Wednesday, February 14, 2018

Q&A with Dawn Hatanaka: Exploring the Canadian Obesity Network

Although it is Canada's largest obesity association, made up of healthcare professionals, researchers, policy makers and people with an interest in obesity, I had not heard of the Canadian Obesity Network (CON) prior to my rotation at mdBriefCase.

In the excerpts below, I’ve summarized my interview with Dawn Hatanaka, the Director of Education for CON, who is responsible for the organization’s educational initiatives. Dawn explains the association’s origins, goals, achievements as well as what we can expect from the future of CON. I’m hoping that after sharing this excerpt, more healthcare professionals will be aware of CON as both an organization and its offerings.

What is the Canadian Obesity Network and why was it created? 
The Canadian Obesity Network - Réseau canadien en obésité, or CON-RCO, is our official acronym and I like to think we’re Canada’s authority on evidence-based approaches for obesity prevention, treatment and policy. CON-RCO was started in 2006 to create a coordinated response to obesity care; from prevention, treatment to policy across the board. 

When we launched, everything was siloed and piecemealed across the country, so the thought was the network would join obesity research and funding along with prevention and treatment strategies. As of January 2018, the network has about 15,000 professional members and we just opened to the public in 2015 with around 2,000 public supporters. 
  

You mentioned CON started targeting a scientific community but later opened to the public for membership. Why the change? 
Our mission has always been to improve the lives of Canadians affected by obesity but to do so, we needed to reach out to them. At a 2015 CON workshop – which brought together people living with obesity, healthcare professionals, researchers, policy makers and collaborators - everyone agreed that Canadians living with obesity needed a credible source of resources about their health and how to advocate for themselves. So in June of 2015, the Public Engagement Committee was established, where all members are people living with obesity in Canada and managing their obesity in different ways. They’re our spokespeople across the country for the public and have actively participated in activities to help raise the voice of Canadians affected with obesity, through social media, media interviews, speaker bureaus, education activities and practice and policy committees around the country. 

What would you say are CON’s current goals right now? 
Our official goals are addressing social stigma associated with obesity, changing the way policy makers and health professionals approach obesity and improving access to evidence-based prevention and treatment resources. 
While we continue with what one could say are lofty goals, the things we do to reach them change yearly. We continue to deliver education programs for healthcare professionals, we’ve partnered with government agencies and others working in population health policies because there has been a lot of unintentional consequences of population health messaging which deter people from seeking out treatment due to that stigma. We’re also supporting obesity research, through collaboration with the Canadian Institute of Health Research (CIHR) and leveraging 1.5 billion dollars in funding for obesity research. 

Many of the myths and messages in the public are very patient centric. What are the major initiatives CON has spearheaded recently to combat these myths? 
Last year we started a “Bust The Bias” campaign over social media only. These short videos [on CON’s YouTube channel] talk about all these myths and why they’re wrong. We placed them in the public eye and shared them with our partner associations to increase people’s exposure to the content. For example, the bariatric clinic in Ottawa have all of them rolling on their TVs in the waiting room all the time. 



What would you say is the biggest challenge the network faces as an organization? 
Getting obesity recognized as a chronic disease across the board is our biggest challenge so far. Despite CON-RCO, Canadian Medical Association, American Medical Association and the WHO declaring obesity to be a chronic disease, the provinces and territories don’t recognize it as a chronic disease nor do they treat it that way. They still categorize obesity as a result of poor lifestyle choices.

Obesity is not on their radar and I think it’s one of the things that CON-RCO needs to do; mobilize that advocacy side and the public to ask because you’re never going to get something if you don’t ask. 


What would you say are the key milestones CON has made since its inception? 
There are a couple of key things. The number of Canadian physicians taking the American Board of Obesity Management (ABOM) exam almost doubled between 2016 and 2017. We also launched the Certified Bariatric Educator program in 2016, which started out with very small numbers but continues to grow with interest in Canada as well as internationally.

I also think with the CMA declaring obesity as a chronic medical disease in October 2015 was a big thing. We had champions within the CMA that had been pushing this agenda forward for years. Of course, the report card that was released last year was huge because you can finally put some numbers and grades to show people [the issues surrounding access to obesity treatments]. 


Where would you like to see CON in the next 5-10 years and what steps must be taken to get there? 
Provincial and territorial governments need to recognize the position that CMA and CON have taken - that obesity is a chronic disease and they need to put resources towards it and change their approach accordingly. I’d also like to see employers & health insurers do the same – that would be amazing.

