specific antigens. Although beneficial, passive immunity is temporary until the antibodies are gone (wane), since the body has not produced the antibodies.
3. Acquired (adaptive) immunity is a type of immunity that develops from immunological memory. The body is exposed to a specific antigen (which is attached to a pathogen) and develops antibodies to that specific antigen (Khan Academy, n.d.). The next time said antigen invades, the body has a memory of the specific antigen and already has antibodies to fight it off. Acquired immunity can occur from exposure to an infection, wherein a person gets a disease and develops immunity as a result. Acquired immunity also occurs from vaccination wherein the vaccine mimics a particular disease, causing an immune response in the vaccinated individual without getting them ill.

Vaccines are a product given orally, nasally, or by injection to prevent people from acquiring specific diseases. The types of diseases that are prevented by vaccines are called “vaccine-preventable diseases.” Examples of these diseases include chickenpox (varicella) and human papilloma virus (HPV) – though vaccine-preventable diseases will be discussed in detail in Chapter 2.

As noted by the World Health Organization (n.d.), vaccines are a safe and proven tool to prevent life-threatening infectious diseases. “Vaccines work by taking advantage of antigen recognition and the antibody response” (Khan Academy, n.d., under Vaccines). “A vaccine contains the antigens of a [specific] pathogen that causes disease” (Khan Academy, n.d., under Vaccines). For example, the measles vaccine contains the antigens specific to measles. When a person is vaccinated against measles, the immune system responds by stimulating antibody-producing cells that make measles antibodies. As a result, if the body comes into contact with measles infection in the future, the body is prepared to fight it. See Video Clip 1.1 for a description of what vaccines are and how they work.

Video Clip 1.1: “What are vaccines and how do they work?” by Oregan State University Ecampus. CC BY-NC-SA 4.0

A YouTube element has been excluded from this version of the text. You can view it online here: https://ecampusontario.pressbooks.pub/immunizations/?p=29

Vaccines play an important role in healthy communities for several reasons:

• First, they stimulate a person’s immune system to develop antibodies against diseases for protection against that disease.
• Second, they protect others by limiting the spread of disease (community immunity). This is important in order to protect vulnerable individuals such as infants, older adults, and those who are ill and unable to receive vaccines for a variety of reasons, including weakened immune systems.

Community immunity, also known as herd immunity, is a concept referring to “protection from contagious disease that an individual benefits from as a result of living in a community where a critical number of people are vaccinated” (Boyd, 2016, para 2). This means that vaccination provides protection to the vaccinated person and also the whole community. In general, more than 90% of the population needs to be immune in order to protect those who are not eligible to be vaccinated; however, the level of herd protection required also depends on the disease. For example, contagious diseases such as measles, which is spread through the air, requires more than 95% protection for community immunity. See Image 1.2 illustrating community immunity through the visual of ‘group protection’ that is acquired when more than 90% of the population is immunized. Video Clip 1.2 explains community immunity in further detail.

Community immunity makes it more difficult for contagious disease to enter and spread across a population, thereby significantly reducing the chances of an outbreak. It is important as it affords some protection for vulnerable people who cannot receive vaccines or do not have an effective immune response to certain vaccines. Certain people cannot receive vaccines, including infants, pregnant people, people with immuno-compromising conditions, people on immunosuppressants, and other vulnerable groups.

Video Clip 1.2: “Herd Immunity and Immunizations” by North Carolina School of Science and Mathematics. CC-BY-NC-SA

A YouTube element has been excluded from this version of the text. You can view it online here: https://ecampusontario.pressbooks.pub/immunizations/?p=32

Not all vaccines are the same. The way in which the body responds to a vaccine depends on the type of vaccine being administered. It is important for health professionals to understand the type of vaccines being administered and how it induces an immune response. This section includes descriptions of different types of vaccines.

Live-attenuated Vaccines

Table 1.1: Vaccine Types

The components of vaccines used in Canada are extremely safe. See Image 1.4 for an illustration of vaccine components and Table 1.2 for a description of the components.

Serious side effects like allergic reactions are very rare. Chemicals used in vaccines enhance their effectiveness, preserve or stabilize the pathogen, kill unwanted viruses, or act as a suspension to hold the product. Some vaccines contain trace amounts of culture material like egg protein used to grow the virus or bacteria. It is important for health professionals to familiarize themselves with some of the common components (also referred to as ingredients) in vaccines, particularly if a client has an allergy or expresses concern in this regard. For a comprehensive list of vaccines and their components visit Canadian Immunization Guide, Key Immunization Information.

Table 1.2: Vaccine Components

1. How do vaccines prevent disease?
2. Why is community immunity important?
3. What concerns and questions do you think clients will have about the components of vaccines? How should health professionals respond to these concerns and questions?

The key takeaways of this chapter are:

• Immunity is the capacity of the body to resist pathogens.
• There are several types of immunity, including innate immunity, passive immunity, and acquired/active immunity.
• Vaccination is a safe and effective way to achieve acquired immunity.
• Community immunity (also known as herd immunity) refers to protection from contagious disease that an individual gains as a result of living in a community where a critical number of people are vaccinated.
• More than 90% of the population needs to be immune in order to protect those who are not eligible to be vaccinated.
• The more analogous the vaccine is to the original disease-causing pathogen, the greater the body’s immune response.
• Vaccine components are extremely safe and are important to enhance effectiveness, preserve and stabilize the vaccine, prevent unwanted contamination, and detoxify or inactivate the live germ or toxin in some vaccines.

Boyd, R. (2016). It takes a herd. Retrieved from: https://www.aap.org/en-us/aap-voices/Pages/It-Takes-a-Herd.aspx

Government of Canada. (2017). Page 8: Canadian immunization guide: Part 1 – key information. Retrieved from https://www.canada.ca/en/public-health/services/publications/healthy-living/canadian-immunization-guide-part-1-key-immunization-information/page-8-vaccine-administration-practices.html

Khan Academy. (n.d.). Adaptive immunity. Retrieved from: https://www.khanacademy.org/test-prep/mcat/organ-systems/the-immune-system/a/adaptive-immunity

Khan Academy. (n.d). Immune system. MCAT: Organ systems. Retrieved from: https://www.khanacademy.org/test-prep/mcat/organ-systems#concept-intro. Note: All Khan Academy content is available for free at www.khanacademy.org

Khan Academy. (n.d.). The immune system review. Retrieved from: https://www.khanacademy.org/science/high-school-biology/hs-human-body-systems/hs-the-immune-system/a/hs-the-immune-system-review

Vaccines.gov. (2018). Vaccines by disease. Retrieved from https://www.vaccines.gov/diseases

World Health Organization (n.d.). Immunization. Retrieved from: https://www.who.int/topics/immunization/en/

Vaccines are our best defense against many diseases. Vaccine-preventable diseases (VPDs) are diseases caused by bacteria and viruses that can be prevented by vaccines. VPDs can spread through different routes such as the air, respiratory droplets, and bodily contact. Some diseases, such as measles, are extremely contagious. For example, it is possible to contract measles two hours after a person with measles has left the room.

Many of the diseases prevented by vaccines have dramatically declined since the introduction of vaccination programs. However, awareness of VPDs continues to be a priority so that members of the public and health professionals understand why it is important to keep vaccinating against those diseases. When people stop vaccinating, VPDs, such as measles, can recur and spread rapidly around the world.

When a disease is eradicated around the world, vaccines are no longer needed. For example, smallpox was eradicated in 1979. As a result, the smallpox vaccine is no longer provided in routine vaccination programs. Diseases are eliminated when the disease is reduced to zero, or close to zero, in a defined geographical area. Polio, for example, is eliminated in North America and South America.

The immunization schedule in each Canadian province and territory tells health professionals which vaccines should be administered at what time. Here is a link to the immunization schedule for infants and children in each province and territory: https://www.canada.ca/en/public-health/services/provincial-territorial-immunization-information/provincial-territorial-routine-vaccination-programs-infants-children.html.

The immunization schedule includes the recommended timing of all vaccine doses in order to be considered fully protected. There are many determinants that influence the schedule including: burden of disease in the province or territory, effectiveness and safety of vaccines, acceptability, ease of implementation, equity, and cost. When individuals are not on the routine schedule, the likelihood of missing doses and having incomplete vaccinations is increased. It also puts the individual at risk for getting the disease because they are not fully vaccinated. Catch-up schedules are available. If vaccination records are not available, assume the person is unvaccinated and use a catch-up schedule based on current age.

Accelerated immunization schedules are also available under necessary conditions such as outbreaks and unplanned travel. The interval between recommended doses can also often be lessened; however, health professionals should consult the Canadian Immunization Guide for vaccine-specific minimum dose intervals.

