Pharmacology NuRS288 Student Copy PDF

NURS288 Instructor: Georgina Bagstad RN, MN Pharmacology: Pharmacokinetics & Pharmacodynamics Adapted from Heather Bensler EdD & Ruth Swart’s (RN EdD) power point slides Territorial Acknowledgement University of Calgary, located in the heart of Southern Alberta, both acknowledges and pays tri...

NURS288 Instructor: Georgina Bagstad RN, MN Pharmacology: Pharmacokinetics & Pharmacodynamics Adapted from Heather Bensler EdD & Ruth Swart’s (RN EdD) power point slides Territorial Acknowledgement University of Calgary, located in the heart of Southern Alberta, both acknowledges and pays tribute to the traditional territories of the peoples of Treaty 7, which include the Blackfoot Confederacy (comprised of the Siksika, the Piikani, and the Kainai First Nations), the Tsuut’ina First Nation, and the Stoney Nakoda (including Chiniki, Bearspaw, and Goodstoney First Nations). The City of Calgary is also home to the Métis Nation of Alberta (Districts 5 and 6).  NURS 288 Course Learner Outcome Demonstrate beginning knowledge of principles of pharmacology and selected pharmacology that directly impacts the health of the community and the population; Including vaccinations, over-the- counter drugs, herbals, vitamins and mineral usage and laxatives. (5.4) Overview of the Basics of Pharmacology What is Pharmacology? GREEK ORIGINS: “pharmakon” = poison “logia” = study/knowledge of The Science of DRUGS The study of drugs and their interactions with the body Kozier et al. Kozier et al. What is a DRUG?  Any chemical that has an influence on the physiological processes of a living organism  Any exogenous (produced outside the organism) non- nutritive substance that influences bodily function Used interchangeably with MEDICATION Kozier et al. Kozier et al.  Actions of Drugs in the body Pharmacodynamics: the mechanism of drug action (what the drug does to the body) and the relationships between drug concentration and the body’s response (Adams & Urban, 2013) Pharmacokinetics: the study of what the body does to the drug Kozier et al. (absorption, distribution, Kozier et al. 7 Pharmacodyna mics WHAT THE DRUG DOES TO THE BODY Drug Mechanism of Action  Three ways: Through receptors, through enzymes, through non-selective interactions  Cannot cause a cell or tissue to perform a function not part of its natural physiology  At site of action, can modify the rate at which the cell or tissue functions—increase or decrease; or can modify strength of function Excellent Video Resource (slightly higher level than you need): https://www.youtube.com/watch?v=PhfhMBO-w9Q Kozier et al. Kozier et al.  Pharmacodyna mics (what the drug does) RECEPTORS A receptor is the drug's specific target. Usually, a protein located on the surface of a cell membrane or within the cell Most drugs exert their effects by chemically binding with receptors at a cellular level Kozier et al 2018  Pharmacodynamics (What the drug does) RECEPTORS A receptor is the drug’s specific target Usually, a protein located on the surface of a cell membrane or within the cell Most drugs exert their effects by chemically binding with receptors at a cellular level Cell Membrane Kozier et al. Kozier et al. Pharmacodynamics (What the drug does) RECEPTORS Another way to think of cell membrane is like a light socket  Pharmacodyna mics (What the drug does) RECEPTORS Most drugs exert their effects by chemically binding with receptors at a cellular level Another way to think of cell membrane is like a light socket When a drug binds with a receptor and elicits an appropriate response (activate or Induce) (partial or full) We call this drug an AGONIST because it activates the cell to do something If you are the literary type, you might think of it as the protagonist. It does something!! Kozier et al 2018  Pharmacodyna mics (What the drug does) RECEPTORS Most drugs exert their effectsby chemically binding with receptors at a cellular level Agonist: when a drug binds with a receptor and elicits an appropriate response (Activate or Induce) – can be partial or full Antagonist: when a drug binds to a receptor and inhibits cell function by blocking the receptor (Inhibit)- Kozier et al can be partial or full 2018 Pharmacodyna mics (What the drug does) A receptor is the drug’s specific target RECEPTORS Usually, a protein located on the surface of a cell membrane or within the cell Most drugs exert their effects by chemically binding with receptors at a cellular level Agonist: when a drug binds with a receptor and elicits an appropriate response Antagonist: when a drug binds to a receptor and inhibits cell function by blocking the receptor  Affinity: the degree to which the drug attaches and binds Kozier et al