That’s where I think we should go - getting obesity recognized as a chronic disease across the board, which will have a trickle-down effect to increase access to care. We still have a lot more work in the weight bias and stigma space to get people to recognize weight bias and stigma as barriers preventing people from accessing treatment for their chronic disease.

I’ll also mention that we’ve just started writing new Canadian clinical practice guidelines for the management and treatment of obesity in adults which should be released in early 2019. This one is going to be quite different, as the target audience is family physicians and it will be patient-centered. We also have people living with obesity as part of the committee. One of the things the patient group is suggesting is that we have a patient tool kit included so they can talk to their physician and help promote the uptake as well. 


Post Reflection 

After speaking to Dawn, I realized how much CON has to offer to healthcare professionals and to patients as well. It’s also free for healthcare professionals to join and access the various resources available from the Network regarding obesity management. For more information on topics discussed in the interview, please see below for some links:


Cheers,
Aveline

Monday, February 5, 2018

5 Misconceptions Every Pharmacy Student Probably Has About Obesity

Obesity is in some ways like trying to fix a pipe leak – we think we know how to do it, yet 5 minutes into an overflowing washroom, we’re calling the plumber.  

That is exactly how I felt when I was completing the Advanced Obesity Management Program (AOMP) on Advancing Practice, I thought I understood obesity but in fact I had a lot to learn. As a 4th year pharmacy student on the cusp of becoming a licensed pharmacist, I was shocked at how little I knew about obesity as a disease and its management. Even though the prevalence of obesity is widespread, there is still a large knowledge gap among many healthcare professionals; especially pharmacists in my opinion.

Here are the 5 greatest misconceptions I feel pharmacy students have on obesity, which I have also experienced:

Misconception #1: Obesity is solely caused by excessive eating and/or lack of physical activity
From the AOMP, I have learned that obesity is much more complex than just “energy in” versus “energy out”. Important contributors such as genetic pre-disposition, insufficient sleep, psychological stress, hormonal imbalance and medications, have compelling supporting evidence in the development of obesity.1

Misconception #2: Obesity is a risk factor for disease, it is not a chronic disease itself
Obesity is in fact both a risk factor and chronic disease itself, similarly to hypertension. Although pharmacists are well aware that obesity can increase the risk of other diseases (e.g. type 2 diabetes, obstructive sleep apnea, hypertension etc.), it is also important to acknowledge obesity as a chronic disease. This would allow us to change how we manage obesity as well as help reduce the stigma surrounding it.2

Misconception #3: Patients’ willpower and self-control determines their ability to lose weight and keep it off
A patient may be successful in losing weight but the maintenance of weight loss is hard. Despite putting in more effort into a weight loss program, it does not always result in additional weight loss. When I learned that our bodies had an inherent compensatory to maintain our “highest weight”, I had a deeper appreciation for the fight patients had to go through.1 This explains the difficulty of maintaining and further achieving weight loss.

Misconception #4: Body Mass Index (BMI) can be used to define obesity 
For a very long time, I believed BMI was a number that determined if a patient had obesity or not. However, the Canadian Medical Association recommends using clinical measures of health rather than diagnosing obesity with BMI values as it measures body size.2-3 Although BMI can be a useful tool to glean insight into a patient’s health status, it should not be the sole measure of obesity.

Misconception #5: Pharmacists do not have a role in obesity management 
I have been guilty of providing the oversimplified “Eat less, move more” response to patients seeking weight loss advice in the pharmacy and often, would redirect patients to dieticians or family physicians. However, as frontline healthcare workers, we are in the perfect position to initiate conversations about obesity, arrange follow-up monitoring, and provide patient support and encouragement. Most pertinent to our practice is preventing weight gain caused by certain medications dispensed regularly by providing weight management strategies beforehand.

It is definitely a difficult feat to manage obesity, especially when the individuals that patients turn to for help already have misconceptions about the disease and/or patient. Hopefully, as healthcare professionals, we can further educate ourselves on obesity and try to move away from our own biases to help make a significant impact on this disease. To learn more about obesity, click below to discover Advancing Practice’s continuing education program and become certified as a Bariatric Educator:



If you are itching to delve into the obesity conversation, look out for my 3-part interview series where various experts weigh in on the subject of obesity, no pun intended!