Timing and Spacing of Vaccines

If vaccines are given before the recommended age or with less than the minimal spacing between doses, adequate immune response may not be achieved. Modifications to the recommended schedule may be necessary because of missed appointments or illness; however, for the most part, disruptions in the schedule do not necessitate restarting a vaccine series.

Community Immunity / Herd Immunity

By keeping up to date with vaccines, we can prevent the spread of disease to those who may be more likely to contract them, such as:

• babies.
• young children.
• pregnant people.
• people who are severely immunosuppressed.

Recall the discussion of community immunity, also known as herd immunity, from Chapter 1, in which we learned that in general, more than 90% of the population needs to be immune in order to protect those who are not eligible to be vaccinated (shown in the image below).

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Infants and Toddlers

A child’s immune system is not fully developed at birth. In the first year of life, an infant’s immune system develops. This makes an infant more vulnerable to communicable diseases. This is also why infants need many doses of vaccines in the first year of life, to prime the immune system and develop immunity. Vaccines protect infants and children when they are most vulnerable and work best when children are immunized on time. These strategies have significantly reduced infant mortality rates in Canada and across the world.Table 2.1 is an example of a routine government-funded vaccine schedule in early childhood.

Table 2.1: Routine Vaccines During Early Childhood in Ontario

There is variation in how each province and territory approaches vaccine exemptions. In Ontario, for example, under the Ontario Child Care and Early Years Act (2014), children who attend child care centres are required to either be immunized against the diseases listed in Table 2.1 or have a valid exemption. A medical exemption form is completed by a legally qualified medical provider (i.e. physician or nurse practitioner). A parent who has a philosophical or religious objection may complete a different exemption form. In Ontario, exemptions are granted on the grounds that immunizations conflict with the sincerely held convictions of the parents’ religion or conscience or that a legally qualified medical provider gives medical reasons to the child care centre as to why the child should not be immunized (Ontario Child Care and Early Years Act, Reg. 137/15s).

School Age Children

By school entry, students should be up to date with most routine childhood vaccinations. Contagious diseases can spread quickly in a school setting, so it is important to ensure that school aged children are up to date with their immunizations. Table 2.2 is an example of a government-funded vaccine schedule for school-age children.

Table 2.2: Vaccine Schedule for School Age Children in Ontario

In Ontario, under the Immunization of School Pupils Act (1990), students who attend school are required to provide proof of immunization against the following diseases: diphtheria, tetanus, polio, measles, mumps, rubella, meningococcal disease, pertussis, varicella (children born 2010 or later) or have a valid exemption. Parents need to provide a record of their child’s immunization status to the local Public Health Unit. A medical exemption form is completed by a legally qualified medical provider. A parent who has a philosophical or religious objection must attend a mandatory education session and complete the standardized Ministry approved exemption form.

Healthy Adults

Vaccinations are not just for children. Vaccines are safe and protect you and those around you from vaccine-preventable diseases. As we get older, the protection we had from previous vaccinations can decrease for some diseases. Getting another dose, known as a booster, can increase our immunity to provide the best protection. Some adults may have missed one or more of their vaccines when they were a child. They may need to catch up and get these vaccines now. There are also diseases that are more common in adults—even healthy adults—such as shingles. This is why additional vaccines are needed as we get older.

Many Canadian adults are not up to date with their vaccines. Healthcare providers can assess what is needed to be fully protected. The following table is an example based on the Ontario provincial immunization schedule. Table 2.3 is an example of recommended vaccines for health adults.

Table 2.3: Ontario Vaccine Schedule for Healthy Adults

Pregnancy

Pregnancy may lead to altered immune responses that increase risk for infection. Vaccinating in pregnancy prevents disease for the pregnant person and their baby. For example, vaccinating with an inactivated flu is safe and recommended in all pregnancies during flu season. The vaccine lowers the risk of complications from flu during pregnancy and protects infection after the baby is born. See Table 2.4 for routine vaccines during pregnancy.

The other reason to vaccinate during pregnancy is to increase the newborn’s immunity. Because newborn babies are born with rudimentary immune systems, health professionals try to protect the baby in the event of exposure. One method is to vaccinate the pregnant person during pregnancy with, for example, the pertussis vaccine. Another method, called ‘cocooning,’ means vaccinating those around the infant, including the parent and other family members, to ensure they will not infect the newborn. Cocooning can be difficult to do and as a result may not be the preferred strategy.

Table 2.4: Routine Vaccines During Pregnancy

Table 2.5: Common Global Vaccine-Preventable Diseases

As with routine childhood vaccines, travel vaccines can sometimes come in combined formulations.

The National Advisory Committee on Immunization (NACI) is a multi-disciplinary committee of scientific, medical, and public health experts that make recommendations for current and newly approved vaccines in Canada. The Canada Immunization Guide (CIG) is based on NACI recommendations and other factors. NACI’s work focuses on vaccines while the CIG is a comprehensive resource on immunization. The CIG includes information for all health professionals who administer vaccines or manage immunization programs.

In Canada, immunization programs are a shared responsibility across national, provincial, and local public health agencies. See Tables 2.6, 2.7, and 2.8 for a list of these responsibilities. Public health agencies in Canada use a population health approach to improve the health of all Canadians and create healthier communities, including controlling infectious diseases through immunization strategies. While vaccines are a national issue, each level of government has a specific role and there are differences in how immunization programs are implemented across provinces and communities. For example, provincial public health agencies make determinations about the immunization schedule based on the NACI recommendations while the local public health agencies implement and deliver local services. This strategic and systematic approach to immunization allows for a population health approach while simultaneously ensuring outreach at a local level. As a health professional, it is important to familiarize yourself with the role and mandate of various organizations to ease system navigation, including where and when to access information. Furthermore, having a contextual understanding of program implementation allows you to see both the big picture and the local perspectives when thinking about vaccine-preventable illnesses. Video Clip 2.1 provides additional information about the role of public health nurses and vaccines practice in Ontario.

Video Clip 2.1: Interview about Vaccines and the Role of Public Health

A YouTube element has been excluded from this version of the text. You can view it online here: https://ecampusontario.pressbooks.pub/immunizations/?p=100

Table 2.6: Organizational Landscape of Vaccine Research, Delivery, and Evaluation – Federal

Table 2.7: Organizational Landscape of Vaccine Research, Delivery, and Evaluation – Provincial

Table 2.8: Organizational Landscape of Vaccine Research, Delivery, and Evaluation – International

1. What are the main vaccine-preventable diseases in Canada?
2. What is the best way to access current information about vaccine schedules?
3. Should everyone receive vaccines?

The key takeaways of this chapter are:

• Vaccine-preventable diseases are caused by bacteria and viruses that can be prevented by vaccines.
• The timing and spacing of vaccines in a given region can be accessed through provincial/territorial immunization schedules.

Centres for Disease Control and Prevention. (2017). Public Health Image Library (PHIL). Retrieved from: https://phil.cdc.gov/details.aspx?pid=130

Centers for Disease Control and Prevention. (2017). Polio Photos: Photo ID #5578. Retrieved from: https://www.cdc.gov/polio/us/photos.html

Public Health Ontario. (n.d.). Ontario’s Routine Immunization Schedule. Retrieved from: http://www.health.gov.on.ca/en/public/programs/immunization/static/immunization_tool.html

Health professionals are trusted sources of information and their recommendations for vaccination go a long way in motivating clients to get vaccinated. Based on age and risk factors, health professionals should consider which vaccines are required for an individual and a family. To obtain informed consent for vaccination, the individual should know about the disease that the vaccine will prevent and the side effects, benefits, and risks of vaccinating. The health professional should notify the patient before the vaccination visit and share materials about vaccine-preventable diseases (VPD) wherever possible. For example, expecting parents can start the conversation about a vaccination series for their infant in the pre-natal period.

On the Day of Vaccination

Begin the visit asking if the client has any questions about the vaccine. Use a presumptive statement, meaning assume the client is ready to vaccinate. This approach is recommended because it normalizes vaccines as an everyday occurrence that is recommended by the healthcare provider rather than an uncommon, fearful event. For example, “Today you will get your vaccine to protect against tetanus.” Clients may respond with hesitancy if they sense the health professional is unsure or not confident about immunization. The best way to convey confidence is by being a knowledgeable provider.

See Table 3.1 about steps and considerations involved in the pre-vaccination checklist. For further information about effective communication strategies, visit Chapter 5 on Vaccine Hesitancy.

Table 3.1: Pre-Immunization Checklist

Informed Consent

Health professionals should obtain consent from the client or the Substitute Decision Maker (SDM) prior to vaccinating. Consent must be informed, voluntary, related to the treatment being proposed, and not obtained through misrepresentation or fraud (College of Nurses of Ontario, 2017). Health professionals should consult their respective regulatory association for further information and guidelines on obtaining consent.

