Immunization Resources for Pharmacists

Transcription

1 Immunization Resources for Pharmacists TABLE OF CONTENTS Child / Teen Resources Screening Questionnaire Child/Teen... 3 Vaccine Schedule Age 0-6yrs... 5 Catch-Up Schedule 4mo-18yrs... 6 Vaccine Schedule Age 7-18yrs... 7 Summary of Recommendations... 9 Medical Management of Vaccine Reactions Child/Teen Emergency Protocol for Anaphylaxis Child/Teen Ages and Intervals Between Doses Updated WA Mercury Law Adult Resources Screening Questionnaire Adult Vaccine Schedule Adult Guidelines for Vaccinating Pregnant (and breastfeeding) Women. Summary of Recommendations... Contraindications and Precautions... Medical Management of Vaccine Reactions Adult... Emergency Protocol for Anaphylaxis Adult... HALO chart... Pneumococcal polysaccharide vaccine pocket guide... Vaccine Administration: Dose, Route, Site, Needle Size... Administering Intradermal TIV.. 53 Administration Guidelines for Flumist Supplies Checklist for Immunization Clinic Vaccines with Dilutents: How to use them. 56 Billing Medicaid reimbursement Medicare Quick Reference Handling and Storage Vaccine Handling tips Checklist for Safe Handling and Storage... 6 Temperature Log... Emergency Response What to do in case of power failure... Immunization Clinic Tools and Handouts Vaccine Administration Record... Information about Washington State Immunization Information System Notification of Vaccination Letter... 7 Vaccine Information Statement and Inactivate Influenza VIS... 7 Do I need any vaccinations today? Adult questionnaire... 7 Immunization and Pregnancy patient handout... 8 Adult recommendation patient handout... 8 Reliable resources... US Vaccines. Last Updated April

2 THIS PAGE INTENTIONALLY LEFT BLANK 2

3 Patient name: Date of birth: (mo.) (day) (yr.) Screening Checklist for Contraindications to Vaccines for Children and Teens For parents/guardians: The following questions will help us determine which vaccines your child may be given today. If you answer yes to any question, it does not necessarily mean your child should not be vaccinated. It just means additional questions must be asked. If a question is not clear, please ask your healthcare provider to explain it. 1. Is the child sick today? 2. Does the child have allergies to medications, food, a vaccine component, or latex? 3. Has the child had a serious reaction to a vaccine in the past? Yes No Don t Know 4. Has the child had a health problem with lung, heart, kidney or metabolic disease (e.g., diabetes), asthma, or a blood disorder? Is he/she on long-term aspirin therapy? 5. If the child to be vaccinated is between the ages of 2 and 4 years, has a healthcare provider told you that the child had wheezing or asthma in the past 12 months? 6. If your child is a baby, have you ever been told he or she has had intussusception? 7. Has the child, a sibling, or a parent had a seizure; has the child had brain or other nervous system problems? 8. Does the child have cancer, leukemia, HIV/AIDS, or any other immune system problem? 9. In the past 3 months, has the child taken medications that weaken their immune system, such as cortisone, prednisone, other steroids, or anticancer drugs, or had radiation treatments? 10. In the past year, has the child received a transfusion of blood or blood products, or been given immune (gamma) globulin or an antiviral drug? 11. Is the child/teen pregnant or is there a chance she could become pregnant during the next month? 12. Has the child received vaccinations in the past 4 weeks? Form completed by: Date: Form reviewed by: Date: Did you bring your child s immunization record card with you? yes no It is important to have a personal record of your child s vaccinations. If you don t have one, ask the child s healthcare provider to give you one with all your child s vaccinations on it. Keep it in a safe place and bring it with you every time you seek medical care for your child. Your child will need this document to enter day care or school, for employment, or for international travel. Technical content reviewed by the Centers for Disease Control and Prevention Item #P4060 (10/12) Immunization Action Coalition 1573 Selby Ave. St. Paul, MN (651)

4 Information for Health Professionals about the Screening Checklist for Contraindications (Children & Teens) Are you interested in knowing why we included a certain question on the screening checklist? If so, read the information below. If you want to find out even more, consult the references listed at the bottom of this page. 1. Is the child sick today? [all vaccines] There is no evidence that acute illness reduces vaccine efficacy or increases vaccine adverse events (1, 2). However, as a precaution with moderate or severe acute illness, all vaccines should be delayed until the illness has improved. Mild illnesses (such as otitis media, upper respiratory infections, and diarrhea) are NOT contraindications to vaccination. Do not withhold vaccination if a person is taking antibiotics. 2. Does the child have allergies to medications, food, a vaccine component, or latex? [all vaccines] If a person reports they have an allergy to egg, ask if they can eat lightly cooked eggs (e.g., scrambled eggs). If they can, trivalent influenza vaccine (TIV) may be administered. If after eating eggs or egg-containing foods, they have a reaction consisting of only hives, TIV may be given and the person should be observed for at least 30 minutes. If a person experiences a serious systemic or anaphylactic reaction (e.g., hives and either swelling of the lips or tongue, acute respiratory distress, or collapse) after eating eggs, do not administer TIV or live attenuated influenza vaccine (LAIV). It is possible that they may be eligible to be given TIV, but only after they have seen a physician with expertise in the management of allergic conditions. If a person has anaphylaxis after eating gelatin, do not administer LAIV, measles-mumps-rubella (MMR), MMR+varicella (MMRV), or varicella vaccine. A local reaction is not a contraindication. For a table of vaccines supplied in vials or syringes that contain latex, go to gov/vaccines/pubs/pinkbook/downloads/appendices/b/latex-table.pdf. For an extensive table of vaccine components, see reference Has the child had a serious reaction to a vaccine in the past? [all vaccines] History of anaphylactic reaction (see question 2) to a previous dose of vaccine or vaccine component is a contraindication for subsequent doses (1). History of encephalopathy within 7 days following DTP/DTaP is a contraindication for further doses of pertussis-containing vaccine. Precautions to DTaP (not Tdap) include the following: (a) seizure within 3 days of a dose, (b) pale or limp episode or collapse within 48 hours of a dose, (c) continuous crying for 3 or more hours within 48 hours of a dose, and (d) fever of 105 F (40 C) within 48 hours of a previous dose. There are other adverse events that might have occurred following vaccination that constitute contraindications or precautions to future doses. Under normal circumstances, vaccines are deferred when a precaution is present. However, situations may arise when the benefit outweighs the risk (e.g., during a community pertussis outbreak). 4. Has the child had a health problem with lung, heart, kidney, or metabolic disease (e.g., diabetes), asthma, or a blood disorder? Is he/she on long-term aspirin therapy? [LAIV] Children with any of the health conditions listed above should not be given the intranasal, live attenuated influenza vaccine (LAIV). These children should be vaccinated with the injectable influenza vaccine. 5. If the child to be vaccinated is between the ages of 2 and 4 years, has a healthcare provider told you that the child had wheezing or asthma in the past 12 months? [LAIV] Children who have had a wheezing episode within the past 12 months should not be given the live attenuated influenza vaccine. Instead, these children should be given the inactivated influenza vaccine. 6. If your child is a baby, have you ever been told that he or she has had intussusception? [Rotavirus] Infants who have a history of intussusception (i.e., the telescoping of one portion of the intestine into another) should not be given rotavirus vaccine. 7. Has the child, a sibling, or a parent had a seizure; has the child had brain or other nervous system problem? [DTaP, Td, Tdap, TIV, LAIV, MMRV] DTaP and Tdap are contraindicated in children who have a history of encephalopathy within 7 days following DTP/DTaP. An unstable progressive neurologic problem is a precaution to the use of DTaP and Tdap, and a progressive neurologic disorder in a teen is a precaution to the use of Td. For children with stable neurologic disorders (including seizures) unrelated to vaccination, or for children with a family history of seizures, vaccinate as usual (exception: children with a personal or family [i.e., parent or sibling] history of seizures generally should not be vaccinated with MMRV; they should receive separate MMR and VAR vaccines). A history of Guillain-Barré syndrome (GBS) is a consideration with the following: 1) Td/Tdap: if GBS has occurred within 6 weeks of a tetanus-containing vaccine and decision is made to continue vaccination, give age-appropriate Tdap instead of Td if no history of prior Tdap; 2) Influenza vaccine (TIV or LAIV): if GBS has occurred within 6 weeks of a prior influenza vaccination, vaccinate with TIV if at high risk for severe influenza complications. 8. Does the child have cancer, leukemia, HIV/AIDS, or any other immune system problem? [LAIV, MMR, MMRV, RV, VAR] Live virus vaccines (e.g., MMR, MMRV, varicella, rotavirus, and the intranasal live, attenuated influenza vaccine [LAIV]) are usually contraindicated in immunocompromised children. However, there are exceptions. For example, MMR is recommended for asymptomatic HIV-infected children who do not have evidence of severe immunosuppression. Likewise, varicella vaccine should be considered for HIV-infected children with age-specific CD4+ T-lymphocyte percentage at 15% or greater and may be considered for children age 8 years and older with CD4+ T-lymphocyte counts of greater than or equal to 200 cells/µl. Immunosuppressed children should not receive LAIV. Infants who have been diagnosed with severe combined immunodeficiency (SCID) should not be given a live virus vaccine, including rotavirus (RV) vaccine. For details, consult the ACIP recommendations (4, 5, 6). 9. In the past 3 months, has the child taken medications that weaken their immune system, such as cortisone, prednisone, other steroids, or anticancer drugs, or had radiation treatments? [LAIV, MMR, MMRV, VAR] Live virus vaccines (e.g., MMR, MMRV, varicella, LAIV) should be postponed until after chemotherapy or long-term high-dose steroid therapy has ended. For details and length of time to postpone, consult the ACIP statement (1). To find specific vaccination schedules for stem cell transplant (bone marrow transplant) patients, see reference 7. LAIV can be given only to healthy non-pregnant individuals age 2 49 years. 10. In the past year, has the child received a transfusion of blood or blood products, or been given immune (gamma) globulin or an antiviral drug? [LAIV, MMR, MMRV, VAR] Certain live virus vaccines (e.g., LAIV, MMR, MMRV, varicella) may need to be deferred, depending on several variables. Consult the most current ACIP recommendations or the current Red Book for the most current information on intervals between antiviral drugs, immune globulin or blood product administration and live virus vaccines (1, 2). 11. Is the child/teen pregnant or is there a chance she could become pregnant during the next month? [LAIV, MMR, MMRV, VAR] Live virus vaccines (e.g., MMR, MMRV, varicella, LAIV) are contraindicated one month before and during pregnancy because of the theoretical risk of virus transmission to the fetus (1, 6). Sexually active young women who receive a live virus vaccine should be instructed to practice careful contraception for one month following receipt of the vaccine (5, 8). On theoretical grounds, inactivated poliovirus vaccine should not be given during pregnancy; however, it may be given if risk of disease is imminent (e.g., travel to endemic areas) and immediate protection is needed. Use of Td or Tdap is not contraindicated in pregnancy. At the provider s discretion, either vaccine may be administered during the 2nd or 3rd trimester (9). 12. Has the child received vaccinations in the past 4 weeks? [LAIV, MMR, MMRV, VAR, yellow fever] If the child was given either live, attenuated influenza vaccine (LAIV) or an injectable live virus vaccine (e.g., MMR, MMRV, varicella, yellow fever) in the past 4 weeks, they should wait 28 days before receiving another vaccination of this type. Inactivated vaccines may be given at the same time or at any spacing interval. References: 1. CDC. General recommendations on immunization, at 2. AAP. Red Book: Report of the Committee on Infectious Diseases at 3. Table of Vaccine Components: excipient-table-2.pdf. 4. CDC. Measles, mumps, and rubella vaccine use and strategies for elimination of measles, rubella, and congenital rubella syndrome and control of mumps. MMWR 1998; 47 (RR-8). 5. CDC. Prevention of varicella: Recommendations of the Advisory Committee on Immunization Practices. MMWR 2007; 56 (RR-4). 6. CDC. Prevention and Control of Influenza Recommendations of ACIP at 7. CDC. Excerpt from Guidelines for preventing opportunistic infections among hematopoietic stem cell transplant recipients, MMWR 2000; 49 (RR-10), 8. CDC. Notice to readers: Revised ACIP recommendation for avoiding pregnancy after receiving a rubella-containing vaccine. MMWR 2001; 50 (49). 9. CDC. Prevention of pertussis, tetanus, and diphtheria among pregnant and postpartum women and their infants: Recommendations of the ACIP. MMWR 2008; 57 (RR-4). 4 Immunization Action Coalition Item #P4060 p. 2

5 Figure 1. Recommended immunization schedule for persons aged 0 through 18 years (FOR THOSE WHO FALL BEHIND OR START LATE, SEE THE CATCH-UP SCHEDULE [FIGURE 2]). These recommendations must be read with the footnotes that follow. For those who fall behind or start late, provide catch-up vaccination at the earliest opportunity as indicated by the green bars in Figure 1. To determine minimum intervals between doses, see the catch-up schedule (Figure 2). School entry and adolescent vaccine age groups are in bold. Vaccines Birth 1 mo 2 mos 4 mos 6 mos 9 mos 12 mos 15 mos 18 mos mos 2-3 yrs 4-6 yrs 7-10 yrs yrs yrs yrs Hepatitis B 1 (HepB) 1 st dose 2 nd dose 3 rd dose Rotavirus 2 (RV) RV-1 (2-dose series); RV-5 (3-dose series) Diphtheria, tetanus, & acellular pertussis 3 (DTaP: <7 yrs) 1 st dose 2 nd dose See footnote 2 1 st dose 2 nd dose 3 rd dose 4 th dose 5 th dose Tetanus, diphtheria, & acellular pertussis 4 (Tdap: >7 yrs) (Tdap) Haemophilus influenzae type b 5 (Hib) 1 st dose 2 nd dose See footnote 5 3 rd or 4 th dose, see footnote 5 Pneumococcal conjugate 6a,c (PCV13) 1 st dose 2 nd dose 3 rd dose 4 th dose Pneumococcal polysaccharide 6b,c (PPSV23) Inactivated Poliovirus 7 (IPV) (<18years) Influenza 8 (IIV; LAIV) 2 doses for some : see footnote 8 Measles, mumps, rubella 9 (MMR) 1 st dose 2 nd dose 3 rd dose 4 th dose Annual vaccination (IIV only) Annual vaccination (IIV or LAIV) 1 st dose 2 nd dose Varicella 10 (VAR) 1 st dose 2 nd dose Hepatitis A 11 (HepA) 2 dose series, see footnote 11 Human papillomavirus 12 (HPV2: females only; HPV4: males and females) Meningococcal 13 (Hib-MenCY > 6 weeks; MCV4-D>9 mos; MCV4-CRM > 2 yrs.) (3-dose series) see footnote 13 1 st dose booster Range of recommended ages for all children Range of recommended ages for catch-up immunization Range of recommended ages for certain high-risk groups Range of recommended ages during which catch-up is encouraged and for certain high-risk groups Not routinely recommended This schedule includes recommendations in effect as of January 1, Any dose not administered at the recommended age should be administered at a subsequent visit, when indicated and feasible. The use of a combination vaccine generally is preferred over separate injections of its equivalent component vaccines. Vaccination providers should consult the relevant Advisory Committee on Immunization Practices (ACIP) statement for detailed recommendations, available online at Clinically significant adverse events that follow vaccination should be reported to the Vaccine Adverse Event Reporting System (VAERS) online ( or by telephone ( ).Suspected cases of vaccine-preventable diseases should be reported to the state or local health department. Additional information, including precautions and contraindications for vaccination, is available from CDC online ( or by telephone (800-CDC-INFO [ ]). This schedule is approved by the Advisory Committee on Immunization Practices ( the American Academy of Pediatrics ( the American Academy of Family Physicians ( and the American College of Obstetricians and Gynecologists ( NOTE: The above recommendations must be read along with the footnotes of this schedule. Footnotes Recommended immunization schedule for persons aged 0 through 18 years United States, 2013 For further guidance on the use of the vaccines mentioned below, see: 1. Hepatitis B (HepB) vaccine. (Minimum age: birth) Routine vaccination: At birth Administer monovalent HepB vaccine to all newborns before hospital discharge. For infants born to hepatitis B surface antigen (HBsAg) positive mothers, administer HepB vaccine and 0.5 ml of hepatitis B immune globulin (HBIG) within 12 hours of birth. These infants should be tested for HBsAg and antibody to HBsAg (anti-hbs) 1 to 2 months after completion of the HepB series, at age 9 through 18 months (preferably at the next well-child visit). If mother s HBsAg status is unknown, within 12 hours of birth administer HepB vaccine to all infants regardless of birth weight. For infants weighing <2,000 grams, administer HBIG in addition to HepB within 12 hours of birth. Determine mother s HBsAg status as soon as possible and, if she is HBsAg-positive, also administer HBIG for infants weighing 2,000 grams (no later than age 1 week). Doses following the birth dose The second dose should be administered at age 1 or 2 months. Monovalent HepB vaccine should be used for doses administered before age 6 weeks. Infants who did not receive a birth dose should receive 3 doses of a HepB-containing vaccine on a schedule of 0, 1 to 2 months, and 6 months starting as soon as feasible. See Figure 2. The minimum interval between dose 1 and dose 2 is 4 weeks and between dose 2 and 3 is 8 weeks. The final (third or fourth) dose in the HepB vaccine series should be administered no earlier than age 24 weeks, and at least 16 weeks after the first dose. Administration of a total of 4 doses of HepB vaccine is recommended when a combination vaccine containing HepB is administered after the birth dose. Catch-up vaccination: Unvaccinated persons should complete a 3-dose series. A 2-dose series (doses separated by at least 4 months) of adult formulation Recombivax HB is licensed for use in children aged 11 through 15 years. For other catch-up issues, see Figure Rotavirus (RV) vaccines. (Minimum age: 6 weeks for both RV-1 [Rotarix] and RV-5 [RotaTeq]). Routine vaccination: Administer a series of RV vaccine to all infants as follows: 1. If RV-1 is used, administer a 2-dose series at 2 and 4 months of age. 2. If RV-5 is used, administer a 3-dose series at ages 2, 4, and 6 months. 3. If any dose in series was RV-5 or vaccine product is unknown for any dose in the series, a total of 3 doses of RV vaccine should be administered. Catch-up vaccination: The maximum age for the first dose in the series is 14 weeks, 6 days. Vaccination should not be initiated for infants aged 15 weeks 0 days or older. The maximum age for the final dose in the series is 8 months, 0 days. If RV-1(Rotarix) is administered for the first and second doses, a third dose is not indicated. For other catch-up issues, see Figure Diphtheria and tetanus toxoids and acellular pertussis (DTaP) vaccine. (Minimum age: 6 weeks) Routine vaccination: 5 Administer a 5-dose series of DTaP vaccine at ages 2, 4, 6, months, and 4 through 6 years. The fourth dose may be administered as early as age 12 months, provided at least 6 months have elapsed since the third dose. Catch-up vaccination: The fifth (booster) dose of DTaP vaccine is not necessary if the fourth dose was administered at age 4 years or older. For other catch-up issues, see Figure Tetanus and diphtheria toxoids and acellular pertussis (Tdap) vaccine. (Minimum age: 10 years for Boostrix, 11 years for Adacel). Routine vaccination: Administer 1 dose of Tdap vaccine to all adolescents aged 11 through 12 years. Tdap can be administered regardless of the interval since the last tetanus and diphtheria toxoid-containing vaccine. Administer one dose of Tdap vaccine to pregnant adolescents during each pregnancy (preferred during 27 through 36 weeks gestation) regardless of number of years from prior Td or Tdap vaccination. Catch-up vaccination: Persons aged 7 through 10 years who are not fully immunized with the childhood DTaP vaccine series, should receive Tdap vaccine as the first dose in the catch-up series; if additional doses are needed, use Td vaccine. For these children, an adolescent Tdap vaccine should not be given. Persons aged 11 through 18 years who have not received Tdap vaccine should receive a dose followed by tetanus and diphtheria toxoids (Td) booster doses every 10 years thereafter. An inadvertent dose of DTaP vaccine administered to children aged 7 through 10 years can count as part of the catch-up series. This dose can count as the adolescent Tdap dose, or the child can later receive a Tdap booster dose at age years. For other catch-up issues, see Figure Haemophilus influenzae type b (Hib) conjugate vaccine. (Minimum age: 6 weeks) Routine vaccination: Administer a Hib vaccine primary series and a booster dose to all infants. The primary series doses should be administered at 2, 4, and 6 months of age; however, if PRP-OMP (PedvaxHib or Comvax) is administered at 2 and 4 months of age, a dose at age 6 months is not indicated. One booster dose should be administered at age 12 through15 months. Hiberix (PRP-T) should only be used for the booster (final) dose in children aged 12 months through 4 years, who have received at least 1 dose of Hib. Catch-up vaccination: If dose 1 was administered at ages months, administer booster (as final dose) at least 8 weeks after dose 1. If the first 2 doses were PRP-OMP (PedvaxHIB or Comvax), and were administered at age 11 months or younger, the third (and final) dose should be administered at age 12 through 15 months and at least 8 weeks after the second dose. If the first dose was administered at age 7 through 11 months, administer the second dose at least 4 weeks later and a final dose at age 12 through 15 months, regardless of Hib vaccine (PRP-T or PRP-OMP) used for first dose. For unvaccinated children aged 15 months or older, administer only 1 dose.

