4)

60
HEALTH PROMOTION AND
IMMUNIZATIONS

17
:1
Qualifying Exam Preparatory Course

(ID
e
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1
Ed
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COVERED IN THIS PRESENTATION…

se
Jo

Ethical, Legal and

Product
to

Professional Patient Care

Distribution
Responsibilities
ed
ns

Knowledge and
Practice Setting Health Promotion Research
ce

Application
Li

Intra and Inter-

Communication
Professional Quality and Safety
and Education
Collaboration

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Source: [Link]

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 LEGEND
Anti-HBs Antibody to Hepatitis B Surface Antigen IV Intravenous
BCGP Board Certified Geriatric Pharmacist LAIV Live Attenuated Influenza Vaccine
CDE Certified Diabetes Educator MMR Measles, Mumps, Rubella
DTaP Diphtheria Tetanus Acellular Pertussis MMRV Measles, Mumps, Rubella, Varicella

4)
GLP-1 RA Glucagon-Like Peptide-1 Receptor Agonist NACI National Advisory Committee on Immunization

60
HBV Hepatitis B Virus PHAC Public Health Agency Of Canada
HCV Hepatitis C Virus PNEU-C-13 Pneumococcal Conjugate 13-Valent
Hib Haemophilus Influenzae Type B PNEU-P-23 Pneumococcal Polysaccharide 23-Valent

17
HPV Human Papillomavirus PO By Mouth, Orally
ID Intradermal SC Subcutaneous

:1
IIV3 Trivalent Inactivated Influenza Vaccine STI Sexually Transmitted Infection
IIV4 Quadrivalent Inactivated Influenza Vaccine TB Tuberculosis

(ID
IM Intramuscular Td Tetanus Diphtheria
IPV Inactivated Poliomyelitis Vaccine Tdap Tetanus Diphtheria Acellular Pertussis

e
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Ed
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WHAT IS HEALTH PROMOTION?

se
Jo

Health Promotion:
to

• Social and environmental interventions → enable people/communities to improve their health

and have increased control over their health
ed

• Examples:
ns

→ Promoting behaviours that are healthy, establishing healthy public policies, creating
environments that are supportive, and strengthening personal skills
ce

→ Preventative care: vaccines, Point-of-Care testing…etc.

Li

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 WHAT IS HEALTH PROMOTION?

4)
60
The process of enabling people to increase
control over, and to improve, their health

17
– World Health Organization

:1
(ID
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Ed
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WHAT IS THE ROLE OF THE PUBLIC HEALTH AGENCY OF CANADA?

se
Jo

• To protect the health and safety of all Canadians by: H

Minister of Health
• Focusing on preventing diseases and injuries
to

• Responding to public health threats (e.g. Deputy Minister

emergencies and infectious outbreaks)
ed

Associate Deputy
• Promoting physical and mental health Minister
• Involves collaboration of Federal, Branches of Health
ns

Agencies
Provincial/Territorial and municipal governments Canada
Health Products and Public Health
ce

Food Branch Agency of Canada

and more…
Li

Chief Public Health

Officer

Canadian Institutes
of Health Research

Patented Medicines
Prices Review Board

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 WHAT ARE THE DETERMINANTS OF HEALTH?

Conditions in which we are born and raised, live, and

work which impact our health and well-being

4)
60
17
Childhood Housing Education Social support
experiences

:1
(ID
Family income Employment Our communities Access to health

e
services
hi
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Ed
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HOW CAN PHARMACISTS IMPLEMENT HEALTH PROMOTION SERVICES INTO THEIR PRACTICE?
se
Jo

Community outreach programs Point-of-care testing

Interprofessional collaboration Cardiovascular clinic

to

Diabetes care (CDE) Skin/sun care clinic

ed

Geriatric care (BCGP) Pharmacogenetic Screening

ns

Travel consultation Cannabis consults

ce

Vaccinations Naloxone kits

Li

Smoking cessation Pharmacist prescription renewals and adaptions

Medication reviews Minor ailments

Pharmaceutical opinions

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 CANADA AND HEALTH PROMOTION

4)
60
17
:1
Government of Canada | Health promotion

(ID
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DISCUSSION
se
Jo
to
ed

What are examples of

ns

barriers to health and wellness?

ce
Li

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 IMMUNIZATIONS - ROUTES OF ADMINISTRATION
There are 5 routes of administration for injectable drugs:
Intramuscular (IM): injection into muscle tissue
• Most vaccines and vitamin B12
• Of the non-QDIV parenteral routes, this has the fastest onset because muscle tissue is highly vascular

4)
Subcutaneous (SC): injection into tissue below the dermis of the skin

60
• Insulin, GLP-1 RA, most biologic drugs and some vaccines are administered in this way
• Generally, has a slower onset of action than IM injections

17
Intradermal (ID): injection directly into the dermis of the skin
• This is often used for skin reaction tests (e.g. tuberculosis skin test)

:1
Intravenous (IV): injection directly into the venous blood

(ID
• Many hospital drugs are administered in this way
• This route of injection will not be covered in this course

Subcutaneous (SC): injection into tissue below the dermis of the skin

e
• Examples: FluMist® (nasal spray influenza vaccine), naloxone nasal spray
• This route is not very common
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TYPES OF IMMUNITY: REVIEW OF VACCINES

se
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Passive Immunity: Temporary protection Active Immunity: Lasting protection

to

Antibody produced by one human or other - Immune system is stimulated to produce cellular
animal is transferred to another and humoral immunity
- Antibodies produced from exposure to pathogen
ed
ns