Preparation

Health professionals should ensure the client has met the criteria to vaccinate and screen for any contraindications, potential drug interactions, or precautions (see Chapter 4 on Vaccine Safety).  Table 3.2 details criteria the health professional should actively verify prior to immunization. Remind the client that they will need to remain at the healthcare facility for a minimum of 15 minutes after receiving the vaccine in order for potential side effects to be monitored.

Table 3.2: Health Professional Criteria Before Vaccine Administration

Health professionals are responsible for minimizing the spread of illness and disease and should incorporate routine infection control practices before, during, and after administering vaccines. Perform hand hygiene at regular intervals, like before preparing the vaccine, after removing gloves, when hands are soiled, etc. Gloves are not routinely used when vaccinating unless your own hands are not intact (e.g., your hands have an open wound, rash), or if the client has an open wound, rash, or bodily fluids near the injection site. Use of gloves may prevent proper hand hygiene between patients. Keep a safe and clean environment. Avoid surfaces that are dirty or potentially contaminated. Separate empty vials and dispose in designated waste management system (sharps container). Before injection, cleanse the skin with an alcohol preparation pad and allow for the alcohol to dry. If alcohol is unavailable, use soap and water.

Vaccine Preparation

When preparing vaccines, it is important for healthcare professionals to follow aseptic technique when accessing vials. Vaccines must be withdrawn from the vial immediately before use and generally should be administered by the same person. Do not pre-load syringes as a routine practice. Pre-loading syringes has the potential to disrupt vaccine stability, increase vaccine administration errors and wastage, as well as increase risk of contamination. Before withdrawing content of a vial into the syringe, wipe the access diaphragm (also referred to as the stopper) with an alcohol preparation pad (70% alcohol) while using friction. Allow the alcohol to dry before inserting the syringe. Always use a sterile syringe to withdraw from vial. When withdrawing, hold the vial upside down and aspirate required quantity into syringe. Once the vaccine is drawn, immediately withdraw the needle from the vial and expel any air bubbles. Safety-engineered needles are preferable to avoid needle stick injuries. If vaccines are pre-filled by the manufacturer, do not transfer to safety-engineered syringe.

Single-dose Vials

Single-dose vials are manufactured for one-time use. They should not be reused, and the leftover contents should not be pooled. Single-dose vials are preferred because they minimize the risk of transmission of pathogens and vial contamination.

Multi-dose Vials

Multi-dose vials contain more than one dose of the vaccine and often contain an antimicrobial preservative to prevent bacterial growth. The number of doses per vial varies. For example, IMOVAX Polio multi-dose vial contains ten doses. Health professionals should always label the date of first use and discard open multi-dose vials according to the manufacturer monograph or within 28 days, whichever is shorter. If contamination is suspected, discard multi-dose vials immediately.

Vaccine Reconstitution

Reconstitution is the process involved when vaccines need to be mixed with a diluent. Some manufacturers use concentrated freeze-dried powder (also called lyophilized vaccine) that requires a liquid diluent. Vaccines should always be reconstituted per manufacturer guidelines with the diluent provided by the manufacturer. Examples of diluents are sterile water, sodium chloride and an adjuvant suspension. The majority of vaccines must be administered immediately after reconstituting. Some vaccines can last up to 24 hours after reconstitution (example Hiberix [Hib]). Health professionals should consult the monograph for recommended time between reconstitution and use. When reconstituting vaccines, the health professional should introduce the diluent down the side of the vaccine vial and not directly into the vaccine powder. Mixing should be done carefully in a swirling motion until the suspension is uniform.

Depending on the vaccine dose, health professionals should use a 1 mL or 3 mL syringe. Depending on the site of administration, it is important to select the right needle size to optimize the immune response and reduce the risk of injection site reactions. For example, vaccines with adjuvants need to be injected into the muscle and not the subcutaneous tissue to prevent inflammation and formation of granulomas. Furthermore, vaccine absorption can be impaired if the vaccine is inadvertently injected into lymphatic circulation. When selecting a needle length for an intramuscular (IM) injection, consider a length that is long enough to reach deep tissue without involving underlying bone, nerves, or blood vessels. Longer needles often result in less redness and swelling when compared to shorter needles. The selection of the right needle should be determined by: 1) route of administration; 2) the client’s age and size of muscle mass; 3) viscosity of the vaccine or passive immunizing agent. Table 3.3 offers needle selection guidelines to inform clinical judgement, which are then visualized in Images 3.2 and 3.3. It is important to note that the needle size recommendations are based on the practice of having the skin stretched flat between thumb and forefinger at the time of administration.

Table 3.3: Needle Selection Guidelines

Content in the Table 3.3 was adapted, with editorial changes, from: Page 8: Canadian Immunization Guide: Part 1 – Key Immunization Information by the Government of Canada and is reproduced under non-commercial conditions.

Health professionals should indicate the vaccine type, route, amount, expiry date, and lot number when documenting. As per professional standards, all documentation should be legible, descriptive, specific, and signed. Health professionals should also document the client’s reaction to the vaccine and update the client’s immunization card if available.

The recommendations for the site and route for each vaccine are evidence-informed. Health professionals should adhere to instructions outlined in the vaccine monograph. Vaccine efficacy may decrease and the risk for local adverse events may increase if not administered correctly. See Table 3.4 for additional considerations for route of administration.

Table 3.4: Considerations for Route of Administration

Attribution Statement

Content in this section was adapted, with editorial changes, from: Page 8: Canadian Immunization Guide: Part 1 – Key Immunization Information by the Government of Canada and is reproduced under non-commercial conditions.

Health professionals play an important role in minimizing pain and distress for clients. Indeed, if comfort measures are not addressed, it can lead to fear and avoidance for future interventions. According to Health Canada, it is estimated that 25% of adults have a fear of needles and as many as 10% have a needle phobia. Often persons develop fears of needles in early childhood. Healthcare providers should provide the most painful vaccine last, administer simultaneous vaccines as one if possible, and instruct clients to avoid aspirin or other blood thinners before vaccines. Table 3.5 lists specific pain management strategies by age group.

Table 3.5: Immunization Pain Management Strategies

If the health professional has administered a vaccine by injection, apply light pressure to the site for several seconds with a dry cotton ball to minimize bleeding. Adhesive bandages or cotton balls with tape are optional but avoid any blood from staining clothing. Clients should be kept under observation for at least 15 minutes after vaccination and preferably 30 minutes when a specific concern is present. Inform client to take oral analgesics such as acetaminophen or ibuprofen as needed for minor adverse reactions following vaccination. Health professionals should remind clients to report any concerns following immunization. The provider can assess the concerns and determine if it is appropriate to report an adverse event following immunization (AEFI).

Vaccines must be carefully stored and handled from the time of manufacturing to administration. Health professionals need to be cognizant of the harmful impact that excessive heat and cold can have on vaccines, rendering them ineffective or destroyed. Errors in storage or handling also contribute to vaccine wastage. Consult the product monograph or local public health authority for information on proper storage conditions for each vaccine, including temperature. As a health professional, it is important to review the policies and procedures developed by the Public Health Agency of Canada (PHAC) (2015) and your provincial/territorial Ministry of Health and Local Public Health organization.

PHAC (2015) outlines a set of procedures to follow when handling and storing vaccines. These procedures include but are not limited to:

• Each office/location should have an identified staff member who is the primary vaccine coordinator and another member as a backup. Both should be fully trained in vaccine storage and handling protocols.
• Always refer to the vaccine product monograph for the most current information about storage information.
• Refrigerators and freezers, used for vaccine storage, must be dedicated to the storage of vaccines only. They should be placed in an area that is not accessible to the public.
• Refrigerators and freezer units must have a calibrated temperature monitoring device that provides continuous recording or minimum/maximum temperatures that are properly monitored, i.e. checked and documented twice a day.
• The majority of vaccines should be stored in a refrigerator at temperatures of +2 to +8 degrees Celsius. Some vaccines must be kept in a freezer at temperatures of -15 degrees Celsius or lower. Doors of units should be kept closed and opened a limited number of times.
• Units should have a sign that says: “Do not adjust refrigerator or freezer temperature controls. Notify primary vaccine coordinator or the backup/delegate coordinator if adjustments are necessary.”
• Vaccines should be placed in labelled, mesh baskets and stored in the middle of the unit rather than in doors or drawers. Stock should be rotated so that vaccines with approaching expiry dates are positioned at the front and used first.
• Vaccines are stored in their original packaging.
• Some vaccines are light sensitive and health professionals should refer to the product information of each vaccine to determine restrictions.

Each site must have a contingency plan in place for vaccine storage in the event of electricity disruptions or unit malfunctions. If procedures have not been adhered to, and/or the temperature decreases in the required unit, notify the primary vaccine coordinator at your site and the local public health unit.