6 For further guidance on the use of the vaccines mentioned below, see: For other catch-up issues, see Figure 2. Vaccination of persons with high-risk conditions: Hib vaccine is not routinely recommended for patients older than 5 years of age. However one dose of Hib vaccine should be administered to unvaccinated or partially vaccinated persons aged 5 years or older who have leukemia, malignant neoplasms, anatomic or functional asplenia (including sickle cell disease), human immunodeficiency virus (HIV) infection, or other immunocompromising conditions. 6a. Pneumococcal conjugate vaccine (PCV). (Minimum age: 6 weeks) Routine vaccination: Administer a series of PCV13 vaccine at ages 2, 4, 6 months with a booster at age 12 through 15 months. For children aged 14 through 59 months who have received an age-appropriate series of 7-valent PCV (PCV7), administer a single supplemental dose of 13-valent PCV (PCV13). Catch-up vaccination: Administer 1 dose of PCV13 to all healthy children aged 24 through 59 months who are not completely vaccinated for their age. For other catch-up issues, see Figure 2. Vaccination of persons with high-risk conditions: For children aged 24 through 71 months with certain underlying medical conditions (see footnote 6c), administer 1 dose of PCV13 if 3 doses of PCV were received previously, or administer 2 doses of PCV13 at least 8 weeks apart if fewer than 3 doses of PCV were received previously. A single dose of PCV13 may be administered to previously unvaccinated children aged 6 through 18 years who have anatomic or functional asplenia (including sickle cell disease), HIV infection or an immunocompromising condition, cochlear implant or cerebrospinal fluid leak. See MMWR 2010;59 (No. RR-11), available at Administer PPSV23 at least 8 weeks after the last dose of PCV to children aged 2 years or older with certain underlying medical conditions (see footnotes 6b and 6c). 6b. Pneumococcal polysaccharide vaccine (PPSV23). (Minimum age: 2 years) Vaccination of persons with high-risk conditions: Administer PPSV23 at least 8 weeks after the last dose of PCV to children aged 2 years or older with certain underlying medical conditions (see footnote 6c). A single revaccination with PPSV should be administered after 5 years to children with anatomic or functional asplenia (including sickle cell disease) or an immunocompromising condition. 6c. Medical conditions for which PPSV23 is indicated in children aged 2 years and older and for which use of PCV13 is indicated in children aged 24 through 71 months: Immunocompetent children with chronic heart disease (particularly cyanotic congenital heart disease and cardiac failure); chronic lung disease (including asthma if treated with high-dose oral corticosteroid therapy), diabetes mellitus; cerebrospinal fluid leaks; or cochlear implant. Children with anatomic or functional asplenia (including sickle cell disease and other hemoglobinopathies, congenital or acquired asplenia, or splenic dysfunction); Children with immunocompromising conditions: HIV infection, chronic renal failure and nephrotic syndrome, diseases associated with treatment with immunosuppressive drugs or radiation therapy, including malignant neoplasms, leukemias, lymphomas and Hodgkin disease; or solid organ transplantation, congenital immunodeficiency. 7. Inactivated poliovirus vaccine (IPV). (Minimum age: 6 weeks) Routine vaccination: Administer a series of IPV at ages 2, 4, 6 18 months, with a booster at age 4 6 years. The final dose in the series should be administered on or after the fourth birthday and at least 6 months after the previous dose. Catch-up vaccination: In the first 6 months of life, minimum age and minimum intervals are only recommended if the person is at risk for imminent exposure to circulating poliovirus (i.e., travel to a polio-endemic region or during an outbreak). If 4 or more doses are administered before age 4 years, an additional dose should be administered at age 4 through 6 years. A fourth dose is not necessary if the third dose was administered at age 4 years or older and at least 6 months after the previous dose. If both OPV and IPV were administered as part of a series, a total of 4 doses should be administered, regardless of the child s current age. IPV is not routinely recommended for U.S. residents aged 18 years or older. For other catch-up issues, see Figure Influenza vaccines. (Minimum age: 6 months for inactivated influenza vaccine [IIV]; 2 years for live, attenuated influenza vaccine [LAIV]) Routine vaccination: Administer influenza vaccine annually to all children beginning at age 6 months. For most healthy, nonpregnant persons aged 2 through 49 years, either LAIV or IIV may be used. However, LAIV should NOT be administered to some persons, including 1) those with asthma, 2) children 2 through 4 years who had wheezing in the past 12 months, or 3) those who have any other underlying medical conditions that predispose them to influenza complications. For all other contraindications to use of LAIV see MMWR 2010; 59 (No. RR-8), available at Administer 1 dose to persons aged 9 years and older. For children aged 6 months through 8 years: For the season, administer 2 doses (separated by at least 4 weeks) to children who are receiving influenza vaccine for the first time. For additional guidance, follow dosing guidelines in the 2012 ACIP influenza vaccine recommendations, MMWR 2012; 61: , available at pdf/wk/mm6132.pdf. For the season, follow dosing guidelines in the 2013 ACIP influenza vaccine recommendations. 9. Measles, mumps, and rubella (MMR) vaccine. (Minimum age: 12 months for routine vaccination) Routine vaccination: Administer the first dose of MMR vaccine at age 12 through 15 months, and the second dose at age 4 through 6 years. The second dose may be administered before age 4 years, provided at least 4 weeks have elapsed since the first dose. Administer 1 dose of MMR vaccine to infants aged 6 through 11 months before departure from the United States for international travel. These children should be revaccinated with 2 doses of MMR vaccine, the Additional information For contraindications and precautions to use of a vaccine and for additional information regarding that vaccine, vaccination providers should consult the relevant ACIP statement available online at For the purposes of calculating intervals between doses, 4 weeks = 28 days. Intervals of 4 months or greater are determined by calendar months. Information on travel vaccine requirements and recommendations is available at cdc.gov/travel/page/vaccinations.htm. For vaccination of persons with primary and secondary immunodeficiencies, see Table 13, Vaccination of persons with primary and secondary immunodeficiencies, in General Recommendations on Immunization (ACIP), available at mmwrhtml/rr6002a1.htm; and American Academy of Pediatrics. Immunization in Special Clinical Circumstances. In: Pickering LK, Baker CJ, Kimberlin DW, Long SS eds. Red book: 2012 report of the Committee on Infectious Diseases. 29th ed. Elk Grove Village, IL: American Academy of Pediatrics. 6 first at age 12 through 15 months (12 months if the child remains in an area where disease risk is high), and the second dose at least 4 weeks later. Administer 2 doses of MMR vaccine to children aged 12 months and older, before departure from the United States for international travel. The first dose should be administered on or after age 12 months and the second dose at least 4 weeks later. Catch-up vaccination: Ensure that all school-aged children and adolescents have had 2 doses of MMR vaccine; the minimum interval between the 2 doses is 4 weeks. 10. Varicella (VAR) vaccine. (Minimum age: 12 months) Routine vaccination: Administer the first dose of VAR vaccine at age 12 through 15 months, and the second dose at age 4 through 6 years. The second dose may be administered before age 4 years, provided at least 3 months have elapsed since the first dose. If the second dose was administered at least 4 weeks after the first dose, it can be accepted as valid. Catch-up vaccination: Ensure that all persons aged 7 through 18 years without evidence of immunity (see MMWR 2007;56 [No. RR-4], available at have 2 doses of varicella vaccine. For children aged 7 through 12 years the recommended minimum interval between doses is 3 months (if the second dose was administered at least 4 weeks after the first dose, it can be accepted as valid); for persons aged 13 years and older, the minimum interval between doses is 4 weeks. 11. Hepatitis A vaccine (HepA). (Minimum age: 12 months) Routine vaccination: Initiate the 2-dose HepA vaccine series for children aged 12 through 23 months; separate the 2 doses by 6 to 18 months. Children who have received 1 dose of HepA vaccine before age 24 months, should receive a second dose 6 to 18 months after the first dose. For any person aged 2 years and older who has not already received the HepA vaccine series, 2 doses of HepA vaccine separated by 6 to 18 months may be administered if immunity against hepatitis A virus infection is desired. Catch-up vaccination: The minimum interval between the two doses is 6 months. Special populations: Administer 2 doses of Hep A vaccine at least 6 months apart to previously unvaccinated persons who live in areas where vaccination programs target older children, or who are at increased risk for infection. 12. Human papillomavirus (HPV) vaccines. (HPV4 [Gardasil] and HPV2 [Cervarix]). (Minimum age: 9 years) Routine vaccination: Administer a 3-dose series of HPV vaccine on a schedule of 0, 1-2, and 6 months to all adolescents aged years. Either HPV4 or HPV2 may be used for females, and only HPV4 may be used for males. The vaccine series can be started beginning at age 9 years. Administer the second dose 1 to 2 months after the first dose and the third dose 6 months after the first dose (at least 24 weeks after the first dose). Catch-up vaccination: Administer the vaccine series to females (either HPV2 or HPV4) and males (HPV4) at age 13 through 18 years if not previously vaccinated. Use recommended routine dosing intervals (see above) for vaccine series catch-up. 13. Meningococcal conjugate vaccines (MCV). (Minimum age: 6 weeks for Hib-MenCY, 9 months for Menactra [MCV4-D], 2 years for Menveo [MCV4-CRM]). Routine vaccination: Administer MCV4 vaccine at age years, with a booster dose at age 16 years. Adolescents aged 11 through 18 years with human immunodeficiency virus (HIV) infection should receive a 2-dose primary series of MCV4, with at least 8 weeks between doses. See MMWR 2011; 60: available at: For children aged 2 months through 10 years with high-risk conditions, see below. Catch-up vaccination: Administer MCV4 vaccine at age 13 through 18 years if not previously vaccinated. If the first dose is administered at age 13 through 15 years, a booster dose should be administered at age 16 through 18 years with a minimum interval of at least 8 weeks between doses. If the first dose is administered at age 16 years or older, a booster dose is not needed. For other catch-up issues, see Figure 2. Vaccination of persons with high-risk conditions: For children younger than 19 months of age with anatomic or functional asplenia (including sickle cell disease), administer an infant series of Hib-MenCY at 2, 4, 6, and months. For children aged 2 through 18 months with persistent complement component deficiency, administer either an infant series of Hib-MenCY at 2, 4, 6, and 12 through 15 months or a 2-dose primary series of MCV4-D starting at 9 months, with at least 8 weeks between doses. For children aged 19 through 23 months with persistent complement component deficiency who have not received a complete series of Hib-MenCY or MCV4-D, administer 2 primary doses of MCV4-D at least 8 weeks apart. For children aged 24 months and older with persistent complement component deficiency or anatomic or functional asplenia (including sickle cell disease), who have not received a complete series of Hib- MenCY or MCV4-D, administer 2 primary doses of either MCV4-D or MCV4-CRM. If MCV4-D (Menactra) is administered to a child with asplenia (including sickle cell disease), do not administer MCV4-D until 2 years of age and at least 4 weeks after the completion of all PCV13 doses. See MMWR 2011;60:1391 2, available at For children aged 9 months and older who are residents of or travelers to countries in the African meningitis belt or to the Hajj, administer an age appropriate formulation and series of MCV4 for protection against serogroups A and W-135. Prior receipt of Hib-MenCY is not sufficient for children traveling to the meningitis belt or the Hajj. See MMWR 2011;60:1391 2, available at mm6040.pdf. For children who are present during outbreaks caused by a vaccine serogroup, administer or complete an age and formulation-appropriate series of Hib-MenCY or MCV4. For booster doses among persons with high-risk conditions refer to acip-list.htm#mening.

7 FIGURE 2. Catch-up immunization schedule for persons aged 4 months through 18 years who start late or who are more than 1 month behind United States 2013 The figure below provides catch-up schedules and minimum intervals between doses for children whose vaccinations have been delayed. A vaccine series does not need to be restarted, regardless of the time that has elapsed between doses. Use the section appropriate for the child s age. Always use this table in conjunction with Figure 1 and the footnotes that follow. Vaccine Minimum Age for Dose 1 Hepatitis B 1 Birth 4 weeks Persons aged 4 months through 6 years Minimum Interval Between Doses Dose 1 to dose 2 Dose 2 to dose 3 Dose 3 to dose 4 Dose 4 to dose 5 8 weeks and at least 16 weeks after first dose; minimum age for the final dose is 24 weeks Rotavirus 2 6 weeks 4 weeks 4 weeks 2 Diphtheria, tetanus, pertussis 3 6 weeks 4 weeks 4 weeks 6 months 6 months 3 Haemophilus influenzae type b 5 6 weeks 4 weeks if first dose administered at younger than age 12 months 8 weeks (as final dose) if first dose administered at age months No further doses needed if first dose administered at age 15 months or older 4 weeks 5 if current age is younger than 12 months 8 weeks (as final dose) 5 if current age is 12 months or older and first dose administered at younger than age 12 months and second dose administered at younger than 15 months No further doses needed if previous dose administered at age 15 months or older 8 weeks (as final dose) This dose only necessary for children aged 12 through 59 months who received 3 doses before age 12 months Pneumococcal 6 6 weeks 4 weeks if first dose administered at younger than age 12 months 8 weeks (as final dose for healthy children) if first dose administered at age 12 months or older or current age 24 through 59 months No further doses needed for healthy children if first dose administered at age 24 months or older 4 weeks if current age is younger than 12 months 8 weeks (as final dose for healthy children) if current age is 12 months or older No further doses needed for healthy children if previous dose administered at age 24 months or older 8 weeks (as final dose) This dose only necessary for children aged 12 through 59 months who received 3 doses before age 12 months or for children at high risk who received 3 doses at any age Inactivated poliovirus 7 6 weeks 4 weeks 4 weeks 6 months 7 minimum age 4 years for final dose Meningococcal 13 6 weeks 8 weeks 13 see footnote 13 see footnote 13 Measles, mumps, rubella 9 12 months 4 weeks Varicella months 3 months Hepatitis A months 6 months Tetanus, diphtheria; tetanus, diphtheria, pertussis 4 7 years 4 4 weeks Persons aged 7 through 18 years 4 weeks if first dose administered at younger than age 12 months 6 months if first dose administered at 12 months or older 6 months if first dose administered at younger than age 12 months Human papillomavirus 12 9 years Routine dosing intervals are recommended 12 Hepatitis A months 6 months Hepatitis B 1 Birth 4 weeks 8 weeks (and at least 16 weeks after first dose) Inactivated poliovirus 7 6 weeks 4 weeks 4 weeks 7 6 months 7 Meningococcal 13 6 weeks 8 weeks 13 Measles, mumps, rubella 9 12 months 4 weeks Varicella months 3 months if person is younger than age 13 years 4 weeks if person is aged 13 years or older NOTE: The above recommendations must be read along with the footnotes of this schedule. Footnotes Recommended immunization schedule for persons aged 0 through 18 years United States, 2013 For further guidance on the use of the vaccines mentioned below, see: 1. Hepatitis B (HepB) vaccine. (Minimum age: birth) Routine vaccination: At birth Administer monovalent HepB vaccine to all newborns before hospital discharge. For infants born to hepatitis B surface antigen (HBsAg) positive mothers, administer HepB vaccine and 0.5 ml of hepatitis B immune globulin (HBIG) within 12 hours of birth. These infants should be tested for HBsAg and antibody to HBsAg (anti-hbs) 1 to 2 months after completion of the HepB series, at age 9 through 18 months (preferably at the next well-child visit). If mother s HBsAg status is unknown, within 12 hours of birth administer HepB vaccine to all infants regardless of birth weight. For infants weighing <2,000 grams, administer HBIG in addition to HepB within 12 hours of birth. Determine mother s HBsAg status as soon as possible and, if she is HBsAg-positive, also administer HBIG for infants weighing 2,000 grams (no later than age 1 week). Doses following the birth dose The second dose should be administered at age 1 or 2 months. Monovalent HepB vaccine should be used for doses administered before age 6 weeks. Infants who did not receive a birth dose should receive 3 doses of a HepB-containing vaccine on a schedule of 0, 1 to 2 months, and 6 months starting as soon as feasible. See Figure 2. The minimum interval between dose 1 and dose 2 is 4 weeks and between dose 2 and 3 is 8 weeks. The final (third or fourth) dose in the HepB vaccine series should be administered no earlier than age 24 weeks, and at least 16 weeks after the first dose. Administration of a total of 4 doses of HepB vaccine is recommended when a combination vaccine containing HepB is administered after the birth dose. Catch-up vaccination: Unvaccinated persons should complete a 3-dose series. A 2-dose series (doses separated by at least 4 months) of adult formulation Recombivax HB is licensed for use in children aged 11 through 15 years. For other catch-up issues, see Figure Rotavirus (RV) vaccines. (Minimum age: 6 weeks for both RV-1 [Rotarix] and RV-5 [RotaTeq]). Routine vaccination: Administer a series of RV vaccine to all infants as follows: 1. If RV-1 is used, administer a 2-dose series at 2 and 4 months of age. 2. If RV-5 is used, administer a 3-dose series at ages 2, 4, and 6 months. 3. If any dose in series was RV-5 or vaccine product is unknown for any dose in the series, a total of 3 doses of RV vaccine should be administered. Catch-up vaccination: The maximum age for the first dose in the series is 14 weeks, 6 days. Vaccination should not be initiated for infants aged 15 weeks 0 days or older. The maximum age for the final dose in the series is 8 months, 0 days. If RV-1(Rotarix) is administered for the first and second doses, a third dose is not indicated. For other catch-up issues, see Figure Diphtheria and tetanus toxoids and acellular pertussis (DTaP) vaccine. (Minimum age: 6 weeks) Routine vaccination: Administer a 5-dose series of DTaP vaccine at ages 2, 4, 6, months, and 4 through 6 years. The fourth dose may be administered as early as age 12 months, provided at least 6 months have elapsed since the third dose. Catch-up vaccination: The fifth (booster) dose of DTaP vaccine is not necessary if the fourth dose was administered at age 4 years or older. For other catch-up issues, see Figure Tetanus and diphtheria toxoids and acellular pertussis (Tdap) vaccine. (Minimum age: 10 years for Boostrix, 11 years for Adacel). Routine vaccination: Administer 1 dose of Tdap vaccine to all adolescents aged 11 through 12 years. Tdap can be administered regardless of the interval since the last tetanus and diphtheria toxoid-containing vaccine.