Cheerio,
Aveline

References:
  1.  Chaput, J.-P., Ferraro, Z. M., Prud’homme, D., & Sharma, A. M. (2014). Widespread misconceptions about obesity. Canadian Family Physician60(11), 973–975.
  2.  An Obesity Manifesto: Debunking the Myths - Medscape - Feb 23, 2017. Retrieved from https://www.medscape.com/viewarticle/875964#vp_1
  3. Rich P. CMA recognizes obesity as a disease. Oct 9, 2015. Retrieved from www.cma.ca/En/Pages/cmarecognizes-obesity-as-a-disease.aspx2015.

Thursday, January 25, 2018

The Newest Kid on the Block

Hi mdBriefCase team!

My name is Aveline and I’m the latest 4th year pharmacy student from UofT completing my rotation at mdBriefCase. This will be my second last rotation before I nose-dive into my books for my licensing exam this coming May and face the (scary) real world.

It was a pleasure meeting most of the office today and I hope to get to know everyone a little better as I complete my 5 weeks of rotation here.

Some fun facts about me:
  • I love baking! My dream is to own a double-door oven.
  • I’m obsessed with Lego and I’ve recently obtained a model set of the Taj Mahal.
  • Dogs and classical art memes are my kryptonite.
  • The spelling of my name has been the bane of my existence; Ellen, Eveline, Evelyn, Avelyn. I’ve heard it all.

mdBriefCase will be my first experience in a non-direct patient care setting and it will definitely be a 180 degree flip from what I’m used to, but I shall fear not and accept the challenges ahead. I intend to make the most of my time here, so I hope you don’t mind me asking tons of questions. 😊

Please look forward to my blog posts, newsletter and presentation in the upcoming 5 weeks!

Cheers,
Aveline Tung 

Friday, December 1, 2017

Tramadol: A Case of Misclassification?


Although tramadol was being considered for classification as a controlled drug back in 2007, it remained an uncontrolled drug.1 A decade later, Health Canada is reconsidering the decision and may re-categorize tramadol as an opioid.1

Tramadol is a painkiller that increases serotonin levels in the body like antidepressants do, leading to some analgesia.1 In addition, CYP2D6 in the liver then converts tramadol to a compound called M1, which is an opioid that provides pain relief similarly to morphine.1 One thing to remember is the pharmacogenomics involved with the conversion of tramadol to M1.1 Some individuals have weak CYP2D6 activity and do not receive the opioid effect, whereas, others may have rapid conversion and acquire a large opioid effect.1

The classification of Tramadol as an opioid is being contemplated due to multiple health care professionals voicing concerns as well as a report on opioid trends from the Canadian Institute for Health Information (CIHI) released last week.2 According to the report, tramadol prescriptions have increased 30% and daily doses have increased by 23% between 2012 and 2016.3 Despite the Canadian non-opioid classification, CIHI included tramadol in their report on opioids because the World Health Organization classifies it as an opioid, as does the United States’ Drug Enforcement Administration and the manufacturers' scientific description.2

Tramadol has the potential to be abused, misused, and can cause dependence especially at higher doses.2,4 Its classification as a non-opioid makes for minimal reporting requirements resulting in a lack of data to help us measure the extent of its abuse and misuse in Canada.2

The opioid crisis does not look like it will resolve any time soon as there is no simple solution for the problem. Therefore, making even the smallest of changes, such as modifying the classification of tramadol to an opioid and the resulting alterations in reporting requirements, could prove crucial.

Now we wait and see if Health Canada will make this change.

References:
1. Juurlink, D. (2017, November 27). Why Health Canada must reclassify tramadol as an opioid. The Globe and Mail. Retrieved from https://www.theglobeandmail.com/opinion/why-health-canada-must-reclassify-tramadol-as-an-opioid/article37089174/

2. Howlett, K. (2017, November 22). Health Canada eyes opioid restrictions for popular painkiller. The Globe and Mail. Retrieved from https://www.theglobeandmail.com/news/national/health-canada-eyes-opioid-restrictions-for-popular-painkillertramadol/article37048483/

3. Canadian Institute for Health Information. (2017). Pan-Canadian Trends in the Prescribing of Opioids. Ontario: Canadian Institute for Health Information. Retrieved from https://www.cihi.ca/sites/default/files/document/pan-canadian-trends-opioid-prescribing-2017-en-web.pdf




4Purdue Pharma. (2016). PRODUCT MONOGRAPH INCLUDING PATIENT MEDICATION INFORMATION : Zytram XL®. Pickering. Retrieved from http://purdue.ca/wp-content/uploads/2015/12/Zytram-XL-PM-EN.pdf?4eb3c6