1. What is involved in informed consent prior to administering a vaccine?
2. What infection prevention and control measures should be taken in relation to vaccine administration?
3. What do health professionals need to know about vaccine storage and handling?

The key takeaways of this chapter are:

• Vaccine administration requires careful consideration.
• Health professionals should consult pre-immunization checklists to ensure safe practice.
• Health professionals can help reduce pain and distress from immunization.
• Vaccine storage and handling are important considerations for health professionals.

College of Nurses of Ontario. (2017). Practice Guideline. Retrieved from: http://www.cno.org/globalassets/docs/policy/41020_consent.pdf

Government of Canada. (2017). Page 8: Canadian Immunization Guide: Part 1 – Key Information. Retrieved from https://www.canada.ca/en/public-health/services/publications/healthy-living/canadian-immunization-guide-part-1-key-immunization-information/page-8-vaccine-administration-practices.html#t2

Public Health Agency of Canada. (2015). National vaccine storage and handling guidelines for immunization providers. Retrieved from: https://www.canada.ca/en/public-health/services/publications/healthy-living/national-vaccine-storage-handling-guidelines-immunization-providers-2015.html

Canada has one of the best vaccine safety programs in the world. There is a strong system in place to monitor the safety of vaccines. Every batch of vaccine is tested according to strict guidelines for safety and quality before it is used. After vaccines are given, severe or unusual reactions are monitored by public health agencies at the local, provincial, and national level.

Health professionals play an important role in the implementation and evaluation of vaccines throughout the vaccine life cycle. When health professionals are knowledgeable about the rigour of vaccine testing both pre and post-licensure, it positions them to have informed conversations with clients and respond to concerns related to vaccine safety. Before any vaccine is approved for use in Canada, it must meet numerous requirements including in-depth scientific reviews on efficacy, stability, teratogenicity, toxicity, and safety. After vaccines have been licensed for use, rigorous evaluation continues to ensure ongoing safety. Post-marketing surveillance of adverse events following immunization add to the continuous safety checks following vaccine licensure.

Before Health Canada issues a notice of compliance (NOC) (commonly known as a “license”) the vaccine must meet a number of sequential tests. During clinical trial phases, the number of subjects participating in the vaccine study increases incrementally, making the population being studied more heterogenous as the phases advance. Regulatory oversight occurs at each stage to ensure safety and identify possible risk. A condensed version of the various stages of pre-license approval are described in Table 4.1. The vaccine is considered for licensing (also referred to as “authorized for marketing”) once it has a proven positive benefit-to-risk profile.

Table 4.1: Pre-License Evaluation Stages

Attribution Statement

Content in Table 4.1 was adapted, with editorial changes, from Page 2 of the Canada Immunization Guide: Part 2 – Vaccine Safety by the Government of Canada and is reproduced under non-commercial conditions.

Under the Food and Drugs Act (1985) and Regulations, pharmaceutical companies are legally required to report serious adverse reactions related to a vaccine. The Canada Vigilance Program offers oversight after vaccines have been licensed, with systemic safeguards to ensure that vaccines have continued monitoring. The program includes safety reports, surveillance systems, risk management plans, and product risk/benefit assessments.

Safety Reports

According to the Food and Drugs Act (1985), pharmaceutical companies are required to prepare an annual report that comprehensively analyzes all adverse drug reactions occurring anywhere in the world. Drug companies are also responsible for notifying Health Canada if they become aware of any significant issues that could affect the benefit-risk profile.

Canadian Adverse Events Following Immunization Surveillance System (CAEFISS)

All health professionals must report adverse events following immunization (AEFI) to local authorities, who report to provincial authorities, who in turn report to federal authorities. CAEFISS is responsible for using this information for ongoing safety monitoring and AEFI investigations in Canada. An AEFI may or may not have a causal relationship to the use of the vaccine.

Evaluation of Vaccines Post-License

The safety profile of a vaccine is heavily scrutinized before licensure. Rigorous monitoring and evaluation continues once the vaccine is available to the general population to identify potential rare side effects and frequency of adverse events following immunization. This period is often referred to as the post-marketing period because the vaccine continues to be monitored after it is licensed. Table 4.2 outlines the various stages of post-license evaluations.

Table 4.2: Post-License Evaluation Stages

AEFIs should be reported:

• When the event has a temporal association with a vaccine. A causal relationship does not need to be proven before reporting.
• When the event is serious or unexpected (e.g., life threatening or results in death, requires hospitalization or prolongation of an existing hospitalization, results in residual disability, or causes congenital malformation).
• If there is any doubt as to whether or not an event should be reported, health professionals should always choose to report the event.

Table 4.3 is an example of a protocol for reporting adverse events. Each province and territory has their own reporting system outlining local and provincial/territorial activities. It is important that health professionals know what and how to report in their jurisdiction. The Public Health Agency of Canada has a national reporting form that is available. Completed forms are sent to the local public health unit. All reports are eventually reported up to CAEFISS at a national level.

Table 4.3: Adverse Event Type Requiring Reporting

As a health professional, it is important to monitor adverse events and follow the steps below:

Step 1

• Advise clients to contact you or your team if they experience an adverse event after vaccination.

Step 2

• Complete either the local form or the Public Health Agency of Canada form for reporting an AEFI. A user guide is available.
• Submit the completed form to the local public health unit or consult them if you have any questions.

Attribution Statement

Table 4.3 was adapted with editorial changes from “Adverse Event Following Immunization Reporting for Health Care Providers in Ontario” by Public Health Ontario. Contact the copyright holder for appropriate permission. 

It is always important to assess the client after administering a vaccine. Health professionals need to recognize the difference between severe events such as anaphylaxis (see next section) and non-severe events that may occur immediately after vaccine administration. Table 4.4 outlines some symptoms that may seem severe and mimic the signs of anaphylaxis but do not pose a life-threatening risk.

Table 4.4: Non-Severe Events

Anaphylaxis is a potentially life-threatening allergic reaction resulting from exposure to an allergen. Although anaphylaxis is extremely rare (one per one million doses administered), health professionals who administer vaccines need to know the signs and symptoms of anaphylaxis and how to administer appropriate interventions without delay.

Signs and symptoms of anaphylaxis (see Table 4.5) typically develop within minutes of exposure to an allergen. In fact, most instances of anaphylaxis occur within the first 30 minutes of exposure to an allergen, although some reactions may develop later. Clinical signs involve at least two body systems to classify the reaction as anaphylaxis. It is important for providers to recognize that symptoms of anaphylaxis vary, but the treatment is the same. Severe anaphylaxis includes obstructive swelling of the upper airway with bronchospasms and hypotension. A sudden drop in blood pressure can cause shock and loss of consciousness. If a client loses consciousness it is rarely the only manifestation of anaphylaxis and is typically a late event.

Table 4.5: Anaphylaxis Signs and Symptoms

Responding to Anaphylaxis

Health professionals should review their institutional policies for medical directives in the management of anaphylaxis and know where to access an anaphylaxis management kit. Epinephrine is the treatment of choice for anaphylaxis. Prompt administration of epinephrine is the priority and should not be delayed because failure to administer epinephrine promptly could result in serious anaphylaxis. The risk of administering epinephrine inappropriately is less severe than anaphylaxis. If uncertain, err on the side of treatment; there are no contraindications to the use of epinephrine. If time is lost early in the treatment of an acute anaphylactic episode, subsequent management can become more difficult.

Some basic procedures for responding to anaphylaxis are outlined in Table 4.6.

Table 4.6: Procedure for Responding to Anaphylaxis

This section was remixed with editorial and content changes from the Canadian Immunization Guide by the Government of Canada and is reproduced under non-commercial conditions.

It is important for health professionals to equip themselves with the correct information about vaccines and vaccine safety. Table 4.7 provides quick facts for health professionals to promote evidence-informed discussions about vaccine safety.

Table 4.7: Quick Facts for Vaccine Safety

Attribution Statement

This section was adapted with editorial changes, retrieved from Page 5: Canadian Immunization Guide: Part 1 – Key Immunization Information by the Government of Canada and is reproduced under non-commercial conditions.

1. Why are vaccines safe?
2. Who should avoid vaccines?
3. What do health professionals need to know about vaccine safety?
4. How can health professionals best communicate information about vaccine safety to clients?

The key takeaways of this chapter are:

• Vaccine safety is a highly regulated, scrutinous process in Canada.
• Vaccines undergo various stages of research before receiving license issuance by Health Canada.
• Vaccine evaluation is ongoing, even after licensure. Post-marketing surveillance is important to ensure vaccines continue to be safe and to detect rare or serious adverse events.
• Health professionals are required by law to report adverse events following immunization.
• Adverse events following immunization should be reported when the event is serious or unexpected, and there is no other clear cause for the event. A causal relationship is not required to report the adverse event.

