2021 Influenza Immunization Guidance for B.C. Pharmacies

Table below summarizes the types of publicly funded influenza vaccine products expected for 2021/2022 and the intended age group(s) for each of the products.

*Fluzone® High-Dose Quadrivalent was authorized for use in Canada for adults ≥ 65 years in June 2020 and marketing for the trivalent formulation has been discontinued as of February 2021. See Fluzone® High-Dose Quadrivalent Q&A for more information.

*Fluzone® High-Dose Quadrivalent will not be distributed to pharmacies through wholesalers. This product will be supplied through public health for use in residents of LTC/AL facilities and First Nations communities.

For influenza vaccine product details, see BCCDC Part 4 – Biological Products of the BC Immunization Manual.

For a summary of the vaccines for influenza season 2021/22 see BCCDC Summary - New for Influenza Season 2021/22

Two provincial online influenza courses have been updated for the 2021/22 season and are now available on LearningHub.

• Foundations of Influenza: Disease & Vaccines course: https://learninghub.phsa.ca/Courses/19654/
• Seasonal Influenza Updates 2021 – 2022 course: https://learninghub.phsa.ca/Courses/26666/

Updated October 19, 2021: Per the recent Ministry of Health announcement that influenza vaccination is free for B.C. residents six months and older this year, the eligibility criteria for publicly-funded influenza vaccine has been expanded to “Anyone else who wishes to reduce their risk of influenza.” See 2021/22 Seasonal Influenza Vaccine Eligibility.

As per College HPA bylaws, a drug administration-certified pharmacist can administer a drug by intranasal route to a child 2 years of age and older; and a drug by injection to individuals 5 years old age older.

Before administering any vaccine, pharmacists must obtain informed consent as per CPBC’s Standards, Limits and Conditions for Drug Administration.

A link or copy of the HealthLink BC File for influenza vaccines can be provided to each patient as part of the consent process.

See BCPhA example consent forms for immunization:

• Injectable Influenza Vaccine Consent Form (Written) 
• Injectable Influenza Vaccine Consent Form (Verbal) 
• FluMist® Vaccine Consent Form (Written)
• FluMist® Vaccine Consent Form (Verbal)
• General Consent for Immunization (Written)

Update Dec. 6 2021:

For Pharmacies located in NH only:

Due to some delays in the direct distribution system to pharmacies, and excess vaccine within NH Health Units, pharmacies can now order influenza products for pick up from public health, as stock availability permits. To order vaccine, complete online form here.

Reporting: Continue to follow regular health authority reporting of vaccine utilization of any doses administered from vaccine received from your local health unit:

• CVP Report of Influenza Vaccine Utilization
• CVP Influenza Vaccine for those 6 months to 8 years; Pneumococcal Vaccine for All Ages.

Unused vaccine picked up from PHU: Pharmacies are to keep any unused influenza products from NH until contacted for the annual flu harvest of vaccine. Note, that your local health unit will only accept back the influenza vaccine that was obtained from health authority stock. Vaccine will be identified with a NH sticker when they are picked up from public health.

For pharmacies located in FHA only 

Pharmacies can use this online form to request Flumist nasal spray for pick up from the local public health unit. The form can also be used to request vaccine for residents of Assisted Living or First Nations communities who are aged 65+. All other vaccines should continue to be ordered through your primary distributor.

This is the first year that influenza vaccines will be distributed directly to pharmacies from their primary wholesaler.

Total allocations

Each pharmacy’s total allocation for the season has been calculated based on 2020 (or 2019 if 2020 not available) throughput with an increase of 15% to account for potential additional demand this year. Pharmacies with no prior influenza administration data have been provided an allocation based on an average throughput of comparable pharmacies.

Product mixes: This year, four different influenza vaccine products will be delivered to pharmacies through direct distribution:

• Fluzone® Quadrivalent (multi-dose vial and pre-filled syringe)
• Flulaval® Tetra (multi-dose vial)
• Afluria® Tetra Quadrivalent (multi-dose vial)
• FluMist® Quadrivalent – (only limited quantities are available in the province).

Each individual pharmacy’s product mix has been assigned based on available supply. The majority of pharmacies will be receiving some supply of Fluzone® Quadrivalent pre-filled syringes (thimerosal-free); however this product makes up a smaller percentage of the total supply so the majority of each pharmacies supply will consist of the influenza quadrivalent vaccines in the multi-dose vial format.

FluMist® is not included in the initial allocations. Pharmacies will be able to order FLuMist® directly with their distributor starting October 25, 2021. More details to follow.

Initial allocations: First two shipments

Initial allocations will be a percentage of your total allocation based on available supply.  As is the case every year, vaccines arrive into the province in multiple shipments between September and November, allocations to pharmacies need to be limited and synchronized to vaccine arrival dates into the province to ensure vaccine utilization is maximized to meet the demand. In addition, other key indicators that determine your initial allocation include your maximum weekly throughput from the previous two years as well as the throughput in the first two weeks following your commencement of influenza vaccination campaign.