8 For further guidance on the use of the vaccines mentioned below, see: Administer one dose of Tdap vaccine to pregnant adolescents during each pregnancy (preferred during 27 through 36 weeks gestation) regardless of number of years from prior Td or Tdap vaccination. Catch-up vaccination: Persons aged 7 through 10 years who are not fully immunized with the childhood DTaP vaccine series, should receive Tdap vaccine as the first dose in the catch-up series; if additional doses are needed, use Td vaccine. For these children, an adolescent Tdap vaccine should not be given. Persons aged 11 through 18 years who have not received Tdap vaccine should receive a dose followed by tetanus and diphtheria toxoids (Td) booster doses every 10 years thereafter. An inadvertent dose of DTaP vaccine administered to children aged 7 through 10 years can count as part of the catch-up series. This dose can count as the adolescent Tdap dose, or the child can later receive a Tdap booster dose at age years. For other catch-up issues, see Figure Haemophilus influenzae type b (Hib) conjugate vaccine. (Minimum age: 6 weeks) Routine vaccination: Administer a Hib vaccine primary series and a booster dose to all infants. The primary series doses should be administered at 2, 4, and 6 months of age; however, if PRP-OMP (PedvaxHib or Comvax) is administered at 2 and 4 months of age, a dose at age 6 months is not indicated. One booster dose should be administered at age 12 through15 months. Hiberix (PRP-T) should only be used for the booster (final) dose in children aged 12 months through 4 years, who have received at least 1 dose of Hib. Catch-up vaccination: If dose 1 was administered at ages months, administer booster (as final dose) at least 8 weeks after dose 1. If the first 2 doses were PRP-OMP (PedvaxHIB or Comvax), and were administered at age 11 months or younger, the third (and final) dose should be administered at age 12 through 15 months and at least 8 weeks after the second dose. If the first dose was administered at age 7 through 11 months, administer the second dose at least 4 weeks later and a final dose at age 12 through 15 months, regardless of Hib vaccine (PRP-T or PRP-OMP) used for first dose. For unvaccinated children aged 15 months or older, administer only 1 dose. For other catch-up issues, see Figure 2. Vaccination of persons with high-risk conditions: Hib vaccine is not routinely recommended for patients older than 5 years of age. However one dose of Hib vaccine should be administered to unvaccinated or partially vaccinated persons aged 5 years or older who have leukemia, malignant neoplasms, anatomic or functional asplenia (including sickle cell disease), human immunodeficiency virus (HIV) infection, or other immunocompromising conditions. 6a. Pneumococcal conjugate vaccine (PCV). (Minimum age: 6 weeks) Routine vaccination: Administer a series of PCV13 vaccine at ages 2, 4, 6 months with a booster at age 12 through 15 months. For children aged 14 through 59 months who have received an age-appropriate series of 7-valent PCV (PCV7), administer a single supplemental dose of 13-valent PCV (PCV13). Catch-up vaccination: Administer 1 dose of PCV13 to all healthy children aged 24 through 59 months who are not completely vaccinated for their age. For other catch-up issues, see Figure 2. Vaccination of persons with high-risk conditions: For children aged 24 through 71 months with certain underlying medical conditions (see footnote 6c), administer 1 dose of PCV13 if 3 doses of PCV were received previously, or administer 2 doses of PCV13 at least 8 weeks apart if fewer than 3 doses of PCV were received previously. A single dose of PCV13 may be administered to previously unvaccinated children aged 6 through 18 years who have anatomic or functional asplenia (including sickle cell disease), HIV infection or an immunocompromising condition, cochlear implant or cerebrospinal fluid leak. See MMWR 2010;59 (No. RR-11), available at cdc.gov/mmwr/pdf/rr/rr5911.pdf. Administer PPSV23 at least 8 weeks after the last dose of PCV to children aged 2 years or older with certain underlying medical conditions (see footnotes 6b and 6c). 6b. Pneumococcal polysaccharide vaccine (PPSV23). (Minimum age: 2 years) Vaccination of persons with high-risk conditions: Administer PPSV23 at least 8 weeks after the last dose of PCV to children aged 2 years or older with certain underlying medical conditions (see footnote 6c). A single revaccination with PPSV should be administered after 5 years to children with anatomic or functional asplenia (including sickle cell disease) or an immunocompromising condition. 6c. Medical conditions for which PPSV23 is indicated in children aged 2 years and older and for which use of PCV13 is indicated in children aged 24 through 71 months: Immunocompetent children with chronic heart disease (particularly cyanotic congenital heart disease and cardiac failure); chronic lung disease (including asthma if treated with high-dose oral corticosteroid therapy), diabetes mellitus; cerebrospinal fluid leaks; or cochlear implant. Children with anatomic or functional asplenia (including sickle cell disease and other hemoglobinopathies, congenital or acquired asplenia, or splenic dysfunction); Children with immunocompromising conditions: HIV infection, chronic renal failure and nephrotic syndrome, diseases associated with treatment with immunosuppressive drugs or radiation therapy, including malignant neoplasms, leukemias, lymphomas and Hodgkin disease; or solid organ transplantation, congenital immunodeficiency. 7. Inactivated poliovirus vaccine (IPV). (Minimum age: 6 weeks) Routine vaccination: Administer a series of IPV at ages 2, 4, 6 18 months, with a booster at age 4 6 years. The final dose in the series should be administered on or after the fourth birthday and at least 6 months after the previous dose. Catch-up vaccination: In the first 6 months of life, minimum age and minimum intervals are only recommended if the person is at risk for imminent exposure to circulating poliovirus (i.e., travel to a polio-endemic region or during an outbreak). If 4 or more doses are administered before age 4 years, an additional dose should be administered at age 4 through 6 years. A fourth dose is not necessary if the third dose was administered at age 4 years or older and at least 6 months after the previous dose. If both OPV and IPV were administered as part of a series, a total of 4 doses should be administered, regardless of the child s current age. IPV is not routinely recommended for U.S. residents aged 18 years or older. For other catch-up issues, see Figure Influenza vaccines. (Minimum age: 6 months for inactivated influenza vaccine [IIV]; 2 years for live, attenuated influenza vaccine [LAIV]) Routine vaccination: Administer influenza vaccine annually to all children beginning at age 6 months. For most healthy, nonpregnant persons aged 2 through 49 years, either LAIV or IIV may be used. However, LAIV should NOT be administered to some persons, including 1) those with asthma, 2) children 2 through 4 years who had wheezing in the past 12 months, or 3) those who have any other underlying medical conditions that predispose them to influenza complications. For all other contraindications to use of LAIV see MMWR 2010; 59 (No. RR-8), available at Additional information For contraindications and precautions to use of a vaccine and for additional information regarding that vaccine, vaccination providers should consult the relevant ACIP statement available online at pubs/acip-list.htm. For the purposes of calculating intervals between doses, 4 weeks = 28 days. Intervals of 4 months or greater are determined by calendar months. Information on travel vaccine requirements and recommendations is available at page/vaccinations.htm. For vaccination of persons with primary and secondary immunodeficiencies, see Table 13, Vaccination of persons with primary and secondary immunodeficiencies, in General Recommendations on Immunization (ACIP), available at and American Academy of Pediatrics. Immunization in Special Clinical Circumstances. In: Pickering LK, Baker CJ, Kimberlin DW, Long SS eds. Red book: 2012 report of the Committee on Infectious Diseases. 29th ed. Elk Grove Village, IL: American Academy of Pediatrics. 8 Administer 1 dose to persons aged 9 years and older. For children aged 6 months through 8 years: For the season, administer 2 doses (separated by at least 4 weeks) to children who are receiving influenza vaccine for the first time. For additional guidance, follow dosing guidelines in the 2012 ACIP influenza vaccine recommendations, MMWR 2012; 61: , available at For the season, follow dosing guidelines in the 2013 ACIP influenza vaccine recommendations. 9. Measles, mumps, and rubella (MMR) vaccine. (Minimum age: 12 months for routine vaccination) Routine vaccination: Administer the first dose of MMR vaccine at age 12 through 15 months, and the second dose at age 4 through 6 years. The second dose may be administered before age 4 years, provided at least 4 weeks have elapsed since the first dose. Administer 1 dose of MMR vaccine to infants aged 6 through 11 months before departure from the United States for international travel. These children should be revaccinated with 2 doses of MMR vaccine, the first at age 12 through 15 months (12 months if the child remains in an area where disease risk is high), and the second dose at least 4 weeks later. Administer 2 doses of MMR vaccine to children aged 12 months and older, before departure from the United States for international travel. The first dose should be administered on or after age 12 months and the second dose at least 4 weeks later. Catch-up vaccination: Ensure that all school-aged children and adolescents have had 2 doses of MMR vaccine; the minimum interval between the 2 doses is 4 weeks. 10. Varicella (VAR) vaccine. (Minimum age: 12 months) Routine vaccination: Administer the first dose of VAR vaccine at age 12 through 15 months, and the second dose at age 4 through 6 years. The second dose may be administered before age 4 years, provided at least 3 months have elapsed since the first dose. If the second dose was administered at least 4 weeks after the first dose, it can be accepted as valid. Catch-up vaccination: Ensure that all persons aged 7 through 18 years without evidence of immunity (see MMWR 2007;56 [No. RR-4], available at have 2 doses of varicella vaccine. For children aged 7 through 12 years the recommended minimum interval between doses is 3 months (if the second dose was administered at least 4 weeks after the first dose, it can be accepted as valid); for persons aged 13 years and older, the minimum interval between doses is 4 weeks. 11. Hepatitis A vaccine (HepA). (Minimum age: 12 months) Routine vaccination: Initiate the 2-dose HepA vaccine series for children aged 12 through 23 months; separate the 2 doses by 6 to 18 months. Children who have received 1 dose of HepA vaccine before age 24 months, should receive a second dose 6 to 18 months after the first dose. For any person aged 2 years and older who has not already received the HepA vaccine series, 2 doses of HepA vaccine separated by 6 to 18 months may be administered if immunity against hepatitis A virus infection is desired. Catch-up vaccination: The minimum interval between the two doses is 6 months. Special populations: Administer 2 doses of Hep A vaccine at least 6 months apart to previously unvaccinated persons who live in areas where vaccination programs target older children, or who are at increased risk for infection. 12. Human papillomavirus (HPV) vaccines. (HPV4 [Gardasil] and HPV2 [Cervarix]). (Minimum age: 9 years) Routine vaccination: Administer a 3-dose series of HPV vaccine on a schedule of 0, 1-2, and 6 months to all adolescents aged years. Either HPV4 or HPV2 may be used for females, and only HPV4 may be used for males. The vaccine series can be started beginning at age 9 years. Administer the second dose 1 to 2 months after the first dose and the third dose 6 months after the first dose (at least 24 weeks after the first dose). Catch-up vaccination: Administer the vaccine series to females (either HPV2 or HPV4) and males (HPV4) at age 13 through 18 years if not previously vaccinated. Use recommended routine dosing intervals (see above) for vaccine series catch-up. 13. Meningococcal conjugate vaccines (MCV). (Minimum age: 6 weeks for Hib-MenCY, 9 months for Menactra [MCV4-D], 2 years for Menveo [MCV4-CRM]). Routine vaccination: Administer MCV4 vaccine at age years, with a booster dose at age 16 years. Adolescents aged 11 through 18 years with human immunodeficiency virus (HIV) infection should receive a 2-dose primary series of MCV4, with at least 8 weeks between doses. See MMWR 2011; 60: available at: For children aged 2 months through 10 years with high-risk conditions, see below. Catch-up vaccination: Administer MCV4 vaccine at age 13 through 18 years if not previously vaccinated. If the first dose is administered at age 13 through 15 years, a booster dose should be administered at age 16 through 18 years with a minimum interval of at least 8 weeks between doses. If the first dose is administered at age 16 years or older, a booster dose is not needed. For other catch-up issues, see Figure 2. Vaccination of persons with high-risk conditions: For children younger than 19 months of age with anatomic or functional asplenia (including sickle cell disease), administer an infant series of Hib-MenCY at 2, 4, 6, and months. For children aged 2 through 18 months with persistent complement component deficiency, administer either an infant series of Hib-MenCY at 2, 4, 6, and 12 through 15 months or a 2-dose primary series of MCV4-D starting at 9 months, with at least 8 weeks between doses. For children aged 19 through 23 months with persistent complement component deficiency who have not received a complete series of Hib-MenCY or MCV4-D, administer 2 primary doses of MCV4-D at least 8 weeks apart. For children aged 24 months and older with persistent complement component deficiency or anatomic or functional asplenia (including sickle cell disease), who have not received a complete series of Hib-MenCY or MCV4-D, administer 2 primary doses of either MCV4-D or MCV4-CRM. If MCV4-D (Menactra) is administered to a child with asplenia (including sickle cell disease), do not administer MCV4-D until 2 years of age and at least 4 weeks after the completion of all PCV13 doses. See MMWR 2011;60:1391 2, available at mmwr/pdf/wk/mm6040.pdf. For children aged 9 months and older who are residents of or travelers to countries in the African meningitis belt or to the Hajj, administer an age appropriate formulation and series of MCV4 for protection against serogroups A and W-135. Prior receipt of Hib-MenCY is not sufficient for children traveling to the meningitis belt or the Hajj. See MMWR 2011;60:1391 2, available at For children who are present during outbreaks caused by a vaccine serogroup, administer or complete an age and formulation-appropriate series of Hib-MenCY or MCV4. For booster doses among persons with high-risk conditions refer to htm#mening.

9 Summary of Recommendations for Child/Teen Immunization (Age birth through 18 years) (Page 1 of 4) Vaccine name and route Hepatitis B (HepB) Give DTaP, DT (Diphtheria, tetanus, acellular pertussis) Give Tdap, Td (Tetanus, diphtheria, acellular pertussis) Give Inactivated Polio (IPV) Give SC or Schedule for routine vaccination and other guidelines (any vaccine can be given with another) Vaccinate all children age 0 through 18yrs. Vaccinate all newborns with monovalent vaccine prior to hospital discharge. Give dose #2 at age 1 2m and the final dose at age 6 18m (the last dose in the infant series should not be given earlier than age 24wks). After the birth dose, the series may be completed using 2 doses of single-antigen vaccine or up to 3 doses of Comvax (ages 2m, 4m, 12 15m) or Pediarix (ages 2m, 4m, 6m), which may result in giving a total of 4 doses of hepatitis B vaccine. If mother is HBsAg-positive: give the newborn HBIG + dose #1 within 12hrs of birth; complete series at age 6m or, if using Comvax, at age 12 15m. If mother s HBsAg status is unknown: give the newborn dose #1 within 12hrs of birth. If low birth weight (less than 2000 grams), also give HBIG within 12hrs. For infants weighing 2000 grams or more whose mother is subsequently found to be HBsAg positive, give the infant HBIG ASAP (no later than 7d of birth) and follow HepB immunization schedule for infants born to HBsAg-positive mothers. Give to children at ages 2m, 4m, 6m, 15 18m, 4 6yrs. May give dose #1 as early as age 6wks. May give #4 as early as age 12m if 6m have elapsed since #3. Do not give DTaP/DT to children age 7yrs and older; use Tdap or Td. If possible, use the same DTaP product for all doses. For children and teens lacking previous Tdap: give Tdap routinely at age 11 12yrs and vaccinate older teens on a catch-up basis; then boost every 10yrs with Td. Make special efforts to give Tdap to children and teens who are 1) in contact with infants younger than age 12m and 2) healthcare workers with direct patient contact. Give Tdap to pregnant adolescents during each pregnancy (preferred during weeks gestation), regardless of number of years since prior Td or Tdap. Give to children at ages 2m, 4m, 6 18m, 4 6yrs. May give dose #1 as early as age 6wks. Not routinely recommended for U.S. residents age 18yrs and older (except certain travelers). Schedule for catch-up vaccination and related issues Do not restart series, no matter how long since previous dose. 3-dose series can be started at any age. Minimum intervals between doses: 4wks between #1 and #2, 8wks between #2 and #3, and at least 16wks between #1 and #3. #2 and #3 may be given 4wks after previous dose. #4 may be given 6m after #3. If #4 is given before 4th birthday, wait at least 6m for #5 (age 4 6yrs). If #4 is given after 4th birthday, #5 is not needed. Children as young as age 7yrs and teens who are unvaccinated or behind schedule should complete a primary Td series (spaced at 0, 1 2m, and 6 12m intervals); substitute Tdap for any dose in the series, preferably as dose #1. Tdap should be given regardless of interval since previous Td. The final dose should be given on or after the 4th birthday and at least 6m from the previous dose. If dose #3 is given after 4th birthday, dose #4 is not needed if dose #3 is given at least 6m after dose #2. Contraindications and precautions (mild illness is not a contraindication) Contraindication Previous anaphylaxis to this vaccine or to any of its components. Precautions Moderate or severe acute illness. For infants who weigh less than 2000 grams, see ACIP recs.* Special Notes on Hepatitis B Vaccine (HepB) Dosing of HepB: Monovalent vaccine brands are interchangeable. For people age 0 through 19yrs, give 0.5 ml of either Engerix-B or Recombivax HB. Alternative dosing schedule for unvaccinated adolescents age 11 through 15yrs: Give 2 doses Recombivax HB 1.0 ml (adult formulation) spaced 4 6m apart. (Engerix-B is not licensed for a 2-dose schedule.) For preterm infants: Consult ACIP hepatitis B recommendations (MMWR 2005; 54 [RR-16]).* Contraindications Previous anaphylaxis to this vaccine or to any of its components. For DTaP/Tdap only: encephalopathy not attributable to an identifiable cause, within 7d after DTP/DTaP/Tdap. Precautions Moderate or severe acute illness. History of arthus reaction following a prior dose of tetanus or diphtheria toxoid-containing vaccine; defer vaccination until at least 10yrs have elapsed since the last tetanus toxoid-containing vaccine. Guillain-Barré syndrome (GBS) within 6wks after previous dose of tetanus-toxoid-containing vaccine. For DTaP only: Any of these events following a previous dose of DTP/DTaP: 1) temperature of 105 F (40.5 C) or higher within 48hrs; 2) continuous crying for 3hrs or more within 48hrs; 3) collapse or shock-like state within 48hrs; 4) seizure within 3d. For DTaP/Tdap only: Progressive or unstable neurologic disorder, uncontrolled seizures, or progressive encephalopathy until a treatment regimen has been established and the condition has stabilized. Contraindication Previous anaphylaxis to this vaccine or to any of its components. Precautions Moderate or severe acute illness. Pregnancy. * This document was adapted from the recommendations of the Advisory Committee on Immunization Practices (ACIP). To obtain copies of these recommendations, visit CDC s website at pubs/acip-list.htm or visit the Immunization Action Coalition (IAC) website at Technical content reviewed by the Centers for Disease Control and Prevention This table is revised periodically. Visit IAC s website at to make sure you have the most current version. Item #P2010 (2/13) Immunization Action Coalition 1573 Selby Avenue Saint Paul, MN (651) admin@immunize.org 9