with the 2018 receptor  The stronger the affinity the great the response from the cell or tissue  Pharmacodynamics (What the drug does): Enzyme Interactions  Enzymes catalyze biochemical reactions in a cell inhibi Selective or enhanc interaction: the of ts a specific Drug es enzyme action  The drug binds to the enzyme and alters the enzyme’s interaction with its normal target molecules in the body Kozier et al. Kozier et al. Pharmacodynamics (What the drug does) Non-selective Interactions  Do NOT interact with receptors or enzymes to alter a physiological or biological function of the body  Target to alter cell membranes and cellular processes  Example: Cancer drugs, antibiotics Kozier et al. Kozier et al. (2018) Practice Question A nursing student is explaining how an agonist works. Which statement suggests medication requires educatio the student more A.n?"An agonist stimulates an action" B. "An agonist aids in the enhancement of an action" C. "An agonist opposes the action and blocks reception" D. "An agonist causes a response when they bind to the receptor site" 1 Kozier et al. 8 1 9 Pharmacokine tics 2 0 Pharmacokinetics: What the Body Does to the Drug Absorption Distribution Metabolism Excretion Kozier et al. (2018) Pharmacokinetics...  Dependent on patient factors: renal function, hepatic function, genetic makeup, gender, age, size, body composition, ethnicity, culture, development, environment, illness  Dependant on route of administration  Good video on routes on administration: https://www.khanacademy.org/science/health-and- medicine/mental-health/drug-abuse-and-drug-addictions/v/routes-of-drug-entry  Dependent on chemical properties of drug: molecule size lipid solubility Kozier et al. Pharmacokinetics: Absorption https:// www.youtube.com/watch?v=pWW- aq7iSa0 bloodstream for distribution to Movement the tissues of drug Extent/Amount from Absorbed of Drug site of = Bioavailability: administration intoInfluenced the by route of administration Rate of absorption is determined by form of drug and route of administration: Correct—Aligned Kozier et al.  Let’s Talk ROUTES of Medication Administration Enteral- GI System (oral, sublingual, buccal, nasogastric and gastronomy tubes This Photo by Unknown Author is licensed This Photo by Unknown Author is licensed This Photo by Unknown Author is licensed under CC BY-NC under CC BY-NC- ND under CC BY This Photo by Unknown Author is licensed under CC BY 2 Kozier et al. 3 Pharmacokine tics: Absorption Enteral Route Drug is absorbed through the gastrointestinal tract (oral, buccal, sublingual, rectal) Influenced by: Form of drug Presence of food or fluids ingested with drug Acidity of stomach Motility of GI tract Status of the absorptive surface Rate of blood flow This Photo by Unknown Author is licensed ENTER AL ROUT E: Oral Meds First-Pass Effect: Initial metabolism of the drug absorbed from the GI tract, in the liver, before it reaches the systemic circulation through the bloodstream; reduces bioavailability 2 6 First Pass (Enteral Route) ….is like having to pay …it each reduces howgo- much roundis available med This Photo by Unknown Author is licensed under CC BY-NC  Let’s Talk ROUTES of Medication Administration Topical – refers to medications applied to the skin or mucous membranes to produce a local effect. Skin is the most common, though it can include the mucous membranes of the eyes, ears, nose, respiratory tract, urinary tract, vagina, or rectum. Absorption rate differs between routes. Avoids the 1st pass effect. Can also be in the form of a transdermal patch. This Photo by Unknown Author is nde licensed u CC BY-NC-ND r This Photo by Unknown Author is licensed under CC BY This Photo by Unknown Author is licensed This Photo by Unknown Author is licensed under CC BY- under CC BY-ND SA Kozier et al. 27 Topical Route Medication is applied to a circumscribed area of the body Intended to affect only the area to which they are applied Topical applications include: This Photo by Dermatological preparations (applied to Unknown Author is licensed under CC BY-SA the skin) Instillations and irrigations (applied into a body cavity or orifice such as This Photo by the urinary bladder, eyes, ears, nose, Unknown Author is licensed under CC BY-NC-ND rectum or vagina) Inhalation (administered into the Kozier et al. 28 respiratory tract) NG tube………PEG tube Kozier et al. Let’s Talk ROUTES of Medication Administration Parenteral- Refers to routes other than enteral and topical. Includes intravenous (IV), intramuscular (IM), subcutaneous, intradermal. Less commonly intra-arterial, intraosseseous (bone), intrathecal (body cavity), or intracardiac (heart). 