Adverse Events, vaccination sites, and handling vaccines

Question 1

Nature of possible adverse vaccine events:

Answer 1

1. Allergic or immune-mediated in nature
2. Inflammatory or neoplastic in nature

Question 2

what types of allergic or immune mediated vaccine reaction are there?

Answer 2

Type 1: (IgE mediated)
Type 2: (IgG & IgM mediated)
Type 3: (immune complex)
Type 4: (delayed type hypersensitivity)

Question 3

what is a type 1 allergic (hypersensitivity)/ immune-mediated reaction? What are the symptoms and when will we see them?

Answer 3

Type 1: (IgE mediated) Angioedema (swelling of head & ears), urticaria (hives), acute onset diarrhea, collapse, vomiting, shock & death. Within first 24 hrs of vax being given.

Question 4

what is a type 2 allergic (hypersensitivity)/ immune-mediated reaction? What are the symptoms and when will we see them?

Answer 4

Type 2: (IgG & IgM mediated). immune-mediated hemolytic anemia (IMHA), immune-mediated thrombocytopenia (ITP). Weeks & months after vax was given.

Question 5

what is a type 3 allergic (hypersensitivity)/ immune-mediated reaction? What are the symptoms and when will we see them?

Answer 5

Type 3: (immune complex). cutaneous ischemic vasculopathy (rabies vaccine) at injection site or elsewhere, immune-mediated disease affecting various organs (e.g. kidneys, joints). Weeks & months after vax was given.

Question 6

what is a type 4 allergic (hypersensitivity)/ immune-mediated reaction? What are the symptoms and when will we see them?

Answer 6

Type 4: (delayed type hypersensitivity) not clearly described in relation to vaccines. Usually with decreased cellular immunity & release of pro-inflammatory cytokines. More than 12 hours after inciting event.

Question 7

what types of inflammatory or neoplastic vaccine reactions are there, from most to least common?

Answer 7

Transient non-specific systemic signs
Transient injection site reactions
Sustained injection site reactions
Tumorigenesis

Question 8

what sort of transient, non-specific symptoms might we expect as an inflammatory/ neoplastic vaccine reaction?

Answer 8

Transient non-specific systemic signs: lethargy, anorexia, fever, generalised soreness, shifting lameness, regional lymphadenopathy

Question 9

what type of transient injection site reactions might we expect as an inflammatory/ neoplastic response? What are the signs?

Answer 9

Transient injection site reactions: palpable or visible lumps caused by local inflammation/swelling, abscess or granuloma; pain on site, pruritus (itchiness)

Question 10

what type of sustained injection site reaction might we expect after a vaccine? what are the signs?

Answer 10

Sustained injection site reactions: hair loss, discolouration of skin, necrosis of skin, granuloma

Question 11

what is involved in a tumorgenesis vaccine reaction?

Answer 11

Tumorigenesis: malignant transformation of mesenchymal cells in susceptible individuals

Question 12

What is FISS?

Answer 12

FISS = Feline Injection Site Sarcoma
aka: vaccine site sarcoma; vaccine associated fibrosarcoma; vaccine associated sarcoma

Question 13

do we see FISS more in cats or dogs?

Answer 13

Almost exclusive in cats; very rare in dogs. Recognised since 1991 -> research is ongoing

Question 14

when in a cats lifetime would we most likely see the onset of a FISS?

Answer 14

Existing data shows 7-9 y.o age of onset vs. cats with non- vaccine associated sarcomas

Question 15

What types of cancers do we usually see with FISS?

Answer 15

Many tumour types identified: fibrosarcoma; malignant fibrous histiocytoma; rhabdomyosarcoma…

Question 16

what vaccines are most associated with FISS?

Answer 16

Historically, associated with FeLV and Rabies vaccines. But possible with any vaccination and other injectable agents

Question 17

what is considered as the trigger for subsequent malignant transformation in FISS?

Answer 17

Chronic inflammatory reactions are considered the trigger for subsequent malignant transformation

Question 18

what is the rate of occurence of FISS?

Answer 18

Rate of occurrence: estimated at 1-4 in every 10,000 vaccinated cats in the USA

Question 19

what vaccination site should we avoid in dogs?

Answer 19

• Avoid inter-scapular area

Question 20

what should we record about a vaccine that we administrate?