10 Summary of Recommendations for Child/Teen Immunization (Age birth through 18 years) (Page 2 of 4) Vaccine name and route Schedule for routine vaccination and other guidelines (any vaccine can be given with another) Schedule for catch-up vaccination and related issues Contraindications and precautions (mild illness is not a contraindication) Influenza Inactivated influenza vaccine (IIV) Give Live attenuated influenza vaccine (LAIV) Give intranasally Varicella (Var) (Chickenpox) Give SC MMR (Measles, mumps, rubella) Give SC Vaccinate all children and teens age 6m through 18yrs. LAIV may be given to healthy, non-pregnant people age 2 49yrs. Give 2 doses, spaced 4wks apart, to children age 6m through 8yrs who 1) are first-time vaccinees or 2) who meet any of the additional guidance in the current year s ACIP influenza vaccine recommendations*. For IIV, give 0.25 ml dose to children age 6 35m and 0.5 ml dose if age 3yrs and older. If LAIV and either MMR, Var, and/or yellow fever vaccine are not given on the same day, space them at least 28d apart. Give dose #1 at age 12 15m. Give dose #2 at age 4 6yrs. Dose #2 of Var or MMRV may be given earlier if at least 3m since dose #1. If the 2nd dose was given at least 4wks after 1st dose, it can be accepted as valid. Give a 2nd dose to all older children/ teens with history of only 1 dose. MMRV may be used in children age 12m through 12yrs (see note below). Note: For the first dose of MMR and varicella given at age 12 47mos, either MMR and Var or MMRV may be used. Unless the parent or caregiver expresses a preference for MMRV, CDC recommends that MMR and Var be used for the first doses in this age group. Give dose #1 at age 12 15m. Give MMR at age 6 through 11m if traveling internationally; revaccinate with 2 doses of MMR at age 12 15m (and at least 4wks later). The dose given at younger than 12m does not count toward the 2-dose series. Give dose #2 at age 4 6yrs. Dose #2 may be given earlier if at least 4wks since dose #1. For MMRV: dose #2 may be given earlier if at least 3m since dose #1. Give a 2nd dose to all older children and teens with history of only 1 dose. MMRV may be used in children age 12m through 12yrs (see note above). If younger than age 13yrs, space dose #1 and #2 at least 3m apart. If age 13yrs and older, space at least 4wks apart. May use as postexposure prophylaxis if given within 5d. If Var and either MMR, LAIV, and/or yellow fever vaccine are not given on the same day, space them at least 28d apart. If MMR and either Var, LAIV, and/or yellow fever vaccine are not given on the same day, space them at least 28d apart. When using MMR for both doses, minimum interval is 4wks. When using MMRV for both doses, minimum interval is 3m. Within 72hrs of measles exposure, give 1 dose of MMR as postexposure prophylaxis to susceptible healthy children age 12m and older. Contraindications Previous anaphylaxis to this vaccine, to any of its components, including egg protein. For LAIV only: age younger than 2yrs; pregnancy; chronic pulmonary (including asthma), cardiovascular (except hypertension), renal, hepatic, neurological/neuromuscular, hematologic, or metabolic (including diabetes) disorders; immunosuppression (including that caused by medications or HIV); for children and teens ages 6m through 18yrs, current long-term aspirin therapy; for children age 2 through 4yrs, wheezing or asthma within the past 12m, per healthcare provider statement. For children/teens who experience only hives with exposure to eggs, give IIV with additional safety precautions as found in the 2012 ACIP influenza recommendations, pages * Precautions Moderate or severe acute illness. History of Guillain-Barré syndrome (GBS) within 6wks of a previous influenza vaccination. For LAIV only: Receipt of specific antivirals (i.e., amantadine, rimantadine, zanamivir, or oseltamivir) 48hrs before vaccination. Avoid use of these antiviral drugs for 14d after vaccination. Contraindications Previous anaphylaxis to this vaccine or to any of its components. Pregnancy or possibility of pregnancy within 4wks. Children on high-dose immunosuppressive therapy or who are immunocompromised because of malignancy and primary or acquired immunodeficiency, including HIV/AIDS (although vaccination may be considered if CD4+ T-lymphocyte percentages are either 15% or greater in children age 1 through 8yrs or 200 cells/µl or greater in children age 9yrs and older). Precautions Moderate or severe acute illness. If blood, plasma, and/or immune globulin (IG or VZIG) were given in past 11m, see ACIP s General Recommendations on Immunization* regarding time to wait before vaccinating. Receipt of specific antivirals (i.e., acyclovir, famciclovir, or valacyclovir) 24hrs before vaccination, if possible; delay resumption of these antiviral drugs for 14d after vaccination. For MMRV only, personal or family (i.e., sibling or parent) history of seizures. Note: For patients with humoral immunodeficiency or leukemia, see ACIP recommendations.* Contraindications Previous anaphylaxis to this vaccine or to any of its components. Pregnancy or possibility of pregnancy within 4wks. Severe immunodeficiency (e.g., hematologic and solid tumors; receiving chemotherapy; congenital immunodeficiency; long-term immunosuppressive therapy, or severely symptomatic HIV). Note: HIV infection is NOT a contraindication to MMR for children who are not severely immunocompromised (consult ACIP MMR recommendations [MMWR 1998;47 [RR-8] for details*). Vaccination is recommended if indicated for 1) children age 12m through 5yrs whose CD4+ T-lymphocyte percentage has been greater than 15% for at least 6m or 2) for children age 6yrs and older whose CD4+ T-lymphocyte counts have been 200 cells/µl or greater for at least 6m. Precautions Moderate or severe acute illness. If blood, plasma, or immune globulin given in past 11m, see ACIP s General Recommendations on Immunization* regarding time to wait before vaccinating. History of thrombocytopenia or thrombocytopenic purpura. For MMRV only, personal or family (i.e., sibling or parent) history of seizures. Need for tuberculin skin testing (TST). If TST needed, give TST before or on same day as MMR, or give TST 4wks following MMR. February

11 Summary of Recommendations for Child/Teen Immunization (Age birth through 18 years) (Page 3 of 4) Vaccine name and route Schedule for routine vaccination and other guidelines (any vaccine can be given with another) Schedule for catch-up vaccination and related issues Contraindications and precautions (mild illness is not a contraindication) Hib (Haemophilus influenzae type b) Give Pneumococcal conjugate (PCV13) Give Pneumococcal polysaccharide (PPSV23) Give or SC Human papillomavirus (HPV) (HPV2, Cervarix) (HPV4, Gardasil) Give ActHib (PRP-T): give at ages 2m, 4m, 6m, 12 15m (booster dose). PedvaxHIB or Comvax (containing PRP-OMP): give at ages 2m, 4m, 12 15m (booster dose). Dose #1 of Hib vaccine should not be given earlier than age 6wks. Give final dose (booster dose) no earlier than age 12m and a minimum of 8wks after the previous dose. Hib vaccines are interchangeable; however, if different brands of Hib vaccines are administered for dose #1 and dose #2, a total of 3 doses is necessary to complete the primary series in infants. Any Hib vaccine may be used for the booster dose. Hib is not routinely given to children age 5yrs and older. Hiberix (PRP-T) is approved ONLY for the booster dose at age 12m through 4yrs. Give at ages 2m, 4m, 6m, 12 15m (booster dose). Dose #1 may be given as early as age 6wks. When children are behind on PCV13 schedule, minimum interval between doses given to children younger than age 12m is 4wks; for doses given at 12m and older, it is 8wks. For age 24 59m and healthy: if unvaccinated or any incomplete schedule or if 4 doses of PCV7 or any other age-appropriate complete PCV7 schedule, give 1 supplemental dose of PCV13 at least 8wks after the most recent dose. For high-risk** children age 24 71m: Give 2 doses at least 8wks apart if they previously received fewer than 3 doses; give 1 dose at least 8wks after the most recent dose if they previously received 3 doses. PCV13 is not routinely given to healthy children age 5yrs and older. **High-risk: Those with sickle cell disease; anatomic or functional asplenia; chronic cardiac, pulmonary, or renal disease; diabetes; cerebrospinal fluid leaks; HIV infection; immunosuppression; diseases associated with immunosuppressive and/or radiation therapy; or who have or will have a cochlear implant. Give 1 dose at least 8wks after final dose of PCV13 to high-risk** children age 2yrs and older. For children who have an immunocompromising condition or have sickle cell disease or functional or anatomic asplenia, give a 2nd dose of PPSV 5yrs after previous PPSV (consult ACIP PPSV recommendations at Give 3-dose series of either HPV2 or HPV4 to girls and 3-dose series of HPV4 to boys at age 11 12yrs on a 0, 1 2, 6m schedule. (May be given as early as age 9yrs.) Give a 3-dose series of either HPV2 or HPV4 to all older girls/ women (through age 26yrs) and 3-dose series of HPV4 to all older boys/men (through age 21yrs) who were not previously vaccinated. All Hib vaccines: If #1 was given at age 12 14m, give booster in 8wks. Give only 1 dose to unvaccinated children age 15 through 59m. ActHib: #2 and #3 may be given 4wks after previous dose. If #1 was given at age 7 11m, only 3 doses are needed; #2 is given 4 8wks after #1, then boost at age 12 15m (wait at least 8wks after dose #2). PedvaxHIB and Comvax: #2 may be given 4wks after dose #1. For minimum intervals, see 3rd bullet at left. For age 7 11m: If history of 0 doses, give 2 doses of PCV13, 4wks apart, with a 3rd dose at age 12 15m; if history of 1 or 2 doses, give 1 dose of PCV13 with a 2nd dose at age 12 15m at least 8wks later. For age 12 23m: If unvaccinated or history of 1 dose before age 12m, give 2 doses of PCV13 8wks apart; if history of 1 dose at or after age 12m or 2 or 3 doses before age 12m, give 1 dose of PCV13 at least 8wks after most recent dose; if history of 4 doses of PCV7 or other age-appropriate complete PCV7 schedule, give 1 supplemental dose of PCV13 at least 8wks after the most recent dose. For age 24 71m and at high risk**: If unvaccinated or any incomplete schedule of 1 or 2 doses, give 2 doses of PCV13, 1 at least 8wks after the most recent dose and another dose at least 8wks later; if any incomplete series of 3 doses, or if 4 doses of PCV7 or any other age-appropriate complete PCV7 schedule, give 1 supplemental dose of PCV13 at least 8wks after the most recent PCV7 dose. For children age 6 through 18yrs with functional or anatomic asplenia (including sickle cell disease), HIV infection or other immunocompromising condition, cochlear implant, or CSF leak, consider giving 1 dose of PCV13 regardless of previous history of PCV7 or PPSV. Minimum intervals between doses: 4wks between #1 and #2; 12 wks between #2 and #3. Overall, there must be at least 24wks between doses #1 and #3. If possible, use the same vaccine product for all doses. Contraindications Previous anaphylaxis to this vaccine or to any of its components. Age younger than 6wks. Precaution Moderate or severe acute illness. Contraindication Previous anaphylaxis to a PCV vaccine, to any of its components, or to any diphtheria toxoid-containing vaccine. Precaution Moderate or severe acute illness. Contraindication Previous anaphylaxis to this vaccine or to any of its components. Precaution Moderate or severe acute illness. Contraindication Previous anaphylaxis to this vaccine or to any of its components. Precautions Moderate or severe acute illness. Pregnancy. 11 February 2013

12 Summary of Recommendations for Child/Teen Immunization (Age birth through 18 years) (Page 4 of 4) Vaccine name and route Schedule for routine vaccination and other guidelines (any vaccine can be given with another) Schedule for catch-up vaccination and related issues Contraindications and precautions (mild illness is not a contraindication) Rotavirus (RV) Give orally Hepatitis A (HepA) Give Rotarix (RV1): give at ages 2m, 4m. RotaTeq (RV5): give at ages 2m, 4m, 6m. May give dose #1 as early as age 6wks. Give final dose no later than age 8m 0 days. Give 2 doses spaced 6 to 18m apart to all children at age 1yr (12 23m). Vaccinate all previously unvaccinated children and adolescents age 2yrs and older who - Want to be protected from HAV infection and lack a specific risk factor. - Live in areas where vaccination programs target older children. - Travel anywhere except U.S., W. Europe, N. Zealand, Australia, Canada, or Japan. - Have chronic liver disease, clotting factor disorder, or are adolescent males who have sex with other males. - Use illicit drugs (injectable or non-injectable). - Anticipate close personal contact with an international adoptee from a country of high or intermediate endemicity during the first 60 days following the adoptee s arrival in the U.S. Do not begin series in infants older than age 14wks 6 days. Intervals between doses may be as short as 4wks. If prior vaccination included use of different or unknown brand(s), a total of 3 doses should be given. Minimum interval between doses is 6m. Children who are not fully vaccinated by age 2yrs can be vaccinated at subsequent visits. Consider routine vaccination of children age 2yrs and older in areas with no existing program. Give 1 dose as postexposure prophylaxis to incompletely vaccinated children and teens age 12m and older who have recently (during the past 2wks) been exposed to hepatitis A virus. Contraindications Previous anaphylaxis to this vaccine or to any of its components. If allergy to latex, use RV5. History of intussusception. Diagnosis of severe combined immunodeficiency (SCID). Precautions Moderate or severe acute illness. Altered immunocompetence other than SCID. Chronic gastrointestinal disease. Spina bifida or bladder exstrophy. Contraindication Previous anaphylaxis to this vaccine or to any of its components. Precaution Moderate or severe acute illness. Meningococcal conjugate (MCV4) Give Hib-MenCY Give Meningococcal polysaccharide (MPSV4) Give SC Give quadrivalent MCV (Menactra [MCV4-D] or Menveo [MCV4-CRM]) dose #1 routinely at age 11 through 12yrs and a booster dose at age 16yrs. Give MCV4 to all unvaccinated teens age 13 through 18yrs; if vaccinated at age 13 15yrs, give booster dose at age 16 18yrs with a minimum interval of at least 8 weeks between doses. Give 1 initial dose to unvaccinated first-year college students age 19 21yrs who live in residence halls; give booster dose if most recent dose given when younger than age 16yrs. Give Hib-MenCY (MenHibrix) to children age 2 through 18m with persistent complement component deficiency or anatomic/functional asplenia; give at ages 2, 4, 6, 12 15m For children age 19 through 23m with persistent complement component deficiency, give either an infant series of Hib-MenCY at ages 2, 4, 6, 12 15m or give 2 doses of MCV4-D starting at age 9m, at least 8wks apart. Give either brand of MCV4 to unvaccinated children age 24m and older with persistent complement component deficiency or anatomic or functional asplenia; give 2 doses, 2 m apart. If MCV4-D is given, it must be separated by 4wks from the final dose of PCV13. If previously vaccinated with MPSV4 or MCV4 and risk of meningococcal disease persists, revaccinate with MCV4 in 3yrs (if previous dose given when younger than age 7yrs) or in 5yrs (if previous dose given at age 7yrs or older). Then, give additional booster doses every 5yrs if risk continues. When administering MCV4 to children and teens with HIV infection, give 2 initial doses, separated by 8wks. Minimum ages for MCV: 6 wks (Hib- MenCY), 9m (MCV4-D), 2yrs (MCV4- CRM). Contraindication Previous anaphylaxis to this vaccine or to any of its components. Precaution Moderate or severe acute illness. Note: Only use MPSV4 if there is a permanent contraindication or precaution to MCV4. 12 February 2013

13 Medical Management of Vaccine Reactions in Children and Teens All vaccines have the potential to cause an adverse reaction. To minimize adverse reactions, patients should be carefully screened for precautions and contraindications before vaccine is administered. Even with careful screening, reactions can occur. These reactions can vary from trivial and inconvenient (e.g., soreness, itching) to severe and life threatening (e.g., anaphylaxis). If reactions occur, staff should be prepared with procedures for their management. The table below describes procedures to follow if various reactions occur. Reaction Symptoms Management Localized Psychological fright and syncope (fainting) Anaphylaxis Soreness, redness, itching, or swelling at the injection site Slight bleeding Continuous bleeding Fright before injection is given Extreme paleness, sweating, coldness of the hands and feet, nausea, light-headedness, dizziness, weakness, or visual disturbances Fall, without loss of consciousness Loss of consciousness Sudden or gradual onset of generalized itching, erythema (redness), or urticaria (hives); angioedema (swelling of the lips, face, or throat); severe bronchospasm (wheezing); shortness of breath; shock; abdominal cramping; or cardiovascular collapse Apply a cold compress to the injection site. Consider giving an analgesic (pain reliever) or antipruritic (antiitch) medication. Apply an adhesive compress over the injection site. Place thick layer of gauze pads over site and maintain direct and firm pressure; raise the bleeding injection site (e.g., arm) above the level of the patient s heart. Have patient sit or lie down for the vaccination. Have patient lie flat or sit with head between knees for several minutes. Loosen any tight clothing and maintain an open airway. Apply cool, damp cloths to patient s face and neck. Examine the patient to determine if injury is present before attempting to move the patient. Place patient flat on back with feet elevated. Check the patient to determine if injury is present before attempting to move the patient. Place patient flat on back with feet elevated. Call 911 if patient does not recover immediately. See Emergency Medical Protocol for Management of Anaphylactic Reactions in Children and Teens on the next page for detailed steps to follow in treating anaphylaxis. (page 1 of 3) Technical content reviewed by the Centers for Disease Control and Prevention, July Item #P3082a (7/11) Immunization Action Coalition 1573 Selby Ave. St. Paul, MN (651)

14 Medical Management of Vaccine Reactions in Children and Teens (continued) (page 2 of 3) Supplies you may need at a community immunization clinic First-line treatment: Aqueous epinephrine 1:1000 dilution, in ampules, vials of solution, or prefilled syringes, including epinephrine autoinjectors (e.g., EpiPen). If EpiPens are to be stocked, both EpiPen Jr. (0.15 mg) and adult EpiPens (0.30 mg) should be available. Secondary treatment option: Diphenhydramine (Benadryl) injectable (50 mg/ml solution) or oral (12.5 mg/5 ml liquid, 25 or 50 mg capsules/tablets) Syringes: 1 and 3 cc, 22 25g, 1", 1½", and 2" needles for epinephrine and diphenhydramine (Benadryl) Alcohol wipes Tourniquet Pediatric & adult airways (small, medium, and large) Pediatric & adult size pocket masks with one-way valve Oxygen (if available) Stethoscope Sphygmomanometer (blood pressure measuring device) child, adult and extra-large cuffs) Tongue depressors Flashlight with extra batteries (for examination of mouth and throat) Wrist watch with ability to count seconds Cell phone or access to an onsite phone Emergency medical protocol for management of anaphylactic reactions in children and teens 1. If itching and swelling are confined to the injection site where the vaccination was given, observe patient closely for the development of generalized symptoms. 2. If symptoms are generalized, activate the emergency medical system (EMS; e.g., call 911) and notify the on-call physician. This should be done by a second person, while the primary nurse assesses the airway, breathing, circulation, and level of consciousness of the patient. 3. Drug Dosing Information: a. First-line treatment: Administer aqueous epinephrine 1:1000 dilution (i.e., 1 mg/ml) intramuscularly; the standard dose is 0.01 mg/kg body weight, up to 0.3 mg maximum single dose in children and 0.5 mg maximum in adolescents (see chart on next page). b. Secondary treatment option: For hives or itching, you may also administer diphenhydramine either orally or by intramuscular injection; the standard dose is 1 2 mg/kg body weight, up to 30 mg maximum dose in children and 50 mg maximum dose in adolescents (see chart on next page). 4. Monitor the patient closely until EMS arrives. Perform cardiopulmonary resuscitation (CPR), if necessary, and maintain airway. Keep patient in supine position (flat on back) unless he or she is having breathing difficulty. If breathing is difficult, patient s head may be elevated, provided blood pressure is adequate to prevent loss of consciousness. If blood pressure is low, elevate legs. Monitor blood pressure and pulse every 5 minutes. 5. If EMS has not arrived and symptoms are still present, repeat dose of epinephrine every 5 15 minutes for up to 3 doses, depending on patient s response. 6 Record all vital signs, medications administered to the patient, including the time, dosage, response, and the name of the medical personnel who administered the medication, and other relevant clinical information. 7. Notify the patient s primary care physician. (page 2 of 3) Item #P3082a (7/11) Immunization Action Coalition 1573 Selby Ave. St. Paul, MN (651)

