Seasonal Preparedness Resource

Last Updated: December 2, 2025

No Results Found 0/0

This resource is designed to help clinicians plan and prepare for respiratory season. It offers guidance on chronic condition optimization, practice management, immunizations, seasonal illness testing and management and IPAC recommendations.

Summary checklist

The following image provides a high-level summary of key seasonal preparedness activities. For more information, explore the detailed content below.  

Expand All

Chronic condition optimization

Chronic conditions like asthma, COPD, and heart failure often worsen during respiratory season. Proactive management—including timely assessment, individualized action plans and appropriate education for people living with these conditions— can help reduce complications, improve outcomes and support stability during high-risk periods. 

Jump to:

Asthma and COPD

Key messages1–5

  • Minimize exposure to known triggers and optimize daily therapy.
  • Encourage vaccination and good hygiene to prevent respiratory infections.
  • Support self-management with a personalized action plan and ensure medication readiness.

COPD and asthma are chronic respiratory diseases that can worsen during respiratory season due to cold air, viral infections and other environmental triggers.

Both conditions are associated with significant morbidity during respiratory season, but with proper management, most exacerbations are preventable.

Risk stratification
Click for details
Close

Risk stratification

COPD5,8–10
  • The risk of acute exacerbation can be assessed by:
    • History of past acute exacerbations of COPD (i.e., timing, frequency, severity and hospitalizations).
    • Severe and worsening airflow obstruction (based on spirometry results).
    • Presence of chronic bronchitis.
  • Low risk of exacerbation:  ≤1 moderate exacerbation in the past year and did not require ER visit or hospitalization.
  • High risk of exacerbation:  ≥ 2 moderate or ≥1 severe exacerbation in the last year, requiring hospital admission or ED visit.
Asthma 4,6
  • Mild exacerbation: an increase in asthma symptoms from baseline that does not require systemic steroids, an emergency department visit, or a hospitalization. Differentiating this from chronic poorly controlled asthma may only occur retrospectively.
  • Severe exacerbation: an exacerbation requiring any of the following:
    • Systemic steroids
    • Emergency department visit
    • Hospitalization
  • Higher risk of exacerbation:
    • History of severe exacerbation requiring systemic steroids, ED visit and/or hospitalization
    • Poorly controlled asthma
    • SABA overuse (>2 inhalers/year)
    • Current smoker or vape use

Management optimization for respiratory season

Annual review & risk assessment4,6,11,12
  • Conduct an annual assessment (or more frequent if control is poor or after a recent exacerbation) to prepare for respiratory season:
    • Evaluate symptom control, lung function (spirometry as needed) and history of exacerbations.
    • Review medication adherence, inhaler technique and trigger exposures.
    • Identify comorbidities impacting control (e.g., GERD, OSA, depression).
    • Identify impact of social determinants on accessing supports (e.g., education, employment, housing, income, geographic location, transportation, access to care).
Prevent respiratory infections1,3,5,12
  • Immunizations:
    • Annual influenza (OHIP covered)
    • SARS-CoV-2 (OHIP covered)
    • Pneumococcal – consult current recommendations
    • RSV prevention product (OHIP covered for high-risk individuals 60+ and may be purchased for others 60+)
    • TD (booster) – every 10 years (COPD-specific)
    • Shingles (OHIP covered for those between 65-70 years old) (COPD-specific)
    • See seasonal and respiratory immunizations section for more information.
  • Hygiene and exposure reduction:
    • Handwashing and hand sanitizers
    • Avoid face touching
    • Avoid close contact with sick individuals
    • Clean and disinfect surfaces (caution around cleaning agents that can trigger asthma symptoms)
    • Masking in crowded indoor spaces; encourage in cold, windy or high-pollen conditions to help manage allergies.
  • Encourage smoking cessation.
  • Refer to pulmonary rehabilitation if indicated for individuals living with COPD with high symptom burden and risk of exacerbation. See the Lung Health foundation virtual Fitness for Breath classes and exercise videos for more information.
Manage triggers
  • Ensure individuals are prepared and understand common seasonal triggers and environmental control strategies.
Season
Triggers
Strategies

Summer12–16 

  • Environmental triggers: pollen, pet dander, dust mites, mould, smog, humidity 
  • Heat 
  • Smoke: cigarette, cigar, fireplace, wood burning stove or campfire 
  • Overexertion 
  • Check the Pollen Count and local Air Quality Health Index before going outside. Discuss what these numbers mean and how they can make symptoms worse.
  • Schedule physical activity during cooler parts of the day (e.g., morning or evening) and indoors when possible. 
  • Avoid scented products and smoke. 
  • Take breaks when overexerted. 
  • Stay hydrated.
  • Use AC and keep windows closed to minimize exposure to allergens. For more information for OW and ODSP individuals see: https://link.cep.health/sphtml25

Respiratory season1,3,14,15

  • Environmental triggers: cold air (wear mask/scarf), viral infections (see prevent respiratory infections section).
  • Holiday-specific exposures: real trees may carry mould or dust.
  • Allergen and irritant reduction. 
  • Consider Air Quality Health Index before going outside
  • Rinse trees or opt for artificial trees. Clean stored decorations before use. 
  • Improve air filtration (provide recommendations), avoid scented products and smoke, minimize dust/mould. 
  • Ensure individuals are up to date with immunizations. See prevent respiratory infections for more information. 

Self-management and action plans5-7,11,12

Provide/refresh individualized action plans, including strategies for control (e.g., adherence, environmental considerations, trigger management), when to seek urgent care (worsening symptoms), medication management/adjustments, etc. Hospitalization may act as a natural trigger to initiate discussions with patients and their families on advanced care planning. 

Ensure medication readiness (30-day supply), and correct use of inhalers.

Encourage individuals to carry relievers at all times (e.g., at home and at work) and regularly check dose counter.

Referrals

Consider referral to specialized care for:4,6,7,17

Specialized care may include respirologists, allergists, Certified Respiratory Educator (CRE), Certified Asthma Educator (CAE) or other trained professionals.6,7 

Patient resources

Patient resources

Asthma

COPD

Heart failure

Key messages

  • Support self-management in different seasons with a personalized action plan.
  • Support management of any comorbidities that may be impacted by seasonal changes, such as COPD.
  • Encourage Immunization as part of seasonal activities in the person’s individualized care plan.