Government of Canada. (2016). Page 2: Canadian Immunization Guide: Part 2 – Vaccine Safety. Retrieved from: https://www.canada.ca/en/public-health/services/publications/healthy-living/canadian-immunization-guide-part-2-vaccine-safety/page-2-vaccine-safety.html

Government of Canada. (2016). Page 4: Canadian Immunization Guide: Part 2 – Vaccine Safety. Retrieved 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

Government of Canada. (2016). Page 5: Canadian Immunization Guide: Part 1 – Key Immunization Information. Retrieved from: https://www.canada.ca/en/public-health/services/publications/healthy-living/canadian-immunization-guide-part-1-key-immunization-information/page-5-communicating-effectively-immunization.html

Public Health Ontario. (n.d.). Adverse Event Following Immunization Reporting: For Health Care Providers in Ontario. Retrieved from: https://www.publichealthontario.ca/-/media/documents/aefi-reporting-overview.pdf?la=en

Vaccine hesitancy is the reluctance or refusal to vaccinate despite the availability of vaccines (WHO, 2019). The term ‘vaccine hesitancy’ is intentionally used to depolarize antivaccine rhetoric (Larson et al., 2014). Several factors have been cited as contributing to vaccine hesitance including heuristic thinking, the success of vaccination, the perceived unnaturalness of vaccines, the scientific method that can sometimes produce conflicting results, the suspicion of pharmaceuticals or biological materials, the presence of adjuvants in vaccines, and loss of public confidence (Jacobson, Sauver, Rutten, 2015). It is important for health professionals to recognize that given all these factors, there is no singular form of vaccine hesitancy. Instead, it remains a complex and context specific phenomenon that varies across time, place, and vaccine. People who are vaccine hesitant may not refuse all vaccines. They may ask to delay some vaccines or accept vaccines on a different schedule.

Effects of Vaccine Hesitancy

Vaccine hesitancy has been reported in 90% of countries in the world (WHO, 2019). Outbreaks of preventable diseases such as influenza, varicella, pneumococcal disease, measles, and pertussis have been linked to communities with high vaccine refusal rates. In Ontario, vaccine refusal has been linked to resurgences of rubella and measles outbreaks. Even small declines in vaccine coverage rates translate into significant outcomes. An American study found that a 5% reduction in Measles, Mumps, and Rubella (MMR) vaccination in children aged 2-11 led to a three-fold increase in measles cases with an estimated $2.1 million cost to the public healthcare sector (Lo & Hotez, 2017). Dubé and MacDonald (2016) remind health professionals that while vaccine hesitancy is an important public health issue, it should not eclipse the need for continued encouragement and support the majority of people who vaccinate. Video Clip 5.1 is a recreation of a conversation between healthcare providers exhibiting vaccine hesitancy related to the flu shot.

Video Clip 5.1: Conversation on Vaccine Hesitancy among Health Professionals

A YouTube element has been excluded from this version of the text. You can view it online here: https://ecampusontario.pressbooks.pub/immunizations/?p=163

In Canada, about 20% of the population is vaccine hesitant, meaning they have some concerns about vaccination but are not firm vaccine refusers (Dubé et al., 2016). They are distinct from vaccine refusers who make up less than 5% of the population.

According to the World Health Organization (WHO) (2019) vaccine hesitancy is influenced by factors such as: confidence, complacency and, convenience.

Confidence

Refers to a lack of trust in the effectiveness and safety of vaccines, the system that delivers them – including the reliability of the health professional – and/or the motivations of policy-makers who make determinations about vaccines.

Complacency

Refers to a low perceived risk of vaccine-preventable diseases and therefore it is assumed vaccines are not needed. Other issues are considered more important.

Convenience

Refers to the degree to which the comfort, convenience, time, place, and quality of a vaccine affects uptake of the vaccine. This continuum ranges from total acceptance to complete refusal. The concern is that hesitancy can lead to refusal, and unvaccinated clusters may emerge as disease outbreaks (Gangarosa et al., 1998; Jansen et al., 2003).

The success of vaccines means that many parents today have not witnessed the serious consequences of vaccine-preventable diseases like polio, diphtheria, tetanus, and measles. This has led parents to worry more about vaccine adverse effects than the consequences of the diseases themselves. Misinformation on social media and the internet about vaccine ingredients and side-effects may also contribute to lack of vaccine confidence.

When communicating with a client, it is best to focus your responses on the specific questions or concerns rather than overwhelming the client with too much information. Image 5.1 demonstrates the disconnect that can exist between provider and client priorities and perceptions. It has been well-documented that merely correcting misinformation with more information may not be an effective strategy to increase vaccine uptake. Health professionals should avoid strategies that may reinforce misinformation, such as handouts that describe vaccine myths, repeating misinformation to parents, or using elaborate arguments to contest misinformation (Lewandowsky, Ecker, Seifert, Schwarz, & Cook, 2012). Spending too much time talking about myths can strengthen the myth for the client (McClure, Cataldi, & O’Leary, 2017). Instead, health professionals should invite clients to have healthy skepticism towards vaccine hesitant sources, to focus on facts, and to keep their language simple and clear.

Health professionals are the most trusted advisor and influencer of vaccination decisions. It is important that you have the knowledge, attitude, and skills to work with clients who have questions about vaccines and it is important to understand and acknowledge the client’s concerns. Effective communication is the best way for health professionals to address vaccine hesitancy. Always speak positively about vaccination. If a health professional appears unsure about vaccine safety or cannot explain why vaccination is important, you can contribute to the client’s hesitancy. Here are some tips (Table 5.1) for effectively communicating with all clients about vaccines. See also Video Clip 5.2 for a recreation of a discussion between the healthcare provider and parents displaying vaccine hesitancy.

Table 5.1: Communication Tips to Address Vaccine Hesitancy

Video Clip 5.2: Health Professional Discussion with Parents who have 2-month old child

A YouTube element has been excluded from this version of the text. You can view it online here: https://ecampusontario.pressbooks.pub/immunizations/?p=169

Attribution Statement

Parts of this section are adapted from Page 5: Canadian Immunization Guide: Part 1 – Key Immunization Information by the Government of Canada and are reproduced under non-commercial conditions.

There is no panacea to address vaccine hesitancy. Instead, health professionals need to access a variety of tools and approaches to best collaborate with their clients. Presumptive statements and motivational interviewing have been identified as effective tools for communicating about vaccines.

Presumptive Statements

Presumptive statements reinforce vaccination as a normative choice, without inadvertently suggesting that clients should be worried about vaccines. Healthcare professionals can use presumptive statements such as “your child’s next vaccine is due in two months…” or “I see your child is getting the one-year vaccines today.”

Motivational Interviewing

Motivational interviewing (MI) emerged in the 1980s as an approach to establish a safe and open environment for persons managing substance abuse. It is a client-centered approach that supports clients’ motivations to change and addresses internal ambivalence (Miller & Rollnick, 2013). MI was recently applied to vaccine hesitancy because of its appreciative-inquiry qualities. Appreciative-inquiry privileges strengths and motivations of clients, rather than focusing on the negativity of antivaccination. Health professionals should consider the principles of MI as a tool among other strategies. There are five principles of MI: 1) express empathy through reflection; 2) develop discrepancy between client goals, values, and behaviours; 3) avoid argument and direct confrontation; 4) adjust to client resistance rather than opposing it directly; 5) encourage self-efficacy and optimism (Miller & Rollnick, 1991, p. 51-52). This approach relies on health professionals collaborating with clients and actively encouraging their participation in decision making, see Table 5.2 for motivational interviewing tips.

Table 5.2: Motivational Interviewing Tips

Table 5.3 provides an overview of helpful strategies for providers to implement when communicating with someone who is vaccine hesitant compared to someone who has refused a (or multiple) vaccines. This is not suggest that these are mutual exclusive ways-of-being, but to highlight that your strategies may shift as a healthcare provider.

Table 5.3: How to respond to vaccine hesitancy vs. vaccine refusal

Although parents use the internet and social media for medical information, they still look to healthcare providers for trusted advice. It is important that health professionals have the knowledge, attitude, and skills to counsel clients who have questions about vaccines. Respectful dialogue between parents and their child’s healthcare provider is crucial to address vaccine hesitancy. Most often, parents express concerns related to vaccine safety and efficacy, and therefore healthcare providers are an important informational resource. It is important to clearly identify the risks and benefits of vaccines.

Growing Your Communication Skills

Effective communication skills can be developed with practice. When learning about the power of one-to-one conversations, you can make use of a number of techniques to strengthen your skills. First, it is important to look within and understand your personal bias. You should have a good sense of population diversity and societal beliefs. Always aim for simplicity and tailor information to match your client’s needs. Use story-telling to make an impact and understand that an emotional perception may be stronger than logic or fact. People may not remember what you said, but they remember what they thought you said.

