Immunization Competencies for Health Professionals

The following members of the Professional Education Working Group contributed to the development of the Immunization Competencies for Health Professionals:

Ms. Mary Appleton Canadian Coalition for Immunization Awareness and Promotion Ms. Lyne Cantin Public Health Agency of Canada Ms. Gina Dumaresq Health Canada Dr. Bernard Duval Institut national de la santé publique du Québec Ms. Céline Farley Institut national de la santé publique du Québec Dr. Ian Gemmill Kingston, Frontenac, and Lennox and Addington Health Unit Dr. Danielle Grenier Canadian Paediatric Society Ms. Pat Griffin Canadian Association of Schools of Nursing Ms. Beth Halperin Dalhousie University Ms. Alexandra Henteleff Manitoba Health Ms. Joan Johnston Canadian Nurses Association Dr. Barbara Law Public Health Agency of Canada Ms. Joy Loewen Capital Health - Edmonton Area Dr. Fawziah Marra Canadian Pharmacist Association Ms. Suzanne Mayotte Public Health Agency of Canada Dr. Carol McConnery College of Family Physicians of Canada Dr. Shelly McNeil Capital Health - Nova Scotia Ms. Jackie Millette Canadian Paediatric Society Ms. Louise Pagé Public Health Agency of Canada Mr. Jim Parker University of Manitoba Dr. Geneviéve Petit Direction de santé publique et de l'évaluation de l'Estrie Ms. Karen Pielak BC Centre for Disease Control Ms. Susan Ross Health Canada Ms. Bonnie Rushowick Health Canada - Saskatchewan Region Ms. Lynette Leeseberg Stamler Canadian Association of Schools of Nursing Dr. Ruta Valaitis Canadian Association of Schools of Nursing

As a starting point for Immunization Competencies for Health Professionals, the working group used a document prepared by the U.K. Health Protection Agency entitled Core Curriculum for Immunisation Training and adapted it to the Canadian context.

The levels of proficiency (aware, knowledgeable, or proficient) used to develop the Immunization Competencies Levelling Tool was adapted from a document prepared by the Northwest Center for Public Health Practice, University of Washington School of Public Health and Community Medicine entitled Informatics Competencies for Public Health Professionals.

Preamble

The competencies contained in the handbook Immunization Competencies for Health Professionals were developed to support the application of the National Guidelines for Immunization Practices, published in the Canadian Immunization Guide. The aim of this handbook is to promote safe and competent practices to achieve higher vaccine coverage rates. This effort will enable and maintain the highest possible degree of community protection against vaccine-preventable diseases.

The competencies range from knowledge of the scientific basis of immunization to essential immunization practices and contextual issues relevant to immunization. Each competency is supported by a learning domain and a number of guiding learning objectives.

This handbook does not dictate how to teach or assess health professionals. Instead, it lays out the essential topics for effective immunization that are universal to a wide range of health professionals. These can be adapted and incorporated into all immunization training or performance evaluations. As such, the immunization competencies provide the framework stakeholders can use to tailor education programs to the needs of health professionals based on their level of experience, practice setting, and degree of involvement with immunization.

The competencies can be used by:

Professional education is one of the initiatives undertaken by the Public Health Agency of Canada (PHAC) to support the National Immunization Strategy, launched in 2003. In 2005, PHAC formed the Professional Education Working Group (PEWG) with members representing front-line health professionals, immunization program planners, professional societies, and academics from across Canada. PEWG is a sub-group of the Canadian Immunization Committee, a federal, provincial, and territorial group of public health officials providing leadership, advice, and recommendations to PHAC on implementing the strategy and on issues affecting immunization in Canada.

PEWG is responsible for making recommendations regarding professional development strategies and learning opportunities for health professionals in the field of immunization. The Immunization Competencies were developed in consultation with immunization program planners from federal, provincial, and territorial jurisdictions; expert advisory committees on immunization; health professional educators; licensing bodies and professional societies; health education accreditors; vaccine regulators; and vaccine manufacturers (Appendix A).

As part of its supporting role, PHAC is involved in the development of learning opportunities and resources that can help health professionals achieve and maintain the immunization competencies. PHAC encourages provincial and territorial jurisdictions, educational institutions, health professional organizations, and other stakeholders to use and incorporate the Immunization Competencies into their respective activities. The desired result is an expanded and diverse set of immunization education resources to support a similarly diverse set of health professionals.

Appendix C includes a levelling tool to assist in identifying levels of proficiency based on the specific responsibilities and performance requirements of a given set of health professionals in a given work setting.