Heart Failure is a clinical condition where the heart is unable to pump enough blood to meet the demands of the body. The condition is complex, progressive and ultimately fatal. Heart Failure is often found alongside other conditions, with 37% of Ontarians experiencing four or more co-occurring chronic conditions. Seasonal weather such as extreme heat, may impact people with cardiovascular disease such as heart failure. While there is still more research needed on the ways in which the heat impacts cardiovascular disease and to what extent, it is important to consider this risk to cardiovascular health.18,19

Symptoms and Severity

Heart Failure’s hallmark symptoms include shortness of breath, fatigue and ankle swelling. There are different categories of people living with Heart Failure which include18,20,21:

The NYHA classification also describes degrees of symptom severity among people living with Heart Failure (PWHF). For more information, see CEP’s Heart Failure tool.

Seasonal preparedness for HF patients12,18

Review care plans
  • Review a person with Heart Failure’s at least every 6 months.
  • Consider timing follow-up appointments just before high-risk times of the year.
  • Consider the way seasonal changes may impact management of their condition and ensure the PWHF and their care partners are knowledgeable about seasonal changes to their care plan.
Prevent exacerbating illnesses
  • Relevant immunizations available in Ontario include:
    • Annual influenza (OHIP covered)
    • SARS-CoV-2 (OHIP covered)
    • Pneumococcal – consult current recommendations
    • RSV prevention product (OHIP covered for high-risk individuals 60+ and may be purchased for others 60+)
    • Shingrix (OHIP covered for seniors 65-70 who have not had a Zostavax® II vaccine) 
Be aware of worsening heart failure
  • Ensure the PWHF is aware of warning signs of worsening heart failure, has a plan for monitoring their symptoms and knows when to take action.
  • When gradual, worsening symptoms are reported, they should be assessed by a clinician and have their medications adjusted (as needed) within 48 hours.
  • For information on coordination of care and referrals see CEP’s Heart Failure tool or seek support from the Best Care program.
Season
Triggers
Strategies

Summer12,18,19,22

  • Heat and increased exertion (e.g., outdoor activities).
  • Dehydration, electrolyte imbalance, and related medication effects. 
  • Increased sodium intake (e.g., summer BBQs, etc.)  
  • Seasonal exacerbation of comorbid conditions.
  • Discuss safe exercise practices and if modifications need to be made during a heat wave. If unsure about safely meeting the physical activity goals, consider consulting a physiotherapist or kinesiologist. 
  • Counsel the person with heart failure about appropriate hydration during hotter than usual times. Be aware that the evidence base to support fluid restriction is limited, and severely limiting intake may have adverse consequences.
  • Consider any changes needed to prescribed diuretic medication.
  • Encourage the PWHF to monitor weight and symptoms daily to detect early signs of worsening heart failure. 
  • Monitor the individual’s dry weight and volume status. 
  • Counsel on appropriate diet and sodium intake. 
  • Discuss and share resources on self-management strategies for the season.
  • Discuss management of co-occurring conditions, such as COPD in summer.

Winter12,18,23,24

  • Cold weather and increased exertion (e.g., snow removal, walking through heavy snow).
  • Reduced physical activity.  
  • Seasonal illnesses, such as respiratory viruses (possible increased risk of worsening heart failure).  
  • Risk of weather impacts, social isolation and travel considerations. 
  • Increased sodium intake (holiday events, etc.).  
  • Seasonal exacerbation of comorbid conditions.
  • Advise keeping warm and wearing appropriate layers of clothing.
  • Discuss safe exercise practices and if modifications need to be made during cold weather. If unsure about safely meeting the physical activity goals, consider consulting a physiotherapist or kinesiologist. 
  • Encourage the PWHF to obtain annual immunizations.
  • Encourage the PWHF to monitor weight and symptoms daily to detect early signs of worsening heart failure.  
  • Encourage the PWHF to maintain a supply of their prescribed medication in case of winter weather and difficulty with travel. 
  • Counsel on appropriate diet and sodium intake.  
  • Discuss and share resources on self-management strategies for the season.
  • Discuss management of co-occurring conditions such as COPD in winter.

Patient resources

Practice management during respiratory season

This section shares strategies to optimize managing your practice, helping streamline workflows and improve efficiency during the busy fall and winter seasons. It draws on ideas, and resources from various primary care practice models across Ontario. You are encouraged to select and adapt strategies that best fit your context. 

Jump to:

Planning and proactive strategies

Patient communication and education12
  • Share educational messages and resources to help patients make informed decisions (e.g., when to seek in-person care vs self-manage symptoms). 
Proactive patient outreach12,25
  • Encourage seasonal immunizations for all eligible patients. Use multiple channels to maximize engagement. 
    • Clinic website, email campaigns and social media posts that include a booking link or front-desk contact details. 
    • Clinic voicemail message with reminders about seasonal immunizations. 
    • Signage displayed in waiting room as a seasonal reminder. 
    • Recall reminders within EMR to identify eligible patients and prompt outreach activities. 
    • Printed letters sent by mail or direct telephone calls to patients without email access, especially older adults. 
  • Identify high-risk patients for whom seasonal vaccines are recommended, recognizing that eligibility and risk groups vary by vaccine (e.g., age 5 and under, older adults, comorbidities, chronic diseases such as COPD and asthma). 
  • Reach out to high-risk patients with seasonal vaccine recommendations, information on accessing testing and antiviral options.
  • Consider hosting a dedicated ‘Vaccine Day’ to administer the flu shot and other recommended respiratory illnesses vaccines. 
  • Direct patients to convenient vaccination sites, including community pharmacies, as needed.

Effective teamwork and workflow strategies

 Teamwork and coordination12,27-31 
  • If feasible, ensure nurses are integrated into vaccination planning and delivery. For example, nurses played a key role in supporting their teams during the COVID-19 pandemic. These same roles are also critical during respiratory illness season. See contributions for ideas.
  • Consider implementing instant messaging tools to facilitate communication with staff.
  • Hold regular clinical and staff meetings to share learnings from webinars, review workflows and discuss challenges.
  • Consider employing the following strategies to involve other team members in vaccination efforts. See table.
  • If delegating controlled acts in your practice, consider OMA’s delegation checklist to ensure you have met CPSO’s standards and confirm that all staff are trained.