1. What is vaccine hesitancy and what role do health professionals play in addressing it?
2. How can health professionals effectively communicate with clients about vaccine hesitancy?
3. What facts can best support an evidence-informed discussion about vaccines?

The key takeaways of this chapter are:

• Vaccine hesitancy is complex and nuanced. Strategies to address it should reflect this reality.
• It is important to communicate effectively with clients through presumptive statements, motivational interviewing, and therapeutic relationship building.
• Clear, simple, evidence-informed language about vaccines is an important strategy to mitigate vaccine hesitancy.
• Health professionals play an important role in addressing vaccine hesitancy.

Caring for kids. (2016). When parents choose not to vaccinate: Risks and responsibilities. Retrieved from: https://www.caringforkids.cps.ca/handouts/when-parents-choose-not-to-vaccinate-risks-and-responsibilities

Dubé, E., Bettinger, J. A., Fisher, W. A., Naus, M., Mahmud, S. M., & Hilderman, T. (2016). Vaccine acceptance, hesitancy and refusal in Canada: Challenges and potential approaches. Canada Communicable Disease Report, 42(12), 246-251.

Dubé, E., & MacDonald, N.E. (2016). Managing risks of vaccine hesitancy and refusals. Lancet. Infectious Diseases, 16(5), 518-9.

Gangarosa, E. J., Galazka, A. M., Wolfe, C. R., Phillips, L. M., Miller, E., Chen, R. T., & Gangarosa, R. E. (1998). Impact of anti-vaccine movements on pertussis control: the untold story. The Lancet, 351(9099), 356-361.

Government of Canada. (2016). Page 5: Canadian Immunization Guide: Part 1 – Key Immunization Information. Retrieved from: https://www.canada.ca/en/public-health/services/publications/healthy-living/canadian-immunization-guide-part-1-key-immunization-information/page-5-communicating-effectively-immunization.html

Jacobson, R.M., Sauver, J.L., Rutten, L.J.F. (2015). Vaccine Hesitancy. Mayo Clin Proc. 90(11), 1562-1568.

Jansen, V. A., Stollenwerk, N., Jensen, H. J., Ramsay, M. E., Edmunds, W. J., & Rhodes, C. J. (2003). Measles outbreaks in a population with declining vaccine uptake. Science, 301(5634), 804-804.

Larson H, Jarrett C, Eckersberger E, et al. (2014) Understanding vaccine hesitancy around vaccines and vaccination from a global perspective: a systematic review of published literature: 2007-2012. Vaccine, 32, 2150–2159.

Lewandowsky, S., Ecker, U. K., Seifert, C. M., Schwarz, N., & Cook, J. (2012). Misinformation and its correction: Continued influence and successful debiasing. Psychological Science in the Public Interest, 13(3), 106-131.

Lo, N.C. & Hotez, P. J. (2017). Public Health and Economic Consequences of Vaccine Hesitancy for Measles in the United States. JAMA Pediatrics, 171(9), 887-892.

MacDonald, N. E., Harmon, S., Dubé, E., Taylor, B., Steenbeek, A., Crowcroft, N., & Graham, J. (2018). Is physician dismissal of vaccine refusers an acceptable practice in Canada? A 2018 overview. Paediatrics & child health, 24(2), 92-97.

McClure, C. C., Cataldi, J. R., & O’Leary, S. T. (2017). Vaccine hesitancy: where we are and where we are going. Clinical therapeutics, 39(8), 1550-1562.

Miller, W. R., & Rollnick, S. (1991). Motivational interviewing: Preparing people to change addictive behavior. New York, NY, US: The Guilford Press.

Miller, W. R., & Rollnick, S. (2013). Applications of motivational interviewing. Motivational interviewing: Helping people change (3rd edition). New York, NY, US: Guilford Press.

R Shen S, Dubey V. (2019). Addressing vaccine hesitancy: Clinical guidance for primary care physicians working with parents. Canadian Family Physician, 65(3), 175-181. http://www.cfp.ca/content/65/3/175

World Health Organization. (2012). If you choose not to vaccinate your child, understand the risks and responsibilities. Retrieved from: http://www.euro.who.int/__data/assets/pdf_file/0004/160753/If-you-choose_EN_WHO_WEB.pdf?ua=1

World Health Organization (2019). Ten Threats to Global Health in 2019. Retrieved from: https://www.who.int/emergencies/ten-threats-to-global-health-in-2019

Vaccines are one of the greatest achievements in the history of medicine and continue to save millions of lives every year. But a persistent group of voices – the anti-vaccination movement – is undermining those public health successes by spreading fear and misinformation. In recent years, cases of vaccine-preventable diseases, such as measles, have started to surge in Canada and some developing countries, due in large part to vaccine hesitancy, which the World Health Organization (WHO) has declared a top global health threat.

To understand the risks posed by anti-vaccination activists and how public health professionals can combat the rising tide of misinformation, it is important to examine how this movement evolved and why the methods of anti-vaccination activists are often effective.

The Roots of Anti-Vaccine Activism

The anti-vaccination movement has been around since the invention of vaccines in the late 1700s when the first successful vaccine was developed for smallpox, an infectious disease that killed three out of every ten infected. Throughout the 19th century, anti-vaccination groups formed and held rallies, protests, and even riots to bring attention to false beliefs about vaccines.

Those early anti-vaccine activists argued the vaccine was unsafe and that focusing on better sanitation and hygiene were the real keys to combatting smallpox. The anti-vaccination advocates were well-organized and gained significant public support, as well as favourable coverage in the media, which hampered the rollout and delivery of vaccination programs.

Today’s anti-vaccine movement is similar to those early activists in terms of the false messages they send about the supposed dangers of vaccines. One marked difference is the platform that current anti-vaccination advocates use to promote messaging. The Internet – and the rise of social media, in particular – have allowed activists to speak on a large, global stage and develop sophisticated methods to influence and persuade audiences.

The dawn of the Internet age in the 1990s coincided with the publication of a now-infamous research paper that falsely connected the measles, mumps, and rubella (MMR) vaccine to autism. That paper, by disgraced former doctor Andrew Wakefield, was highly flawed and would eventually be debunked and retracted. Despite these measures, Wakefield’s paper continues to circulate online and has attracted legions of followers.

Social media plays an increasingly large role in the way people access information. A 2018 study published by the Pew Research Center found that nearly 70% of Americans got news from social media. Of those, 43% reported Facebook as the top source of daily news.

These findings pose a challenge to vaccine programs, as Facebook and other social media sites do not discriminate between legitimate news organizations and those that promote misinformation. Unlike traditional media outlets, social media pages do not need to abide by editorial codes of conduct, follow the tenets of accountability and transparency, or even stick to facts. In the context of vaccinations, this has resulted in the proliferation of social media pages that attempt to persuade the public using any means, even if it involves veering far from the truth.

Video Clip 6.1: Interview about the History of Vaccine Hesitancy

A YouTube element has been excluded from this version of the text. You can view it online here: https://ecampusontario.pressbooks.pub/immunizations/?p=190

The legacy of Wakefield’s flawed research lives on today, with many anti-vaccine activists falsely claiming a connection between the MMR vaccine and autism. But the criticisms of vaccines have also evolved and are now much broader. Some of the more common misinformation about vaccines includes:

• The human papillomavirus (HPV) vaccine causes sterility.
• The current vaccine schedule is responsible for a wide range of chronic childhood illnesses, from asthma to attention deficit hyperactivity disorder (ADHD) to learning disabilities.
• Vaccines cause brain damage.
• Vaccines are the real cause of sudden infant death syndrome (SIDS).

Anti-vaccine activists falsely claim there are vast conspiracies to suppress this information and that governments, health officials, and the media are being paid by pharmaceutical companies to conceal the truth.

Not everyone who hears these messages will believe them. But research shows that exposure to such ideas can influence how people think. A 2014 study by Daniel Jolley and Karen M. Douglas found that people who listened to anti-vaccine messages said they would be much less likely to vaccinate their children afterward. These messages are ubiquitous online and have permeated everyday thinking. A survey conducted by Angus Reid in 2019 found that 30% of parents said the science on vaccines is not clear. About one in four survey respondents said vaccines come with a serious risk of adverse events.

Anti-vaccine activists are not concerned with the truth. They routinely twist facts and use false data to promote misinformation. But one of the most effective tools is the use of emotionally charged stories about children who have supposedly died or been irreparably harmed by vaccines. Most, if not all, of these stories are fabricated. For instance, the family of a Newfoundland girl who died of cancer discovered that their daughter’s image was being used on the social media page of an anti-vaccine group. The group falsely claimed the girl died as the result of vaccines.