The Canadian Context

Vaccine Approval - Health Canada Biologics and Genetic Therapies Directorate

All vaccines authorized for sale in Canada are reviewed and approved by the Biologics and Genetic Therapies Directorate (BGTD) of Health Canada. Like all medicines, vaccines must undergo rigorous review and testing before they are approved for use. Health Canada also supervises all aspects of vaccine production by the manufacturers to ensure safety, sterility, and quality.

Before a new vaccine can be submitted to Health Canada for approval, its manufacturer must collect sufficient scientific evidence from pre-clinical and clinical human trials (typically carried out over several years) that show the vaccine is safe, effective, and of high quality and that it produces the desired immune response. The manufacturer must then include this evidence along with information on how the vaccine was developed and manufactured, as well as how it will be routinely tested, in a New Drug Submission filed with the BGTD .

As part of the process for approving vaccines, members of the BGTD perform on-site inspections and evaluations of the vaccine manufacturer's establishment(s) to assess the quality of the production process and ensure that the necessary quality controls and internationally recognized Good Manufacturing Practices are being used. The manufacturer must also provide at least three sample batches or "lots" of the vaccine to the BGTD for testing in its laboratories. The BGTD approves a vaccine only when its safety, effectiveness, and quality have been thoroughly proved and when the benefits of the vaccine greatly outweigh any risks associated with it. If the above requirements have been satisfied after thorough review of the New Drug Submission, the on-site evaluation(s), and the independent laboratory testing of samples, the vaccine is issued a Drug Identification Number and a Notice of Compliance indicating that it is approved for sale in Canada.

All vaccines sold in Canada undergo ongoing lot release evaluation even after they have been approved. The manufacturer must submit the results of testing for each lot of vaccine to be sold in Canada and lot samples for independent evaluation by the BGTD . In order to sell new lots of the vaccine, manufacturers must ensure that each new lot is the same in its specific characteristics as the ones tested before authorization was given. This method allows experts to reasonably determine that the new lots are as safe and effective as previous ones. If a vaccine lot meets all required specifications, a formal release letter is issued to approve the sale of that lot in Canada.

Optimal Use - The National Advisory Committee on Immunization

The National Advisory Committee on Immunization (NACI) is an independent committee of recognized experts (in the fields of paediatrics, infectious diseases, immunology, medical microbiology, internal medicine, and public health) that provides expert advice on vaccines to PHAC . After Health Canada authorizes a vaccine for sale in Canada, the NACI evaluates all available scientific information about that vaccine and then makes recommendations about its optimal use. For information on the list of immunizing agents and the companies that have received approval to market them in Canada, consult the Canadian Immunization Guide.

Immunization Programs - The Provinces and Territories

In Canada, provinces and territories are responsible for the development of publicly funded immunization programs, including the purchase of vaccines. Each provincial or territorial ministry of Health uses NACI 's recommendations to develop its program and schedules for children and adults. While the provinces and territories decide which vaccines to purchase, most of the vaccines used in publicly funded immunization programs in Canada are purchased through a bulk purchasing program coordinated by Public Works and Government Services Canada. In some cases, provinces may purchase vaccines on their own behalf. All vaccine purchases must follow a process that is open, fair, and transparent and must respect Canada's obligations under applicable national and international trade agreements. The vaccine procurement process is intended to ensure that equal consideration is given to all eligible vaccines that have met the stringent requirements for approval in Canada.

Post-Marketing Surveillance - Public Health Agency of Canada

After any vaccine is approved to be sold in Canada, mandatory and voluntary post-market surveillance and adverse event reporting occur. Vaccine manufacturers are required by law to report serious adverse events following immunization within 15 days of notification of the occurrence. Public health nurses, doctors, and other healthcare workers in Canada also report these events to the Centre for Immunization and Respiratory Infectious Diseases (CIRID) at PHAC . After removal of any identifying personal information, such events reported at the provincial or territorial level are then referred to the Canadian Adverse Events Following Immunization Surveillance System. Selected serious events, particularly those affecting children, are also reported by the Immunization Monitoring Program - Active (IMPACT). IMPACT is administered by the Canadian Paediatric Society with funding from the Centre for Immunization and Respiratory Infectious Diseases of the Public Health Agency of Canada.

The goal of this national vaccine safety surveillance is to monitor all vaccines used in Canada and to detect, as quickly as possible, any evidence of concern regarding safety. If unexpected or increased side effects due to vaccines occur, the BGTD and CIRID decide on the best course of action needed to resolve these situations.

Effective, Competent Practice - The National Immunization Strategy

The development of the National Immunization Strategy (NIS) was first endorsed by the federal/provincial/territorial deputy ministers of Health in June 1999, under the direction of the Advisory Committee on Population Health. In 2002, the deputy ministers agreed in principle to the concept of a strategy and endorsed the National Immunization Strategy: Final Report in June 2003.