15 Medical Management of Vaccine Reactions in Children and Teens (continued) (page 3 of 3) For your convenience, approximate dosages based on weight and age are provided in the charts below. Please confirm that you are administering the correct dose for your patient. First-Line Treatment: Epinephrine (the recommended dose for epinephrine is 0.01 mg/kg body weight) Infants and Children Teens Age Group Range of weight (lb) Range of weight (kg)* 1 mg/ml injectable (1:1000 dilution) intramuscular Minimum dose: 0.05 ml Epinephrine Dose 1 6 months 9 19 lb kg 0.05 ml (or mg) off label 7 36 months lb kg 0.1 ml (or mg) off label months lb kg 0.15 ml (or mg) 0.15 mg 5 7 years lb kg ml (or mg) 0.15 mg 8 10 years lb kg ml (or mg) 0.15 mg or 0.3 mg years lb kg ml (or mg) 0.3 mg 13 years & older 100+ lb 46+ kg 0.5 ml (or mg) 0.3 mg EpiPen (Dey, L.P.) Epinephrine auto-injector 0.15 mg or 0.3 mg Note: If body weight is known, then dosing by weight is preferred. If weight is not known or not readily available, dosing by age is appropriate. *Rounded weight at the 50th percentile for each age range Maximum dose for children Maximum dose for teens Secondary Treatment Option: Diphenyhydramine (the recommended dose for diphenhydramine [Benadryl] is 1 2 mg/kg body weight) Age Group Range of weight (lb) Range of weight (kg)* Diphenhydramine Dose 12.5 mg/5 ml liquid 25 mg or 50 mg tablets 50 mg/ml injectable (IV or ) Infants and Children 7 36 months lb kg 10 mg 20 mg months lb kg 15 mg 30 mg 5 7 years lb kg 20 mg 30 mg Teens 8 12 years lb kg 30 mg 13 years & older 100+ lb 46+ kg 50 mg Note: If body weight is known, then dosing by weight is preferred. If weight is not known or not readily available, dosing by age is appropriate. *Rounded weight at the 50th percentile for each age range Maximum dose for children Maximum dose for teens Sources Boyce JA, Assa ad A, Burks AW, et al. Guidelines for the Diagnosis and Management of Food Allergy in the United States: Report of the NIAID-Sponsored Expert Panel. Allergy Clin Immunol 2010; 126(6):S1 S57. Simons FE, Camargo CA. Anaphylaxis: Rapid recognition and treatment. In: UpToDate, Bochnew BS (Ed). UpToDate: Waltham, MA, These standing orders for the medical management of vaccine reactions in child and teenage patients shall remain in effect for patients of the until rescinded or until. name of clinic date Medical Director s signature Effective date Item #P3082a (7/11) Immunization Action Coalition 1573 Selby Ave. St. Paul, MN (651)

16 Medical Management of Vaccine Reactions in Children and Teens (continued) (page 3 of 3) For your convenience, approximate dosages based on weight and age are provided in the charts below. Please confirm that you are administering the correct dose for your patient. First-Line Treatment: Epinephrine (the recommended dose for epinephrine is 0.01 mg/kg body weight) Infants and Children Teens Age Group Range of weight (lb) Range of weight (kg)* 1 mg/ml injectable (1:1000 dilution) intramuscular Minimum dose: 0.05 ml Epinephrine Dose 1 6 months 9 19 lb kg 0.05 ml (or mg) off label 7 36 months lb kg 0.1 ml (or mg) off label months lb kg 0.15 ml (or mg) 0.15 mg 5 7 years lb kg ml (or mg) 0.15 mg 8 10 years lb kg ml (or mg) 0.15 mg or 0.3 mg years lb kg ml (or mg) 0.3 mg 13 years & older 100+ lb 46+ kg 0.5 ml (or mg) 0.3 mg EpiPen (Dey, L.P.) Epinephrine auto-injector 0.15 mg or 0.3 mg Note: If body weight is known, then dosing by weight is preferred. If weight is not known or not readily available, dosing by age is appropriate. *Rounded weight at the 50th percentile for each age range Maximum dose for children Maximum dose for teens Secondary Treatment Option: Diphenyhydramine (the recommended dose for diphenhydramine [Benadryl] is 1 2 mg/kg body weight) Age Group Range of weight (lb) Range of weight (kg)* Diphenhydramine Dose 12.5 mg/5 ml liquid 25 mg or 50 mg tablets 50 mg/ml injectable (IV or ) Infants and Children 7 36 months lb kg 10 mg 20 mg months lb kg 15 mg 30 mg 5 7 years lb kg 20 mg 30 mg Teens 8 12 years lb kg 30 mg 13 years & older 100+ lb 46+ kg 50 mg Note: If body weight is known, then dosing by weight is preferred. If weight is not known or not readily available, dosing by age is appropriate. *Rounded weight at the 50th percentile for each age range Maximum dose for children Maximum dose for teens Sources Boyce JA, Assa ad A, Burks AW, et al. Guidelines for the Diagnosis and Management of Food Allergy in the United States: Report of the NIAID-Sponsored Expert Panel. Allergy Clin Immunol 2010; 126(6):S1 S57. Simons FE, Camargo CA. Anaphylaxis: Rapid recognition and treatment. In: UpToDate, Bochnew BS (Ed). UpToDate: Waltham, MA, These standing orders for the medical management of vaccine reactions in child and teenage patients shall remain in effect for patients of the until rescinded or until. name of clinic date Medical Director s signature Effective date Item #P3082a (7/11) Immunization Action Coalition 1573 Selby Ave. St. Paul, MN (651)

17 Vaccine and dose number Recommended and Minimum Ages and Intervals Between Doses of Routinely Recommended Vaccines 1,2 Recommended age for this dose Minimum age for this dose Recommended interval to next dose Minimum interval to next dose Hepatitis B (HepB)-1 3 Birth Birth 1-4 months 4 weeks HepB months 4 weeks 2-17 months 8 weeks HepB months 24 weeks Diphtheria-tetanus-acellular pertussis (DTaP) months 6 weeks 2 months 4 weeks DTaP-2 4 months 10 weeks 2 months 4 weeks DTaP-3 6 months 14 weeks 6-12 months 6 months 5,6 DTaP months 12 months 3 years 6 months 5 DTaP years 4 years Haemophilus influenzae type b (Hib)-1 3,7 2 months 6 weeks 2 months 4 weeks Hib-2 4 months 10 weeks 2 months 4 weeks Hib months 14 weeks 6-9 months 8 weeks Hib months 12 months Inactivated poliovirus (IPV) months 6 weeks 2 months 4 weeks IPV-2 4 months 10 weeks 2-14 months 4 weeks IPV months 14 weeks 3-5 years 6 months IPV years 4 years Pneumococcal conjugate (PCV) months 6 weeks 8 weeks 4 weeks PCV-2 4 months 10 weeks 8 weeks 4 weeks PCV-3 6 months 14 weeks 6 months 8 weeks PCV months 12 months Measles-mumps-rubella (MMR) months 12 months 3-5 years 4 weeks MMR years 13 months Varicella (Var) months 12 months 3-5 years 12 weeks 11 Var years 15 months Hepatitis A (HepA) months 12 months 6-18 months 5 6 months 5 HepA-2 >18 months 18 months Influenza, inactivated (TIV) 12 >6 months 6 months 13 1 month 4 weeks Influenza, live attenuated (LAIV) years 2 years 1 month 4 weeks Meningococcal conjugate (MCV4) years 2 years 4-5 years 8 weeks MCV years 11 years (+ 8 weeks) Meningococcal polysaccharide (MPSV4) years 15 5 years 5 years MPSV4-2 7 years Tetanus-diphtheria (Td) years 7 years 10 years 5 years Tetanus-diphtheria-acellular pertussis (Tdap) 16 >11 years 7 years Pneumococcal polysaccharide (PPSV)-1 2 years 5 years 5 years PPSV years Human papillomavirus (HPV) years 9 years 2 months 4 weeks HPV-2 HPV years (+ 2 months) years (+ 6 months) 9 years (+ 4 weeks) 9 years (+24 weeks) 4 months 12 weeks 19 Rotavirus (RV) months 6 weeks 2 months 4 weeks RV-2 4 months 10 weeks 2 months 4 weeks RV months 14 weeks Herpes zoster 22 >60 years 60 years 17

18 1 Combination vaccines are available. Use of licensed combination vaccines is generally preferred to separate injections of their equivalent component vaccines. When administering combination vaccines, the minimum age for administration is the oldest age for any of the individual components; the minimum interval between doses is equal to the greatest interval of any of the individual components. 2 Information on travel vaccines including typhoid, Japanese encephalitis, and yellow fever, is available at Information on other vaccines that are licensed in the US but not distributed, including anthrax and smallpox, is available at 3 Combination vaccines containing a hepatitis B component (Comvax, Pediarix, and Twinrix) are available. These vaccines should not be administered to infants younger than 6 weeks because of the other components (i.e., Hib, DTaP, HepA, and IPV). 4 HepB-3 should be administered at least 8 weeks after HepB-2 and at least 16 weeks after HepB-1, and should not be administered before age 24 weeks. 5 Calendar months. 5 The minimum recommended interval between DTaP-3 and DTaP-4 is 6 months. However, DTaP-4 need not be repeated if administered at least 4 months after DTaP-3. 7 Children receiving the first dose of Hib or PCV vaccine at age 7 months or older require fewer doses to complete the series. 8 If PRP-OMP (Pedvax-Hib) was administered at ages 2 and 4 months, a dose at age 6 months is not required. 9 A fourth dose is not needed if the third dose was administered on or after the 4 th birthday and at least 6 months after the previous dose. 10 Combination measles-mumps-rubella-varicella (MMRV) vaccine can be used for children aged 12 months through 12 years. (See CDC. General recommendations on Immunization: recommendations of the ACIP. MMWR 2011;60[No. RR-2],7.) 11 For persons beginning the series on or after the 13 th birthday, the minimum interval from varicella-1 to varicella-2 is 4 weeks. 12 One dose of influenza vaccine per season is recommended for most people. Children younger than 9 years of age who are receiving influenza vaccine for the first time should receive 2 doses this season. See current influenza recommendations for other factors affecting the decision to administer one vs. two doses to children younger than 9 years. 13 The minimum age for inactivated influenza vaccine varies by vaccine manufacturer and formulation. See package inserts for vaccinespecific minimum ages. 14 Revaccination with meningococcal vaccine is recommended for previously vaccinated persons who remain at high risk for meningococcal disease. (See CDC. Updated recommendations from the ACIP for vaccination of persons at prolonged increased risk for meningococcal disease. MMWR 2009;58:[1042-3]) 15 Menactra may be given as young as 9 months for high-risk children. 16 Only one dose of Tdap is recommended. Subsequent doses should be given as Td. For one brand of Tdap (Adacel), the minimum age is 11 years. For management of a tetanus-prone wound in a person who has received a primary series of a tetanus-toxoid containing vaccine, there is no minimum interval between a previous dose of any tetanus-containing vaccine and Tdap. 17 A second dose of PPSV 5 years after the first dose is recommended for persons <65 years of age at highest risk for serious pneumococcal infection, and for those who are likely to have a rapid decline in pneumococcal antibody concentration. (See CDC. Prevention of pneumococcal disease: recommendations of the ACIP. MMWR 1997;46[No. RR-8].) 18 Bivalent HPV vaccine (Cervarix) is approved for females 10 through 25 years of age. Quadravalent HPV vaccine (Gardasil) is approved for males and females 9 through 26 years of age. 19 The minimum age for HPV-3 is based on the baseline minimum age for the first dose (108 months) and the minimum interval of 24 weeks between the first and third doses. Dose 3 need not be repeated if it is given at least 16 weeks after the first dose (and if the intervals between doses 1 and 2 and doses 2 and 3 are maintained at 4 weeks and 12 weeks, respectively). 20 The first dose of rotavirus must be administered between 6 weeks 0 days and 14 weeks 6 days. The vaccine series should not be started after age 15 weeks 0 days. Rotavirus should not be administered to children older than 8 months 0 days, regardless of the number of doses received before that age. 21 If two doses of Rotarix are administered as age appropriate, a third dose is not necessary. 22 Herpes zoster vaccine is recommended as a single dose for persons 60 years of age and older. Adapted from Table 1, ACIP General Recommendations on Immunization. February

19 Legal Limits of Mercury-Containing Vaccines in Washington State PARENT/PUBLIC INFORMATION November, 2008 What is mercury and what is thimerosal? 1 Mercury is a naturally occurring element found in the earth s crust, air, soil and water. Mercury has been released into the environment through volcanic eruptions, weathering of rocks and burning of coal. Once released, certain types of bacteria in the environment can change mercury to methylmercury. Methylmercury makes its way through the food chain in fish, animals, and humans. At high levels, it can be toxic to people. Thimerosal a preservative still used in some vaccines is a mercury-containing organic compound which has a different form of mercury called ethylmercury. Studies comparing ethylmercury and methylmercury suggest that they are processed differently in the human body. Ethylmercury is broken down and excreted much more rapidly than methylmercury. It appears that ethylmercury (the type of mercury in the influenza vaccine) is removed from the body more quickly than methylmercury (the type of mercury in the environment). What are Washington s legal limits on mercury in vaccines? As of July 1, 2007, Washington State law requires that pregnant women and children under 3 years of age be given vaccines that have no more than 0.5 micrograms of mercury per 0.5 milliliter dose. The law makes an exception for mercury content of influenza vaccine and allows pregnant women and children under age three to get influenza vaccine if it has 1.0 microgram of mercury per 0.5 milliliter dose, or less. Your doctor or nurse can help explain the size of these amounts. The law also states that in the case of an outbreak or vaccine shortage, the Secretary of the Department of Health may suspend the law s mercury limits for the duration of that outbreak or shortage. Which vaccines have more mercury in them than Washington law allows for pregnant women and children under three? Currently, only the following three vaccines have too much mercury in them: o multi-dose vials of influenza vaccines (although there are influenza vaccines that are mercury-free); o a vaccine that protects against Japanese Encephalitis. 1 Information about mercury, methylmercury thimerosal and ethylmercury stated in the answer to this question was taken from the following two sources: Children s Hospital of Philadelphia at and the Food and Drug Administration at 19

20 How do these limits affect me and my family? Few vaccines are now manufactured with more mercury than the law allows. However, the law may affect you or your family in the following ways: 1. If you are pregnant, you must get a flu shot with 1.0 microgram of mercury per 0.5 milliliter dose, or less. 2. If you have a child under three years of age, he or she must get a flu shot with 1.0 microgram of mercury per 0.5 milliliter dose, or less. 3. You (or your child) may not get vaccinated against Japanese Encephalitis in Washington State if you are: o traveling to certain countries in Asia where Japanese Encephalitis occurs, AND o you will be staying in these countries longer than one month, AND o you are pregnant, OR o your child is under age three. Where can I get more information? For more information about vaccines, go to: To find an immunization clinic, call The Family Health Hotline at

21 Adult Resources 21

22 THIS PAGE INTENTIONALLY LEFT BLANK 22

23 Patient name: Date of birth: (mo.) (day) (yr.) Screening Questionnaire for Adult Immunization For patients: The following questions will help us determine which vaccines you may be given today. If you answer yes to any question, it does not necessarily mean you should not be vaccinated. It just means additional questions must be asked. If a question is not clear, please ask your healthcare provider to explain it. 1. Are you sick today? 2. Do you have allergies to medications, food, a vaccine component, or latex? Yes No Don t Know 3. Have you ever had a serious reaction after receiving a vaccination? 4. Do you have a long-term health problem with heart disease, lung disease, asthma, kidney disease, metabolic disease (e.g., diabetes), anemia, or other blood disorder? 5. Do you have cancer, leukemia, AIDS, or any other immune system problem? 6. Do you take cortisone, prednisone, other steroids, or anticancer drugs, or have you had radiation treatments? 7. Have you had a seizure or a brain or other nervous system problem? 8. During the past year, have you received a transfusion of blood or blood products, or been given immune (gamma) globulin or an antiviral drug? 9. For women: Are you pregnant or is there a chance you could become pregnant during the next month? 10. Have you received any vaccinations in the past 4 weeks? Form completed by: Form reviewed by: Date: Date: Did you bring your immunization record card with you? yes no It is important for you to have a personal record of your vaccinations. If you don t have a personal record, ask your healthcare provider to give you one. Keep this record in a safe place and bring it with you every time you seek medical care. Make sure your healthcare provider records all your vaccinations on it. Technical content reviewed by the Centers for Disease Control and Prevention, October Item#P4065 (10/11) Immunization Action Coalition 1573 Selby Ave. St. Paul, MN (651)

24 Information for Health Professionals about the Screening Questionnaire for Adults Are you interested in knowing why we included a certain question on the Screening Questionnaire? If so, read the information below. If you want to find out even more, consult the references listed at the bottom of this page. 1. Are you sick today? [all vaccines] There is no evidence that acute illness reduces vaccine efficacy or increases vaccine adverse events (1). However, as a precaution with moderate or severe acute illness, all vaccines should be delayed until the illness has improved. Mild illnesses (such as upper respiratory infections or diarrhea) are NOT contraindications to vaccination. Do not withhold vaccination if a person is taking antibiotics. 2. Do you have allergies to medications, food, a vaccine component, or latex? [all vaccines] If a person reports they have an allergy to egg, ask if they can eat lightly cooked eggs (e.g., scrambled eggs). If they can, trivalent influenza vaccine (TIV) may be admininistered. If after eating eggs or egg-containing foods, they have a reaction consisting of only hives, TIV may be given and the person should be observed for at least 30 minutes. If a person experiences a serious systemic or anaphylactic reaction (e.g., hives and either swelling of the lips or tongue, acute respiratory distress, or collapse) after eating eggs, do not administer TIV or live attenuated influenza vaccine (LAIV). It is possible that they may be eligible to be given TIV, but only after they have seen a physician with expertise in the management of allergic conditions. If a person has anaphylaxis after eating gelatin, do not administer MMR or varicella vaccine. Local reactions are not contraindications. For a table of vaccines supplied in vials or syringes that contain latex, go to pubs/pinkbook/downloads/appendices/b/latex-table.pdf. For an extensive list of vaccine components, see reference Have you ever had a serious reaction after receiving a vaccination? [all vaccines] History of anaphylactic reaction (see question 2) to a previous dose of vaccine or vaccine component is a contraindication for subsequent doses (1). Under normal circumstances, vaccines are deferred when a precaution is present. However, situations may arise when the benefit outweighs the risk (e.g., during a community pertussis outbreak). 4. Do you have a long-term health problem with heart disease, lung disease, asthma, kidney disease, metabolic disease (e.g., diabetes), anemia, or other blood disorder? [LAIV] People with any of these health conditions should not be given the intranasal live attenuated influenza vaccine (LAIV). Instead, they should be vaccinated with the injectable influenza vaccine. 5. Do you have cancer, leukemia, AIDS, or any other immune system problem? [LAIV, MMR, VAR, ZOS] Live virus vaccines (e.g., LAIV, measles-mumps-rubella [MMR], varicella [VAR], zoster [ZOS]) are usually contraindicated in immunocompromised people. However, there are exceptions. For example, MMR vaccine is recommended and varicella vaccine should be considered for adults with CD4+ T-lymphocyte counts of greater than or equal to 200 cells/µl. Immunosuppressed people should not receive LAIV. For details, consult the ACIP recommendations (3, 4, 5). 6. Do you take cortisone, prednisone, other steroids, or anticancer drugs, or have you had radiation treatments? [LAIV, MMR, VAR, ZOS] Live virus vaccines (e.g., LAIV, MMR, VAR, ZOS) should be postponed until after chemotherapy or long-term high-dose steroid therapy has ended. For details and length of time to postpone, consult the ACIP statement (1, 5). To find specific vaccination schedules for stem cell transplant (bone marrow transplant) patients, see reference 6. LAIV can be given only to healthy non- pregnant people younger than age 50 years. 7. Have you had a seizure or a brain or other nervous system problem? [influenza, Td/Tdap] Tdap is contraindicated in people who have a history of encephalopathy within 7 days following DTP/DTaP given before age 7 years. An unstable progressive neurologic problem is a precaution to the use of Tdap. For people with stable neurologic disorders (including seizures) unrelated to vaccination, or for people with a family history of seizure, vaccinate as usual. A history of Guillain-Barré syndrome (GBS) is a consideration with the following: 1) Td/Tdap: if GBS has occurred within 6 weeks of a tetanus-containing vaccine and decision is made to continue vaccination, give Tdap instead of Td if no history of prior Tdap; 2) Influenza vaccine (TIV/LAIV): if GBS has occurred within 6 weeks of a prior influenza vaccine, vaccinate with TIV if at high risk for severe influenza complications. 8. During the past year, have you received a transfusion of blood or blood products, or been given immune (gamma) globulin or an antiviral drug? [LAIV, MMR, VAR] Certain live virus vaccines (e.g., LAIV, MMR, VAR) may need to be deferred, depending on several variables. Consult the most current ACIP recommendations for current information on intervals between antiviral drugs, immune globulin or blood product administration and live virus vaccines. (1) 9. For women: Are you pregnant or is there a chance you could become pregnant during the next month? [MMR, LAIV, VAR, ZOS] Live virus vaccines (e.g., MMR, VAR, ZOS, LAIV) are contraindicated one month before and during pregnancy because of the theoretical risk of virus transmission to the fetus. Sexually active women in their childbearing years who receive live virus vaccines should be instructed to practice careful contraception for one month following receipt of the vaccine. On theoretical grounds, inactivated poliovirus vaccine should not be given during pregnancy; however, it may be given if risk of disease is imminent and immediate protection is needed (e.g., travel to endemic areas). Use of Td or Tdap is not contraindicated in pregnancy. At the provider s discretion, either vaccine may be administered during the 2nd or 3rd trimester. (1, 3, 4, 5, 7, 8) 10. Have you received any vaccinations in the past 4 weeks? [LAIV, MMR, VAR, yellow fever] If the person to be vaccinated was given either LAIV or an injectable live virus vaccine (e.g., MMR, VAR, ZOS, yellow fever) in the past 4 weeks, they should wait 28 days before receiving another vaccination of this type. Inactivated vaccines may be given at any spacing interval if they are not administered simultaneously. References: 1. CDC. General recommendations on immunization, at 2. Table of Vaccine Components: excipient-table-2.pdf. 3. CDC. Measles, mumps, and rubella vaccine use and strategies for elimination of measles, rubella, and congenital rubella syndrome and control of mumps. MMWR 1998; 47 (RR-8). 4. CDC. Prevention of varicella: Recommendations of the Advisory Committee on Immunization Practices. MMWR 2007; 56 (RR-4). 5. CDC. Prevention and control of influenza recommendations of ACIP, at 6. CDC. Excerpt from Guidelines for preventing opportunistic infections among hematopoietic stem cell transplant recipients, MMWR 2000; 49 (RR-10), 7. CDC. Notice to readers: Revised ACIP recommendation for avoiding pregnancy after receiving a rubella-containing vaccine. MMWR 2001; 50 (49). 8. CDC. Prevention of pertussis, tetanus, and diphtheria among pregnant and postpartum women and their infants: Recommendations of the ACIP. MMWR 2008; 57 (RR-4). 24 Immunization Action Coalition Item #P4065 p. 2