3 This Photo by Unknown Author is licensed under Kozier et al. This Photo by Unknown Author is licensed 0 CC BY-NC-ND under CC BY-NC-ND Benefits of Parenteral Route Skip the First Pass Effect!! Kozier et al. 31 Absorption Continued The process by which the drug mov from the administration to the molecule es site of The blood. rate of is influenced by the o administration absorption heavily route f Influenced by factors like: Drug concentration and dose (usually the higher the dose the faster and greater the response) GI tract: digestive motility, presence/absence of food, health of gut Blood flow to absorption site Drug interactions (eg. certain foods and drugs can influence absorption) Kozier et al. 32  Pharmacokinetics: Distribution https:// www.youtube.com/watch?v=6erefsW Transport of drug in the body bloodstream to Diabetic Foot CVxg site of by the intended Ulcer action Drugs are not passive rather they interact with components agents, and may beblood chemically and physical changed before reaching their target. Distribution is influenced by several key factors: Blood flow to tissues (areas with less blood supply have slower distribution- eg. adipose tissue) This Photo Tissue storage: some tissues accumulate and by Unknown Author is store drugs. licensed under CC Drug solubility (next slide) BY-SA Drug protein binding (following slide) As soon as drug enters bloodstream (circulation), metabolism and excretion begin: kidney and liver Kozier et al.  Distribution: Drug Solubility The physical properties of a drug influence how it moves through the body Lipid solubility is an important characteristic because it determines how quickly a drug is absorbed, mixes within the blood stream, crosses membranes, and becomes localized in body tissues. Lipid soluble drugs absorb more rapidly than water soluble drugs because they are not limited by the barriers that normally stop water-soluble 3 4 is licensed This Photo by Unknown Author Distribution: Protein Binding of Drugs Many drugs bind reversibly to plasma proteins (albumin) to form drug-protein complexes that are too large to cross capillary membranes. The bound drugs continue to circulate in the bloodstream and are unavailable to their site of action until they become unbound. Only unbound or free drugs can reach their target or be excreted by the kidneys. The number of binding sites on a plasma protein is limited. Kozier et al. 35 Drugs may be highly protein bound or not. It’s Pharmacokinetics: Metabolism Also known as Biotransformation or detoxification The process used by the body to chemically change a drug molecule Involves hundreds of complex biochemical pathways and reactions that alter the structure and function of drugs, nutrients, vitamins, and minerals. Primary site of drug metabolism is the liver, though the kidney and intestinal tract also have high metabolic rates. The types of metabolic reactions are specific to the type of cell In most cases, metabolic reactions change the drug to make it easier to excrete from the body (eg. from lipid toKozier et al. 36 Pharmacokinetics: Metabolism If a patient has liver or kidney disease, they may not metabolize the medication adequately and the medication may reach toxic levels. You need to be aware of your patient’s medical history AND how medications are metabolized Pharmacokinetics: Excretion (Elimination of drugs) Drugs will continue to act on the body until they are either metabolized to an inactive form I’m importa or removed from the body by excretion. nt and The rate of excretion determines its so are you! concentration in the blood and its duration of action. Pathological states, especially liver or kidney disease, often increase the duration and intensity of drug action in the body because they interfere with excretion Drugs are excreted via the kidneys, liver, lungs, and glandular secretions (eg. saliva or Kozier et al.  Pharmacokinetics: Excretion (Elimination of drugs) Drugs will continue to act on the body until they are either metabolized to an inactive form I’m or removed from the body by excretion. importa The rate of excretion determines its nt and so are concentration in the blood and its duration of you! action. Pathological states, especially liver or kidney disease, often increase the duration and intensity of drug action in the body because they interfere with excretion Drugs are excreted via the kidneys, liver, lungs, and glandular secretions (eg. saliva or Kozier et al. Let’s talk about time… The GOAL is to achieve consistent levels of drug in the body 4 0 Terms you need to know Describe the reactions of the body to the drug = the drug’s effects  Onset = time required for the drug to elicit a therapeutic response  Peak = time required for a drug to reach its maximum therapeutic response  Duration