Initial allocations will be auto-shipped directly to pharmacies from their primary distributor between Monday October 4 and Friday October 15.The initial allocation is intended to last approximately 2 to 2 ½  weeks of the campaign.

A second allocation will be auto-shipped directly to pharmacies by no later than November 3.  This second allocation is intended to last approximately 1 to 1 ½ weeks.  Pharmacies do not need to place an order or confirm this second allocation of vaccine; it will be auto shipped based on your first week of throughput and your remaining inventory on hand.

The BCPhA team will contact every pharmacy by email informing you of the following information:

• Estimated initial dose allotment to kick off the season.
• Projected total allocation of flu doses for the season.

Please look out for that email with further details on allocation and actions you need to take in confirming the supply. For pharmacy chains, operations team are contacted to confirm the details.

Ordering process

After the initial two auto-shipments, starting November 8, 2021 onwards, pharmacies will be able to place re-orders of vaccine with their primary distributor. Vaccine supplies will be limited per pharmacy based on inventory on hand and real-time throughput of this year's flu season.

Ancillary supplies and PPE

Pharmacies are to continue to source their own ancillary supplies and protective personnel equipment (PPE) e.g., medical masks.

Infection, Prevention and Control Measures

BCCDC guidance outlines the infection prevention and control measures required for the set-up and safe operation of COVID-19 immunizations in community settings (e.g., community pharmacies, community centres).

See also Guidance for Influenza Vaccine Delivery in the Presence of COVID-19 (October 15, 2021). The infection, prevention and control recommendations have been updated as per Provincial Infection Control Network (PICNet) guidance, including:

• Physical distancing or maintaining a distance of two metres between two or more people is no longer required. However, space arrangement at immunization clinics should ensure that people have enough space available to be respectful of others’ personal space.
• Capacity limits for higher occupancy waiting rooms/areas are no longer required, but avoid overcrowding and ensure respectful personal space can be maintained.
• Immunizers, staff and volunteers in an immunization clinic must continue to wear a medical mask, however the use of additional PPE, such as eye protection, should be based on a point-of-care risk assessment, and per additional precautions, where indicated.

Further information can be found on BCCDC Infection Control webpage.

Vaccine Preparation and Administration Technique

See the BCPhA vaccine preparation and administration technique for intramuscular injections.

• Health Authorities will continue to manage influenza supply for long-term care (LTC) and assisted living facilities (AL) as they have in previous years.
  • Some regions manage directly with LTC and AL facilities, who in turn will contact their pharmacy service providers to coordinate pick-up of vaccine (where necessary) as well as plans on administering doses for residents and staff.
  • Some regions will continue to ask pharmacies to place orders on behalf of the facilities they service. Immunization for LTC and AL facilities will likely begin toward the end of September (exact dates TBD).
• Influenza vaccine for these facilities should NOT be ordered from your pharmacy wholesaler.
• The product being used for residents of LTC and AL facilities this year is Fluzone® High-Dose Quadrivalent. 
• Pharmacies may start providing influenza vaccination services to residents and staff in LTC and AL facilities at the direction of the Health Authority including prior to the campaign launch date. Pharmacies planning to provide influenza clinics to residents of Independent Living facilities or other congregate living facilities should provide influenza vaccines no early than the official start date. Residents in these other facilities do not qualify for publicly funded Fluzone® High-Dose Quadrivalent vaccine.
  • As a rule, if a pharmacy does not receive Fluzone® High-Dose Quadrivalent for a site from their Health Authority, then this site is not considered long-term care or assisted living. A pharmacy cannot begin administering influenza vaccines prior to the official start date to these sites

Health Authorities working with pharmacy providers to immunize health care workers (HCW) staff at Health Authority (HA) facility clinics will coordinate the provision of influenza vaccine supply directly with pharmacies. Influenza vaccine for these clinics should NOT be ordered from your pharmacy wholesaler. 

• It is highly recommended that pharmacies use an appointment booking application this year.
• The provincial central booking system (ImmsBC) will not be available for flu vaccinations.
• BCPhA will be maintaining a centralized booking page and listing pharmacies who have inventory availability. Pharmacies out of supply will be removed daily until new vaccines are delivered.
• The BCPhA booking tool will also have a centralized appointment search by city and date feature added in time for this year’s flu season.  