25 Recommended Adult Immunization Schedule United States Note: These recommendations must be read with the footnotes that follow containing number of doses, intervals between doses, and other important information. VACCINE AGE GROUP years years years years years 65 years Influenza 2,* Tetanus, diphtheria, pertussis (Td/Tdap) 3,* Varicella 4,* Human papillomavirus (HPV) Female 5,* Human papillomavirus (HPV) Male 5,* 1 dose annually Substitute 1-time dose of Tdap for Td booster; then boost with Td every 10 yrs 2 doses 3 doses 3 doses Zoster 6 Measles, mumps, rubella (MMR) 7,* Pneumococcal polysaccharide (PPSV23) 8,9 Pneumococcal 13-valent conjugate (PCV13) 10,* Meningococcal 11,* Hepatitis A 12,* Hepatitis B 13,* *Covered by the Vaccine Injury Compensation Program For all persons in this category who meet the age requirements and who lack documentation of vaccination or have no evidence of previous infection; zoster vaccine recommended regardless of prior episode of zoster Recommended if some other risk factor is present (e.g., on the basis of medical, occupational, lifestyle, or other indication) No recommendation 1 or 2 doses 1 or 2 doses 1 dose 1 or more doses 2 doses 3 doses 1 dose 1 dose Report all clinically significant postvaccination reactions to the Vaccine Adverse Event Reporting System (VAERS). Reporting forms and instructions on filing a VAERS report are available at or by telephone, Information on how to file a Vaccine Injury Compensation Program claim is available at or by telephone, To file a claim for vaccine injury, contact the U.S. Court of Federal Claims, 717 Madison Place, N.W., Washington, D.C ; telephone, Additional information about the vaccines in this schedule, extent of available data, and contraindications for vaccination is also available at gov/vaccines or from the CDC-INFO Contact Center at 800-CDC-INFO ( ) in English and Spanish, 8:00 a.m. - 8:00 p.m. Eastern Time, Monday - Friday, excluding holidays. Use of trade names and commercial sources is for identification only and does not imply endorsement by the U.S. Department of Health and Human Services. The recommendations in this schedule were approved by the Centers for Disease Control and Prevention s (CDC) Advisory Committee on Immunization Practices (ACIP), the American Academy of Family Physicians (AAFP), the American College of Physicians (ACP), American College of Obstetricians and Gynecologists (ACOG) and American College of Nurse-Midwives (ACNM). VACCINE Influenza 2,* Tetanus, diphtheria, pertussis (Td/Tdap) 3,* Varicella 4,* Human papillomavirus (HPV) Female 5,* Human papillomavirus (HPV) Male 5,* Zoster 6 Measles, mumps, rubella (MMR) 7,* Pneumococcal polysaccharide (PPSV23) 8,9 INDICATION Pregnancy Pneumococcal 13-valent conjugate (PCV13) 10,* Meningococcal 11,* Hepatitis A 12,* Hepatitis B 13,* 1 dose Tdap each pregnancy Immunocompromising conditions (excluding human immunodeficiency virus [HIV]) 4,6,7,10,15 Contraindicated Contraindicated Contraindicated HIV infection CD4+ T lymphocyte count 4,6,7,10,14,15 < 200 cells/μl 1 dose IIV annually *Covered by the Vaccine Injury Compensation Program For all persons in this category who meet the age requirements and who lack documentation of vaccination or have no evidence of previous infection; zoster vaccine recommended regardless of prior episode of zoster Recommended if some other risk factor is present (e.g., on the basis of medical, occupational, lifestyle, or other indications) No recommendation 200 cells/μl 3 doses through age 26 yrs 3 doses through age 26 yrs Men who have sex with men (MSM) 1 dose IIV or LAIV annually Heart disease, chronic lung disease, chronic alcoholism 1 or 2 doses 1 or more doses 2 doses 3 doses Asplenia (including elective splenectomy and persistent complement component deficiencies) 10,14 1 dose 2 doses 1 dose 1 or 2 doses Chronic liver disease 1 dose IIV annually Kidney failure, end-stage renal disease, receipt of hemodialysis Substitute 1-time dose of Tdap for Td booster; then boost with Td every 10 yrs 3 doses through age 26 yrs 3 doses through age 21 yrs Diabetes Healthcare personnel 1 dose IIV or LAIV annually These schedules indicate the recommended age groups and medical indications for which administration of currently licensed vaccines is commonly indicated for adults ages 19 years and older, as of January 1, For all vaccines being recommended on the Adult Immunization Schedule: a vaccine series does not need to be restarted, regardless of the time that has elapsed between doses. Licensed combination vaccines may be used whenever any components of the combination are indicated and when the vaccine s other components are not contraindicated. For detailed recommendations on all vaccines, including those used primarily for travelers or that are issued during the year, consult the manufacturers package inserts and the complete statements from the Advisory Committee on Immunization Practices ( Use of trade names and commercial sources is for identification only and does not imply endorsement by the U.S. Department of Health and Human Services. 25

26 Footnotes Recommended Immunization Schedule for Adults Aged 19 Years and Older United States, Additional information Additional guidance for the use of the vaccines described in this supplement is available at htm. Information on vaccination recommendations when vaccination status is unknown and other general immunization information can be found in the General Recommendations on Immunization at Information on travel vaccine requirements and recommendations (e.g., for hepatitis A and B, meningococcal, and other vaccines) are available at 2. Influenza vaccination Annual vaccination against influenza is recommended for all persons aged 6 months and older. Persons aged 6 months and older, including pregnant women, can receive the inactivated influenza vaccine (IIV). Healthy, nonpregnant persons aged 2 49 years without high-risk medical conditions can receive either intranasally administered live, attenuated influenza vaccine (LAIV) (FluMist), or IIV. Health-care personnel who care for severely immunocompromised persons (i.e., those who require care in a protected environment) should receive IIV rather than LAIV. The intramuscularly or intradermally administered IIV are options for adults aged years. Adults aged 65 years and older can receive the standard dose IIV or the high-dose IIV (Fluzone High-Dose). 3. Tetanus, diphtheria, and acellular pertussis (Td/Tdap) vaccination Administer one dose of Tdap vaccine to pregnant women during each pregnancy (preferred during weeks gestation), regardless of number of years since prior Td or Tdap vaccination. Administer Tdap to all other adults who have not previously received Tdap or for whom vaccine status is unknown. Tdap can be administered regardless of interval since the most recent tetanus or diphtheria-toxoid containing vaccine. Adults with an unknown or incomplete history of completing a 3-dose primary vaccination series with Td-containing vaccines should begin or complete a primary vaccination series including a Tdap dose. For unvaccinated adults, administer the first 2 doses at least 4 weeks apart and the third dose 6 12 months after the second. For incompletely vaccinated (i.e., less than 3 doses) adults, administer remaining doses. Refer to the Advisory Committee on Immunization Practices (ACIP) statement for recommendations for administering Td/Tdap as prophylaxis in wound management (see footnote #1). 4. Varicella vaccination All adults without evidence of immunity to varicella (as defined below) should receive 2 doses of single-antigen varicella vaccine or a second dose if they have received only 1 dose. Special consideration for vaccination should be given to those who have close contact with persons at high risk for severe disease (e.g., health-care personnel and family contacts of persons with immunocompromising conditions) or are at high risk for exposure or transmission (e.g., teachers; child care employees; residents and staff members of institutional settings, including correctional institutions; college students; military personnel; adolescents and adults living in households with children; nonpregnant women of childbearing age; and international travelers). Pregnant women should be assessed for evidence of varicella immunity. Women who do not have evidence of immunity should receive the first dose of varicella vaccine upon completion or termination of pregnancy and before discharge from the health-care facility. The second dose should be administered 4 8 weeks after the first dose. Evidence of immunity to varicella in adults includes any of the following: documentation of 2 doses of varicella vaccine at least 4 weeks apart; U.S.-born before 1980 except health-care personnel and pregnant women; history of varicella based on diagnosis or verification of varicella disease by a health-care provider; history of herpes zoster based on diagnosis or verification of herpes zoster disease by a health-care provider; or laboratory evidence of immunity or laboratory confirmation of disease. 5. Human papillomavirus (HPV) vaccination Two vaccines are licensed for use in females, bivalent HPV vaccine (HPV2) and quadrivalent HPV vaccine (HPV4), and one HPV vaccine for use in males (HPV4). For females, either HPV4 or HPV2 is recommended in a 3-dose series for routine vaccination at age 11 or 12 years, and for those aged 13 through 26 years, if not previously vaccinated. For males, HPV4 is recommended in a 3-dose series for routine vaccination at age 11 or 12 years, and for those aged 13 through 21 years, if not previously vaccinated. Males aged 22 through 26 years may be vaccinated. HPV4 is recommended for men who have sex with men (MSM) through age 26 years for those who did not get any or all doses when they were younger. Vaccination is recommended for immunocompromised persons (including those with HIV infection) through age 26 years for those who did not get any or all doses when they were younger. A complete series for either HPV4 or HPV2 consists of 3 doses. The second dose should be administered 1 2 months after the first dose; the third dose should be administered 6 months after the first dose (at least 24 weeks after the first dose). HPV vaccines are not recommended for use in pregnant women. However, pregnancy testing is not needed before vaccination. If a woman is found to be pregnant after initiating the vaccination series, no intervention is needed; the remainder of the 3-dose series should be delayed until completion of pregnancy. Although HPV vaccination is not specifically recommended for health-care personnel (HCP) based on their occupation, HCP should receive the HPV vaccine as recommended (see above). 6. Zoster vaccination A single dose of zoster vaccine is recommended for adults aged 60 years and older regardless of whether they report a prior episode of herpes zoster. Although the vaccine is licensed by the Food and Drug Administration (FDA) for use among and can be administered to persons aged 50 years and older, ACIP recommends that vaccination begins at age 60 years. Persons aged 60 years and older with chronic medical conditions may be vaccinated unless their condition constitutes a contraindication, such as pregnancy or severe immunodeficiency. Although zoster vaccination is not specifically recommended for HCP, they should receive the vaccine if they are in the recommended age group. 7. Measles, mumps, rubella (MMR) vaccination Adults born before 1957 generally are considered immune to measles and mumps. All adults born in 1957 or later should have documentation of 1 or more doses of MMR vaccine unless they have a medical contraindication to the vaccine, or laboratory evidence of immunity to each of the three diseases. Documentation of provider-diagnosed disease is not considered acceptable evidence of immunity for measles, mumps, or rubella. Measles component: A routine second dose of MMR vaccine, administered a minimum of 28 days after the first dose, is recommended for adults who are students in postsecondary educational institutions; work in a health-care facility; or plan to travel internationally. Persons who received inactivated (killed) measles vaccine or measles vaccine of unknown type during should be revaccinated with 2 doses of MMR vaccine. Mumps component: A routine second dose of MMR vaccine, administered a minimum of 28 days after the first dose, is recommended for adults who are students in a postsecondary educational institution; work in a health-care facility; or plan to travel internationally. Persons vaccinated before 1979 with either killed mumps vaccine or mumps vaccine of unknown type who are at high risk for mumps infection (e.g., persons who are working in a health-care facility) should be considered for revaccination with 2 doses of MMR vaccine. Rubella component: For women of childbearing age, regardless of birth year, rubella immunity should be determined. If there is no evidence of immunity, women who are not pregnant should be vaccinated. Pregnant women who do not have evidence of immunity should receive MMR vaccine upon completion or termination of pregnancy and before discharge from the health-care facility. HCP born before 1957: For unvaccinated health-care personnel born before 1957 who lack laboratory evidence of measles, mumps, and/or rubella immunity or laboratory confirmation of disease, health-care facilities should consider vaccinating personnel with 2 doses of MMR vaccine at the appropriate interval for measles and mumps or 1 dose of MMR vaccine for rubella. 8. Pneumococcal polysaccharide (PPSV23) vaccination Vaccinate all persons with the following indications: all adults aged 65 years and older; 26 adults younger than age 65 years with chronic lung disease (including chronic obstructive pulmonary disease, emphysema, and asthma); chronic cardiovascular diseases; diabetes mellitus; chronic renal failure; nephrotic syndrome; chronic liver disease (including cirrhosis); alcoholism; cochlear implants; cerebrospinal fluid leaks; immunocompromising conditions; and functional or anatomic asplenia (e.g., sickle cell disease and other hemoglobinopathies, congenital or acquired asplenia, splenic dysfunction, or splenectomy [if elective splenectomy is planned, vaccinate at least 2 weeks before surgery]); residents of nursing homes or long-term care facilities; and adults who smoke cigarettes. Persons with immunocompromising conditions and other selected conditions are recommended to receive PCV13 and PPSV23 vaccines. See footnote #10 for information on timing of PCV13 and PPSV23 vaccinations. Persons with asymptomatic or symptomatic HIV infection should be vaccinated as soon as possible after their diagnosis. When cancer chemotherapy or other immunosuppressive therapy is being considered, the interval between vaccination and initiation of immunosuppressive therapy should be at least 2 weeks. Vaccination during chemotherapy or radiation therapy should be avoided. Routine use of PPSV23 is not recommended for American Indians/Alaska Natives or other persons younger than age 65 years unless they have underlying medical conditions that are PPSV23 indications. However, public health authorities may consider recommending PPSV23 for American Indians/Alaska Natives who are living in areas where the risk for invasive pneumococcal disease is increased. When indicated, PPSV23 should be administered to patients who are uncertain of their vaccination status and there is no record of previous vaccination. When PCV13 is also indicated, a dose of PCV13 should be given first (see footnote #10). 9. Revaccination with PPSV23 One-time revaccination 5 years after the first dose is recommended for persons aged 19 through 64 years with chronic renal failure or nephrotic syndrome; functional or anatomic asplenia (e.g., sickle cell disease or splenectomy); and for persons with immunocompromising conditions. Persons who received 1 or 2 doses of PPSV23 before age 65 years for any indication should receive another dose of the vaccine at age 65 years or later if at least 5 years have passed since their previous dose. No further doses are needed for persons vaccinated with PPSV23 at or after age 65 years. 10. Pneumococcal conjugate 13-valent vaccination (PCV13) Adults aged 19 years or older with immunocompromising conditions (including chronic renal failure and nephrotic syndrome), functional or anatomic asplenia, CSF leaks or cochlear implants, and who have not previously received PCV13 or PPSV23 should receive a single dose of PCV13 followed by a dose of PPSV23 at least 8 weeks later. Adults aged 19 years or older with the aforementioned conditions who have previously received one or more doses of PPSV23 should receive a dose of PCV13 one or more years after the last PPSV23 dose was received. For those that require additional doses of PPSV23, the first such dose should be given no sooner than 8 weeks after PCV13 and at least 5 years since the most recent dose of PPSV23. When indicated, PCV13 should be administered to patients who are uncertain of their vaccination status history and there is no record of previous vaccination. Although PCV13 is licensed by the Food and Drug Administration (FDA) for use among and can be administered to persons aged 50 years and older, ACIP recommends PCV13 for adults aged 19 years and older with the specific medical conditions noted above. 11. Meningococcal vaccination Administer 2 doses of meningococcal conjugate vaccine quadrivalent (MCV4) at least 2 months apart to adults with functional asplenia or persistent complement component deficiencies. HIV-infected persons who are vaccinated also should receive 2 doses. Administer a single dose of meningococcal vaccine to microbiologists routinely exposed to isolates of Neisseria meningitidis, military recruits, and persons who travel to or live in countries in which meningococcal disease is hyperendemic or epidemic. First-year college students up through age 21 years who are living in residence halls should be vaccinated if they have not received a dose on or after their 16th birthday. MCV4 is preferred for adults with any of the preceding indications who are aged 55 years and younger; meningococcal polysaccharide vaccine (MPSV4) is preferred for adults aged 56 years and older. Revaccination with MCV4 every 5 years is recommended for adults previously vaccinated with MCV4 or MPSV4 who remain at increased risk for infection (e.g., adults with anatomic or functional asplenia or persistent complement component deficiencies). 12. Hepatitis A vaccination Vaccinate any person seeking protection from hepatitis A virus (HAV) infection and persons with any of the following indications: men who have sex with men and persons who use injection or noninjection illicit drugs; persons working with HAV-infected primates or with HAV in a research laboratory setting; persons with chronic liver disease and persons who receive clotting factor concentrates; persons traveling to or working in countries that have high or intermediate endemicity of hepatitis A; and unvaccinated persons who anticipate close personal contact (e.g., household or regular babysitting) with an international adoptee during the first 60 days after arrival in the United States from a country with high or intermediate endemicity. (See footnote #1 for more information on travel recommendations). The first dose of the 2-dose hepatitis A vaccine series should be administered as soon as adoption is planned, ideally 2 or more weeks before the arrival of the adoptee. Single-antigen vaccine formulations should be administered in a 2-dose schedule at either 0 and 6 12 months (Havrix), or 0 and 6 18 months (Vaqta). If the combined hepatitis A and hepatitis B vaccine (Twinrix) is used, administer 3 doses at 0, 1, and 6 months; alternatively, a 4-dose schedule may be used, administered on days 0, 7, and 21 30, followed by a booster dose at month Hepatitis B vaccination Vaccinate persons with any of the following indications and any person seeking protection from hepatitis B virus (HBV) infection: sexually active persons who are not in a long-term, mutually monogamous relationship (e.g., persons with more than one sex partner during the previous 6 months); persons seeking evaluation or treatment for a sexually transmitted disease (STD); current or recent injection-drug users; and men who have sex with men; health-care personnel and public-safety workers who are potentially exposed to blood or other infectious body fluids; persons with diabetes younger than age 60 years as soon as feasible after diagnosis; persons with diabetes who are age 60 years or older at the discretion of the treating clinician based on increased need for assisted blood glucose monitoring in long-term care facilities, likelihood of acquiring hepatitis B infection, its complications or chronic sequelae, and likelihood of immune response to vaccination; persons with end-stage renal disease, including patients receiving hemodialysis; persons with HIV infection; and persons with chronic liver disease; household contacts and sex partners of hepatitis B surface antigen-positive persons; clients and staff members of institutions for persons with developmental disabilities; and international travelers to countries with high or intermediate prevalence of chronic HBV infection; and all adults in the following settings: STD treatment facilities; HIV testing and treatment facilities; facilities providing drug-abuse treatment and prevention services; health-care settings targeting services to injection-drug users or men who have sex with men; correctional facilities; end-stage renal disease programs and facilities for chronic hemodialysis patients; and institutions and nonresidential daycare facilities for persons with developmental disabilities. Administer missing doses to complete a 3-dose series of hepatitis B vaccine to those persons not vaccinated or not completely vaccinated. The second dose should be administered 1 month after the first dose; the third dose should be given at least 2 months after the second dose (and at least 4 months after the first dose). If the combined hepatitis A and hepatitis B vaccine (Twinrix) is used, give 3 doses at 0, 1, and 6 months; alternatively, a 4-dose Twinrix schedule, administered on days 0, 7, and followed by a booster dose at month 12 may be used. Adult patients receiving hemodialysis or with other immunocompromising conditions should receive 1 dose of 40 μg/ml (Recombivax HB) administered on a 3-dose schedule at 0, 1, and 6 months or 2 doses of 20 μg/ml (Engerix-B) administered simultaneously on a 4-dose schedule at 0, 1, 2, and 6 months. 14. Selected conditions for which Haemophilus influenzae type b (Hib) vaccine may be used 1 dose of Hib vaccine should be considered for persons who have sickle cell disease, leukemia, or HIV infection, or who have anatomic or functional asplenia if they have not previously received Hib vaccine. 15. Immunocompromising conditions Inactivated vaccines generally are acceptable (e.g., pneumococcal, meningococcal, and influenza [inactivated influenza vaccine]), and live vaccines generally are avoided in persons with immune deficiencies or immunocompromising conditions. Information on specific conditions is available at