Strategy

Practical application

Engage nurses and pharmacists as educators and administrators 

Leverage trusted relationships to provide vaccine education, address hesitancy and administer seasonal vaccines. 

Target outreach efforts 

Assign nurses or allied staff (e.g., social workers) to reach high-risk or underserved populations through reminder calls, community clinics or home visits. 

Embed vaccine promotion within care 

Incorporate seasonal immunization discussions into routine visits for chronic disease management, wellness checks and follow-ups. 

Where possible, integrate team-based planning 

Involve social workers, pharmacists, administrative staff and allied health professionals in scheduling, coordinating patient communications and information documentation. 

Managing patient access12
  • Encourage patients to see other clinicians in the same clinic if their regular clinician is unavailable. 
  • Schedule symptomatic patients at the end of the day to minimize exposure. 
  • If feasible:
    • Have multiple staff members answer incoming calls to improve responsiveness. 
    • Offer expanded weekday evening and weekend hours to increase accessibility when demand is high. 
    • Schedule overlapping appointments to maximize efficiency. 
    • Reserve 30 minutes daily for same-day appointments, prioritizing patients with respiratory concerns and with flexibility to increase this when demand is high. 
  • Consult OMA’s scheduling tips to help improve scheduling efficiency. 
Optimizing workflows12
  • Use public health disease surveillance data to help inform clinical identification of illnesses.
  • Train front office staff to screen calls for priority, severity, appointment type (in-person vs virtual) and timing (e.g., end of day for symptomatic patients). 
  • Use direct EMR-based email communication (e.g., sending requisitions) to patients, without adding to staff workload. 

 

Documentation and EMR efficiency12 
  • Remind patients to request that labs, specialists and other external providers (e.g., pharmacists) copy your practice on test results and visit notes to ensure complete and accurate documentation. 
  • Consider using templated notes to improve efficiency. For those interested, AI Scribes may be a helpful option. 
  • Ask patients to keep their immunizations records up to date and record vaccinations in the EMR immunizations section.

Immunization tracking options for patients:

Seasonal and respiratory immunizations

Jump to:

Seasonal immunizations can be ordered through usual vaccine sources (e.g., local public health unit or OGPMSS) in the same manner as routine immunization products.

Role of Public Health Units (PHUs) vs primary care in immunizations:32

  • PHUs: Manage inventory and distribute vaccines and immunizing agents to primary care and pharmacies
  • Primary care: Administer vaccines to eligible Ontarians OR advise patients where to get immunized (e.g., community pharmacies). See COVID-19 and flu vaccine pharmacy locations.

Influenza (annual seasonal vaccines and trivalent preparations) 

Eligibility and availability35,36

Universal Influenza Immunization Program (UIIP)

  • Free influenza vaccine each year for individuals ≥ 6 months who live, work, or go to school in Ontario.  
  • Individuals without a health card can receive the influenza vaccine from: 
    • Community health centres 
    • Participating pharmacies 
    • Local public health units or other community clinics  

Individuals can contact their local public health unit if they require assistance locating the influenza vaccine. 

New for 2025: Switch from quadrivalent inactivated vaccines (QIV) to trivalent inactivated vaccines (TIV) for influenza vaccines.35

High-risk populations

The following individuals are at increased risk of influenza-related complications or are more likely to require hospitalization and should receive the influenza vaccine as soon as it becomes available in the fall: 

  • Adults ≥ 65 years.  
  • All children 6 months to 4 years of age. 
  • Individuals 6 months of age and older with the following underlying health conditions: 
    • Cardiac or pulmonary disorders. 
    • Conditions or medications which compromise the immune system. 
  • To optimize co-administration with the COVID-19 vaccine, priority populations may also receive the influenza vaccine as soon as it becomes available in the fall. 

General population

All individuals (6 months of age and older without contraindications) who do not belong to the high-risk or priority populations may receive the influenza vaccine starting on October 27, 2025. Individuals in the following two groups are particularly recommended to receive the influenza vaccine, once eligible: 

  • Individuals capable of transmitting influenza to those listed in the high-risk populations section above and/or to infants under 6 months of age: 
    • Household contacts (adults and children) of individuals at high risk of influenza-related complications.  
    • Persons who provide care to children ≤ 4 years of age. 
    • Members of a household expecting a newborn during the influenza season.   
Available products and indications35,36 

Publicly funded influenza vaccines available include: 

Trivalent Inactivated Vaccine (TIV) for individuals ≥6 months of age

High-Dose Trivalent Inactivated Vaccine (TIV-HD) for ≥65 years

Adjuvanted Trivalent Inactivated Vaccine (TIV-adj) for ≥65 years

Billing:37

Family Health Organization (FHO) or Family Health Network (FHN)

  • Sole purpose for visit: G590 — flu vaccine
  • With assessment: G590 — flu vaccine + assessment fee code

Fee for service

Sole purpose for visit:

  • Fee: $5.65 + $5.60
  • Fee code: G590 + G700

Add-on visit:

  • Fee: $5.65
  • Fee code: G590

Note: The TIV-HD and TIV-adj vaccines should be offered, when available, over TIV influenza vaccines for adults 65 years of age and older. 

Vaccine schedule35,36

Age

# of doses recommended for the current season 

6 months to under 9 years of age – Not previously immunized with any influenza vaccine in their lifetime 

2 doses at least 4 weeks apart* 

6 months to under 9 years of age – Previously immunized with at least one dose of any influenza vaccine in their lifetime 

1 dose

≥ 9 years 

1 dose

*It is NOT necessary to use the same vaccine product for both doses. 

Contraindications35,36
Influenza vaccines should not be given to:
  • Individuals who have had an anaphylactic reaction to a specific influenza vaccine, or to any of the components (offer another influenza vaccine that does not contain that component) except for egg.
Precautions35,36 

  • Postpone in individuals with serious acute illnesses until their symptoms have improved.
  • Individuals who have developed Guillain-Barré Syndrome (GBS) within six weeks of a previous influenza vaccination should generally not be vaccinated; however, this should be weighed against the risks of not being vaccinated against influenza.

 

COVID-19

Eligibility and availability38

High-risk populations group 1

The following individuals are at increased risk of COVID-19 and should receive COVID-19 vaccine dose(s) as soon as it becomes available in the fall AND should receive an additional dose in the spring: 

  • Adults ≥ 80 years  
  • Individuals ≥ 6 months who are moderately to severely immunocompromised (due to specific underlying condition or treatment). 