• To improve patient immunization records in the Provincial Immunization Registry (PIR), vaccination data from PharmaNet is being extracted to the PIR.
• To ensure a complete record in the PIR, pharmacists should include the vaccine lot number and site when entering vaccination claims in PharmaNet.
• “Directions for Use” field (aka the SIG field):
  • For injection route of administration: Enter lot number and injection arm (either RIGHT or LEFT), separated by an underscore ___.
  • For intranasal route of administration: Enter lot number and BILATERAL, separated by an underscore___.
  • Do not enter other information in the SIG field, as the entire content of the SIG field will be included in the PIR

Vaccination Claim Reminders:

• Record immunizations in PharmaNet on the day they are given. The date of claim is assumed to be the administration date and will be used as such for the PIR record.
• As PharmaNet data is extracted to PIR to update a patient’s immunization record, if a change to a claim is required, ensure it is backdated to the original service/administration date.
• Prescriber should be entered as the administering pharmacist.
• Use the appropriate influenza vaccine PIN.
• Enter the quantity as the fluid volume of the vaccine (e.g., 0.5 mL).
• Do not enter a drug cost or fee.
• When you submit a claim, PharmaNet will indicate that it is not a benefit and will reject the claim. This is expected. You will still be reimbursed for the service. Do not reverse the claim.
• No intervention code is needed for vaccine administration fee claims. You do not need to enter the DE intervention code to ensure the patient is not charged; however, do not charge the patient a cost for a publicly-funded vaccination in any circumstance. If the DE intervention code has been entered, the vaccination administration fee will still be paid.
• Pharmacies can administer the publicly funded vaccines to Canadians that are non-residents of B.C. and would qualify for an influenza vaccine in their home province or territory. However, PharmaCare does not pay administration fees for any influenza vaccines given to anyone who is not a B.C. resident.

Reimbursement: Pharmacare covers a $12.10 drug administration fee for all publicly funded influenza vaccines, including FluMist® Quadrivalent, for B.C. residents.

This year there will likely not be an official end to the influenza season announced. However, given the current demand for influenza vaccine, pharmacies may review their inventory and begin to dispose of excess influenza vaccine. Pharmacies are encouraged to retain enough supply to fulfill any requests for vaccine until their expiration date.

This year pharmacies should NOT return any vaccine to their local health unit and should dispose of vaccine through their existing commercial biomedical waste processes. Pharmacies do not have to report on wastage this year as these figures are being tracked in aggregate for all pharmacies within each Health Authority.  

Co-administration of COVID-19 vaccine and influenza vaccine: As per BCCDC Part 4- Biological page for COVID-19 vaccines, COVID-19 vaccines can be administered concomitantly or at any time before or after the administration of another inactivated or live vaccine.

Please refer to Part 4 of HPA Bylaws Schedule F – Certified Practice – Drug Administration by Injection and Intranasal Route Standards, Limits and Conditions for guidance on legal and professional duties when providing immunizations.

For Pharmacists

• Guidance for Influenza Vaccine Delivery in the Presence of COVID-19
• Continuity of Immunization Services During COVID-19
• BCCDC Immunization Manual – Part 3 Management of Anaphylaxis in a Non-Hospital Setting
• BCCDC Immunization Manual – Part 4 Biological Products (Vaccines & Immune Globulins)
• BCCDC Immunization Manual – Part 5 Adverse Events Following Immunization
• Reporting Adverse Events Following Immunization – For BC Community Vaccine Providers
• Adverse Event Following Immunization (AEFI) Case Report Form
• NACI recommendations, statements, and updates
• Canadian Immunization Guide on Influenza and Statement on Seasonal Influenza Vaccine for 2021-2022
• Immunizing Children – Suggested Best Practice Tips for BC Community Pharmacists

For Patients

• Influenza (Flu) Immunization: Myths and Facts #12c (updated September 2020).
• The following Influenza HealthlinkBC Files have been updated for the 2021/22 influenza season:
  • Why Seniors Should Get the Inactivated Influenza (Flu) Vaccine #12a
  • Facts about Influenza (the Flu) #12b
  • Inactivated Influenza (Flu) Vaccine #12d
  • Live Attenuated Influenza (Flu) Vaccine #12e

Previous Flu Resources

• 2020/2021 Flu Resources
• 2019/2020 Flu Resources

The following provides links to BC Health Authorities information on influenza services (clinics, products etc):

North Health
https://www.northernhealth.ca/for-health-professionals/immunization-resources-tools#current-issue

Interior Health
http://www.interiorhealth.ca/sites/Partners/ImmunizationResourcesTools/Pages/default.aspx

First Nations Health
http://www.fnha.ca/what-we-do/communicable-disease-control/influenza-information

Fraser Health
https://www.fraserhealth.ca/health-topics-a-to-z#topictags=Influenza&e=0

Vancouver Coastal
http://www.vch.ca/public-health/communicable-diseases-immunizations/flu-shots-flu-clinics

PHSA
http://www.phsa.ca/health-info/staying-healthy/preventing-infection/immunization/influenza

Island Health
https://www.islandhealth.ca/learn-about-health/the-flu-influenza