VS.
Natural Artificial Natural Artificial
ce

Immunity an infant Antibodies from an Survives infection Production of

receives from its immune individual from a disease- antibodies in
Li

mother used for treatment causing organism response to

controlled exposure
to a pathogen
through vaccination

What is the difference between

live and inactivated vaccines?
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 MECHANISM OF ACTION
• Vaccinations produce active immunity
• Immune response produced is similar to that caused by a natural infection
• Vaccinations produce immunologic memory that can last for many years

4)
• Protection comes without complications/risks of actual disease
• There are two types of vaccine formulations:

60
Live attenuated Inactivated

17
• Live bacterium or virus in a (weakened) form • Inactivated form or antigenic fragments
Live b
• Agent must replicate to be effective • Agent is not live so it cannot replicate
Agen

:1
• In immunodeficient patients uncontrolled • Does not cause disease, even in
In im
replication can cause severe disease - AVOID immunodeficient patients - SAFE
replic

(ID
• Has a cellular and humoral immune response • Immune response is primarily humoral
Has a
• Always requires more than one dose

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EXAMPLES OF VACCINES
se

• Severe asthma: defined as currently on oral or high dose inhaled glucocorticosteroids or active wheezing
Jo

Vaccine Type Vaccine Examples Contraindications

Vaccin
• Anaphylactic reaction to vaccine
• Bacillus Calmette-Guérin (BCG) components
to

• Measles • Rubella • Severe asthma OR* medically attended

• Mumps • Smallpox wheezing 7 days prior to vaccination
LIVE,
ed

• Rotavirus • Typhoid (oral) • Rotavirus: pts with congenital GI LIV

ATTENUATED
• Live attenuated influenza • Varicella (chickenpox) malformation or history of intussusception
VACCINES
(intranasal influenza vaccine) • Yellow fever • Immunocompromised patients VACC
ns

• Pregnancy
• MMR, MMRV, BCG in pts with active
ce

untreated TB
• Acellular pertussis • Anaphylactic reaction to vaccine
Cholera & travelers' diarrhea components
Li

•
• Diphtheria toxoid • Meningococcal
• H. influenzae type b • Pneumococcal
INACTIVATED
• Hepatitis A, Hepatitis B • Rabies
VACCINES
• Human papillomavirus • Tetanus toxoid VACC
• Inactivated herpes zoster • Inactivated influenza
• Inactivated poliomyelitis • Typhoid (injectable)
• Japanese encephalitis
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 VACCINATION SCHEDULES
Use the following two resources to review provincial and federal recommendations:
• Provincial and territorial health agencies have created vaccination schedules which can be
accessed using the following online tool: [Link]

4)
calendrier/[Link]
• Health Canada has published a summary of the current routine vaccination schedule for infants

60
and children in all provinces and territories: [Link]
health/services/provincial-territorial-immunization-information/provincial-territorial-routine-

17
[Link] (Last update October 2024)
• Canadian Immunization Guide has a section on general recommendations for immunization

:1
schedules: [Link]
[Link]

(ID
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IMMUNIZATION PROCEDURE
se
Jo

All immunizations should follow the 6 steps outlined below to:

• Minimize the risk of severe reactions or unintended consequences
to

• Ensure patient understands the risks, benefits, and side effects of the vaccine
• Fulfill documentation requirements
ed
ns
ce

Document
Provide Get
Screen vaccine/ Administer Monitor
Li

vaccine informed
patients patient injection patient
information consent
information

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 IMMUNIZATION PROCEDURE
• Provide information
• Benefits and risks of the vaccine (risk of disease in absence of vaccination)
• Common side effects, contraindications, myths, and misconceptions

4)
• Obtain informed consent

60
• Immunization CANNOT be given without patient’s informed consent
• Informed consent is NOT required for life-saving injections

17
• Document
• Product name, manufacturer and lot number, route of administration, indication, patient

:1
information, immunizer, date/time administered, post-injection adverse effects and
management, follow-up

(ID
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PREPARING TO ADMINISTER
se
Jo

• Choose correct needle LENGTH and GAUGE to minimize tissue injury and patient discomfort
• Note: the higher the gauge, the smaller the opening of the needle
to

• Use a longer needle if there is more SC fat

Route Needle gauge Needle length (inches)

ed

Route
Adult: 5/8 inch
ns

Subcutaneous 25 Subcut
Child : 5/8 inch
Deltoid muscle
ce

Intramuscular 22-25 Adult: 5/8 – 1½ inch* Intram

Child: 5/8 – 1 inch
Li

*A 5/8” to 1” needle may be used for IM injection if <130 lbs, in deltoid muscle,
skin stretched tight and at 90-degree angle

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 ADMINISTRATION & FINAL STEPS
• Select site free from infection and injury
• Cleanse area with alcohol swab and allow the alcohol to dry
• Target area by gently stretching the skin (IM) or pinching the skin (SC)

4)
• Use a dart-like motion with steady pressure

60
• Inject at:
• 90° angle for IM

17
• 45° angle for SC
• Have patient remain under surveillance for approximately 15 minutes after the injection

:1
(ID
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SUBCUTANEOUS INJECTIONS
se
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INJECTION SITE
to

• Generally:
– For children under 12 months of age,
ed

45°
use the fatty tissue overlying the
Skin
anterolateral thigh
ns

– For children 12 months or older and

Subcutaneous
ce

adults, use the fatty tissue overlying tissue

the upper triceps area or the
Muscle
Li

anterolateral thigh

SUBCUTANEOUS

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 INTRAMUSCULAR INJECTIONS

INJECTION SITE

4)
• Generally:
– For children under 12 months of age:

60
90°
anterolateral thigh muscle
Skin
– For children aged 12 months to 12

17
years: deltoid muscle of the arm or
Subcutaneous
the anterolateral thigh muscle

:1
tissue
– For adolescents and adults: deltoid Muscle
muscle of the arm preferred

(ID
INTRAMUSCULAR

e
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MONITORING FOR REACTIONS

se
Jo

1. Before releasing patient, monitor for at least 15 minutes for immediate adverse reactions
2. Two of the more serious immediate reactions are syncope (anxiety-related) and anaphylaxis
to

3. Other adverse reactions such as injection site pain, redness and swelling are more common
and are delayed onset reactions
ed

4. Adverse reactions that you become aware of should be reported via Canadian Adverse Events
Following Immunization Surveillance System (CAEFISS) (a public health post-market vaccine
ns

safety monitoring system run by Health Canada which can be accessed via a web site)
ce
Li

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 ANAPHYLAXIS

• Anaphylaxis is a life-threatening
allergic reaction involving multiple
organ systems

4)
• Symptoms can progress rapidly and

60
may be life-threatening if airway
obstruction or a severe drop in
blood pressure occurs

17
• Most effective treatment for

:1
anaphylaxis is epinephrine
administered as an IM injection in
the thigh

(ID
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NEEDLE-STICK INJURY PREVENTION

se
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✓ Infection control guidelines are designed to protect

providers and patients from exposure to diseases
spread by blood and bodily fluids
to

✓ Providers should treat blood and other bodily fluids of ALL patients as a potential source of
infectious disease
ed

✓ The following precautions should be taken:

ns

✓ Wear gloves if likely to touch body substances or mucous membranes

✓ Wear eye protection and face mask if likely to be splashed
ce

✓ Wear lab coat or gown if likely to be soiled

✓ Place needles in sharps containers (do NOT recap)
Li

✓ Remove gloves using aseptic technique and wash hand immediately

✓ Place soiled articles in plastic bag for disposal
✓ Place soiled linen in laundry bag

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 STORING VACCINES/BIOLOGICS
• To protect against loss of efficacy, vaccines, and biologics must be transported and stored in a
cold environment with specific temperature requirements called COLD CHAIN
• The cold chain is strictly monitored and regulated by monitoring refrigerator temperatures and

4)
reporting cold chain incidents to public health unit
• Pharmacies must have medication storage refrigerators that meet standards of temperature

60
consistency and maintaining a record of the temperature is required
• GENERAL GUIDELINES

17
• Liquid vaccines and reconstituted products must be kept at +2⁰C to +8 ⁰C

:1
• Reconstituted products must be used in the timeframe specified by the manufacturer
• Frozen products must be stored between -15 ⁰C to -50 ⁰C

(ID
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EXAMPLES OF VACCINATIONS BY PHARMACISTS

se
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NEW: COVID-19 Vaccine

• Hepatitis A • Pneumococcal disease

to

• Hepatitis B • Tuberculosis • H
ed

• Herpes Zoster • Rabies • H

ns

• Haemophilus Influenza Type B • Varicella Virus • H

ce

• Meningitis • Typhoid Disease • H

Li

• Human Papillomavirus • Yellow Fever • M

• Japanese Encephalitis • Influenza • H

• Ja

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 HEPATITIS A

DISEASE SYMPTOMS AND Viral infection of the liver; flu-like symptoms (fatigue, fever),
DISEA
COMPLICATIONS GI symptoms, pale stools, jaundice, paralysis, death (rare)
COMP

4)
• Contaminated food or water (i.e. fecal-oral route)

60
DISEASE SPREAD • Sexual contact, needle sharing
DISEA
Hand-to-mouth contact, person-to-person contact

17
•
Pre-exposure immunization in those 6 months of age and

:1
VACCINE INDICATION older (e.g. protection against virus when travelling to
VACCI
endemic countries)

(ID
VACCINE ADVERSE EFFECTS Local reaction (soreness, swelling, redness at injection site)
VACCI
2 doses: initial dose followed by a booster dose at 6-36
DOSING SCHEDULE
months afterwards (depending on product) DOSIN

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HEPATITIS B
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DISEASE SYMPTOMS Viral infection of the liver; same symptoms as hepatitis A for acute
DISEAS
AND COMPLICATIONS infection - chronic infection can cause liver cancer, cirrhosis, death
AND C
• Mother to newborn during delivery
to

DISEASE SPREAD
• Contact with blood or bodily fluids (e.g. sexually transmitted) DISEAS
Routine immunization in children
ed

•
• Pre-exposure immunization for high-risk groups (e.g. protection
VACCINE INDICATION
ns

against virus when travelling to endemic areas, injection drug VACCIN

users, men who have intercourse with men, health care workers
ce

at risk of bodily fluid or blood exposure)

VACCINE SIDE EFFECTS Local reaction (soreness, swelling and redness at injection site)
VACCIN
Li

• Various forms: monovalent recombinant HB, HA/HB combination

• Generally 3 doses administered at 0, 1 and 6 months
DOSING SCHEDULE
• Age and schedule may vary by province (e.g. Ontario has 2-dose DOSIN
schedule in the 7th grade)

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 PREVENTION OF VIRAL HEPATITIS

Hepatitis B immune He
Hepatitis A vaccines Hepatitis B vaccines
globulin (HBIg)
• Inac