of action = the length of time that the drug concentration is sufficient (without more doses) for the drug to elicit a therapeutic response  Half-life= time it takes for ½ of a given amount of medication in the body to be removed. Concentration in the blood:  Peak level= highest blood level of drug (strongest effect of med)  Trough level = lowest blood level of drug (lowest effect) 4  poisono Kozier et al. Minimum effective concentration 1 Half-Life https://www.youtube.com/watch?v=X5XoRK8j87o Time it takes for ½ of a given amount of medication in the body to be removed Measures rate at which drug is eliminated from the body Used to determine the steady state (when the drug eliminated is equal to the drug absorbed per dose) GOAL: Achieve a consistent levels of drug in the body Kozier et al. Lingo: Adverse Drug Effects & Although Side Effects every drug has the potential to produce adverse events, most pharmacotherapy can be conducted without significant undesirable effects. Adverse drug effects: undesirable, unfavorable, unintended and potentially harmful reaction caused by the administration of a medication. Side effects: are types of drug effects that are predictable, secondary to the intended purpose and may occur even at therapeutic doses. What’s the difference? Severity, predictability, and potential harm 4 3 Patient Safety with Medication Administration  Abbreviations: PO Per oral (by mouth)  Know accepted ones NPO Nothing by mouth (nil per os)  Beware of “dangerous” ones OD Once daily (not acceptable but still used) (see p. 803) BID Twice daily  Types of Orders: TID Three times a day  STAT (immediate) QID Four times a day  Single order (one time dose) HS Before bed  Standing order: may or may Q2H Every 2 hours … not have a termination date. …  PRN: permits nurse to give medication STAT Immediately when needed (in nurse’s judgement) PRN When needed  Protocol order: set of criteria AC Before meals (ante cibum) or orders under which PC After meals (post cibum) medication is to be given (re: insulin) Kozier et al.  What you must know before administering a Med WHAT YOU NEED TO KNOW!! Name of medication Generic and Brand Name Know Purpose for taking the medication Indication Drug Action Action Intended effect Therapeutic effect your Pharmacokinetics ADME patient Is there a reason they should not take the medication? Contraindications, allergies not just What should I watch out for? Adverse Reactions/Side Effects the How and how much do I give? Route? Dose? Safe Dose? medicat When will it start working? Peak? How long will it last? Onset, Peak, Duration ion Kozier et al Is there anything I need to monitor? Assess for? Nursing Implications 2018 Evaluate? 45  Who is our 6 patient? 6 What is the med? Kozier et al. 46 (2018) Davis Drug Guide https://ebookcentral-proquest- com.ezproxy.lib.ucalgary.ca/lib/uc algary- ebooks/detail.action?docID=640 1990 Free access to Ucalgary Students Kozier et al. 47 Acetaminophen What is Acetaminophen? Common over the counter medication What is the generic name & brand name? Think about the organ that detoxifies Acetaminophen Too much of this medication can cause irreversible damage to this organ What is the maximum amount of acetaminophen that can be taken in 24 hours? Why? Kozier et al. 48 Kozier et al. 49 Kozier et al. 50 Why do you think medication errors happen? How can we prevent medication errors? Kozier et al. 51 Three checks 1. Compare the medication label to the MAR as you remove the drug from the storage area 2. Compare the medication label to the Mar as you prepare each drug 3. Compare the medication label to the MAR at the patient beside before administering each drug Kozier et al. 52 What are the Ten Rights of Medication Administration? Right patient/client Right medication Right dose Right time Right route Right client education Right documentation  Ten Rights Video https://youtu.be/XDudRuOJNhs Review The names of the 10 Rights are a little different than what is listed in the textbook (so I include both) but the explanations Textbook are solid, and I want to introduce and Lecture you to Tammy (who spoke at the Video military panel) Right Patient Right Patient Right Medication Right Medication/Drug Right Reason Right Reason Right Dose Right Dose Right Time Right Frequency/Right Time (I would put these two together and she separates them) Right Route Right Route Right Client Education She mentions client education under the right to refuse Right Documentation Right Documentation Right to Refuse Right to Refuse 54 Kozier et al. Right Evaluation Right Follow Up (same thing, different wording)  A hospitalized patient has had difficulty sleeping for the past two nights due to post-surgical incisional pain. The