Adults aged 65 to 79 years should receive COVID-19 vaccine dose(s) as soon as it becomes available in the fall AND may receive an additional dose in the spring.  

High-risk populations group 2

The following individuals are at increased risk of SARS-CoV-2 exposure or severe COVID-19 and should receive COVID-19 vaccine dose(s) as soon as it becomes available in the fall: 

  • Residents in long-term care homes and other congregate living settings who are aged 17 years and under. 

Priority populations

To co-administrator with influenza vaccine, the following individuals, may receive COVID-19 vaccine dose(s) as soon as it becomes available in the fall: 

  • Children 6 months to 4 years of age 

General population

All individuals (6 months of age and older) who do not belong to the high-risk or priority populations may receive COVID-19 vaccine dose(s) in the fall, starting on October 27, 2025. 

New for 2025/2026: 

  • High-risk groups and priority populations remain the same; however, high-risk populations have been divided into two groups.  
  • For individuals who have completed their primary series, only the minimum interval between subsequent doses is specified. 

The lists above focus on individuals impacted by seasonal respiratory concerns. For the full list, see:  MOH COVID fact sheet, 2025. 

Available products and indications38

The COVID-19 vaccines available include:

Moderna Spikevax

Pfizer-BioNTech Comirnaty

Vaccination schedule38
Co-administation38
  • The COVID-19 vaccines may be given at the same time as other vaccines, or at any time before or after other non-COVID-19 vaccines (live or non-live vaccines), including influenza and respiratory syncytial virus (RSV) vaccines and/or the RSV monoclonal antibody. 
  • If multiple injections are to be given at the same visit, separate limbs should be used or administer into the same muscle separated by at least 2.5 cm (1”).  
Contraindications and precautions38

Individuals with hypersensitivities may receive the COVID-19 vaccine under medical supervision. 

Precautions: 

  • Hypersensitivities and allergies to formulation 
  • Acute illness  
  • Bleeding disorders 
  • Myocarditis and/or pericarditis following vaccination 
  • Guillain-Barré Syndrome 
  • Bell’s palsy 
  • Multisystem Inflammatory Syndrome in children or adults (MIS-C or MIS-A) 

Fall doses can be received until March 31.  

Spring doses may be given only to severely immunocompromised individuals until August 31. 

RSV immunization for older adults

RSV prevention products authorized in Canada for individuals aged 60 and over:39-40 

Arexvy 

Abrysvo 

Both immunization products are recommended by NACI for RSV prevention in older adults.39-41 

Product

Dose

Timing and setting

Arexvy 

1 dose

(0.5 mL, intramuscular injection) 

  • Beginning of RSV season for optimal protection.  
  • Available before, during or at the end of RSV season  (Ontario RSV site). 
  • Primary care (publicly funded) 
  • Pharmacy with prescription (privately funded) 

Abrysvo*** 

Same dosing as above

Same timing and setting as above

***Also available for pregnant individuals (32-26 weeks’ gestation) as part of the infant RSV prevention program. 

Eligibility and availability42-44
  • Adults aged 75 and older (new for 2025-2026) 
  • Adults aged 60 and older who are: 
    • Residents of long-term care homes, Elder Care Lodges, or retirement homes, including similar settings (e.g., co-located facilities). 
    • Individuals in hospital receiving alternate level of care (ALC), including similar settings (e.g., complex continuing care, hospital transitional programs). 
    • Individuals living with glomerulonephritis (GN) who are moderately to severely immunocompromised. 
    • Individuals receiving hemodialysis or peritoneal dialysis. 
    • Recipients of solid organ or hematopoietic stem cell transplants. 
    • Individuals experiencing homelessness. 
    • Individuals who identify as First Nations, Inuit, or Métis.  

If individuals received an RSV immunization in a previous season, they do not need another dose this respiratory season as studies show multi-year protection.42

Publicly funded RSV vaccines can be ordered through usual methods, via local public health units or the Ontario Government Pharmaceutical and Medical Supply Services (OGPMSS).42 

Billing: Use code ‘489— RSV Respiratory syncytial virus’ with the G538A fee code when an RSV immunization is given to a patient.45,46

RSV prevention for infants47  

Ontario is offering two products to prevent RSV in infants: 

  • Beyfortus (Nirsevimab)— A monoclonal antibody given to infants (just before first RSV season or second season for high-risk children) 
  • Abrysvo— An immunization product given during pregnancy (32-36 weeks gestational age) 

NACI recommends prioritizing the use of Beyfortus given its long-lasting effectiveness and protection. 

Pneumococcal

Eligibility and availability33,34
  • Invasive pneumococcal disease (IPD) is more common in winter and spring. 
  • Recommended for:
    • Routine program for infants and children 6 weeks to 4 years 
    • Routine program for 65+  
    • High risk program for those aged 6 weeks and older with certain conditions:  
      • Chronic cardiac disease   
      • Chronic respiratory disease, excluding asthma, except those treated with high dose corticosteroid therapy
Available products and indications33

Ontario’s publicly funded pneumococcal program has transitioned to two new vaccines:

Pneu-C-15

Pneu-C-20

The pneumococcal conjugate (Pneu-C) vaccine that is available for individuals aged 18 years and older per program eligibility is Prevnar 20 (Pneu-C-20). 

Type of vaccine

Vaccine name and eligible groups in Ontario

Pneumococcal conjugate

(Pneu-C) 

  • Prevnar 20 (Pneu-C-20): Individuals ≥6 weeks of age and older at high risk for IPD and individuals ≥65 years of age at low risk for IPD. 
  • Vaxneuvance (Pneu-C-15): Children 6 weeks to 4 years of age at low risk for IPD.  
  • Prevnar 13 (Pneu-C-13): No longer publicly funded. Individuals previously eligible should receive either Pneu-C-15 or Pneu-C-20 depending on risk for IPD. 