4)
• Inactivated vaccine • Induces production of • Pooled Ig from donors to • Pref
• Preferred for pre- anti-HBs provide immediate short- exp

60
exposure prophylaxis • Response for adults term passive immunity • Use
• Used for postexposure decreases with age, • Used in post-exposure prop

17
prophylaxis highest response rate prophylaxis • Safe
• Safe, well-tolerated observed between 5 and • Given with hepatitis • Sing

:1
• Single or in combination 15 years of age vaccines at different com
with HBV vaccine • Safe, well-tolerated injection site vacc

(ID
• Revaccination may be • No effect on antibody
needed in hypo/non- response to vaccine
responders (e.g. elderly,
immunosuppressed)

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Ed
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PREVENTION OF VIRAL HEPATITIS

se

Patient Characteristics (high risk individuals who should be vaccinated) Hep A Vaccine Hep B Vaccine
Jo

Patien
Infants and pre-adolescent children X
People with end-stage renal disease or recipients of dialysis X
to

People who receive repeated plasma-derived clotting factor X X

replacement
ed

People with HIV infections X

ns

People with chronic liver disease including HCV X X

Health care and emergency service workers who have exposure to blood X
ce

in the workplace that may contain virus

People handling HAV-infected primates or involved in research on HAV X
Li

People in training in school of dentistry, laboratory technology, X

medicine, nursing and other allied health professions
Illicit drug users of both injectable and non-injectable drugs X X
Legend:
x = Highly recommended
? = Recommended when there is evidence for sustained HAV transmission

Source: Adapted from Dale C, Yim C. Viral Hepatitis, Acute. In: Gray Jean, editor. e-Therapeutics+ [Internet]. Ottawa (ON): Canadian Pharmacists Association, 2019. Available from: [Link]
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 PREVENTION OF VIRAL HEPATITIS
Patient Characteristics (high risk individuals who should be vaccinated) Hep A Vaccine Hep B Vaccine
People with multiple sexual partners, persons with a history of STIs X
Men who have sex with men X X

4)
Household and sexual contacts of people identified as HB-positive X

60
Staff and inmates of long-term correctional facilities v X

17
Patients and staff of institutions for the developmentally challenged v X
International travellers to HA- or HB- endemic areas X X

:1
Recipients of solid organ or stem cell transplantation X
Individuals who emigrated from highly HBV-endemic areas X

(ID
Legend:
x = Highly recommended
v = Recommended when there is evidence for sustained HAV transmission

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Source: Adapted from Dale C, Yim C. Viral Hepatitis, Acute. In: Gray Jean, editor. e-Therapeutics+ [Internet]. Ottawa (ON): Canadian Pharmacists Association, 2019. Available from: [Link]
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Ed
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HERPES ZOSTER (SHINGLES)

se
Jo

Painful rash and blisters, often presents as a stripe of blisters around left or
DISEASE SYMPTOMS
right side of torso, vision loss, postherpetic neuralgia (burning nerve pain DISEAS
AND COMPLICATIONS
to

even after shingles resolution) AND CO

• Caused by reactivation of an initial varicella-zoster infection (chickenpox)
ed

DISEASE SPREAD • An individual who acquires an initial varicella infection will develop
DISEAS
chickenpox, not shingles
ns

• Prevention of herpes zoster

VACCINE INDICATION
• 50 years of age or older VACCIN
ce

VACCINE SIDE EFFECTS Soreness, swelling and redness at injection site, headache
VACCIN
• Shingrix® (NON-LIVE, recombinant zoster vaccine): 2 doses
Li

DOSING SCHEDULE intramuscularly

• Initial dose (month 0) followed by a second dose 2-6 months later DOSIN

After a shingles infection, when

can one get the vaccine?

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 HAEMOPHILUS INFLUENZA TYPE B (HIB)
Bacterial infection most commonly affecting children <5 years:
DISEASE SYMPTOMS AND
meningitis, fever and chills, pneumonia, otitis media, developmental
COMPLICATIONS
delays

4)
DISEASE SPREAD Respiratory droplets, cough, sneezing, close contact
Routine immunization for prevention of Hib and associated

60
VACCINE INDICATION
complications

17
VACCINE SIDE EFFECTS Soreness, swelling and redness at injection site, headache

• Usually with DTaP-IPV-Hib vaccine

:1
• Routine immunization of infant: at 2, 4, 6, and 12-23 months of age
DOSING SCHEDULE
(4th dose usually given at 18 months)

(ID
• Schedule may vary depending on province or territory

Note: After age 5, Hib is no longer required in healthy individuals. If an adult has not had
DTaP-IPV-Hib, unless immunocompromised, they will receive DTaP and IPV only

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Ed
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INVASIVE MENINGOCOCCAL DISEASE

se
Jo

Bacterial infection most commonly affecting children < 5 years; causes

DISEASE SYMPTOMS
meningitis, sepsis, brain damage, neurologic disabilities, hearing
AND COMPLICATIONS
to

impairment, amputations, death

Person-to-person, mucosal contact with respiratory droplets from infected
DISEASE SPREAD
persons (e.g. coughing, sneezing)
ed

VACCINE INDICATION Routine immunization for prevention of invasive meningococcal disease

ns

VACCINE SIDE EFFECTS Soreness, swelling and redness at injection site, headache
• 3 different vaccines: Men-C, Men-B, and quadrivalent (A, C, Y, W-135)
ce

DOSING SCHEDULE • Generally 2 or 3 doses depending on age of initial starting dose, (specific
to provincial schedule, type of vaccine available)
Li