nurse brings the patient’s pain medication to the room and provides patient teaching about the medication. The patient does not think he needs the medication because he is afraid he will become addicted. This is an example of which right of medication administration? A. Right client B. Right education C. Right evaluation D. Right to refuse 5 Kozier et al. 5 Discuss Pharmacolo gy and Community Context: Self-Medication with OTC drugs, Herbals, Vitamins, Minerals and Laxatives Things to consider It’s important that we build trust relationship with clients so that they will share what OTC medications, herbal remedies, and substances they are using. (eg. drug to drug interactions) Use resources such as the Natural and Non- prescription Health Products Directorate (NNHPD) to find up to date information such as: Vitamins and minerals Herbal remedies Homeopathic medicines Traditional medicines such as traditional Chinese medicines 5 7 Consider... THIS SOUNDS LIKE THE FACTORS INFLUENCING SEDOHS!! 1. Income and Social Status DRUG ACTION 2. Social Support Networks 3. Social Environments 4. Education 5. Working Conditions 6. Physical Environments 7. Biology and Genetics 8. Personal Health Practices and Coping Skills 9. Healthy Childhood Development 10. Health Services 11. Culture 12. Gender Sato T. (2018) Pharmacokinetics, Pharmacodynamics, and Toxicities: What Should We Know About Genetic Factors that Affect the Pharmacotherapy of Pulmonary Diseases?. In: Kaneko T. (eds) Clinical Relevance of Genetic Factors in Pulmonary Diseases. Respiratory Disease Series: Diagnostic Tools and Disease Managements. Springer, Singapore. https://doi.org/10.1007/978-981-10- Social Determinants of Health on Medication Adherence Food Insecuíity & Housing instability is associated with pooíeí medication adheíence. Patient education is impoítant but if SeDofH aíe not consideíed we may be missing ways that we could help patients to safely take theií medications. An inteíesting systematic íeview on this topic: Wildeí ME, Kulie P, Jensen C, Levett P, Blanchaíd J, Dominguez LW, Poítela M, Síivastava A, Li Y, McCaíthy ML. ľhe Impact of Social Deteíminants of Health on Medication Adheíence: a Systematic Review and Meta-analysis. J Gen Inteín Med. 2021 May;36(5):1359-1370. doi: 10.1007/s11606-020- 06447-0. Epub 2021 Jan 29. PMID: 33515188; PMCID: PMC8131473. Kozier et al. 59 Lifespan Considerations Pregnancy: Awareness that certain medications are harmful to the fetus Infants and Children: Require smaller dosages due to smaller body size and immaturity of organs; may not tolerate certain medications Adolescents: May have adverse reactions to previously tolerated medications Adults: May develop new allergic reactions to previously tolerated medications Older Adults: Changes due to ageing can alter body’s tolerance and absorption of certain medications and ability to Kozier et al. 60 Infant and Children Population Increased susceptibility to drug reactions and toxicity Dosage calculations are required and are based on age, weight and body surface area (BSA) Kozier et al. 61 Adolescent and Adult Populations Awareness that chronic illnesses have potential to alter functioning of certain organs/systems that may influence individual’s reaction to certain medications Kozier et al. 62 Older Adult Population  65 years of age or older  Consume a larger proportion of all medications than do other population groups  Lower blood protein levels (metabolism)  Kidneys do not work as effectively (excretion)  Combination of prescription, Over-the- Counter (OTC) medications, Herbals, Vitamins  At risk for polypharmacy Kozier et al. 63 What is Polypharmacy? “Administration of more medications than clinically indicated, representing unnecessary drug use” “Prescribing cascade”– the development of adverse effects from one or more of the medications taken for which another drug is prescribed Individual takes prescription medications for disease conditions—usually comorbidities such as CHF, HTN, DM, HTN— requiring multiple medications Often also take Over-the-counter (OTC) medications, Herbals, Vitamins Occurs more frequently with older adult Kozier et al. 64 Adverse Drug Reaction-Related Hospitalizations Among Seniors In 2016, 0.7% of seniors were hospitalized for an ADR. This rate increased dramatically among seniors using more drugs. Seniors using >10 drugs made up 21.1% of the seniors population and accounted for 58.6% of ADR-related hospitalizations. Kozier et al. 65 6 6 Adverse Drug Reaction-Related Hospitalizations Among Seniors In 2016, 0.7% of Common Reasons for Hospitalization of Older seniors were Adults Related to Medications hospitalized for an ADR. Falls Cognitive impairment This rate increased