Pneumococcal polysaccharide

(Pneu-P) 

  • Pneumovax 23 (Pneu-P-23): No longer publicly funded. Individuals previously eligible should receive Pneu-C-20. 
Vaccination schedule for adults meeting the following low-risk criteria:33

Age

# of previously received Pneu-P-23 doses 

# of Pneu-C-20 doses recommended  

18 to 64 years 

0 doses

0 doses

≥ 65 years 

0 doses

1 dose

≥ 65 years 

1 dose

0 doses  

Vaccination schedule for those meeting the following high-risk criteria:33
  • Chronic cardiac disease   
  • Chronic respiratory disease, excluding asthma, except those with asthma treated with high-dose corticosteroid therapy

Age

# of previously received Pneu-P-23 doses 

# of Pneu-C-20 doses recommended (0.5ml/dose) 

18 to 64 years 

0 doses

1 dose

18 to 64 years

1 dose

0 doses

≥65 years 

0 to 1 doses

1 dose 

Pneu-C-20 should be given 1 year after last dose of Pneu-P-23   

≥65 years 

2 doses

0 doses

Co-administration intervals33

  • Pneu-C and Pneu-C: 8 weeks minimum
  • Pneu-P-23 and Pneu-C: 1 year minimum
  • Pneu-C-20 vaccines may be given at the same time with other vaccines, or at any time before or after other vaccines.

Contraindications and precautions33

  • A pneumococcal conjugate vaccine should not be given to:
    • Individuals with a history of anaphylaxis after previous administration, and/or
    • Anaphylactic hypersensitivity to any component of the vaccine.
  • Only postpone administration of the pneumococcal vaccine for individuals with severe acute illness. Immunization should not be delayed because of minor acute illness, with or without fever.

Reporting adverse events following immunizations (AEFI)

Monitor adverse events:48

Storing and transporting vaccines

Maintaining the cold chain—from manufacturer to administration—is essential as breaks (temperature excursions) can cause irreversible potency loss.49 

Key practices:49,50

  • Store refrigerated vaccines at +2°C to +8°C; frozen vaccines at –15°C or colder, or as specified by product monograph (do not refreeze thawed vaccines). 
  • Keep vaccines in original packaging to prevent light/physical damage. 
  • Monitor and record storage/transport temperatures. 
  • Do not use expired or mishandled doses. 
  • Transport with insulated containers and temperature monitoring. 
  • Dispose of vaccines according to jurisdictional standards.  

 

 

Vaccine confidence and equitable access

Jump to:

Vaccine hesitancy12,27,31,51,52

Addressing hesitancy requires individualized and community-based approaches that consider the individual’s unique circumstances, lived experiences and cultural contexts. Promote respectful dialogue grounded in cultural safety and trauma-informed care, recognizing that hesitancy may stem from multiple factors.

Factors influencing vaccine hesitancy: 
  • Limited understanding of vaccines/limited information available in their language of choice.  
  • Conflicting/misleading information. 
  • Information overload/burnout. 
  • Limited access to vaccination services (or needing to go to multiple locations for different vaccines). 
  • Financial barriers (e.g., ability to take time off, cost of travel). 
  • Mistrust in institutions or industry motives.  
  • Concerns about side effects, pain or anxiety. 
  • Misconception of vaccine effectiveness. 
  • Sociocultural or religious beliefs.  

*PrOTCT Framework modified with permission from the Centre for Effective Practice. (December 2021) Constantinescu, Ivers. N., Grindrod. K. PrOTCT Framework: Ontario. Toronto: Centre for Effective Practice.

Improving access for underserved populations 

Culturally competent and safe care is essential to improving vaccination uptake and addressing inequities in the health system.53,54 

Supportive strategies52,54

Design supportive health care environments to create positive vaccination experiences, such as building trusted relationships, co-administration of vaccines to reduce travel time and costs, and embedding culturally safe practices. 

Build information environments with tailored communication and outreach (community-informed and culturally relevant) that fill in information gaps and counter misinformation. 

Indigenous considerations55

While overall vaccine confidence among First Nations, Inuit and Métis populations is high, coverage across regions remains uneven. These differences are shaped by systemic, social and intrapersonal factors that can act as barriers or facilitators to vaccine uptake. 

Barriers and facilitators

Barriers:

  • Mistrust in healthcare institutions
  • Patronizing or stigmatizing vaccine campaigns
  • Limited access to booking technologies
  • Language barriers
  • Travel challenges
  • Ineffective communication

Facilitators:

  • Clear, respectful communication about vaccine safety and importance
  • Prioritization of Indigenous populations in rollout
  • Consistency in vaccine brands for multi-dose series
  • Holistic supports (e.g., co-administering vaccines to reduce travel)

 

Barriers:

  • Circulation of misinformation within communities 
  • Anti-immunization attitudes within communities  

Facilitators:

  • Positive, trusting interactions with healthcare providers 
  • Supportive community environments 

 

Barriers:

  • Misconceptions about vaccines 
  • Previous negative health experiences 
  • Perception that alternatives (e.g., homeopathic medicine, vitamin D, natural immunity) are just as effective 
  • Preference for Traditional medicine over Western medicine 

Facilitators:

  • Altruism (desire to protect others) 
  • Trust in providers and health systems 
  • Strong personal perception of risk 

 

Seasonal illness testing and management

Jump to:

Symptoms:

While certain seasonal illnesses may be associated with particular symptom patterns, there is substantial overlap and variability in how illnesses present. Symptoms alone may not reliably distinguish between influenza, COVID-19, RSV, or other seasonal illnesses. Testing should be guided by clinical judgment, local epidemiology, and testing availability rather than symptom profiles alone.12

Testing

Eligibility and access: 

Interpretation and guidance:

  • Treat suspected influenza empirically with antivirals for those who are eligible for treatment, as testing is not routinely available in primary care and is not required when clinical suspicion is high. See influenza antiviral use section. 

 

Eligibility:

Publicly funded testing is available for individuals with COVID-19 symptoms and belonging to any of the following groups:  

  • 65 years of age or older 
  • 18 years of age or older and with at least one condition that puts them at higher risk of severe COVID-19 
  • Immunocompromised
  • In certain high-risk settings (e.g., hospital) or congregate settings with medically or socially vulnerable individuals (e.g., long-term care) 
  • In the context of suspected or confirmed outbreak  

Asymptomatic patients are not eligible for publicly funded testing. 

Access:

Interpretation and guidance:

  • Positive result: No confirmatory PCR needed for positive RATs to confirm diagnosis or to access to treatment for those who are eligible. 
  • Negative RAT: Less likely to be infected; for those eligible for treatment, repeat in 24–48 hours if symptoms persist. 
  • Negative PCR: Can be confident the individual is uninfected. 