Thursday, November 23, 2017

Being a Wise Pharmacist


The Canadian Pharmacist Association (CPhA) just released a campaign called Choosing Wisely Canada for pharmacists.1 This campaign was created to help pharmacists have discussions with patients to identify if treatments are warranted, have evidence to support use, and/or can cause harm to patients.1 The recommendations were made by asking Canadian pharmacists and pharmacy researchers to provide their input, which were then reviewed by an expert committee.The final list was created considering the relevance to pharmacy practice, possible impact and supporting evidence.1 The six evidence-based recommendations were made for pharmacists to help optimize patient care and safety.1

1.   Don’t use a medication to treat the side effects of another medication unless absolutely necessary.2

It is important to clarify if a symptom is part of a medical condition or a side effect to a medication.2 You do not want to initiate a prescribing cascade, as it can lead to polypharmacy.2 The polypharmacy can then generate to more side effects, drug interactions, impact adherence and patient’s quality of life.2

For more information read: The prescribing cascade revisited.

2.   Don’t recommend the use of over-the-counter medications containing codeine for the management of acute or chronic pain.2 Counsel patients against their use and recommend safe alternatives.2

According to evidence, use of over-the-counter pain medication containing codeine is not supported over non-opioid options.2 Codeine has the potential to be abused and cause dependence.2 Furthermore, the codeine containing medications tend to have high doses of the simple analgesics (acetaminophen, aspirin or ibuprofen) which can cause adverse effects with misuse (i.e. liver toxicity, peptic ulcers and renal damage).2 
3.   Don’t start or renew drug therapy unless there is an appropriate indication and reasonable expectation of benefit in the individual patient. 2

About 66% of Canadians over the age of 65 take five or more drugs.2 Polypharmacy increases risk of adverse drug reactions and can lead to hospitalization.2 Pharmacists should clarify the therapeutic indication for all medications and only renew prescriptions if benefits of therapy are known to be greater than the risks.2

A tool to help with this task: Check up on “checking”

4.   Don’t renew long-term proton pump inhibitor (PPI) therapy for gastrointestinal symptoms without an attempt to stop or reduce (taper) therapy at least once per year for most patients.2

PPIs are safe and well-tolerated for short term use in of gastroesophageal reflux disease, but can cause adverse effects if used long term, such as: increased risk of fracture, C. difficile infection and diarrhea, community-acquired pneumonia (CAP), hypocobalaminemia and hypomagnesemia.2 Recommend H2-receptor antagonists or lifestyle changes for patients that have used PPIs for 4 weeks and are no longer symptomatic.2 Note: This recommendation does not apply for Barrett esophagus, severe esophagitis grade C or D, or known history of bleeding gastrointestinal ulcers.2

Tools to help with this task: Bye-Bye PPI and PPI Deprescribing Algorithm

5.   Question the use of antipsychotics as a first-line intervention to treat primary insomnia in any age group.2

Many people have been using antipsychotics for an off-label indication of insomnia.However, there is no evidence to support first-line use in guidelines and there are side effects to consider (i.e. weight gain and metabolic disorders).2


6.   Don’t prescribe or dispense benzodiazepines without building a discontinuation strategy into the patient’s treatment plan (except for patients who have a valid indication for long-term use).2

Benzodiazepines are often prescribed for anxiety disorders and insomnia.2 Long term use in elderly patients can lead to tolerance, dependence, adverse effects (i.e. sedation, impaired memory, falls) and hospitalization.2 Guidelines recommend using other options before benzodiazepines.2 If prescribed they should not be used long term and a treatment plan should be developed (i.e. taper schedule).2

A tool to help with this task: Benzodiazepine and Z-drug Deprescribing Algorithm


These six changes have the potential to make a large impact on patient care and safety. What do you think about these new recommendations? Email me to share your success stories.

A video of the recommendations available as well: 6 Things Pharmacists & Patients Should Question - Choosing Wisely Canada


References

     1. Canadian Pharmacists Association. (2017, November 21). Choosing Wisely Canada. Retrieved from https://www.pharmacists.ca/pharmacy-in-canada/choosing-wisely-canada/

     2. Canadian Pharmacists Association. (2017, November). Six Things Pharmacists and Patients Should Question. Retrieved from https://choosingwiselycanada.org/pharmacist/



Friday, November 17, 2017

Medical Marijuana in Pharmacies - Will it Happen?