The NIS stipulates the need for continued collaboration and partnerships with federal, provincial, and territorial partners and other stakeholders to improve the effectiveness and efficiency of immunization programs in Canada. In addition, a key activity of the NIS is the development of a national professional education component to support the achievements and maintenance of a safe and competent practice to better protect Canadians from vaccine-preventable diseases.

Application of Basic Biomedical Sciences to Immunization

1. The Immune System and Vaccines

Competency: Explains how vaccines work using basic knowledge of immune system.

Learning Objectives

The health professional will be able to perform the following:

  1. Compare and contrast innate and adaptive immunity.
  2. Differentiate between the primary and memory immune response to a vaccine.
  3. Differentiate between passive and active immunity.
  4. Explain why some vaccines induce a memory response while others do not.
  5. Name some host- and vaccine-related factors that affect the immune response to vaccines.
  6. Explain how the immunization schedule accommodates factors that affect the immune response to vaccines.
  7. Respond to the concern that giving too many vaccines will overload the immune system.
  8. Discuss the pros and cons of immunity gained through immunization as opposed to wild-type infection.

Key Terms: Active immunity, antibody, antigen, B-lymphocyte (B-cell), booster, cell-mediated immunity (CMI), herd/community immunity, humoral immunity, memory response, passive immunity, primary immune response, protective level, T-lymphocyte (T-cell).

Suggested Content for Training

2. Vaccine-Preventable Diseases

Competency: Demonstrates an understanding of the rationale and benefit of immunization, as relevant to the practice setting.

Learning Objectives

The health professional will be able to perform the following:

  1. Describe the key clinical features, including acute and long-term complications, of each vaccine-preventable disease.
  2. Describe the key epidemiologic features of each vaccine-preventable disease.
  3. Describe the historical impact of immunization on the epidemiology of vaccine-preventable disease.
  4. For each of the vaccines administered in the practice setting, formulate a response to the question "Why should I be immunized when vaccine-preventable diseases are so rare in Canada?"
  5. Explain why accurate diagnosis of vaccine-preventable diseases is important.

Key Terms: Carriage, clinical features, communicability, complications, contagiousness, endemic, epidemic, epidemiology, incubation period, imported, natural infection, pandemic, reservoir, serotypes, serogroups, transmissibility, vaccine-preventable disease.

Suggested Content for Training

3. Vaccine Development and Evaluation

Competency: Integrates into practice knowledge about the main steps in vaccine development and evaluation.

Learning Objectives

The health professional will be able to perform the following:

  1. Describe, in general terms, the process to obtain marketing approval for vaccines in Canada.
  2. Describe what can be learned about vaccines after they are approved for marketing, via surveillance activities and more formal post-marketing studies.
  3. Characterize, in broad terms, the key roles and responsibilities for each of the following relative to the post-marketing assessment of vaccine safety and effectiveness:

Key Terms: Effectiveness, efficacy, immunogenicity, package insert, post-marketing, product monograph, reactogenicity, surveillance.

Suggested Content for Training

4. The Types of Immunizing Agents and Their Composition

Competency: Applies the knowledge of the components and properties of immunizing agents as needed for safe and effective practice.

Learning Objectives

The health professional will be able to perform the following:

  1. Classify each immunizing agent used in practice as live attenuated, inactivated, or subunit.
  2. Demonstrate the ability to describe live attenuated, inactivated, and subunit immunizing agents to an audience with minimal or no science knowledge.
  3. Compare the major advantages and disadvantages of live attenuated versus inactivated/subunit immunizing agents.
  4. Identify key differences in the immune response to purified polysaccharide versus polysaccharide protein conjugate vaccines.
  5. Describe, in general terms, the purpose, action and potential concerns of each of the following components that may be present in a given vaccine product: adjuvant, preservative, additives, glass vial, stopper, and pre-filled syringe.
  6. Locate and utilize current information resources on the types and content of immunizing agents used in practice.

Key Terms: Active immunizing agent, additive, adjuvant, allergens, combination vaccine, inactivated vaccine, live attenuated vaccine, passive immunizing agent, polysaccharide, preservative, protein conjugate, purified protein, subunit vaccine, toxoid.

Suggested Content for Training

5. Population Health

Competency: Applies relevant principles of population health for improving immunization coverage rates.

Learning Objectives

The health professional will be able to perform the following:

  1. Use specific examples to show how immunization is a population-based health strategy.
  2. Explain the concept of herd immunity (also called community immunity) in non-scientific terms.
  3. Explain, using examples, why vaccine-preventable diseases return when immunization coverage rates decrease.
  4. Explain how immunization registries can benefit not only individuals but also populations.
  5. Present the case for the importance of having a highly immunized healthcare workforce.
  6. Use health promotion planning model to identify barriers (economic, educational, system-based, and social factors) to immunization uptake.
  7. Use health promotion strategies to improve immunization coverage rates.