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 HUMAN PAPILLOMAVIRUS
• Typically self-limiting (i.e. resolves on its own)
DISEASE SYMPTOMS • May be associated with cervical and anogenital cancers
AND COMPLICATIONS • May cause non-cancerous lesions (e.g. genital warts, warts on oral mucosa and
respiratory tract)

4)
• Sexually transmitted: direct skin or mucosa contact
DISEASE SPREAD • Most infected individuals are asymptomatic, can spread virus to other

60
unknowingly
• Prevention of HPV and cervical cancer

17
VACCINE INDICATION • Recommended for all persons 9 to 26 years, but older individuals may still get
it
VACCINE SIDE EFFECTS • Soreness, swelling and redness at injection site, headache

:1
• 3 different types of the vaccine: Bivalent (2vHPV), and nine-valent (9vHPV:
Gardasil 9®)

(ID
• Example for 9vHPV:
→ individuals 9-20 years of age: 1 dose schedule (a 2-dose schedule may be
DOSING SCHEDULE
considered as an alternative)

e
→ individuals ≥ 21 years of age: 2 doses (at least 6 months apart)
→ Immunocompromised or HIV infection: 3 doses
•
hi
Age of vaccination and schedule may vary depending on province or territory
oc
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Ed
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JAPANESE ENCEPHALITIS
se
Jo

DISEASE SYMPTOMS • Often asymptomatic, flu-like symptoms, confusion, coma and

AND COMPLICATIONS neuropsychiatric complications, death
to

• Bite of infected mosquito (RNA virus from Flaviviridae family)

DISEASE SPREAD
• Rural areas of Southeast Asia
ed

• Prevention of infection with virus

VACCINE INDICATION
• Individuals travelling to endemic areas and are at higher risk of disease
ns

VACCINE SIDE EFFECTS • Soreness, swelling and redness at injection site, headache
• 2 doses (days 0 and 28); accelerated schedule (days 0 and 7) possible for
ce

those between 18-65 years of age

DOSING SCHEDULE • Last dose should be at least 1 week prior to potential exposure
Li

• Booster should be given if travelling again or continue to be at risk of

exposure 1 year after previous dose

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 PNEUMOCOCCAL INFECTION

DISEASE SYMPTOMS
AND Pneumonia, sinus and/or ear infection, meningitis, septicemia, deafness, death
COMPLICATIONS

4)
Respiratory droplets, sneezing, coughing, saliva; direct oral contact or or
DISEASE SPREAD
indirect contact with the respiratory secretions of infected individual

60
VACCINE
Prevention of Streptococcus pneumoniae infection and complications
INDICATION

17
VACCINE SIDE
Soreness, swelling and redness at injection site, headache
EFFECTS

:1
• Pneumococcal Conjugate 13-valent Vaccine (Pneu-C-13; Prevnar®13 )
• Pneumococcal Conjugate 15-valent Vaccine (Pneu-C-15; Vaxneuvance®)

(ID
• Pneumococcal Conjugate 20-valent Vaccine (Pneu-C-20; Prevnar®20)
DOSING SCHEDULE
• Pneumococcal Polysaccharide 23-valent Vaccine (Pneu-P-23;
Pneumovax®23 )
• Pneumococcal Conjugate 21-valent Vaccine (Pneu-C-21) *NEW*

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CHILDHOOD IMMUNIZATION – PNEUMOCOCCAL VACCINE FYI

se
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H
Healthy infants (2 to less than 12 months of age)
to

• Pneu-C-13 vaccine 3 dose schedule: 2 months, 4 months and

ed

12 months of age OR
• Pneu-C-13 vaccine 4 dose schedule: 2 months, 4 months and
ns

6 months followed by a dose at 12 to 15 months of age

ce
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 CHILDHOOD IMMUNIZATION –
NEW PNEUMOCOCCAL VACCINES
Healthy infants (2 to less than 12 months of age)

2 months to <7 months 7 months to < 12 months

4)
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Choice of vaccine: Pneu-C-15 or Pneu-C-20
→ 3 doses at: 2, 4, and 12 months of age Choice of vaccine: Pneu-C-15 or Pneu-C-20
→ 2 doses of either vaccine, 8 weeks apart,

17
OR
→ 4 doses at: 2, 4, 6, and 12-15 months of age followed by a 3rd dose 12-15 months of age

:1
Healthy infants (12 months+)

(ID
→ Assessment required to determine # of doses needed to complete the
immunization series

e
→ Pneumococcal vaccine not recommended for children past 5 years of
age hi
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ADULT IMMUNIZATION – PNEUMOCOCCAL VACCINE

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No Prior Vaccination Prior Vaccination and

aged 65+
to

A single dose of Pneu-C-20 OR Pneu-C-21 can be

ed

Previous immunization Previous immunization

given to: with Pneu-P-23 with Pneu-C-13 only
• Adults aged 65+
ns

• All adults aged 50-64 with risk factors (e.g.

chronic heart disease, chronic liver disease,
ce

chronic kidney disease, chronic lung disease, Give a single dose Consider a single
diabetes mellitus, immunocompromised) of Pneu-C-20 or dose of Pneu-C-20
• Adults aged 18-49 who are
Li

Pneu-C-21 at least or Pneu-C-21 at

immunocompromised (e.g. sickle cell anemia, 1 year after last least 1 year after
HIV, immunocompromising therapy) dose last dose

A series of Pneu-C-15 followed by Pneu-P-23 (1 year later) may be considered as an alternative if Pneu-C-20
or Pneu-C-21 are not available
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 RABIES INFECTION