Incontinence dramatically among Constipation seniors using more drugs. Delirium Seniors using >10 drugs made up Diarrhea 21.1% of the seniors population Gastrointestinal Bleeding and accounted for 58.6% of ADR-related hospitalizations. What is the CHN https://secure.cihi.ca/free_products/dr ug-use- Role in this among-seniors-2016-en-web.pdf OTC drugs, Herbals, Vitamins, Minerals and Laxatives No prescription needed--Self- medication Most commonly used OTCs: Analgesics, Laxatives, Nonsteroidal anti-inflammatory drugs (NSAIDs) Patient Education required Kozier et al. 67 OTCs... Over-the-counter medications (OTC) Most commonly used: Analgesics, Laxatives, Nonsteroidal anti- inflammatory drugs (NSAIDs), along with Herbals, Vitamins, Minerals Analgesics: “Pain medicines”  Response is individual—what works for one person may not work for another  Beware of side effects  Beware of similar products in different medications  Should not be used for extended length of time—have recommendations on packages  Acetaminophen—fever, headaches, common aches and pains  NSAIDs—pain and fever relief, reduce inflammation (swelling) from Kozier et al. 68 OTCs continued Laxatives: Relieve and prevent constipation Overuse can lead to bowel dependency and decreased function of bowels Can interfere with absorption of some medications and nutrients; electrolyte imbalance Encourage fiber-rich foods, fluids, exercise Natural is best! Kozier et al. 69 7 0 Communicable Diseases: Influenza--Vaccine preventable disease Communicable Diseases Illnesses caused by an infectious agent or its toxins resulting from direct or indirect transmission of the infectious agent or its products from an infected individual or via an animal, vector or the inanimate environment to a susceptible animal or human host. “Communicable diseases kill more than 14 million people each year mainly in the developing world” (Alley, 2020, p. 220)- these is pre-COVID-19 As of March 2nd, 2021, it is estimated that 22,045 deaths from COVID-19 Infections in Canada (PHAC, 2020) As of November 3, 2021, 29,056 deaths Factors key to controlling infection Understanding the infectious agents, the host and the environment (epidemiological triangle) Describe the different types of infectious agents Bacteria Viruses Fungi Parasites: Include protozoa and helminths Bacterial and viral infections can cause similar symptoms such as coughing and sneezing, fever, inflammation, vomiting, diarrhea, fatigue, and cramping -- all of which are ways the immune system tries to rid the body of infectious organisms Bacterial and viral infections are dissimilar in their structural and in the way they respond to medications  General Signs and Symptoms of Infection Fever Burning or pain with Chills and sweats urination; Increased urination Change in cough or a new Redness, soreness, or cough swelling in Sore throat any area, including Shortness of breath surgical wounds Nasal congestion Diarrhea Stiff neck Vomiting General Signs and symptoms are usually Newtheonset result of pain of the immune system’s response to the infectious Specific signsagent andand can be similar symptoms arefor dueviral toor bacterial infectious agent and system infected Vaccinati ons THE PHARMACOKINETICS OF VACCINES USING INFLUENZA AS AN EXAMPLE THE S IDE EFFECTS OF VACCINES USING INFLUENZA AS AN EXAMPLE What is A nursing intervention for vaccine preventable Vaccination? diseases One of the greatest contributions to global health apart from the introduction to clean water and sanitation (Greenwood, 2014) Goal to induce long-lasting immunity to specific pathogens without producing the illness The process of introducing foreign proteins or inactive cells (vaccines) into the body to trigger Greenwood, B. (2014).immune activation The contribution of vaccination 369(1645), of the Royal Society B, Transactions to global health: before Past, present, and the future. Philosophical Kozier et al. 1-9. Benefits of Vaccination Considered the most significant achievement in preventative medicine in North America Through vaccination, we have seen the incidence of select diseases drop by up to 100% Prevention of morbidity and mortality In those vaccinated In those around them (herd immunity) Benefit to health and savings in direct medical care costs Kozier et al. Herd Immunity Not immunized but still healthy Immunized and healthy Not immunized, sick and contagious  Immune System Innate/inborn/non-specific Acquired/adaptive/ defense specific defense mechanisms mechanism External Internal defense Active Passive defense Second Line of Immunity Immunity First Line of Defense Third Line of Third Line of Defense Defense HostDefense receives Physical 1. Phagocytes: Macrophages; Direct contact with