While vaccines carry a risk of serious adverse events, including febrile seizure and cellulitis (less than two per million in 2017), according to Public Health Ontario (2018) the overall incidence of harm is small, particularly compared to the risks of contracting a vaccine-preventable illness. About one in 20 children with measles will develop pneumonia and about one in 1,000 will develop encephalitis—inflammation of the brain.

The use of personal stories is an effective response because they connect with people on an emotional level. Public health vaccination campaigns typically focus on the importance of immunization. Those messages are easily drowned out by the photo of a smiling young child depicted by anti-vaccine activists as a “victim” of vaccination. Video Clip 6.2 is an interview with Globe and Mail reporter, Carly Weeks, describing trends in vaccine hesitancy today.

Video Clip 6.2: Interview about Vaccine Hesitancy

A YouTube element has been excluded from this version of the text. You can view it online here: https://ecampusontario.pressbooks.pub/immunizations/?p=192

Del Bigtree is a prominent anti-vaccine activist and an illuminating example of how the movement uses misinformation to spread fear and create mistrust of health professionals. Bigtree rose to prominence as a colleague of Andrew Wakefield’s who helped him develop a film about vaccines. He is a regular speaker at anti-vaccine rallies in the United States and, at times, in Canada. His Facebook page has more than 140,000 likes and his weekly podcast draws thousands of listeners.

Bigtree describes himself as a medical journalist, which lends him a “sense of authority” to discuss issues around vaccines. He speaks forcefully and uses shocking stories to persuade his audience. For instance, at a recent rally, he pinned a yellow star to his clothing and compared the victimization of anti-vaccine activists to the victims of the Holocaust.

Like many others, Bigtree does not simply say “vaccines are bad.” He frames his messages as though he is a protector of public health who must inform individuals about dangers that governments and pharmaceutical companies are conspiring to cover up. He is the head of an organization, called the Informed Consent Action Network, whose stated mandate includes “fighting for parents’ rights,” “protecting children,” and “science-based inquiry.”

These sound like laudable goals. However, the messages he delivers are rife with misinformation, fabrications, and outright lies. For instance, Bigtree claims that no placebo-controlled trials of vaccines have ever been conducted, which he says is proof vaccines are not safe. However, this is false. The reason vaccines are not typically tested against a placebo is that it is unethical to knowingly expose a control group to the risks of a vaccine-preventable illness. No such trial would be ethically approved. This is just one example of an artificial, manufactured controversy employed by anti-vaccination advocates to manipulate, influence, and persuade. Anti-vaccine activists are dedicated to growing audiences on social media and figuring out how to maximize the total number of clicks, likes, and shares. Rising rates of measles outbreaks in unvaccinated populations of developing countries shows that these messages are having an impact.

Image 6.2 provides an example of a mock anti-vaccine website. Notable about this image is the subtle messaging like ‘vaccine awareness’ and ‘informed consent.’ which are intentionally cryptic to allure readership while disguising the ultimate anti-vaccine agenda.

Health professionals are in a position to counter misinformation campaigns with evidence-based arguments. But most are busy focusing on the safe, effective delivery of care, not waging social media battles. Furthermore, many health professionals are uncertain of how to address concerns over vaccination and may be reluctant to confront anti-vaccination advocates. But the resurgence of measles and growing concern over vaccine hesitancy demonstrates a need for nurses, doctors, pharmacists, and other health professionals to play a more significant role in promoting public confidence in vaccines.

The anti-vaccine movement uses emotional stories to spread fear about vaccination, but health professionals can play an important role in reminding the public about the very real risk of vaccine-preventable disease. Many people have never seen a case of measles and did not grow up with a fear of polio. Health professionals can leverage scientific and historical knowledge to promote vaccines as a way of keeping those diseases in the past. You can also reflect on your own experiences to share stories about the harms of not vaccinating. It may be effective to share a story about your individual choice to vaccinate yourself and your family. Health professionals are the gatekeepers of the healthcare system and can make an important difference in the current misinformation battle over vaccines.

1. How did the anti-vaccination movement emerge?
2. How can health professionals effectively communicate with clients about vaccine hesitancy?
3. Why is it important to understand common public misconceptions about vaccines?
4. What role does social media play in conflating facts and misconceptions about vaccines?

The key takeaways of this chapter are:

• The anti-vaccination movement is not new and emerged in response to early vaccine development.
• Anti-vaccination rhetoric often exploits parent fears and concerns.
• Understanding public misconception can better equip health professionals to have effective communication about vaccine hesitancy.
• Health professionals play an important role in addressing vaccine hesitancy.

Angus Reid Institution. (2019). Vast majority of Canadians say vaccines should be mandatory for school aged kids. Retrieved from: http://angusreid.org/mandatory-vaccination-canada/

Government of Canada. (2014). Canadian immunization guide: Part 4 – Active Vaccines. Retrieved from: https://www.canada.ca/en/public-health/services/publications/healthy-living/canadian-immunization-guide-part-4-active-vaccines/page-21-smallpox-vaccine.html

Jolley, D. & Douglas, K. (2014). The effects of anti-vaccine conspiracy theories on vaccination. PLoS One, 9(2), e89177.

Museum of Heath Care at Kingston. (n.d.) Smallpox. Retrieved from: https://www.museumofhealthcare.ca/explore/exhibits/vaccinations/smallpox.html

Public Health Ontario. (2018). Annual Report on Vaccine Safety in Ontario, 2017. Retrieved from: https://www.publichealthontario.ca/-/media/documents/annual-vaccine-safety-report-2017.pdf?la=en#:~:targetText=In%20Ontario%2C%20696%20AEFI%20reports,100%2C000%20population%20(Figure%201).

A number of jurisdictions across Canada have implemented or are working towards expanding the scope of practice so that registered nurses (RNs) can prescribe certain medications (including vaccines) to better meet population health needs and improve timely access to appropriate health care (Canadian Nurses Association, 2015). This shift is part of a global trend towards nurse prescribing as countries look for ways to increase access to care in resource-constrained environments and improve efficiencies in complex health systems (Ladd & Schober, 2018). RN prescribing can also support cost effectiveness and innovative practice models (College and Association of Registered Nurses of Alberta, 2019). In Ontario, expanding the RN scope of practice to include certain prescribing powers aligns with the vision of a patient-oriented health care system (Hoskins, 2015).

Regulation of health professionals falls under provincial/territorial jurisdiction in Canada. This chapter focuses specifically on Ontario health professionals. If you are planning to practice in another jurisdiction, you should refer to the regulatory body in that province or territory for current information on scope of practice for vaccine prescribing and administration.

In May 2017, the Ontario government made changes to the Nursing Act, 1991 to permit RNs to prescribe certain medications (Government of Ontario, 2017). As of September 2019, the College of Nurses of Ontario (CNO) has created a draft regulation for RN prescribing, but this regulation still needs to be passed by the government prior to RN prescribing authority being enacted in Ontario (CNO, 2019b).

RN prescribing will not be an entry-to-practice level competency for RNs in the general class in Ontario (CNO, 2018b). In order to gain the authority to prescribe medications, RNs will be required to complete additional CNO-approved education programs and are accountable for ongoing competence for safe prescribing (CNO, 2018b). Even after completing a CNO-approved education program, RNs will only be able to prescribe medications if their practice environment supports RN prescribing (CNO, 2019a). For instance, RNs in a hospital setting will not be allowed to prescribe medications because the Public Hospitals Act does not currently allow it (CNO, 2019a).

Future RN prescribers will be different from RNs who are registered in CNO’s extended class, commonly known as nurse practitioners (NPs). NPs currently practice autonomously with respect to assessment, diagnosis, and prescription, and an NP’s expanded scope of practice will continue to be broader than what is proposed for RN prescribers.

Any healthcare professional prescribing vaccines requires specific competencies in order to ensure that vaccines, like other medications, are provided in a safe, effective, and ethical manner. In order to promote safe and competent practice, the Public Health Agency of Canada (PHAC) developed a handbook in 2008 entitled Immunization Competencies for Health Professionals.  These foundational competencies include:

• Explaining how vaccines work using basic knowledge of the immune system.
• Understanding the rationale and benefits of immunization.
• Integrating into practice knowledge about the main steps in vaccine development and evaluation.
• Applying knowledge of the components and properties of immunizing agents as needed for safe and effective practice.
• Applying relevant principles of population health for improving immunization coverage rates.
• Communicating effectively about immunization.
• Implementing guidelines for safe storage and handling of vaccines.
• Preparing and administering immunization agents correctly.
• Anticipating, identifying, and managing adverse events following immunization.
• Understanding documentation requirements for immunizations.
• Recognizing and responding to the unique immunization needs of certain population groups.
• Demonstrating an understanding of the immunization system in Canada.
• Addressing immunization issues using an evidence-based approach.
• Acting in accordance with legal and ethical standards in all aspects of immunization practice (PHAC, 2008).