• Flu-like symptoms
DISEASE SYMPTOMS
• Fatal CNS infection
AND COMPLICATIONS
• Paralysis

4)
• Saliva of infected animal

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• Disease of mammals: dogs, skunks, raccoons, bats, foxes
DISEASE SPREAD
• Enters through open skin: bites, broken skin, scratches, respiratory tract, or

17
mucous membranes
• Prevention and post-exposure against rabies
VACCINE INDICATION

:1
• Those working with animals or travelling to endemic areas
VACCINE SIDE EFFECTS • Soreness, swelling, redness at injection site, headache

(ID
• Pre-exposure (prevention): 3 doses (day 0, day 7, and day 21-28)
• Post-exposure prophylaxis (never vaccinated): 4-5 doses depending on
DOSING SCHEDULE
whether immunocompetent versus immunosuppressed

e
• Post-exposure prophylaxis (previously vaccinated): 2 doses
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MEASLES, MUMPS, AND RUBELLA (MMR)

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*Not administered by pharmacists

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DISEASE SYMPTOMS
AND COMPLICATIONS • Fever, cough, Koplik spots, conjunctivitis, rash, runny nose
to

(Measles)
DISEASE SPREAD • Airborne virus, respiratory droplets, direct contact with throat/nasal
ed

(Measles) secretions
VACCINE INDICATION • Prevention of measles, mumps, and rubella
ns

VACCINE SIDE EFFECTS • Soreness, swelling and redness at injection site, rash, headache
ce

• MMRV and MMR

Li

• Childhood immunization: 2 doses (first dose at 12-15 months, second

DOSING SCHEDULE dose at 18 months)
• Adults born during or after 1970: 1 dose or 2 doses in those with high
risk of exposure (e.g. health care workers, military personnel)

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 VARICELLA INFECTION

DISEASE SYMPTOMS • Fever, itching, small blisters, scabs, bacterial infections, pneumonia,
AND COMPLICATIONS encephalitis

4)
DISEASE SPREAD • Airborne virus, sneezing, coughing, fluid from blisters, saliva

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• Prevention of varicella zoster virus infection
VACCINE INDICATION
• Routine immunization (ages 12 months to 13 years old)

17
VACCINE SIDE EFFECTS • Soreness, swelling and redness at injection site, headache
MMRV and univalent

:1
•
• 2 doses: schedule and age of immunization depend on provincial or
DOSING SCHEDULE territorial routine vaccination schedules

(ID
• Recommended to AVOID use of salicylates for 6 weeks after vaccination

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TYPHOID DISEASE (TYPHOID FEVER)

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DISEASE SYMPTOMS Flu-like symptoms, GI symptoms, abdominal perforation, extra-intestinal DISEAS

AND COMPLICATIONS infection, death AND CO
to

Fecal-oral route: ingestion of food or water that is contaminated with feces

DISEASE SPREAD DISEAS
of infected individuals
ed

VACCINE INDICATION Prevention of infection by Salmonella typhi, travelling to endemic region VACCIN
VACCINE SIDE EFFECTS Soreness, swelling and redness at injection site, headache
ns

VACCIN

• Oral (live): four doses - one capsule every other day for a week (day 1,
ce

day 3, day 5, and day 7); the last dose should be given at least 1 week
before travel; swallow capsule (NOT chew) 1 hour prior or 2 hours after a
Li

DOSING SCHEDULE meal with a cold or lukewarm drink; booster is needed every 7 years for DOSIN
those who remain at risk
• IM (inactive): one dose given at least 2 weeks before travel; booster
needed every 3 years for those remaining at risk

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 YELLOW FEVER INFECTION

DISEASE SYMPTOMS AND Flu-like symptoms, jaundice, photophobia, epigastric pain, renal failure,
DISEAS
COMPLICATIONS thrombocytopenia and hemorrhagic symptoms
COMPL

4)
DISEASE SPREAD Mosquito bite: Primarily mosquitoes of the Aedes or Haemogogus species
DISEAS

60
VACCINE INDICATION Prevention of infection, traveling to endemic region
VACCIN
VACCINE SIDE EFFECTS Soreness, swelling and redness at injection site, headache

17
VACCIN
• 1 dose

:1
DOSING SCHEDULE • Re-immunization is recommended for certain individuals after 10
DOSIN
years (controversy over the need for this)

(ID
• History of thymus disease with abnormal immune function (e.g.
Contraindications myasthenia gravis, thymoma or prior thymectomy)
Contra
• Immunodeficiencies (e.g. immunosuppressive therapies or conditions)

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TUBERCULOSIS
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DISEASE SYMPTOMS Infection is usually latent, symptoms of active disease include cough, weight
AND COMPLICATIONS loss, fever, night sweats
to

• Airborne transmission (e.g. inhalation of infected droplets)

DISEASE SPREAD • Extended exposure (weeks) with infected person usually required for
ed

transmission
ns

• Prevention of Mycobacterium tuberculosis infection

ce

• Infants born in high-risk areas

VACCINE INDICATION • NOT recommended for routine use in Canadians but may be considered in
Li

exceptional circumstances (e.g. long-term travellers to endemic areas)

• Vaccine: Bacille Calmette-Guérin (BCG)

DOSING SCHEDULE Single dose

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 INFLUENZA INFECTION
DISEASE SYMPTOMS • Fever, fatigue, cough, headache, muscle pain
AND • Pneumonia (bacterial or viral) and other infections (e.g. sinus)
COMPLICATIONS • Hospitalization, death