Key Terms: Active immunizing agent, additive, adjuvant, allergens, combination vaccine, inactivated vaccine, live attenuated vaccine, passive immunizing agent, polysaccharide, preservative, protein conjugate, purified protein, subunit vaccine, toxoid.

Suggested Content for Training

Essential Immunization Practices

6. Communication

Competency: Communicates effectively about immunization, as relevant to the practice setting(s).

Learning Objectives

The health professional will be able to perform the following:

  1. List the components of the evidence-based decision-making process.
  2. Explain the importance of risk perception for immunization decision making.
  3. Respond appropriately following an assessment of client knowledge, attitudes, and beliefs regarding immunization.
  4. Deliver clear, concise messages about the risks of vaccine-preventable diseases and the benefits and risks of vaccines.
  5. Provide appropriate evidence-based information and resources to clients regarding immunization and vaccines.
  6. Provide guidance to clients so they can correctly identify credible sources of information on immunization and vaccines.
  7. Apply, as appropriate to the practice setting, mass media strategies for public communication.

Key Terms: Credible sources, evidence-based decision making, informed decision making, risk communication, risk perception.

Suggested Content for Training

7. Storage and Handling of Immunization Agents

Competency: Implements Canadian guidelines when storing, handling, or transporting vaccines.

Learning Objectives

The health professional will be able to perform the following:

  1. State where to access the most recent national guidelines dealing with vaccine storage, handling, and transportation.
  2. Describe the national guideline requirements for vaccine storage, handling, and transportation and their importance in maximizing the potency and efficacy of each vaccine.
  3. Outline the key steps for maintaining the cold chain in the practice setting.
  4. Explain actions taken to report and manage breaks in the cold chain or other insults that compromise vaccine integrity.

Key Terms: Min-Max thermometers, National Vaccine Storage and Handling Guidelines for Immunization Providers, potency, efficacy, cold chain, stock rotation.

Suggested Content for Training

8. Administration of Immunizing Agents

Competency: Prepares and administers immunization agents correctly.

Learning Objectives

The health professional will be able to perform the following:

  1. Prepare a checklist for pre-immunization patient assessment, including precautions, contraindications, and indications for rescheduling.
  2. Ensure the seven "Rights" of immunization: right drug, right client, right dose, right time, right route, right reason, and right documentation.
  3. Demonstrate the steps involved in vaccine preparation, including reconstitution, if appropriate, administration, and disposal.
  4. Name the resources that are used to guide the immunization administration process and decision making.
  5. Develop a table listing the vaccine, age, dose, route, site, contraindications/precautions, and side effects for each vaccine used in the practice setting.
  6. Demonstrate the age-appropriate injection sites and proper client positioning used for immunization.
  7. Choose the correct needle length and gauge for the age and size of the client.
  8. Describe actions taken to increase safety in immunization clinics related to the provider, the recipient, and the environment.
  9. Demonstrate the appropriate technique for immunization.
  10. Describe techniques to reduce the pain associated with immunization.

Key Terms: Aseptic technique, Canadian Immunization Guide (CIG), contraindications, expired stock, expiry date, immunization schedules (delayed, interrupted, etc.), injection error, injection site, medication error, minimum vaccine intervals, needle length and gauge, needle stick injury, precautions, reconstitution, rotation of stock, route of administration (intramuscular, subcutaneous, intradermal, intranasal, oral), routine practices, safety-engineered injection devices.

Suggested Content for Training

9. Adverse Events Following Immunization

Competency: Anticipates, identifies, and manages adverse events following immunization, as appropriate to the practice setting.

Learning Objectives

The health professional will be able to perform the following:

  1. Use reliable, evidence-based resources to list the frequencies of the common, uncommon, and rare adverse events associated with vaccines.
  2. Inform recipients and/or their caregivers on what to expect and what to do regarding adverse events that could follow immunizations.
  3. Draft in detail an effective step-by-step response to anaphylaxis.
  4. Document all adverse events following immunization on the appropriate form and submit it to the appropriate agencies.
  5. Distinguish between reporting an adverse event following immunization and proving that immunization caused an adverse event.

Key Terms: Abscess, active surveillance, adverse event following immunization, adverse vaccine reaction, anaphylaxis, anxiety attack, causality, cellulitis, encephalitis, encephalopathy, Guillain-Barré syndrome, hypotonic hyporesponsive episode, induration, injection site reaction, local reaction, nodule at injection site, oculorespiratory syndrome, passive surveillance, serious adverse events, syndromic surveillance.