Health professionals need to be able to anticipate, identify, and manage adverse events that may occur following immunizations (PHAC, 2008). As you have learned in earlier chapters of this resource, adverse events following immunizations are rare. Although these events are rare, monitoring vaccine safety through mandatory adverse event reporting is an important aspect of the immunization program in Ontario. Adverse events following immunization can be reported with a form from the PHAC, which can be submitted to the local public health agency where the patient lives.

Optimizing the Role of Ontario RNs in Immunization Through RN Prescribing

Pending government approval of the proposed CNO regulation, RN prescribing will be authorized for certain medications that will allow RNs to manage non-complex patient care needs (CNO, 2019b). In the first phase of RN prescribing in Ontario, these medications will include some vaccines (CNO, 2019b).

While RNs in Ontario have typically participated in immunization as front-line providers in schools and community settings, this change will allow RNs to not only administer vaccines but prescribe them as well. Given the important role RNs play in primary health care and health promotion, a strategic focus on maximizing the involvement of RNs in immunization should help advance the public health goal of immunization for everyone across the life cycle (International Council of Nurses, 2013).

While Ontario is in the process of expanding the scope of practice for RNs to include prescribing authority for vaccines, NPs and physicians can currently prescribe vaccines to individual patients and may also develop directives that authorize other healthcare providers (such as RNs or registered practical nurses, or – if the ordering practitioner is a physician – physician assistants) to administer vaccines to a larger client population when certain conditions are met and specific circumstances exist. Directives must include a number of detailed components and should be supported by certain facility policies prior to implementation (CNO, 2018a).

To improve influenza vaccination rates, Ontario pharmacists, pharmacy students, and pharmacy interns became authorized to prescribe and administer influenza vaccines in 2012 to clients over the age of five. These pharmacists and pharmacists-in-training need to complete specific injection training requirements and be practicing at a pharmacy registered with Ontario’s Universal Influenza Immunization Program (Ontario College of Pharmacists, n.d.). In December 2016, this scope was expanded to include other vaccines including Hib, hepatitis A, hepatitis B, herpes zoster, HPV, Japanese encephalitis, meningitis, pneumococcal disease, rabies, tuberculosis, typhoid, varicella, and yellow fever (Ontario College of Pharmacists, 2016). In April 2019, the Ontario government announced it may further expand the scope of practice to allow pharmacists to administer influenza vaccines to children under five years of age (Jones, 2019).

Midwives in Ontario need to be aware of current guidelines for vaccination recommendations for pregnant people, who are at greater risk than non-pregnant people for more severe illness from some vaccine-preventable diseases (Association of Ontario Midwives, 2018).  Midwives in Ontario may prescribe and administer certain vaccines to their clients, such as hepatitis B and MMR vaccines (College of Midwives of Ontario, 2014). However, other vaccines recommended in pregnancy, such as pertussis and influenza, may require a referral to another primary care provider. Similarly, providing routine childhood immunizations falls outside the midwifery scope of practice in Ontario. As you learned earlier in this resource, vaccinations typically begin at two months of age, and clients and their infants are discharged from midwifery care at six weeks postpartum. Clients may wish to discuss immunizations with their midwives in the prenatal period, and during their postpartum/newborn visits. As a result, midwives, like other health professionals, should be aware of the childhood immunization schedule in Ontario and where clients can find evidence-based information.

Ontario is in the process of implementing RN prescribing for various medications, including vaccines. This shift is meant to support patient access to health care by optimizing scope of practice for safe and effective care by RNs and follows a similar trend for pharmacists in Ontario. Policy action that supports nurse prescribing of vaccines is an important step in increasing vaccination rates across the life cycle (International Council of Nurses, 2018). Achieving higher vaccine coverage rates to improve population health is an important goal and Ontario is taking steps towards this through implementing RN prescribing authority for vaccines.

1. Why are certain jurisdictions expanding the RN’s scope of practice to include prescribing medications?
2. How do RNs know whether they are able to prescribe medications such as vaccines? What criteria need to be met before an RN is permitted to prescribe a vaccine?

The key takeaways of this chapter are:

• Expanding the scope of practice for RNs to include prescribing medications such as vaccines is meant to improve access to care and better address population health needs.
• As of September 2019, the CNO has created a draft regulation for RN prescribing that, once passed by the government, will enable RNs to prescribe certain medications to their clients.
• RN prescribing in Ontario will not be an entry-to-practice level competency for RNs in the general class; practicing RNs will be required to complete additional CNO-approved education programs before being authorized to prescribe.
• Vaccines will be among the medications that authorized Ontario RN prescribers may prescribe to their clients.
• When prescribing vaccines, health professionals are accountable for ensuring they are competent to prescribe vaccines in a safe, effective, and ethical manner.

Association of Ontario Midwives. (2018). Vaccinations in pregnancy.  Retrieved from https://www.ontariomidwives.ca/vaccinations-pregnancy

Canadian Nurses Association. (2015). Framework for registered nurse prescribing in Canada. Retrieved from https://www.cna-aiic.ca/~/media/cna/page-content/pdf-en/cna-rn-prescribing-framework_e.pdf?la=en

College and Association of Registered Nurses of Alberta. (2019). Registered nurse prescribing Schedule 1 drugs and ordering diagnostic tests: Requirements and standards. Retrieved from https://www.nurses.ab.ca/docs/default-source/document-library/standards/registered-nurse-prescribing-schedule-1-drugs-and-ordering-diagnostic-tests-requirements-and-standards.pdf?sfvrsn=67eba52b_4

College of Midwives of Ontario. (2014, revised 2018). Prescribing and administering drugs. Retrieved from http://www.cmo.on.ca/wp-content/uploads/2015/07/16.Prescribing-and-Administering-Drugs.pdf

College of Nurses of Ontario. (2018a). Directives. Retrieved from https://www.cno.org/globalassets/docs/prac/41019_medicaldirectives.pdf

College of Nurses of Ontario. (2018b, December 10). Draft competencies for RN prescribing. Retrieved from http://www.cno.org/globalassets/1-whatiscno/legislation/draft-competencies-for-regcirculation.pdf

College of Nurses of Ontario. (2019a). FAQs: RN prescribing. Retrieved from http://www.cno.org/en/trending-topics/journey-to-rn-prescribing/qas-rn-prescribing/

College of Nurses of Ontario. (2019b). Journey to RN prescribing. Retrieved from http://www.cno.org/en/trending-topics/journey-to-rn-prescribing/

Government of Ontario. (2017, May 17). Stronger, Healthier Ontario Act (Budget Measures), 2017 [Media release]. Retrieved from https://news.ontario.ca/mof/en/2017/05/stronger-healthier-ontario-act-budget-measures-2017.html

Hoskins, E. (2015, November 4). [Letter from Minister of Health and Long-Term Care to Chair of the Health Professions Regulatory Advisory Council.] Ontario: Ontario Ministry of Health and Long-Term Care. Retrieved from https://hprac.org/en/resources/Minister-Letter-November-4-2015-FINAL-AODA.pdf

International Council of Nurses. (2013). Adult and childhood immunisation: 2013 revised edition. Retrieved from https://www.icn.ch/sites/default/files/inline-files/2013_adult_and_childhood_immunisation.pdf

International Council of Nurses. (2018). The role of nurses in immunisation: A snapshot from OECD countries. Retrieved from https://www.icn.ch/sites/default/files/inline-files/IMMUNISATION_Report%20%28002%29.pdf

Jones, A. (2019, April 18). Ontario may let pharmacists prescribe treatments for minor issues like pink eye. Toronto CityNews. Retrieved from https://toronto.citynews.ca/2019/04/18/ontario-pharmacists-treatments-health-care/

Ladd, E., & Schober, M. (2018). Nurse prescribing from the global vantage point: The intersection between role and policy. Policy, Politics, & Nursing Practice, 19(1-2), 40-49. https://doi.org/10.1177/1527154418797726

Nursing Act, 1991, SO 1991, c 32. Retrieved from https://www.ontario.ca/laws/statute/91n32

Ontario College of Pharmacists. (2016, December 2). New authority for vaccinations (effective Dec 15). Retrieved from http://www.ocpinfo.com/library/news/new-authority-vaccinations-effective-december-15/

Ontario College of Pharmacists. (n.d.). Administering injections. Retrieved from http://www.ocpinfo.com/practice-education/practice-tools/collection/administering-injections/.

Public Health Agency of Canada. (2008). Immunization competencies for health professionals. Retrieved from https://www.canada.ca/en/public-health/services/publications/healthy-living/immunization-competencies-health-professionals.html#ess