Hello rxBriefCase,

Marijuana has been in the news continuously for the past few months, with emphasis on the recreational marijuana deadline in July 2018. A couple weeks ago, the Liquor Control Board Ontario (LCBO) announced the first 14 cities to have shops that will be selling legalized recreational marijuana. Now that the recreational marijuana framework and dispensaries have been established, people have moved on to the next big thing - medicinal cannabis.
Shoppers Drug Mart just posted a job for a medical marijuana brand manager position, despite pharmacies not yet having the role of dispensing medical marijuana.1 Handling medicinal cannabis dispensing has been a goal for Loblaw Companies Ltd., the company which also owns Shoppers Drug Mart, since they applied for a Health Canada license last year.1 Other pharmacy companies are also looking to dispense  medicinal cannabis under the belief that pharmacies are ideal distribution locations, just like for any other prescription medication.1
Based on a recent study, it appears it's not just the pharmacy companies who think this is a promising idea - so does the public.2 The data from the new study done by the Ontario Pharmacist Association (OPA) shows that more than 7 out of 10 adult Ontario residents trust pharmacists to dispense medical marijuana.2 Furthermore, 56% of the survey participants indicated preferring medicinal cannabis being dispensed at pharmacies, compared to other alternatives.2

This is not the way the medical marijuana dispensary framework is currently set up, and not using pharmacists in this process could create safety risks for patients.2 This may be a missed opportunity for patients, as they forgo access to advice and information that could benefit their overall health. Pharmacists are the drug experts and can monitor for treatment effectiveness, side effects and identify potential risks (i.e. drug interactions or contraindications).2

Pharmacists are experts at reviewing prescriptions, dispensing medications, identifying drug interactions and counselling patients. We have a lot of practice with these activities, however, this may not be true when it comes to medical marijuana. Some pharmacists may see this new role as an opportunity to expand on our skill set and apply our drug expertise further. Others may feel uncomfortable dispensing medical marijuana as it will require developing new skills and obtaining new knowledge to provide patients the best care possible. 

With medicinal cannabis potentially being dispensed from pharmacies, it is very important that pharmacists receive education and training to help them prepare for a potential role in medical marijuana dispensing.

What are your thoughts? Do you feel prepared?

Note: There are medical marijuana continuing education options available for pharmacists and other healthcare professionals.



Ontario pharmacists can have their continuing education costs subsidized with the help of allied health professional development funds from HealthForceOntario ($1,500 per year). 



References

1. The Canadian Press. (2017, November 13). Shoppers Drug Mart posts job for medical marijuana brand manager. CBC News. Retrieved from http://www.cbc.ca/news/canada/toronto/shoppers-marijuana-brand-manager-1.4400944


2. Baker, J. (2017, November 12). OPINION: Ontarians trust pharmacists to dispense medicinal cannabis, data shows. Toronto Sun. Retrieved from http://torontosun.com/opinion/columnists/columnist-ontarians-trust-pharmacists-to-dispense-medicinal-cannabis-data-shows

Friday, November 10, 2017

Installing Virus Protection Software

Hello rxBriefCase,

No, I am not referring to the software you install to protect your computer from a virus, but rather the influenza vaccination you provide patients to protect them from the flu. This blog post will provide an overview of important guideline recommendations and answers to common questions.

Recommendations to Remember
  • Two Doses for Children to Start: Any child getting vaccinated for the first time between the ages of 6-months through-8 years-old, will requires two doses, at least four weeks apart.1,2,3 It is recommended that children get their first dose as soon as the vaccine is available for the season.1
  • FluMist Recommendation Change: FluMist, the intranasal vaccine (LAIV4), is no longer the preferred vaccine for children.1,2,3 This means that either the injection or the intranasal vaccination can be used for children, without preference.2,3 Though more child friendly, the intranasal formulation is not considered to have superior effectiveness.2 Alberta and Saskatchewan have stopped covering this intranasal option under their immunization program.9 Read more: Flu shot or nasal spray?
  • Preferred Vaccine in Children: Children under the age of 18 are recommended to receive the quadrivalent vaccine.2,3 The trivalent vaccine provides protection against three different flu viruses (2A, 1B), compared to the quadrivalent which protects from four strains (2A, 2B). The quadrivalent vaccine is recommended for kids under the age of 18 because the morbidity and mortality resulting from B strains is higher in that age group versus the adult population.2,3
  • Pregnancy and Flu Shots: Pregnant women may receive any licensed and recommended (consider age) influenza vaccine.3,4 Data shows the influenza vaccination does not lead to any pregnancy complications or birth defects.4 Note: LAIV should not be used in pregnancy.3
  • Egg Allergy and Flu Shots: An allergy to eggs is no longer a contraindication for flu shots. 2,3 Studies have shown that the use of chicken embryos in the production of the vaccine do not create any issues for patients with egg allergies.5 Patients with an allergy to eggs, like all other patients, should be observed for 15 minutes after receiving the flu shot.1,5 Read more: Algorithm for patients with egg allergies
  • New Vaccine Available for Seniors: There is a new high dose trivalent vaccine (Fluzone High Dose) available for seniors (65+). This vaccine is currently not covered by any province, but it was just announced that it will be covered in Ontario next year.2,3,6 The high dose vaccine is four times as potent. It is suggested for the elderly due to the high disease burden of influenza and their declining immune response.3 The high dose vaccine is predicted to help create a stronger immune response and be more effective for seniors.2,3 Canadian Association of Retired Persons (CARP) supports the high dose vaccine: There’s a new flu vaccine available this year, just for Canadians 65+ (Video)