Suggested Content for Training

10. Documentation

Competency: Documents information relevant to each immunization encounter in accordance with national guidelines for immunization practices and jurisdictional health information processes.

Learning Objectives

The health professional will be able to perform the following:

  1. Describe the role and importance of immunization records.
  2. Identify the information to be documented on an immunization record.
  3. Record an immunization encounter on the appropriate documentation instruments accurately and completely.
  4. Facilitate the transfer of information in the vaccination record to other providers and to appropriate agencies in accordance with requirements.
  5. Record the reason and planned follow-up action when a scheduled immunization is not given.

Key Terms: Bar coding, immunization coverage, immunization record professional chart, immunization record take-home, immunization registry, lot number.

Suggested Content for Training

11. Populations Requiring Special Considerations

Competency: Recognizes and responds to the unique immunization needs of certain population groups.

Learning Objectives

The health professional will be able to perform the following:

  1. Describe the unique immunization needs of certain populations, as relevant to the practice setting, including
  2. Appropriately refer to expert professionals/resources when required to address the immunization needs of certain populations.

Key Terms: International students, medical conditions and pregnancy, new Canadians, occupational risk groups, risk behaviours, special populations, "hard-to-reach" individuals/populations/groups, travellers.

Suggested Content for Training

Contextual Issues Relevant to Immunization

12. The Canadian Immunization System

Competency: Demonstrates an understanding of the immunization system in Canada and its impact on his/her own practice.

Learning Objectives

The health professional will be able to perform the following:

  1. Describe how the National Immunization Strategy (NIS) is relevant to practice.
  2. Distinguish between federal and provincial/territorial responsibilities as related to immunization programs in Canada.
  3. List who can administer immunizations in Canada.
  4. Describe the current status of immunization registries in the province or territory where practice is based.
  5. Describe the process required to introduce a new publicly funded vaccine in a province or territory.
  6. Explain the reasons for the variable immunization schedules among the provinces and territories.
  7. Locate the current immunization schedule for the province or territory of practice.
  8. Identify laws and regulations that may affect immunization delivery programs in provinces and territories.

Key Terms: Canadian Immunization Guide (CIG), immunization schedule.

Suggested Content for Training

13. Immunization Issues

Competency: Addresses immunization issues using an evidence-based approach.

Learning Objectives

The health professional will be able to perform the following:

  1. Describe factors which lead to scepticism regarding immunization for both health professionals and the general public.
  2. Describe the impact that misperceptions regarding immunizing agents have on immunization programs and on the population.
  3. Address misperceptions regarding immunizing agents using an evidence-based approach.
  4. Locate evidence-based sources of information on current issues relating to immunization.
  5. Use evidence-based scientific knowledge to develop clear, concise key messages regarding true immunization benefits and risks.

Key Terms: Canadian Immunization Guide (CIG), immunization schedule.

Suggested Content for Training

14. Legal and Ethical Aspects of Immunization

Competency: Acts in accordance with legal and high ethical standards in all aspects of immunization practice

Learning Objectives

The health professional will be able to perform the following:

  1. Discuss the implications of basic ethical principles, including individual's right, confidentiality, privacy, informed consent, and informed refusal.
  2. Describe the legal requirements relevant to immunization administration, documentation, recording, and reporting.
  3. Describe the legal requirements in the province/territory of immunization practice that relate to immunization status and exclusion from daycare, school, workplace, or other settings.
  4. Identify his/her own professional scope of practice as it relates to immunization (jurisdiction, organization, practice setting - institutions, etc.).
  5. Discuss the ethical issues arising from:
  6. Discuss the responsibility of health professionals to inform patients regarding the availability of all recommended vaccines regardless of whether they are publicly funded or not.
  7. Describe the ethical implications when a provider's beliefs conflict with evidence-based recommendations for immunization.

Key Terms: Assent, benefit, conflict of interest (real and perceived), disclosure, harm, informed consent for immunization, informed consent for registry, mandatory immunization, prejudices, risks, medicolegal, targeted immunization, universal immunization, voluntary immunization.

Suggested Content for Training

List of Acronyms

AFMC Association of Faculties of Medicine of Canada AFPC Association of Faculties of Pharmacy of Canada BGTD Biologics and Genetic Therapies Directorate CAEFISS Canadian Adverse Events Following Immunization Surveillance System CAIRE Canadian Association for Immunization Research and Evaluation CASN Canadian Association of Schools of Nursing CIC Canadian Immunization Committee CIG Canadian Immunization Guide CMA Canadian Medical Association CNA Canadian Nurses Association CNCI Canadian Nursing Coalition for Immunization CPS Canadian Paediatric Society CPhA Canadian Pharmacists Association CPHA Canadian Public Health Association CIRID Centre for Immunization and Respiratory Infectious Diseases CFPC College of Family Physicians of Canada CIQ Comité sur l'immunisation du Québec CHNA Community Health Nurses of Alberta FNSSC Federation of National Specialty Societies of Canada FNIHB First Nations and Inuit Health Branch IMPACT Immunization Monitoring Program - Active MPhA Manitoba Pharmaceutical Association NACI National Advisory Committee on Immunization NIS National Immunization Strategy OPA Ontario Pharmacists' Association PEWG Professional Education Working Group PHAC Public Health Agency of Canada VIC Vaccine Industry Committee VON Victorian Order of Nurses