 

Eligibility and access:

  • In most outpatient cases, lab testing is not performed; diagnosis is typically clinical and nonspecific (e.g., viral respiratory infection). 
  • In hospital settings, a nasopharyngeal swab is often performed. See PHOL’s Respiratory Viruses for more information.

 

Eligibility and access:

  • If suspected based on clinical evidence of invasive disease, collect specimens for S. pneumoniae from normally sterile sites (e.g., blood, CSF), excluding the middle ear. Sputum and bronchial lavages are not considered sterile specimens.
  • Note: Most individuals with suspected IPD are referred and tested in hospital settings.  

Interpretation and guidance:

  • Positive culture: confirmed IPD. 
    • Send isolates to PHOL for serotyping and further characterization. 
  • Negative culture: If IPD still suspected, consider NAAT/PCR testing.  
  • Positive NAAT (from normally sterile site): confirmed IPD. 

Note: These investigations, particularly NAAT/PCR testing, are generally performed on individuals in hospitalized settings. 

 

If pneumonia is suspected: 

  • Perform a physical exam (e.g., listen for abnormal lung sounds such as crackling).
  • Based on symptoms and physical exam results, consider ordering the following for further investigation: 
    • Chest X-ray: Determines presence, location and extent of infection.  
    • Blood test (CBC): Determines presence of infection.
    • Pulse oximetry: Determines oxygen level abnormalities.

Common pneumonia types:

  • Viral pneumonia: Typically caused by the same viruses that lead to upper respiratory tract infections, including influenza and RSV. Viral pneumonia is less serious than bacterial pneumonia but can be life-threatening for seniors, infants, immunocompromised individuals and pregnant individuals. 
  • Bacterial pneumonia: Most commonly caused by Streptococcus pneumoniae (pneumococcus), but also Mycoplasma pneumoniae, Chlamydia pneumoniae, and Legionella pneumophila. Often affects an entire lobe of the lung and can occur at any age. 
  • Mycoplasma pneumoniae, “walking pneumonia”: Majority of infections are asymptomatic but can often be the cause of many upper respiratory tract infections. Symptoms often develop gradually. 
    • For suspicions of mycoplasma pneumoniae, see PHO’s Mycoplasma pneumoniae- Respiratory PCR for more information on testing. 
    • Outbreaks occur every 3 to 7 years, when M. pneumoniae can account for 20-40% of community acquired bacterial pneumonia cases. As there was an increase in M. pneumoniae infections in 2024, cases are expected to be low now.

Management

Engage in shared decision-making with individuals. Set personalized goals, ensuring equitable care by recognizing and addressing systemic barriers and developing a clear self-management plan. This plan should integrate culturally appropriate care and healing practices and clearly outline when individuals should manage symptoms at home versus seek medical attention. 

Self-management tips for seasonal illnesses:12,56,63,72,73-80

Managing symptoms from influenza, COVID-19, RSV and mild pneumonia focuses on:

  • Rest
  • Fluids
  • Over-the-counter (OTC) medication (e.g., acetaminophen or ibuprofen) to reduce fever or aches.

If your symptoms include coughing or irritation:

  • Cough drops, honey (> 1 yr), OTC cough medicine, staying well hydrated
  • Elevate head with an extra pillow at night 
  • Avoid smoking
  • Apply petroleum jelly to irritated skin around nose and lips
  • Nasal irrigation
Illness

 

Management

 

Patient resources

 

Influenza12,56,74

 Consider prescribing antivirals if: 

  • There has been substantial influenza activity in the community.
  • Symptoms are severe and have been present for < 48 hours. 
  • The individual is eligible based on higher risk for complications. 

See influenza antiviral use section.  

 

COVID-1975,76

 Mild to moderate: 

  • Initiate antiviral therapy within the first few days of symptom onset to prevent serious illness in high-risk individuals. See COVID-19 antiviral use section.  

 

For severe to critical COVID-19, hospitalization may be required. 

 

 

RSV72,77

Educate parents about medication for children: 

  • Children < 6 years old should not take OTC cough and cold medicines.  
  • Children > 6 years old should only take the recommended dose.   

 

Healthy children and adults should recover on their own within 1-2 weeks. Severe RSV may require hospital admission for oxygen.  

 

Invasive Pneumococcal Disease (IPD)78,79

Antibiotic therapy is the standard treatment for individuals diagnosed with a pneumococcal infection.  

  • The bacterium that causes IPD usually disappears from the nose and mouth 24 hours after antibiotic treatment has begun. 
  • Hospitalization may be necessary for individuals with bacteremia (pneumococcal bacteria in the bloodstream) for close monitoring and supportive care.

 

Pneumonia63,80

Bacterial pneumonia: Amoxicillin is the first-line treatment:

  • Amoxicillin: 1000 mg PO TID for 5 days

Mycoplasma pneumoniae: Macrolides are generally considered for first-line treatment in adults: 

  • Erythromycin: 25–50 mg/kg/day for 14 days 
  • Clarithromycin: 10–15 mg/kg/day for 10 days 
  • Azithromycin: 10 mg/kg/day for 3 days 
  • Doxycycline: recommended as a second-line treatment, or for certain cases with macrolide-resistance. 
  • Fluoroquinolones: an alternative but generally contraindicated in children.

 

Those with severe pneumonia may need to be hospitalized for additional support (e.g., oxygen, antibiotics). 

 

 

Additional resources
Clinician resources:
Patient resources:

 

Influenza antiviral use12,81

Consider antivirals based on:

    Severity of illness. 

    Presence of risk factors or comorbid medical conditions. 

    Interval between onset of illness and initiation of antiviral therapy. 

    Likely influenza types causing infection. 

    Influenza activity in community (e.g., residence, congregate living centres).

Initiate treatment promptly. Benefits are greater if started within 12 hours of symptom onset.  

Initiate antiviral therapy even if administration of antiviral medication exceeds 48 hours, if:  

    Illness is severe enough to require hospitalization.

    Illness is progressive, severe or complicated.

    Individual belongs to a group at high risk for severe disease.

Influenza severity category
Definition

Non-severe

Sign and symptoms of:

  • Influenza-like illness (e.g., fever, malaise, chills, myalgia, systemic and upper respiratory tract). 
  • Upper respiratory tract symptoms (e.g., rhinorrhea, cough).  
  • GI symptoms of influenza (e.g., diarrhea, vomiting) AND 
  • Absence of any features of severe influenza. 