4)
DISEASE SPREAD Sneezing, coughing, direct/indirect contact with respiratory secretions

60
VACCINE INDICATION All individuals >6 months of age

17
VACCINE SIDE
Soreness, swelling, and redness at injection site, headache
EFFECTS

:1
• Re-immunization is recommended annually
• Live attenuated influenza vaccine (LAIV) is contraindicated in pregnancy,

(ID
immunocompromised patients, children taking acetylsalicylic acid etc.
• Can be used in patients with egg allergies
DOSING SCHEDULE
• Types: recombinant, adjuvanted trivalent, quadrivalent, high-dose
quadrivalent, and live attenuated influenza vaccine (given intranasally)

e
• Vaccine recommended to be taken before November (2 weeks to
develop immune response) hi
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TYPES OF INFLUENZA VACCINE

se

• Inactivated influenza vaccines (IIV)

Jo

• Standard-dose, egg-based, quadrivalent inactivated influenza vaccine (IIV4-SD)

• Standard-dose mammalian cell culture-based quadrivalent inactivated influenza vaccine
to

(IIV4-cc)
• Adjuvanted inactivated trivalent influenza vaccine (IIV3-Adj)
ed

• High-dose inactivated quadrivalent influenza vaccine (IIV4-HD)

• Recombinant influenza vaccine (RIV)
ns

• Live attenuated influenza vaccine (LAIV)

ce
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 INFLUENZA VACCINE
Children between ages of 6 months to 9 years receiving vaccine for first time require two doses spaced out
for a minimum of at least 4 weeks. All other age groups require only one dose

IIV4- IIV4- IIV3- IIV4-

4)
Age group LAIV4 RIV4
SD HD Adj cc Age gr

60
6 – 23 months Yes Yes Yes
6 – 23
2 – 17 years Yes Yes Yes
2 – 17 y

17
18 – 59 years Yes Yes Yes Yes
18 – 59
60 – 64 years Yes Yes Yes
60 – 64

:1
65+ years Yes Yes Yes Yes Yes
65+ ye
Pregnant women Yes Yes Yes

(ID
Pregna

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WHAT ARE THE PROPERTIES OF TRAVELLER’S DIARRHEA AND HOW CAN IT BE PREVENTED?
se

Disease symptoms Loose stools, nausea, vomiting, fever, abdominal cramps lasting up to 5 days (typically self-
Jo

and complications resolves)

Disease spread Foods in endemic areas: fecal-oral contact by eating raw fruits, vegetables, untreated water
to

Prevention of travelers' diarrhea and cholera caused by Enterotoxigenic E. coli/ETEC (efficacy:

Vaccine indication
67%) and V. cholerae (efficacy: 85%)
ed

• Dukoral® PO vaccine that is stored in the fridge

• Do not eat, drink, or take any medicine 1 hour before or after vaccine
ns

Cholera prevention ETEC diarrhea prevention

• Take 3 oral doses at least 7 days apart; last
ce

dose should be taken 1 week before travel date • Take 2 oral doses at least 7
Ages 2 to days apart. Last dose
<6 years • Booster: one booster dose taken 1 week before
Dosing schedule should be taken 1 weeks
Li

travel date if last dose was between 6 months -

before travel
5 years ago
• Booster: 1 booster dose
• Take 2 oral doses at least 7 days apart. Last
taken 1 week before travel
dose should be taken 1 week before travel date
Age >6 date if last dose was
• Booster: 1 booster dose taken 1 week before between 3 months to 5 >6
years
travel date if last dose was between 2-5 years years ago
ago
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 CASE 1
GE, a 66-year-old patient comes into the pharmacy with a prescription for Shingrix®
(recombinant zoster vaccine for shingles) and wants more information about it. GE has a past
medical history significant for type II diabetes (T2DM), hypertension, and a history of
chickenpox. He currently takes ramipril 2.5 mg PO daily, rosuvastatin 20 mg PO HS, and

4)
metformin 500 mg PO BID. He has no allergies to medications. He weighs 140 lbs (BMI:22 kg/m2)

60
and his most recent HbA1C was 7%.

17
:1
(ID
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CASE 1 QUESTIONS
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1. Which of the following is false?

a) Shingrix® is administered in 2 doses at 2-6 months apart
b) He’s at risk for shingles due to his age, T2DM and history of chickenpox
to

c) Shingles is a contagious disease

d) You can offer to administer it as a pharmacist
ed

2. How should Shingrix® be administered?

ns

a) SC at 45 degrees with 5/8” 23G needle

b) SC at 90 degrees with 5/8” 25G needle
c) IM at 90 degrees with 1” 25G needle
ce

d) IM at 90 degrees with 1½ ” 27G needle

Li

3. Which of the following vaccines would you also strongly recommend?

a) Live attenuated influenza
b) Pneumococcal
c) MMR
d) Hepatitis A
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 CASE 2
EM is a 30-year-old patient who is currently 8 months pregnant. She comes into your pharmacy
asking whether she should get the flu shot now that she is pregnant. EM is in good health but
has a history of an egg allergy. EM is currently taking Pregvit® 1 tab PO BID.