Resources

Canadian Online Resources

Canadian Organizations

Provincial and Territorial Immunization Manuals and Guidelines

Alberta

British Columbia

Manitoba

New Brunswick

Newfoundland and Labrador

Northwest Territories

Nova Scotia

Ontario

Prince Edward Island

Québec

Saskatchewan

Yukon

International Online Resources

Articles and Books

Appendix A: Organizations Consulted

Special thanks to the following organizations for providing feedback and comments during the consultation process that supported the development of Immunization Competencies for Health Professionals.

Round 1 Consultation

Round 2 Consultation

Appendix B: Table of Vaccine-Preventable Diseases

Microbial Agent Disease
Medical term Common Term
Bacteria
Bordetella pertussis pertussis whooping cough
Corynebacterium diphtheriae diphtheria
Clostridium tetani tetanus lockjaw
Streptococcus pneumoniae (multiple capsular serotypes) invasive pneumococcal disease pneumococcal meningitis pneumonia
meningitis
sepsis
blood poisoning
epiglottitis
Neisseria meningitidis (serotypes A, B, C, Y, W-135) invasive meningococcal disease, meningococcal meningitis, meningococcemia
Haemophilus influenzae (serotype B) hemophilus meningitis
Mycobacterium tuberculosis (disease agent)
Bacillus Calmette Guérin (vaccine agent)		 tuberculosis TB
Salmonella typhi-murium typhoid fever
Vibrio cholerae cholera
Viruses
poliovirus (types 1,2,3) poliomyelitis polio
Measles virus measles red measles
Mumps virus mumps
Rubella virus rubella, congenital rubella syndrome German measles
Influenza virus (groups A, B) influenza flu
Rotavirus gastroenteritis
Human papillomavirus cancer (cervical, vaginal or vulval), genital warts, condyloma, recurrent respiratory papillomatosis
Hepatitis A virus hepatitis A infectious hepatitis
Hepatitis B virus hepatitis B serum hepatitis
Varicella Zoster Virus varicella chickenpox
herpes zoster shingles, postherpetic neuralgia
Rabies virus rabies
Yellowfever virus yellow fever
Japanese encephalitis virus encephalitis
Variola virus (disease agent) Vaccinia virus (vaccine agent) smallpox

Appendix C: Immunization Competencies Levelling Tool

The Immunization Competencies Levelling Tool is intended to help assess various segments of the public health workforce in order to tailor training programs, practice standards, or performance assessment.

Because of the complexity of the health workforce and the settings in which immunization is provided, levels of proficiency should be adapted as appropriate to the specific performance requirements of a given set of professionals in a given work setting.

How to Use the Levelling Tool

Identify and define the specific segment of health professionals you will be assessing, and use the following scale to identify the level of proficiency for each learning objective:

1. The Immune System and Vaccines

2. Vaccine-Preventable Diseases

3. Vaccine Development and Evaluation

4. The Types of Immunizing Agents and Their Composition

5. Population Health

6. Communication

7. Storage and Handling of Immunization Agents

8. Administration of Immunizing Agents

9. Adverse Events Following Immunization

10. Documentation

11. Populations Requiring Special Considerations

12. The Canadian Immunization System

13. Immunization Issues

14. Legal and Ethical Aspects of Immunization

Appendix D: Glossary

Abscess A localized collection of pus caused by infection. Active immunity The production of antibodies against a specific disease by the immune system, acquired by either contracting the disease or through vaccination. Active immunizing agent Any substance or organism that provokes an immune response (produces immunity) when introduced into the body. Active surveillance An active case-finding based on a regular review of hospital admission records. Canada's pediatric active surveillance system for serious adverse events following immunization, vaccination failures, and selected infectious diseases is called Immunization Monitoring Program - Active (IMPACT). Adaptive immunity The body's second line of defense, which becomes active when innate immune defenses are overcome; it has three key features: specificity, memory and diversity; its mechanisms depend on the ability of the immune system to recognize "non-self" material, to respond to its presence and to dispose of it appropriately. Additive The substances added to vaccines to inactivate a virus or bacteria, stabilize the vaccine, or preserve the vaccine so that it remains potent over time. Examples of vaccine additives include albumin, aluminum hydroxide, and aluminum phosphate. Adjuvant A substance (i.e. aluminum salt) that is added during production to increase the body's immune response to a vaccine. The adjuvant slow the release of antigens, stimulate local inflammation that attracts immune cells to the site, and enlarge the physical size of the antigen for more efficient uptake by antigen processing cells. Adverse event following immunization (AEFI) An undesirable experience or any unexpected medical occurrence in a patient occurring after immunization. Although a temporal relationship exists, a causal relationship is not necessarily established with the treatment or vaccine. The AEFIs are classified as being rare, uncommon, common, or very common. See Serious adverse event. Adverse vaccine reaction Any unexpected or dangerous reaction or unwanted effect caused by the administration of a vaccine. The adverse reaction may occur suddenly, or develop over time. See Serious adverse event. Allergens An antigen causing an allergic or hypersensitive response. Allergens induce the formation of IgE antibodies, a class of antibodies involved in all types of allergic reactions. Anaphylaxis An immediate and severe allergic response. The cardinal features of anaphylaxis as outlined in the Canadian Immunization Guide (pp. 80-84, 7 th ed.) are: itchy urticarial rash in 90% of cases; angioedema (progressive painful swelling) of face and mouth; respiratory symptoms (sneeze, cough, wheeze, dyspnea, laboured breathing); hypotension (can progress to collapse and shock). Antibody A protein found in the blood that is produced in response to foreign substances, (i.e. bacteria or viruses invading the body). Antibodies protect the body from disease by binding to these organisms and destroying them. Antigen Any substance, usually a protein that is capable of inducing an adaptive immune response. Anxiety (or panic) attack A sudden, unexpected period of intense anxiety often accompanied by symptoms such as heart palpitations, dizziness, trouble breathing, and intense fear of dying. Aseptic technique A set of practices and procedures performed under sterile conditions in order to prevent the introduction of micro-organisms, such as fungi, bacteria, and viruses. Assent The agreement of a person to allow diagnosis or treatment when the client does not have the capacity or legal empowerment to give informed consent, such as a child or cognitively impaired adult. Bar coding A method for encoding data using narrow and wide bars and spaces that represent a number or alphanumeric character. Bar coding allows for fast and accurate electronic readability. Bar codes are printed or stamped on products, labels, or other media. Benefit The advantage or improvement in condition provided to an individual or a population. B-lymphocyte (B-cell) A class of lymphocyte so called because they originate and mature in the bone marrow before being released into the bloodstream. B-cells are involved primarily in antibody-mediated immunity and produce antibodies. Booster A second, third, or greater immunization with a specific vaccine that may be necessary to insure that the individual is protected against the infectious disease. Canadian Adverse Events Following Immunization Surveillance System (CAEFISS) The main function of this system is to ensure the continued safety of vaccines on the Canadian market by monitoring adverse events following immunization. Canadian Immunization Guide (CIG) A guide containing information on the immunizing agents available in Canada and their use in the prevention of communicable diseases. Recommendations on routine immunizations are discussed in some detail, and an attempt is made to answer most of the day-to-day queries from providers. Carriage The presence of a potentially disease-causing micro-organism in an individual's body that does not cause the disease in the carrier but may cause others to become infected. Causality The relationship between a cause and its effects. An effect, such as a disease, may have one or many causes, such as risk factors, predisposing factors, or precipitating factors (e.g. heart disease is caused by a combination of factors including genetic and behavioral factors). Cell-mediated immunity (CMI) The immune reactions that are mediated by cells, cytotoxic T lymphocytes (CTL cells) rather than by antibody or other humoral factors (e.g. complement proteins). Cellulitis An infection of the skin and connective tissue characterized by redness, swelling, warmth, and tenderness. May also cause fever or chills. Client A person in the client index or registry. May be a contact, case, control, immunization recipient or other (e.g. guardian of a client). Clinical features The symptoms that are based on direct observation of the patient. Cold chain An unbroken series of storage and distribution activities that maintains a proper temperature range during storage and handling in order to preserve the potency of the vaccine. Combination vaccine A single vaccine that includes antigens for the prevention of several different diseases, or that protects against several strains of a single infectious agent that causes the same disease such as the measles, mumps, and rubella (MMR) vaccine. Communicability The capability to