antibodies Barriers Skin, 1. T Cells (cytotoxic T Antigen mucous, nasal WBCs cells, helper T cells, produced by hair, cilia (neutrophils & suppressor T cells, another source, Chemical monocytes) and memory T Cells either natural 2. Inflammatory 2. B Cells (plasma (eg. breastmilk) barriers cells & memory B reactions or artificial (eg. Oil and sweat, Cells) 3. Fever stomach acid, 3. Antigen presenting immune serum 4. Interferons cerumen (ear 5. Complement cells: Macrophages, or antivenin) wax) and B Cells and system Dendritic cells tissue fluids 6. Natural killer (e.g. vaginal) cells Active versus Passive Immunity Active Immunity: Administration of antigen to the host to induce formation of antibodies and cell-mediated immunity Natural—the formation of antibodies in response to the antigen of an infection Artificial—the formation of antibodies is stimulated by the introduction of the antigen through vaccination Passive Immunity: Administration of antibodies against a specific antigen following host exposure to the antigen Natural—transmission of antibodies from mother to infant through placenta and colostrum Artificial—injection of immune globulins such as tetanus immune globulin, snakebite Why do we have to get a flu shot every year? Small changes in influenza viruses occur continually New virus strains may not be recognized by the body's existing influenza antibodies within the immune system A person infected with a specific influenza virus strain develops antibodies against that specific strain In most years, some or all of the virus strains in the influenza vaccine are updated to align with the against changesinfection from these in the circulating changing influenza viruses Kozier et al. 8 0 How Serious is the Flu? While the majority of those who become ill will recover, it is estimated that influenza causes about 12,200 hospitalizations and 3,500 deaths in Canada each year. Influenza is among the top ten leading causes of death in Canada. Some individuals are at higher risk of developing complications from influenza, including: - Seniors - Infants and young children - Adults and children with existing chronic health conditions - Healthy pregnant women - Indigenous peoples 8 https://myhealth.alberta.ca/Alberta/Pages/influenza- Kozier et al. 1 How Serious is the Flu? The Centers for Disease Control and Prevention (US) conducted a study to assess the effectiveness of influenza vaccine in decreasing influenza related deaths in children (6 months to 17 years of age) Between July 2010 and June 2014, 358 children died from infection with influenza; researchers were able to confirm the vaccine status of 291 of these children: Of the 291 children, 74% were unimmunized The study concluded that influenza vaccination was associated with reduced risk of laboratory-confirmed influenza-associated pediatric death Increasing influenza vaccination could prevent influenza- associated deaths Kozier et al. 82 Influenza Incubation Individuals with influenza are infectious 1 day before symptoms develop and up to 5 days after becoming ill - The period when an infected person is contagious depends on the age and health of the person - Young children and people with weakened immune systems may be contagious for longer than a week The time period from exposure to development of symptoms is about 1 to 3 days, with an average of about 2 days Kozier et al. 83 Influenza Infectivity People infected with influenza can spread the disease to others before they know they are ill, and while they are ill Some people can be infected but have no symptoms These individuals can still spread the virus to others This is important information for those caring for others, such as parents and all health care workers In one published study, 59% of health care Kozier et al. 84 Influenza Vaccine Development Each February, the World Health Organization (WHO) provides a recommendation on the strains to be included in the influenza vaccine for the northern hemisphere Two influenza "A" viruses and one (trivalent vaccine) or two (quadrivalent vaccine) influenza "B" virus are selected based on the characteristics of the current circulating influenza virus strains A new vaccine is reformulated each year to protect against new influenza infections Each vaccine lot is tested on healthy individualsKozier et al. 85 Influenza Vaccine There are currently five trivalent inactivated influenza vaccines (TIV) licensed for use in Canada; one of these is adjuvanted and one is high dose There are currently four quadrivalent influenza vaccines licensed for use in Canada - Three are quadrivalent inactivated influenza vaccine (QIV) - One is a live attenuated influenza vaccine (QLAIV) Kozier et al. 86 How Does An