4)
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17
:1
(ID
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CASE 2 QUESTIONS
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1. What should you advise EM regarding the influenza vaccine?

a) It’s not recommended during pregnancy
b) It’s not recommended due to her egg allergy
to

c) Recommend to administer LAIV4

d) Recommend to administer IIV4-SD
ed

2. Ten-minutes into observation, EM reports of some pain and swelling at the injection
site. What should you do?
ns

a) Immediately administer epinephrine and call 911

b) Do nothing and observe for up to 30 minutes
ce

c) Give her diphenhydramine and send her to the emergency room

d) Tell her not to get the influenza vaccine again
Li

3. One year later, EM comes with her child to the pharmacy for his first flu shot.
Which of the following is appropriate?
a) Administer the live attenuated vaccine
b) Administer 2 live attenuated vaccine doses 4 weeks apart
c) Send EM’s son to his family doctor to receive the flu shot
d) Administer 2 standard dose quadrivalent vaccine doses 4 weeks apart
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 REFERENCES
1. Slayter K. Routine Immunization Schedules. Canadian Pharmacists Association.
2. Sanofi Pasteur. Typhim Vi® [Monograph]. Canadian Pharmacists Association.
3. Crucell. Dukoral® [Monograph]. Canadian Pharmacists Association.
4. Public Health Agency of Canada. Population Health Promotion: An Integrated Model of Population Health and Health Promotion. Updated December 8, 2001. [Link]
[Link]/ph-sp/php-psp/[Link].
5. Ottawa Charter for Health Promotion: An International Conference on Health Promotion, November 17-21, 1986.
6. [Link]
7. Public Health Agency of Canada. About the Agency: What We Do. Updated may 5, 2015. [Link]

4)
8. Public Health Agency of Canada. Mandate. Updated June 16, 2011. [Link] Page 8: Canadian Immunization Guide: Part 1 - Key
Immunization Information - [Link]. [Link]
information/[Link]#p1c7t1.

60
9. Canada PHA of, Canada PHA of. National Vaccine Storage and Handling Guidelines for Immunization Providers 2015. aem. [Link]
health/services/publications/healthy-living/[Link].
10. Canada PHA of, Canada PHA of. Page 3: Canadian Immunization Guide: Part 2 - Vaccine Safety. aem. [Link]
immunization-guide-part-2-vaccine-safety/[Link].
11. Standard for the Administration of Immunizations. Alberta Health Services. [Link]

17
[Link].
12. Canada PHA of, Canada PHA of. Canadian Immunization Guide: Part 2 - Vaccine Safety. aem. [Link]
[Link].
13. Canada PHA of, Canada PHA of. Canadian Immunization Guide: Part 4 - Active Vaccines. aem. [Link]

:1
[Link].
14. Centers for Disease Control and Prevention (CDC). Pneumococcal Conjugate Vaccine: What You Need to Know. February 2022. Vaccine Information Statement: Pneumococcal Conjugate
Vaccine - What you need to know ([Link])
15. Pfizer Canada. Prevnar 20 Product Monograph. May 2022. [Product Monograph Template - Standard] ([Link])

(ID
16. Summary of National Advisory Committee on Immunization (NACI) Statement of February 2024: Public Health Level Recommendations on the Use of Pneumococcal Vaccines in Adults,
Including the Use of 15-Valent and 20-Valent Conjugate Vaccines. Health Camada. February 2024.
17. [Link]
adults-including-use-15-valent-20-valent-conjugate-vaccines/[Link]
18. [Link]
19. Health Promotion. World Health Organization. [Link]

e
20. Vaccine administration practices: Canadian Immunization Guide. Government of Canada. Last update May 2023. [Link]
living/canadian-immunization-guide-part-1-key-immunization-information/[Link]
21.
22.
23.
Updated recommendations on human papillomavirus vaccines - [Link]
Updated recommendations on human papillomavirus vaccines - [Link]
Bacille Calmette-Guérin (BCG) vaccine: Canadian Immunization Guide - [Link]
hi
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CHANGE LOG
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August 2024 commonly used

• Slide 3: Updated legend • Formatting and grammatical changes made throughout
• Slide 4: added another example under Health Promotion February 2025
• Slide 11: added GLP-1 RA to SC route, and added intranasal as an • Formatting changes made throughout
additional route of administration
to

• Slide 18: Added ‘deltoid muscle’ in needle length column under IM

• Slide 12: added minor information to active immunity, and a discussion injection route
question • Slide 35: Removed quadrivalent (4vHPV) as discontinued
• Slide 14: added a minor detail about live attenuated influenza vaccine • Slide 37: Added new product Pneumococcal Conjugate 21-valent Vaccine
ed

• Slide 16: changed “get consent” to “get informed consent” (Pneu-C-21) and information to script
• Slide 25: Changed ‘constant recording of temps’ to maintaining a record
of temps (does not need to be constant monitoring in pharmacies) August 2025
• Slide 27, 28, 33, 34 : some additions/changes
ns

• Formatting changes made throughout

• Slide 32: added discussion question about shingles vaccine • Slide 40: Added Pneu-C-21 option to the tables as per Health Canada
• Slide 35: major changes to HPV indication and dosing schedule. Changed recommendations. Also updated interval between Pneu-P-23 and Pneu-
HPV9 to 9vHPV and did so to other 2 as well as per Gov of Canada C-20 or C-21 to 1 year instead of 5 years
ce

website
• Slide 36: Updated accelerated dosing and booster information for
Japanese encephalitis
Li

• Added slide 39 for the use of newly authorized pneumococcal vaccines

(PNEU-C-15 and PNEU-C-20)
• Added slide 41 as a visual simplification of slide 40 (the slide was taken
from another lecture and adapted)
• Slide 44: minor additions/changes
• Slide 46: re-formatted table and added contraindication
• Slide 47: re-added the slide on Tuberculosis since it’s one of the vaccines
that can be administered by pharmacists
• Slide 50: Removed ‘old abbreviations’ from influenza chart as not

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