Severe

Signs and symptoms of: 

  • Progressive influenza illness (e.g., chest pain, tachypnea, laboured breathing, low blood pressure).   
  • Lower respiratory disease (e.g., hypoxemia, abnormal chest radiograph) with or without any of the following:  
    • Central nervous abnormalities  
    • Cardiovascular complications   
    • Renal abnormalities  
    • Myositis or rhabdomyolysis  
    • Septic shock or multi-organ failure  
    • New or increase respiratory support and/or vasopressor/ionotropic therapy  
    • Exacerbation of chronic medical conditions  

Treatment of non-severe seasonal influenza81

Age

Timeframe of symptom onset

Antiviral

< 1 year

N/A

Antiviral therapy not approved in Canada for treatment of seasonal influenza. 

1 year – < 5 years

All cases.

Oseltamivir  

5 years – < 18 years

With risk factors and within 48 hours.

 

With risk factors and beyond 48 hours.

Oseltamivir, inhaled zanamivir or baloxavir*

 

Oseltamivir or inhaled zanamivir 

≥ 18 years 

With risk factors and within 48 hours.

 

With risk factors and beyond 48 hours. 

Oseltamivir, inhaled zanamivir or baloxavir* 

 

Oseltamivir or inhaled zanamivir 

*Consider baloxavir for individuals who are contraindicated or unable to take oseltamivir or inhaled zanamivir, have influenza illness despite prophylaxis with a neuraminidase inhibitor (NAI), have known or suspected NAI-resistant influenza. Baloxavir has limited availability in Ontario. Updates on access and availability will be shared as they become available.

Treatment for severe seasonal influenza81

Age

Antiviral

< 1 year

Antiviral therapy not approved in Canada for treatment of seasonal influenza.

≥ 1 year

Oseltamivir is recommended as first-line therapy for severe seasonal influenza.

 

For individuals who have a contraindication to or are unable to take oseltamivir, have influenza illness despite oseltamivir prophylaxis, or have known or suspected oseltamivir-resistant influenza, consultation with an infectious disease specialist is recommended. 

Influenza antivirals81

Antiviral

Age and weight group

Treatment (5 days)

Oseltamivir

(PO/OG/NG)

1 – 12 years, and weight ≤ 15 kg 

 

1 – 12 years, and weight > 15 kg – 23 kg 

 

1 – 12 years, and weight > 23 kg – 40 kg  

 

≥ 13 years, and weight < 40 kg  

 

≥ 1 year, and weight > 40 kg

30 mg twice daily

 

45 mg twice daily

 

60 mg twice daily

 

60 mg twice daily

 

75 mg twice daily

Zanamivir 

(Inhaled, Dry Powdered Inhaler)

≥7 years 

10 mg twice daily 

(A second dose should be administered on the first day of treatment whenever possible, with at least 2 hours between doses. On subsequent days, doses should be 12 hours apart at approximately the same time each day). 

Baloxavir

20 kg to < 80 kg

 

Baloxavir for non-severe seasonal influenza in individuals < 12 years old who weigh < 40 kg is considered off-label use in Canada. 

 

≥ 80 kg

Single dose of 40 mg 

 

 

 

 

 

Single dose of 80 mg

Zanamivir (IV)

N/A

Zanamivir (IV) for severe seasonal influenza is considered off-label use in Canada and is administered within hospital settings. 

Peramivir (IV)

N/A

Peramivir is an IV-only antiviral for hospitalized individuals. Peramivir is approved for the treatment of non-severe seasonal influenza and can only be obtained through Health Canada’s Special Access Program. 

COVID-19 antiviral use68

COVID-19 antiviral treatments include: 

    Paxlovid

    Remdesivir**

**Complete the appropriate referral form(s) and submit to Ontario Health atHome. Individuals will receive infusions at a community nursing clinic. At-home service may be provided for homebound patients. 

 Consider antivirals if individuals:68

Have symptoms and test positive for COVID-19 (positive PCR or RAT).

Are at increased risk for severe outcomes, such as:

  • Age ≥ 65 years (regardless of vaccine status and any other risk factors).
  • Immunocompromised (regardless of age, vaccine status or prior COVID-19 infections).

Are at increased risk due to a combination of age and other medical conditions or risk factors (e.g., congregate living settings), based on clinician discretion. 

Parameter
Nirmatrelvir/Ritonavir (Paxlovid)
Remdesivir (Veklury)

Place in therapy

Preferred first-line therapy

Alternative when nirmatrelvir/ritonavir cannot be used 

Prescribing window 

Within 5 days of symptom onset 

Within 7 days of symptom onset 

Dosage

Nirmatrelvir 300 mg and ritonavir 100 mg orally twice daily for 5 days 

 

Dose adjust for renal impairment. For more details, see Paxlovid Prescribing and Drug Interaction Guide (University of Toronto and University of Waterloo). 

200 mg IV single dose on day 1, then 100 mg IV once daily on day 2 and day 3 

When to seek advanced care59,74,83

Consider an ED referral if the individual is experiencing any of the following: 

  • Trouble breathing (working hard to breathe or breathing faster than usual) 
  • Pale skin 
  • Lips that appear white or blue  
  • Extreme fatigue or difficulty waking up 
  • Prolonged or very high fever 
  • Repeated vomiting and unable to keep liquids down 
  • Vomiting or diarrhea containing a large amount of blood  
  • Signs of dehydration (e.g., dry mouth, no urination) 
  • Chest pain or pressure 
  • Dizziness or new onset confusion 
  • Severe muscle pain 
  • Worsening medical conditions 

When referring patients to the ED, contact the charge nurse or physician and provide the individual’s medical history.12

Patient resources

Visit Health811 online or call 811 to speak with a registered nurse 24 hours a day, seven days a week. 

IPAC recommendations

IPAC support:

Public Health Ontario (PHO) supports the Ministry, public health units and professional colleges, but is not a regulatory agency and does not inspect premises or practices. PHO provides resources that assist community-based medical practices in improving routine IPAC practices, medication safety, reprocessing of reusable medical devices and environmental cleaning. 

Need help accessing or applying these IPAC resources? Email ipac@oahpp.ca. 