Inactivated Influenza Vaccine Work? Both humoral and cell-mediated responses play a role in immunity Administration of inactivated influenza vaccine results in the production of circulating IgG antibodies to the viral haemagglutinin as well as a cytotoxic T lymphocyte response Humoral antibody levels, which correlate with vaccine protection, are generally achieved 2 weeks after immunization and immunity usually lasts less than 1 year - Initial antibody response may be lower in the elderly and the immune- compromised Kozier et al. 87 Effectiveness of Influenza Vaccine Vaccine effectiveness depends on the similarity between vaccine strains and the strains in circulation during influenza season, as well as individual factors - Influenza immunization prevents disease in 52-82% of healthy individuals -In the elderly vaccine effectiveness is about half of that of healthy adults; however influenza immunization decreases the incidence of pneumonia, hospital admission and death in the elderly, and reduces exacerbations in persons with chronic obstructive pulmonary disease Vaccine efficacy of 50% or lower in healthy adults has been identified during select seasons Kozier et al. 88 Reactions to Inactivated Influenza Vaccine The majority of people do not have a reaction to TIV/QIV; however, some reactions that may occur are outlined below. These reactions generally start 6 to 12 hours after immunization and can last for 1 to 2 days. Common Reactions Injection site pain, tenderness, redness, swelling Irritability, abnormal crying, malaise, fatigue, anorexia, myalgia, headache, fever, dizziness, gastrointestinal symptoms, arthralgia Uncommon Lymphadenopathy, dizziness, cough, rash, upper respiratory tract infection, injection site pruritis Kozier et al. 89 Reactions to Inactivated Influenza Vaccine Rare Reactions Immediate, allergic-type responses such as hives, angioedema, allergic asthma, systemic anaphylaxis Guillain-Barré Syndrome (GBS) (1 in million risk from vaccine while GBS risk is 17 per million from influenza) Oculorespiratory Syndrome (ORS) (bilateral red eyes 1+ associated respiratory symptom) that starts within 24 hours of vaccination Kozier et al. 90 REVIEW: Client Teaching Disease and effectiveness of vaccine (Informed Consent) Screening (Fit to vaccinate) Side Effects of Vaccine and treatment (Informed Consent) Kozier et al. 91 For your own interest Is an inactivated (killed) vaccine – cannot cause influenza disease in the vaccine recipient The virus is grown in hens’ eggs, inactivated, broken apart and highly purified In addition to the antigen, the vaccine may contain: -Thimerosal (preservative in multi-dose vials) -Trace residual amounts of egg proteins, formaldehyde, kanamycin, neomycin, gentamicin, cetyltrimethylammonium bromide (CTAB), polysorbate 80, sodium deoxycholate and sucrose Check the product monograph as ingredients vary with specific inactivated influenza vaccines https://www.canada.ca/en/public- health/services/publications/healthy-living/canadian-immunization-guide-part-1-key- immunization-information/page-15-contents-immunizing-agents-available-use-canada.html Kozier et al. 93 For your own interest: Thimerosal Multi-dose vials of vaccine contain a preservative called thimerosal (ethylmercury) Ethylmercury is not the same compound as methylmercury - Methylmercury is a known neurotoxin in high concentrations or with prolonged exposure (e.g., ingesting some types of fish) Ethylmercury is eliminated much more quickly and is less likely to reach toxic levels in the blood than methylmercury Studies have found there is no association between immunization with thimerosal- containing vaccines and neurodevelopmental outcomes, including autistic-spectrum disorders Additional information regarding thimerosal is available at http://www.phac- aspc.gc.ca/publicat/ccdr-rmtc/07vol33/acs- 06/index-eng.php Kozier et al. 94 References Alley, S. (2020) Communicable diseases. In Stamler et al. Textbook Centers for Disease Control and Prevention. (2015). Epidemiology and prevention of vaccine- preventable diseases: The pink book. Retrieved from http://www.cdc.gov/vaccines/pubs/pinkbook/index.html Kozier, B., Erb, G., Berman, A., Snyder, S.J., Frandsen, G., Buck, M., Ferguson, L., Yiu, L., & Stamler, L. (2018). Fundamentals of Canadian nursing: Concepts, process, and practice (4th ed.). Toronto, ON, Canada: Prentice Hall Health. Lilley L, Harrington S, & Snyder JS. (2011). Pharmacology for Canadian Health Care Practice. (2nd ed.). Toronto, ON: Evolve, Mosby. Public Health Agency of Canada. (2015). Vaccine-preventable diseases. Retrieved from http://www.phac- aspc.gc.ca/im/vpd-mev/index-eng.php Images Retrieved from https://www.google.ca/search Kozier et al. 92