Common Questions from Patients
When is the best time for me to get the flu shot?
It is recommended to get the vaccine before the onset of influenza cases in the community or by the end of October.1,3 However, getting the vaccine later in the flu season can still be beneficial.1,3

Will the flu shot give me the flu?
No, it will not. You may experience a low-grade fever, aches, or some injection site soreness, redness and swelling.7 

Why did I get the flu even though I got the flu shot?
The flu shot does not guarantee 100% protection, but it is the best way to try and protect yourself and others.8 There are a few possible reasons why you may have gotten the flu despite getting vaccinated. You may have been exposed to the flu virus before you got the flu shot or during the two weeks it takes your body to create antibodies which help provide the protection.8 Also, the virus you may have been exposed to might not have been included in the vaccine for that season.8 The vaccine provides protection for the most common circulating strains, but not all strains.8 Furthermore, the protection one gets depends on their overall health and age. 8

Helpful Links to Help Update Your Influenza Knowledge:

References
  1. Grohskopf LA, Sokolow LZ, Broder KR, et al. Prevention and control of seasonal influenza with vaccines: Recommendations of the Advisory Committee on Immunization Practices — United States, 2017–18 Influenza Season. MMWR Recomm Rep 2017;66 (No. RR-2):1–20. DOI: http://dx.doi.org/10.15585/mmwr.rr6602a1.
  2. Bhaidani, S. [Hey Pharmacist]. (2017, October 4). Giving the Flu Shot? Here's 5 Things to Know
  3. [Video File]. Retrieved from https://www.youtube.com/watch?v=F4P9kyOOY_Q&t=216s
  4. National Advisory Committee on Immunization. Advisory Committee Review: Canadian Immunization Guide Chapter on Influenza and Statement on Seasonal Influenza Vaccine for 2017-2018: https://www.canada.ca/en/public-health/services/publications/healthy-living/canadian-immunization-guide-statement-seasonal-influenza-vaccine-2017-2018.html
  5. Centre for Disease Control and Prevention. (2017, September 19). Flu Vaccine Safety and Pregnancy. Retrieved from https://www.cdc.gov/flu/protect/vaccine/qa_vacpregnant.htm
  6. Centre for Disease Control and Prevention. (2016, September 2). Flu Vaccine and People with Egg Allergies. Retrieved from https://www.cdc.gov/flu/protect/vaccine/egg-allergies.htm#algorithm-graphic
  7. Ministry of Senior Affairs. (2017, November 7). Aging with Confidence: Ontario’s Action Plan for Seniors. Retrieved from https://news.ontario.ca/oss/en/2017/11/aging-with-confidence-ontarios-action-plan-for-seniors.html
  8. Centre for Disease Control and Prevention. (2016, August 25). Seasonal Flu Shot Question and Answers. Retrieved from https://www.cdc.gov/flu/about/qa/flushot.htm
  9. Centre for Disease Control and Prevention. (2017, October 26). Frequently Asked Flu Questions 2017-2018 Influenza Season. Retrieved from https://www.cdc.gov/flu/about/season/flu-season-2017-2018.htm
  10. Mulholland, A. (2017, October 16). Flu shot or nasal spray? Conflicting studies lead to confusion. Retrieved from http://www.ctvnews.ca/health/flu-shot-or-nasal-spray-conflicting-studies-lead-to-confusion-1.3633892