Personal protective equipment26,84
  • Maintain sufficient PPE inventory and order free supplies via the PPE Supply Portal as needed (see PPE Supply Portal FAQs). Appropriate PPE includes medical masks, N95 respirators, eye protection (goggles, face shield), gowns and gloves.
  • Conduct a point-of-care risk assessment (pg 14) for every patient interaction to determine the risk of exposure to infectious agents and apply appropriate personal protective measures.

Equipment

Appropriate use

Medical masks (or N95 respirator, fit-tested, seal checked or equivalent)12,26,84

  • Recommended when providing direct patient care, and in the reception and waiting areas if physical distance or separation by a physical barrier is not feasible. 
  • For health care workers (HCWs): wear a mask for each patient interaction and in meeting rooms/non-patient facing clinical areas. Wear N95 respirator for aerosol-generating procedures or when caring for patients who may have airborne infectious agents (e.g., TB).
    • Replace your mask between patients unless you are following a continuous masking approach (i.e., keeping the same mask for a period of time). 
    • Always discard your mask when soiled, damp or damaged. 
    • Perform hand hygiene before putting on and after removing a mask. 
  • For patients and care partners: Consider continuous/universal masking protocols in common areas. See OCFP’s “Reminder to wear mask” printable sign.  
    • If you are not implementing continuous / universal masking, make masks available and encourage symptomatic patients/care partners to wear one if they are experiencing respiratory symptoms and are able to do so, to minimize exposure and reduce the risk of transmission during respiratory outbreaks.

Gloves84

  • Wear gloves for contact with mucous membranes, non-intact skin (including undiagnosed rashes), blood, bodily fluids, or contaminated equipment or surfaces. 
  • Perform hand hygiene before putting on gloves and after. 
  • Discard gloves immediately after removal. Do not re-use or wash gloves. 
  • Replace gloves between patients. 

Gowns84,85

  • Wear a gown when providing care that may contaminate skin or clothing with bodily fluids. 
  • Discard gowns immediately after removal. Do not re-use or wash gowns. 
  • If you have access to and are using launderable gowns, launder them after each use.
  • Perform hand hygiene after removing a gown. 

Eye protection (disposable or reusable goggles, face shields)84 

  • Put on eye protection when within 2 metres of the patient and splashes or sprays of blood/body fluids/excretions are anticipated (e.g., collecting naso-pharyngeal swab), and remove it immediately after the care activity.
Hand hygiene12,84
  • Practice hand hygiene according to the ‘4 Moments of Hand Hygiene.’ 
  • Ensure hand hygiene products are available in the waiting area: 
    • Alcohol-based hand rub (ABHR) in disposable containers (do not top up) for use when hands are not visibly soiled. Installing non-refillable ABHR dispensers enhances adherence to hand hygiene. 
    • An accessible sink with plain liquid soap in disposable pump bottles (no bar soaps; do not top up) for use when hands are visibly soiled. 
    • Moisturizer compatible with hand hygiene products to help maintain skin integrity. 
  • Ask all patients, visitors and care partners to perform hand hygiene upon arrival and departure. See Toronto Public Health’s hand washing and hand sanitizing posters, available in multiple languages. 
  • Use these short videos to train your staff on proper hand hygiene: How to Hand Rub and How to Hand Wash by PHO.  
Physical space considerations12,26,84
  • Encourage symptomatic patients to identify themselves upon entry. See PHO’s sample reception sign (pg 27). 
  • Where feasible, implement strategies to reduce exposure to symptomatic patients and facilitate physical distancing, such as: 
    • Install hard surface partitions (e.g., glass or plexiglass) in the reception area where HCWs are exposed to potentially infectious patients before to screening. Physical barriers should be cleaned and disinfected regularly and when visibly dirty. 
    • Place symptomatic patients and their accompanying care partners directly into an exam room upon arrival, or in separate waiting areas in rooms that are easy to clean and disinfect (e.g., remove high-touch items such as magazines and toys) (Expert Opinion). If separate rooms are unavailable, use physical barriers such as room dividers or privacy curtains to minimize exposure between symptomatic and non-symptomatic patients. 
    • Designate separate entrances for symptomatic patients. 
    • Designate an exam room closest to the entrance for symptomatic patients. 
    • Move or remove furniture/seating to prevent close contact. If reconfiguration is not possible, implement alternating chair use to maintain spacing. 
    • Re-arrange seating so symptomatic patients are facing away from non-symptomatic patients (i.e., back-to-back seating). 
    • Minimize crowding by limiting the number of care partners that may accompany a patient. 
  • Maintain healthier indoor air quality by using natural ventilation (such as safely opening windows and doors) or filtration devices equipped with HEPA filters to reduce the concentration of infectious respiratory particles in your practice. 
  • Ensure your facility’s HVAC system – responsible for heating, air conditioning and ventilation – is inspected by a qualified professional every 6 months to confirm it is functioning properly.
Healthy workplace policies12,26,84,86,87
  • Ensure HCWs’ immunizations are up to date to protect themselves, indirectly protect patients, and help prevent work absences. 
    • Measles, mumps, rubella (MMR vaccine – 2 doses), pertussis (1 dose Tdap as an adult), varicella (2 doses for those non-immune or presumed so), hepatitis B (complete series), tetanus (every 10 years), influenza (annual vaccine), COVID-19 (annual vaccine).  
  • Implement attendance management policies that outline when symptomatic HCWs should stay home or leave and return to work. 
  • Promote respiratory etiquette when coughing and sneezing. See PHO’s “Cover your cough” printable sign.
    • Turn head away from others, 
    • Cover nose and mouth with a tissue, 
    • Dispose of tissues immediately after use into waste bin, and 
    • Perform hand hygiene after tissue disposal. 
    • Wear a mask to protect others.
Environmental cleaning and disinfection84
  • Clean, disinfect and/or sterilize patient care equipment based on the intended use and potential risk of infection involved. 
  • Clean public areas (waiting areas and offices) with a detergent. 
  • Clean clinical areas (exam rooms and bathrooms) and medical equipment/devices daily with a detergent followed by a hospital-grade disinfectant with a drug identification number (DIN). See list of surface disinfectants approved by Health Canada. 
  • Clean and disinfect high-touch surfaces at least once daily, with increased frequency in areas at higher risk for contamination. 
  • For additional items and their cleaning schedule, see PHO’s frequency of cleaning items (pg 43). 

References