27 Guidelines for Vaccinating Pregnant Women April

28 Guidelines for Vaccinating Pregnant Women Abstracted from recommendations of the Advisory Committee on Immunization Practices (ACIP) April 2013 Risk to a developing fetus from vaccination of the mother during pregnancy is theoretical. No evidence exists of risk to the fetus from vaccinating pregnant women with inactivated virus or bacterial vaccines or toxoids. Live vaccines administered to a pregnant woman pose a theoretical risk to the fetus; therefore, live, attenuated virus and live bacterial vaccines generally are contraindicated during pregnancy. Benefits of vaccinating pregnant women usually outweigh potential risks when the likelihood of disease exposure is high, when infection would pose a risk to the mother or fetus, and when the vaccine is unlikely to cause harm. CDC. General recommendations on immunization: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2011; 60 (No. 2): 26. The table on the following page may be used to find the general rule for vaccinating a pregnant woman with a particular vaccine. The third column of the table refers the reader to the page in this document where more specific information from the appropriate ACIP recommendations will be found. Each quotation from an ACIP recommendation in turn references the entire document, where the quotation(s) may be found in context. Prenatal Screening Pregnant women should be evaluated for immunity to rubella and varicella and be tested for the presence of HBsAg during every pregnancy. Women susceptible to rubella and varicella should be vaccinated immediately after delivery. A woman found to be HBsAg positive should be monitored carefully to ensure that the infant receives HBIG and begins the hepatitis B vaccine series no later than 12 hours after birth and that the infant completes the recommended hepatitis B vaccine series on schedule. Passive Immunization during Pregnancy No known risk exists for the fetus from passive immunization of pregnant women with immune globulin preparations. CDC. General recommendations on immunization: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2011; 60 (No. 2):

29 Vaccine Routinely Recommended Vaccines General Recommendation for Use in Pregnant Women For More Information See Page Hepatitis A Recommended if otherwise indicated. 3 Hepatitis B Recommended in some circumstances. 3 Human Papillomavirus Not recommended. 3 Influenza (Inactivated) Recommended. 3 Influenza (LAIV) Contraindicated. 3 MMR Contraindicated. 4 MCV4 (MenACWY) May be used if otherwise indicated. 4 PCV13 Inadequate data for specific recommendation. 4 PPSV23 Inadequate data for specific recommendation. 4 Polio May be used if needed. 5 Td Should be used if otherwise indicated. 5 Tdap Recommended 5 Varicella Contraindicated. 5 Zoster Contraindicated. 6 Vaccine Anthrax Travel and Other Vaccines General Recommendation for Use in Pregnant Women Low risk of exposure not recommended. High risk of exposure may be used. For More Information See Page BCG Contraindicated. 7 Japanese Encephalitis Inadequate data for specific recommendation. 7 MPSV4 May be used if otherwise indicated. 7 Rabies May be used if otherwise indicated. 7 Typhoid Inadequate data for specific recommendation. 7 Smallpox Pre-exposure contraindicated. Post-exposure recommended. Yellow Fever May be used if benefit outweighs risk

30 Hepatitis A: [Hepatitis A] is an inactivated vaccine, and similar to hepatitis B vaccines, is recommended if another high risk condition or other indication is present. 1 Hepatitis B: Pregnancy is not a contraindication to vaccination. Limited data suggest that developing fetuses are not at risk for adverse events when hepatitis B vaccine is administered to pregnant women. Available vaccines contain noninfectious HBsAg and should cause no risk of infection to the fetus. 2 Pregnant women who are identified as being at risk for HBV infection during pregnancy (e.g., having more than one sex partner during the previous 6 months, been evaluated or treated for an STD, recent or current injection drug use, or having had an HBsAg-positive sex partner) should be vaccinated. 3 Human Papillomavirus: HPV vaccines are not recommended for use in pregnant women. If a woman is found to be pregnant after initiating the vaccination series, the remainder of the 3-dose series should be delayed until completion of pregnancy. Pregnancy testing is not needed before vaccination. If a vaccine dose has been administered during pregnancy, no intervention is needed. 4 Patients and health-care providers should report any exposure to HPV4 [Gardasil] during pregnancy to Merck at telephone, , and any exposure to HPV2 [Cervarix] during pregnancy to GlaxoSmithKline at telephone, Influenza (inactivated): Women in the second and third trimesters of pregnancy are at increased risk for hospitalization from influenza. Because vaccinating against influenza before the season begins is critical, and because predicting exactly when the season will begin is impossible, routine influenza vaccination is recommended for all women who are or will be pregnant (in any trimester) during influenza season, which in the United States is usually early October through late March. 5 Influenza (LAIV): Do not administer LAIV to... pregnant women

31 Measles, Mumps, Rubella (MMR): Measles-mumps-rubella (MMR) vaccine and its component vaccines should not be administered to women known to be pregnant. Because a risk to the fetus from administration of these live virus vaccines cannot be excluded for theoretical reasons, women should be counseled to avoid becoming pregnant for 28 days after vaccination with measles or mumps vaccines or MMR or other rubella-containing vaccines. 7 Because of the importance of protecting women of childbearing age against rubella and varicella, reasonable practices in any vaccination program include asking women if they are pregnant or might become pregnant in the next 4 weeks; not vaccinating women who state that they are or plan to become pregnant; explaining the theoretical risk for the fetus of MMR, varicella, or MMRV vaccine were administered to a woman who is pregnant; and counseling women who are vaccinated not to become pregnant during the 4 weeks after MMR, varicella, or MMRV vaccination.... Routine pregnancy testing of women of childbearing age before administering a live-virus vaccine is not recommended. If a pregnant woman is inadvertently vaccinated or becomes pregnant within 4 weeks after MMR or varicella vaccination, she should be counseled about the theoretical basis of concern for the fetus; however, MMR or varicella vaccination during pregnancy should not be considered a reason to terminate pregnancy. 5 Rubella-susceptible women who are not vaccinated because they state they are or may be pregnant should be counseled about the potential risk for CRS and the importance of being vaccinated as soon as they are no longer pregnant. 8 A registry of susceptible women vaccinated with rubella vaccine between 3 months before and 3 months after conception the "Vaccine in Pregnancy (VIP) Registry" was kept between 1971 and No evidence of CRS occurred in the offspring of the 226 women who received the current RA 27/3 rubella vaccine and continued their pregnancy to term. 8 Meningococcal Conjugate (MCV4 / MenACWY): Pregnancy should not preclude vaccination with MenACWY..., if indicated. Women of childbearing age who become aware that they were pregnant at the time of MenACWY vaccination should contact their health-care provider or the vaccine manufacturer... 9 Pneumococcal Conjugate (PCV13): ACIP has not published pregnancy recommendations for PCV13 at this time. (Use of PCV13 is limited among women of childbearing age.) Pneumococcal Polysaccharide (PPSV23): The safety of pneumococcal polysaccharide vaccine during the first trimester of pregnancy has not been evaluated, although no adverse consequences have been reported among newborns whose mothers were inadvertently vaccinated during pregnancy

32 Polio (IPV): Although no adverse effects of IPV have been documented among pregnant women or their fetuses, vaccination of pregnant women should be avoided on theoretical grounds. However, if a pregnant woman is at increased risk for infection and requires immediate protection against polio, IPV can be administered in accordance with the recommended schedules for adults. 11 Tetanus, Diphtheria, and Pertussis (Tdap); & Tetanus and Diphtheria (Td) : Health-care personnel should administer a dose of Tdap during each pregnancy irrespective of the patient s prior history of receiving Tdap. To maximize the maternal antibody response and passive antibody transfer to the infant, optimal timing for Tdap administration is between 27 and 36 weeks of gestation although Tdap may be given at any time during pregnancy. 12 For women not previously vaccinated with Tdap, if Tdap is not administered during pregnancy, Tdap should be administered immediately postpartum. 12 Available data from... studies do not suggest any elevated frequency or unusual patterns of adverse events in pregnant women who received Tdap and that the few serious adverse events reported were unlikely to have been caused by the vaccine. 13 Wound Management: If a Td booster is indicated for a pregnant woman, health-care providers should administer Tdap. 12 Unknown or Incomplete Tetanus Vaccination: To ensure protection against maternal and neonatal tetanus, pregnant women who never have been vaccinated against tetanus should receive three vaccinations containing tetanus and reduced diphtheria toxoids. The recommended schedule is 0, 4 weeks and 6 through 12 months. Tdap should replace 1 dose of Td, preferably between 27 and 36 weeks gestation Providers are encouraged to report administration of Tdap to a pregnant woman, regardless of trimester, to the appropriate manufacturer s pregnancy registry: for Adacel to sanofi pasteur, telephone and for Boostrix to GlaxoSmithKline Biologicals, telephone For more information about Tdap vaccine for pregnant women, see Varicella Because the effects of the varicella virus on the fetus are unknown, pregnant women should not be vaccinated. Nonpregnant women who are vaccinated should avoid becoming pregnant for 1 month after each injection. For persons without evidence of immunity, having a pregnant household member is not a contraindication for vaccination

33 Wild-type varicella poses a low risk to the fetus.... Because the virulence of the attenuated virus used in the vaccine is less that that of the wild-type virus, the risk to the fetus, if any, should be even lower. 15 Because of the importance of protecting women of childbearing age against rubella and varicella, reasonable practices in any vaccination program include asking women if they are pregnant or might become pregnant in the next 4 weeks; not vaccinating women who state that they are or plan to become pregnant; explaining the theoretical risk for the fetus of MMR, varicella, or MMRV vaccine were administered to a woman who is pregnant; and counseling women who are vaccinated not to become pregnant during the 4 weeks after MMR, varicella, or MMRV vaccination.... Routine pregnancy testing of women of childbearing age before administering a live-virus vaccine is not recommended. If a pregnant woman is inadvertently vaccinated or becomes pregnant within 4 weeks after MMR or varicella vaccination, she should be counseled about the theoretical basis of concern for the fetus; however, MMR or varicella vaccination during pregnancy should not be considered a reason to terminate pregnancy. 5 Because pregnant women might be at higher risk for severe varicella and complications, VZIG [Varicella Zoster Immune Globulin] should be strongly considered for pregnant women without evidence of immunity who have been exposed. Administration of VZIG to these women has not been found to prevent viremia, fetal infection, congenital varicella syndrome, or neonatal varicella. Thus, the primary indication for VZIG in pregnant women is to prevent complications of varicella in the mother rather than to protect the fetus. 15 Any patient who receives VZIG to prevent varicella should receive varicella vaccine subsequently, provided the vaccine is not contraindicated. Varicella vaccination should be delayed until 5 months after VZIG administration. 15 In 1995, Merck and Co., Inc., in collaboration with CDC, established the VARIVAX Pregnancy Registry to monitor the maternal-fetal outcomes of pregnant women who were inadvertently administered varicella vaccine 3 months before or at any time during pregnancy (to report, call: ). 15 Zoster (Shingles): Zoster vaccine is not recommended for use in pregnant women. 16 Women should avoid becoming pregnant for 4 weeks following zoster vaccination.... If a pregnant woman is vaccinated or becomes pregnant within 1 month of vaccination, she should be counseled about potential effects on the fetus. 16 In most circumstances, the decision to terminate a pregnancy should not be based on whether zoster vaccine was administered during pregnancy. Merck & Co., Inc., in collaboration with CDC, has established a pregnancy registry to monitor the maternal-fetal outcomes of pregnant women who are inadvertently administered live-attenuated VZV-based vaccines within 1 month of pregnancy (telephone )

34 Anthrax In a pre-event setting, in which the risk for exposure to aerosolized B. anthracis spores is presumably low, vaccination of pregnant women is not recommended and should be deferred until after pregnancy. 17 In a post-event setting that poses a high risk for exposure to aerosolized B. anthracis spores, pregnancy is neither a precaution nor a contraindication to PEP. Pregnant women at risk for inhalation anthrax should receive AVA and 60 days of antimicrobial therapy as described. 17 BCG BCG vaccination should not be given during pregnancy. Even though no harmful effects of BCG vaccination on the fetus have been observed, further studies are needed to prove its safety. 18 Japanese Encephalitis No controlled studies have assessed the safety, immunogenicity, or efficacy of [Ixiaro] in pregnant women. Preclinical studies of [Ixiaro] in pregnant rats did not show evidence of harm to the mother or fetus. 19 Meningococcal Polysaccharide (MPSV4): Studies of vaccination with MPSV4 during pregnancy have not documented adverse effects among either pregnant women or newborns. On the basis of these data, pregnancy should not preclude vaccination with MPSV4, if indicated. 20 Rabies: Because of the potential consequences of inadequately managed rabies exposure, pregnancy is not considered a contraindication to postexposure prophylaxis. Certain studies have indicated no increased incidence of abortion, premature births, or fetal abnormalities associated with rabies vaccination. If the risk of exposure to rabies is substantial, preexposure prophylaxis also might be indicated during pregnancy. Rabies exposure or the diagnosis of rabies in the mother should not be regarded as reasons to terminate the pregnancy. 21 Typhoid: No data have been reported on the use of any of the... typhoid vaccines among pregnant women. 22 Vaccinia (Smallpox): Because of the limited risk but severe consequences of fetal infection, smallpox vaccine should not be administered in a pre-event setting to pregnant women or to women who are trying to become pregnant

35 Before vaccination, women of childbearing age should be asked if they are pregnant or intend to become pregnant in the next 4 weeks; women who respond positively should not be vaccinated. 23 If a pregnant woman is inadvertently vaccinated or if she becomes pregnant within 4 weeks after smallpox vaccination, she should be counseled regarding concern for the fetus. Smallpox vaccination during pregnancy should not ordinarily be a reason to terminate pregnancy. CDC has established a pregnancy registry to prospectively follow the outcome of such pregnancies and facilitate the investigation of any adverse pregnancy outcome among pregnant women who were inadvertently vaccinated. For enrollment in the registry, contact CDC at Pregnant women who have had a definite exposure to smallpox virus (i.e., face-to-face, household, or close-proximity contact with a smallpox patient) and are, therefore, at high risk for contracting the disease, should... be vaccinated. Smallpox infection among pregnant women has been reported to result in a more severe infection than among nonpregnant women. Therefore the risks to the mother and fetus from experiencing clinical smallpox substantially outweigh any potential risks regarding vaccination. In addition, vaccinia virus has not been documented to be teratogenic, and the incidence of fetal vaccinia is low. 23 When the level of exposure risk is undetermined, the decision to vaccinate should be made after assessment by the clinician and the patient of the potential risks versus the benefits of smallpox vaccination. 24 Yellow Fever: Pregnancy is a precaution for YF vaccine administration, compared with most other live vaccines, which are contraindicated in pregnancy. If travel is unavoidable, and the risks for YFV exposure are felt to outweigh the vaccination risks, a pregnant woman should be vaccinated. If the risks for vaccination are felt to outweigh the risks for YFV exposure, pregnant women should be issued a medical waiver to fulfill health regulations. 25 Because pregnancy might affect immunologic function, serologic testing to document an immune response to the vaccine should be considered. 25 Although no specific data are available, a woman should wait 4 weeks after receiving YF vaccine before conceiving

36 References 1. CDC. Advisory Committee on Immunization Practices (ACIP) recommended immunization schedules for persons aged 0 through 18 years and adults aged 19 years and older United States, MMWR 2013; 62 (Suppl 1): CDC. A comprehensive immunization strategy to eliminate transmission of hepatitis B virus infection in the United States: recommendations of the Advisory Committee on Immunization Practices (ACIP) part 2: immunization of adults. MMWR 2006; 55 (No. RR- 16): CDC. A comprehensive immunization strategy to eliminate transmission of hepatitis B virus infection in the United States: recommendations of the Advisory Committee on Immunization Practices (ACIP) part 1: immunization of infants, children, and adolescents. MMWR 2005; 54 (No. RR-16): CDC. FDA licensure of bivalent human papillomavirus vaccine (HPV2, Cervarix) for use in females and updated HPV vaccination recommendations from the Advisory Committee on Immunization Practices (ACIP). MMWR 2010; 59 (No. 20): CDC. General recommendations on immunization: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2011; 60 (No. 2): CDC. Prevention and control of influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices (ACIP), MMWR 2010; 59 (No. RR-8): CDC. Notice to readers: revised ACIP recommendation for avoiding pregnancy after receiving a rubella-containing vaccine. MMWR 2001; 50 (No. 49): CDC. Measles, mumps, and rubella vaccine use and strategies for elimination of measles, rubella, and congenital rubella syndrome and control of mumps: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 1998; 47 (No. RR-8): 18, CDC. Prevention and control of meningococcal disease: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2013; 62 (No. RR-2): CDC. Prevention of pneumococcal disease: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 1997; 46 (No. RR-8): CDC. Poliomyelitis prevention in the United States: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2000; 49 (No. RR-5): CDC. Updated recommendations for use of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap) in pregnant women Advisory Committee on Immunization Practices (ACIP), MMWR 2013; 62 (No. 7):

37 13. CDC. Updated recommendations for use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine (Tdap) in pregnant women and persons who have or anticipate having close contact with an infant aged <12 months Advisory Committee on Immunization Practices (ACIP), MMWR 2011; 60 (No. 41): CDC. Prevention of pertussis, tetanus, and diphtheria among pregnant and postpartum women and their infants: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2008; 57 (No. RR-4): CDC. Prevention of varicella: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2007; 56 (No. RR-4): 28, CDC. Prevention of herpes zoster: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2008; 57 (No. RR-5): CDC. Use of anthrax vaccine in the United States: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2010; 59 (No. RR-6): CDC website CDC. Japanese encephalitis vaccines: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2010; 49 (No. RR-1): CDC. Prevention and control of meningococcal disease: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2005; 54 (No. RR-7): CDC. Human rabies prevention United States, 2008: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2008; 57 (No. RR-3): CDC. Typhoid immunization: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 1994; 43 (No. RR-14): CDC. Recommendations for using smallpox vaccine in a pre-event vaccination program: supplemental recommendations of the Advisory Committee on Immunization Practices (ACIP) and the Healthcare Infection Control Practices Advisory Committee (HICPAC). MMWR 2003; 52 (No. RR-7): CDC. Vaccinia (smallpox) vaccine: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2001; 50 (No. RR-10): 12 & CDC. Yellow fever vaccine: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2010; 59 (No. RR-7): 13 &