Answer 20

• Record where on body vaccines were given and be specific e.g. Rabies in right hind lateral
thigh, DAPP/core combination in R front shoulder
• Record what route the vaccine was given e.g. SC, IN, IM, PO (buccal)

Question 21

when giving an annual vaccine, what should we check regarding the previous vaccine?

Answer 21

• Look to see where the previous year/month’s vaccine was given – were there any problems in that previous site reported by carer? Can you see or feel any masses, hair loss, skin defects in that area?
• Ask your client if they noticed any problems with last year’s vaccine?

Question 22

if a vaccine can be given SC or IM, which should we choose?

Answer 22

SC

Question 23

what area should we avoid when vaccinating cats? What sites should we use?

Answer 23

• Avoid inter-scapular area. Decreasing vaccine volume at time of vax is not protective

• Distal limb & distal tail recommended to facilitate amputation with 5cm margins in two fascial
planes if required

Question 24

what is the current thought on ventral abdominal SC injections for cats?

Answer 24

Controversial as 5cm margins will still need aggressive tissue removal from abdomen & abdominal cavity – current advice is to avoid this location

Question 25

how can incorrect handling and storage of a vaccine affect efficacy? Where should we look for handling info?

Answer 25

Incorrect handling & storage can decrease efficacy of a vaccine. Must always refer to manufacturer specifications (package insert)

Question 26

what is the vaccine cold chain?

Answer 26

Handling & storage: must be kept in a temperature controlled environment from the time they leave the manufacturer to the time they are administered – known as the vaccine cold chain

Question 27

what temp should refrigerated vaccines be kept at? How should they be stored in the fridge?

Answer 27

-Refrigerated vaccines should be stored between 2 - 8 degrees Celsius (36-46 degrees F)
-Placed centrally in the refrigerator to allow for proper air flow, remove deli & fruit drawers, fridge dedicated to just vaccines (no food)

Question 28

how should vaccines in our clinic be packaged when in storage?

Answer 28

Keep in original packaging, with lids closed until ready to use

Question 29

when should we remove single dose/use vaccines from the fridge?

Answer 29

Single dose/use vaccines (freeze dried & liquid forms) should not be removed from fridge until the time of administration

Question 30

should we reuse needles for vaccines?

Answer 30

A new sterile syringe + needle should be used every time

Question 31

what could a delay in reconstituting and administration of vaccine could result in?

Answer 31

decrease of vaccine efficacy

Question 32

what special characteristics do multi-dose vaccines have to allow for storage?

Answer 32

Multidose vaccines have preservatives to allow for prolonged storage once seal has been opened

Question 33

when diluting a vaccine, what should we use as the diluent?

Answer 33

Always use the diluent provided by manufacturer and not a replacement

Question 34

what is the minimum vaccine info requirements for a medical record? What should you also consider including?

Answer 34

At a minimum a vaccine record should consist of: anatomical location of vaccine administration; route of administration; age at which vaccine was given; frequency of administration e.g. second, third in a series of…

• Consider also including in medical record: what the vaccine covered e.g. RCP, what brand was used, type of vaccine (live, inactivated etc.)

Question 35

vaccine certificate will often contain what from the vaccine vial, with what info?

Answer 35

Vaccine certificate will often have transferable label from vaccine vial that shows expiry date, brand, pathogens vaccinated against

Question 36

what should the veterinary team ensure regarding vaccine administration? What should they provide for the clients? Why is this important?

Answer 36

• ensure consistency in recording information for all clients, at all times
  -provide client hand outs e.g. ’what to expect after a vaccine for your cat/dog’
  -apply a consistent vaccine protocol where possible (including vaccine administration sites) for all dogs & cats

• Consistency within vet team avoids the potential for confusion, keeps recommendations consistent, facilitates client acceptance and compliance

Question 37

what should we do when there is an adverse vaccine reaction?

Answer 37

Do report adverse events to manufacturers and to relevant local authorities

Question 38

who should you ask for information about a specific vaccine?

Answer 38

Ask vaccine manufacturers for information on vaccines when you need it & when your clients ask questions…be knowledgeable about what you are using in your practice

Question 39

what should we base vaccine protocols for an individual on?

Answer 39

Be diligent about catering vaccine protocols for individuals based on their risk factors