spread disease from person to person, or from species to species. Also referred to as being infectious. Community/herd immunity A large percentage of the population is vaccinated in order to prevent the spread of certain infectious diseases. Even individuals not vaccinated (such as newborns and those with chronic illnesses) are offered some protection because the disease has little opportunity to spread within the community. Also known as "herd immunity." Complications A new disease or medical condition that develops during the treatment or course of an existing disease or medical condition. Confidentiality In medicine, confidentiality refers to the right of the patient to have personal identifiable, medical information revealed to a healthcare professional remain private. Limits are placed on how and when such information may be disclosed to a third party. Conflict of interest (real or perceived) A situation where an individual or the organization that they represent has competing professional or personal interest that may make it difficult for them to fulfill their duties in an impartial manner. A conflict of interest may be real or perceived. Contagiousness The degree of transmissibility - ability for a disease to be transmitted from person to person through direct or indirect contact with a bodily discharge of such a patient, or with an object touched by such a patient or by bodily discharges. Contraindication A symptom or condition that makes it likely a life-threatening problem would occur if a vaccine is given. Coverage rate (immunization coverage) The proportion of the target populations that has been vaccinated through the publicly funded programs that provides certain vaccines at little or no cost. Credible sources The clinical trials, academic studies, or other health-related sources of information that are based on scientific evidence. Credible studies or trials should be conducted by qualified scientists or other health professionals. Determinants of health The various factors that when combined together contribute to the overall health status of an individual or population. These include income, educational level, healthcare access, genetics, and lifestyle. Disclosure The release, transfer, or provision of access to, or divulging of individually identifiable health information outside of the entity holding that information. Effectiveness The ability of a vaccine to produce the desired beneficial effect(s) under real-world circumstances. Efficacy The maximum ability of a vaccine to produce a desired effect. Encephalitis The inflammation of the brain caused by a virus; encephalitis can result in permanent brain damage or death. Encephalopathy A general term describing brain dysfunction such as encephalitis, meningitis, seizures and head trauma. Encounter A point of service for any type of subject that is defined by date, time, location and the type of activity (e.g. immunization, disease screening or lab results). An encounter may or may not be associated with and investigation/control record within a subject record. An encounter may or may not be associated with other encounters through an episode. Endemic The continual, low-level presence of disease in a community. Epidemic The occurrence of disease within a specific geographical area or population that is in excess of what is normally expected. Epidemiology A branch of medical science that deals with the incidence, distribution, and control of disease in a population. The sum of the factors controlling the presence or absence of a disease or pathogen. Epidemiological triangle A model for the causation of disease that involves three elements: agent, host, and environment. Episode A descriptive group of one or more encounters. An investigation may have zero to many episodes. Encounters not associated to an investigation or control can also be grouped into one or more episodes. An episode is named by the user or the system and is defined by a start date and (optionally) and end date. Evidence-based decision making The decisions that are based on a careful analysis of accurate data and proven research findings. Expired stock All vaccines and diluents have an expiration date by which they should be used printed on their vials and boxes. Products that are passed their expiration dates are considered expired stock and should not be administered Expiry date The date by which a vaccine or a diluent should be used. Guillain-Barré syndrome A rare neurological disease that occurs when the body's immune system attacks the peripheral nerves in the body, causing loss of reflexes and temporary paralysis. Symptoms include weakness, numbness, tingling and increased sensitivity that spreads over the body. Hard-to-reach (individuals, groups, populations) The individuals, groups, or populations that have the greatest difficulty accessing services (e.g. the disadvantaged, minorities, residents in remote communities). Harm The nature and extent of damage that could be caused by a vaccine. Host A person or other living organism that can be infected by an infectious agent under natural conditions. Humoral immunity The term humoral refers to the extracellular fluids such as serum and lymph; in this case the immune response is mediated by antibodies produced by B-cells as effector molecules. Both B- and T-cells may be involved in this response. Hypotonic-hyporesponsive episode (HHE) A serious adverse reaction to immunization that results in a decrease in level of responsiveness, muscle tone and activity, and pallor. HHE is most commonly reported in response to administration of the whole-cell pertussis vaccine, but also occur with a lower frequency after diphtheria-tetanus (DT) and acellular pertussis-DT (DPT) immunization. Immunity The protection against a disease. There are several types of immunity: passive, active and humoral. The immunity is indicated by the presence of antibodies in the blood and can usually be determined with a laboratory test. Immunization record (professional chart and take-home) A record of all immunization a person has received. A record is kept by the healthcare provider who gave the immunization (professional chart), and in a local or provincial registry and by the individual or their parent or guardian (take-home record). Immunization registry A tool to consolidate immunization records from multiple sources, including any reports of adverse events, into one confidential record. Immunization schedules (delay, interruption, etc.) They outline the optimum timing of primary and secondary immunizations. A delayed immunization schedule may be used when a child receives his or her primary or secondary immunizations after the recommended ages of their regional immunization schedule. When a child's vaccinations are interrupted by more than a month, an accelerated or catch-up immunization schedule should be used. Immunization status A client's immunization status conveys whether they are eligible, due or overdue for a specified vaccine.