38 Principles for Developing Pregnancy Recommendations Formulating policy to guide vaccination of women during pregnancy and breastfeeding is challenging because the evidence-base to guide decisions is extremely limited. In 2008, CDC published Guiding Principles for Developing ACIP Recommendations for Vaccination During Pregnancy and Breastfeeding to provide guidance to help standardize both the process of policy formulation and the format and language of recommendations for pregnant and breastfeeding women to CDC workgroups or subject matter experts developing vaccine statements subsequent to that date. This document can be found online at Breastfeeding and Vaccination Neither inactivated nor live-virus vaccines administered to a lactating woman affect the safety of breastfeeding for women or their infants. Although live viruses in vaccines can replicate in vaccine recipients (i.e., the mother), the majority of live viruses in vaccines have been demonstrated not to be excreted in human milk. Varicella vaccine virus has not been found in human milk. Although rubella vaccine virus might be excreted in human milk, the virus usually does not infect the infant. If infection does occur, it is well tolerated because the virus is attenuated. Inactivated, recombinant, subunit, polysaccharide, and conjugate vaccines, as well as toxoids, pose no risk for mothers who are breastfeeding or for their infants. Breastfeeding is a contraindication for smallpox vaccination of the mother because of the theoretical risk for contact transmission from mother to infant. Yellow fever vaccine should be avoided in breastfeeding women. However, when nursing mothers cannot avoid or postpone travel to areas endemic for yellow fever in which risk for acquisition is high, these women should be vaccinated. CDC. General recommendations on immunization: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2011; 60 (No. 2): 26. Note: The information in this booklet reflects the ACIP s recommendations on vaccinating pregnant or nursing women. Information contained in the vaccine manufacturers package inserts may differ. Package inserts can be found online at

39 FDA Pregnancy Categories Regulation requires that each product be classified under one of five pregnancy categories, on the basis of risk of reproductive and developmental adverse effects or, for certain categories, on the basis of such risk weighted against potential benefits. These categories are: Pregnancy Category A. Adequate and well controlled studies in women fail to demonstrate a risk to the fetus in the first trimester (and there is no evidence of a risk in later trimester), and the possibility of fetal harm appears remote. Pregnancy Category B. Animal reproduction studies have failed to demonstrate a risk to the fetus and there are no adequate and well-controlled studies in pregnant women OR Animal studies have shown an adverse effect, but adequate and well-controlled studies in pregnant women have failed to demonstrate a risk to the fetus during the first trimester (and there is no evidence of risk in later trimesters). Pregnancy Category C. Animal reproduction studies have shown an adverse effect on the fetus and there are no adequate and well-controlled studies in humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks OR Animal reproduction studies have not been conducted and there are no adequate and well-controlled studies in humans. Pregnancy Category D. There is positive evidence of human fetal risk based on adverse reaction data from investigational or marketing experience or studies in humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks. Pregnancy Category X. Studies in animals or humans have demonstrated fetal abnormalities and/or there is positive evidence of human fetal risk based on adverse reaction data from investigational or marketing experience, and the risks involved in the use of the drug in pregnant women clearly outweigh potential benefits. For most vaccines there is a shortage of well-controlled studies, while experience has shown a very favorable risk/benefit ratio. FDA pregnancy categories for vaccines licensed in the U.S. (from the appropriate manufacturers package inserts) are as follows: Pregnancy Category B: Human Papillomavirus, Influenza (Fluzone Intradermal, Fluarix, FluLaval, Agriflu, Afluria, Flublok, Flucelvax), Japanese Encephalitis (Ixiaro), Meningococcal (Menveo), Tdap (Boostrix). Pregnancy Category C: Hepatitis A, Hepatitis B, Influenza (Fluzone, Fluzone High Dose, Fluvirin, FluMist), MMR, Meningococcal (Menactra, Menomune), Pneumococcal, Polio, Td, Tdap (Adacel), Varicella, Zoster, BCG, Rabies, Typhoid, Yellow Fever. Pregnancy Category D: Anthrax, Vaccinia

40 THIS PAGE INTENTIONALLY LEFT BLANK 40

41 Summary of Recommendations for Adult Immunization (Age 19 years & older) (Page 1 of 4) Vaccine name and route People for whom vaccination is recommended Schedule for vaccine administration (any vaccine can be given with another) Contraindications and precautions (mild illness is not a contraindication) Influenza Inactivated Influenza vaccine (IIV) Give or intradermally Live attenuated influenza vaccine (LAIV) Give intranasally Pneumococcal polysaccharide (PPSV) Give or SC Pneumococcal conjugate (PCV13) Give For people through age 18 years, consult Summary of Recommendations for Child/Teen Immunization at p2010.pdf. Vaccination is recommended for all adults. (This includes healthy adults age 19 49yrs without risk factors.) LAIV is approved only for healthy nonpregnant people age 2 49yrs. Adults age 18 through 64yrs may be given any intramuscular IIV product or, alternatively, the intradermal IIV product (Fluzone Intradermal). Adults age 65yrs and older may be given standard-dose IIV or, alternatively, high-dose IIV (Fluzone High-Dose). Note: Healthcare personnel who care for severely immunocompromised people (i.e., those who require care in a protected environment) should receive IIV rather than LAIV. For information on other contraindications and precautions to LAIV, see far right column. For people through age 18 years, consult Summary of Recommendations for Child/Teen Immunization at p2010.pdf. People age 65yrs and older. People younger than age 65yrs who have chronic illness or other risk factors, including chronic cardiac or pulmonary disease (including asthma), chronic liver disease, alcoholism, diabetes, CSF leaks, cigarette smoking, as well as candidates for or recipients of cochlear implants and people living in special environments or social settings (including American Indian/Alaska Natives age 50 through 64yrs if recommended by local public health authorities). Those at highest risk of serious pneumococcal infection, including people who - Have anatomic or functional asplenia, including sickle cell disease. - Have an immunocompromising condition, including HIV infection, leukemia, lymphoma, Hodgkin s disease, multiple myeloma, generalized malignancy, chronic renal failure, or nephrotic syndrome. - Are receiving immunosuppressive chemotherapy (including corticosteroids). - Have received an organ or bone marrow transplant. Give 1 dose every year in the fall or winter. Begin vaccination services as soon as vaccine is available and continue until the supply is depleted. Continue to give vaccine to unvaccinated adults throughout the influenza season (including when influenza activity is present in the community) and at other times when the risk of influenza exists. If 2 or more of the following live virus vaccines are to be given LAIV, MMR, Var, HZV, and/or yellow fever they should be given on the same day. If they are not, space them by at least 28d. Give 1 dose if unvaccinated or if previous vaccination history is unknown. Give a 1-time revaccination to people - Age 65yrs and older if 1st dose was given prior to age 65yrs and 5yrs have elapsed since dose #1. - Age 19 through 64yrs who are at highest risk of fatal pneumococcal infection or rapid antibody loss (see the 3rd bullet in the box to left for listings of people at highest risk) and 5yrs have elapsed since dose #1. Give 1 dose of PCV13 to people age 19yrs and older at highest risk of serious pneumococcal infection (see column to left), and to those who have CSF leaks, or are candidates for or recipient of cochlear implants. If previously vaccinated with PPSV, give PCV13 at least 12m following PPSV; if not previously vaccinated with PPSV, give PCV13 first, followed by PPSV in 8wks. Contraindications Previous anaphylactic reaction to this vaccine, to any of its components, including egg protein. For LAIV only: pregnancy; chronic pulmonary (including asthma), cardiovascular (except hypertension), renal, hepatic, neurological/neuromuscular, hematologic, or metabolic (including diabetes) disorders; immunosuppression (including that caused by medications or HIV). For adults who experience only hives with exposure to eggs, give IIV with additional safety precautions as found in the 2012 ACIP influenza recommendations, pages * Precautions Moderate or severe acute illness. History of Guillain-Barré syndrome (GBS) within 6wks following previous influenza vaccination. For LAIV only: receipt of specific antivirals (i.e., amantadine, rimantadine, zanamivir, or oseltamivir) 48hrs before vaccination. Avoid use of these antiviral drugs for 14d after vaccination. Contraindication Previous anaphylactic reaction to this vaccine, including (for PCV13) to any diphtheria toxoid-containing vaccine, or to any of its components. Precaution Moderate or severe acute illness. * This document was adapted from the recommendations of the Advisory Committee on Immunization Practices (ACIP). To obtain copies of these recommendations, visit CDC s website at pubs/acip-list.htm or visit the Immunization Action Coalition (IAC) website at Technical content reviewed by the Centers for Disease Control and Prevention This table is revised periodically. Visit IAC s website at to make sure you have the most current version. Item #P2011 (2/13) Immunization Action Coalition 1573 Selby Avenue Saint Paul, MN (651) admin@immunize.org 41

42 Summary of Recommendations for Adult Immunization (Age 19 years & older) (Page 2 of 4) Vaccine name and route MMR (Measles, mumps, rubella) Give SC People for whom vaccination is recommended For people through age 18 years, consult Summary of Recommendations for Child/Teen Immunization at p2010.pdf. People born in 1957 or later (especially those born outside the U.S.) should receive at least 1 dose of MMR if they have no laboratory evidence of immunity to each of the 3 diseases or documentation of a dose given on or after the first birthday. People in high-risk groups, such as healthcare personnel (paid, unpaid, or volunteer), students entering college and other post high school educational institutions, and international travelers, should receive a total of 2 doses. People born before 1957 are usually considered immune, but evidence of immunity (serology or documented history of 2 doses of MMR) should be considered for healthcare personnel. Women of childbearing age who do not have acceptable evidence of rubella immunity or vaccination. Schedule for vaccine administration (any vaccine can be given with another) Give 1 or 2 doses (see criteria in 1st and 2nd bullets in box to left). If dose #2 is recommended, give it no sooner than 4wks after dose #1. If a pregnant woman is found to be rubella susceptible, give 1 dose of MMR postpartum. If 2 or more of the following live virus vaccines are to be given LAIV, MMR, Var, HZV, and/or yellow fever they should be given on the same day. If they are not, space them by at least 28d. Within 72hrs of measles exposure, give 1 dose as postexposure prophylaxis to susceptible adults. Note: Routine post-vaccination serologic testing is not recommended. Contraindications and precautions (mild illness is not a contraindication) Contraindications Previous anaphylactic reaction to this vaccine or to any of its components. Pregnancy or possibility of pregnancy within 4wks. Severe immunodeficiency (e.g., hematologic and solid tumors; receiving chemotherapy; congenital immunodeficiency; longterm immunosuppressive therapy; or severely symptomatic HIV). Note: HIV infection is NOT a contraindication to MMR for those who are not severely immunocompromised (i.e., CD4+ T-lymphocyte counts are greater than or equal to 200 cells/µl) for 6 months.* Precautions Moderate or severe acute illness. If blood, plasma, and/or immune globulin were given in past 11m, see ACIP s General Recommendations on Immunization* regarding time to wait before vaccinating. History of thrombocytopenia or thrombocytopenic purpura. Note: If TST (tuberculosis skin test) and MMR are both needed but not given on same day, delay TST for 4 6wks after MMR. Varicella (chickenpox) (Var) Give SC For people through age 18 years, consult Summary of Recommendations for Child/Teen Immunization at p2010.pdf. All adults without evidence of immunity. Note: Evidence of immunity is defined as written documentation of 2 doses of varicella vaccine; a history of varicella disease or herpes zoster (shingles) based on healthcare-provider diagnosis; laboratory evidence of immunity or confirmation of disease; and/or birth in the U.S. before 1980, with the exceptions that follow. - Healthcare personnel born in the U.S. before 1980 who do not meet any of the criteria above should be tested or given the 2-dose vaccine series. If testing indicates they are not immune, give the 1st dose of varicella vaccine immediately. Give the 2nd dose 4 8 wks later. - Pregnant women born in the U.S. before 1980 who do not meet any of the criteria above should either 1) be tested for susceptibility during pregnancy and if found susceptible, given the 1st dose of varicella vaccine postpartum before hospital discharge, or 2) not be tested for susceptibility and given the 1st dose of varicella vaccine postpartum before hospital discharge. Give the 2nd dose 4 8wks later. Give 2 doses. Dose #2 is given 4 8wks after dose #1. If dose #2 is delayed, do not repeat dose #1. Just give dose #2. If 2 or more of the following live virus vaccines are to be given LAIV, MMR, Var, HZV, and/or yellow fever they should be given on the same day. If they are not, space them by at least 28d. May use as postexposure prophylaxis if given within 5d. Note: Routine post-vaccination serologic testing is not recommended. Contraindications Previous anaphylactic reaction to this vaccine or to any of its components. Pregnancy or possibility of pregnancy within 4wks. People on long-term immunosuppressive therapy or who are immunocompromised because of malignancy and primary or acquired immunodeficiency, including HIV/AIDS (although vaccination may be considered if CD4+ T-lymphocyte counts are greater than or equal to 200 cells/µl. See MMWR 2007;56,RR-4). Precautions Moderate or severe acute illness. If blood, plasma, and/or immune globulin (IG or VZIG) were given in past 11m, see ACIP s General Recommendations on Immunization* regarding time to wait before vaccinating. Receipt of specific antivirals (i.e., acyclovir, famciclovir, or valacyclovir) 24hrs before vaccination, if possible; delay resumption of these antiviral drugs for 14d after vaccination. Zoster (shingles) (HZV) Give SC People age 60yrs and older. Give 1-time dose if unvaccinated, regardless of previous history of herpes zoster (shingles) or chickenpox. If 2 or more of the following live virus vaccines are to be given MMR, Var, HZV and/or yellow fever they should be given on the same day. If they are not, space them by at least 28d. Contraindications Previous anaphylactic reaction to any component of zoster vaccine. Primary cellular or acquired immunodeficiency. Pregnancy. Precautions Moderate or severe acute illness. Receipt of specific antivirals (i.e., acyclovir, famciclovir, or valacyclovir) 24hrs before vaccination, if possible; delay resumption of these antiviral drugs for 14d after vaccination. February

43 Summary of Recommendations for Adult Immunization (Age 19 years & older) (Page 3 of 4) Vaccine name and route Hepatitis A (HepA) Give Brands may be used interchangeably. Hepatitis B (HepB) Give Brands may be used interchangeably. Inactivated Polio (IPV) Give or SC People for whom vaccination is recommended For people through age 18 years, consult Summary of Recommendations for Child/Teen Immunization at All people who want to be protected from hepatitis A virus (HAV) infection and lack a specific risk factor. People who travel or work anywhere EXCEPT the U.S., Western Europe, New Zealand, Australia, Canada, and Japan. People with chronic liver disease; injecting and non-injecting drug users; men who have sex with men; people who receive clotting-factor concentrates; people who work with HAV in experimental lab settings; food handlers when health authorities or private employers determine vaccination to be appropriate. People who anticipate close personal contact with an international adoptee from a country of high or intermediate endemicity during the first 60 days following the adoptee s arrival in the U.S. Adults age 40yrs or younger with recent (within 2 wks) exposure to HAV. For people older than age 40yrs with recent (within 2 wks) exposure to HAV, immune globulin is preferred over HepA vaccine. For people through age 18 years, consult Summary of Recommendations for Child/Teen Immunization at All adults who want to be protected from hepatitis B virus infection and lack a specific risk factor. Household contacts and sex partners of HBsAg-positive people; injecting drug users; sexually active people not in a long-term, mutually monogamous relationship; men who have sex with men; people with HIV; people seeking STD evaluation or treatment; hemodialysis patients and those with renal disease that may result in dialysis; diabetics younger than age 60yrs (diabetics age 60yrs and older may be vaccinated at the clinician s discretion [see ACIP recommendations*]); healthcare personnel and public safety workers who are exposed to blood; clients and staff of institutions for the developmentally disabled; inmates of long-term correctional facilities; certain international travelers; and people with chronic liver disease. Note: Provide serologic screening for immigrants from endemic areas. If patient is chronically infected, assure appropriate disease management. For sex partners and household contacts of HBsAg-positive people, provide serologic screening and administer initial dose of HepB vaccine at same visit. For people through age 18 years, consult Summary of Recommendations for Child/Teen Immunization at Not routinely recommended for U.S. residents age 18yrs and older. Note: Adults living in the U.S. who never received or completed a primary series of polio vaccine need not be vaccinated unless they intend to travel to areas where exposure to wild-type virus is likely. Previously vaccinated adults can receive 1 booster dose if traveling to polio endemic areas or to areas where the risk of exposure is high. Schedule for vaccine administration (any vaccine can be given with another) Give 2 doses, spaced 6 12m apart. If dose #2 is delayed, do not repeat dose #1. Just give dose #2. For Twinrix (hepatitis A and B combination vaccine [GSK]) for patients age 18yrs and older only: give 3 doses on a 0, 1, 6m schedule. There must be at least 4wks between doses #1 and #2, and at least 5m between doses #2 and #3. An alternative schedule can also be used at 0, 7d, 21 30d, and a booster at 12m. Give 3 doses on a 0, 1, 6m schedule. Alternative timing options for vaccination include 0, 2, 4m; 0, 1, 4m; and 0, 1, 2, 12m (Engerix brand only). There must be at least 4wks between doses #1 and #2, and at least 8wks between doses #2 and #3. Overall, there must be at least 16wks between doses #1 and #3. Give adults on hemodialysis or with other immunocompromising conditions 1 dose of 40μg/mL (Recombivax HB) at 0, 1, 6m or 2 doses of 20 μg/ ml (Engerix-B) given simultaneously at 0, 1, 2, 6m. Schedule for those who have fallen behind: If the series is delayed between doses, DO NOT start the series over. Continue from where you left off. Refer to ACIP recommendations* regarding unique situations, schedules, and dosing information. Contraindications and precautions (mild illness is not a contraindication) Contraindication Previous anaphylactic reaction to this vaccine or to any of its components. Precaution Moderate or severe acute illness. Contraindication Previous anaphylactic reaction to this vaccine or to any of its components. Precaution Moderate or severe acute illness. Contraindication Previous anaphylactic reaction to this vaccine or to any of its components. Precautions Moderate or severe acute illness. Pregnancy. 43 February 2013

44 Summary of Recommendations for Adult Immunization (Age 19 years & older) (Page 4 of 4) Vaccine name and route People for whom vaccination is recommended Schedule for vaccine administration (any vaccine can be given with another) Contraindications and precautions (mild illness is not a contraindication) Human papillomavirus (HPV) (HPV2, Cervarix) (HPV4, Gardasil) Give Meningococcal conjugate vaccine, quadrivalent (MCV4) Menactra, Menveo Give Meningococcal polysaccharide vaccine (MPSV4) Menomune Give SC For people through age 18 years, consult Summary of Recommendations for Child/Teen Immunization at catg.d/p2010.pdf. All previously unvaccinated women through age 26yrs and men through age 21yrs. All previously unvaccinated men through age 26yrs who 1) have sex with men or 2) are immunocompromised as a result of infection (including HIV), disease, or medications or who lack either of the preceding risk factors but want to be vaccinated. For people through age 18 years, consult Summary of Recommendations for Child/Teen Immunization at catg.d/p2010.pdf. People with anatomic or functional asplenia or persistent complement component deficiency. People who travel to or reside in countries in which meningococcal disease is hyperendemic or epidemic (e.g., the meningitis belt of Sub-Saharan Africa). Microbiologists routinely exposed to isolates of N. meningitidis. First year college students through age 21yrs who live in residence halls; see 5th bullet in the box to the right for details. Give 3 doses on a 0, 2, 6m schedule. Use either HPV2 or HPV4 for women, and only HPV4 for men. There must be at least 4wks between doses #1 and #2 and at least 12wks between doses #2 and #3. Overall, there must be at least 24wks between doses #1 and #3. If possible, use the same vaccine product for all three doses. Give 2 initial doses of MCV4 separated by 2m to adults 55yrs and younger with risk factors listed in 1st bullet in column to left or if vaccinating adults with HIV infection in this age group. Give 1 dose of MPSV4 to adults 56yrs and older with risk factors. Give 1 initial dose to all other adults with risk factors (see 2nd 4th bullets in column to left). Give booster doses every 5yrs to adults with continuing risk (see the 1st 3rd bullets in column to left for listings of people with possible continuing risk). MCV4 is preferred over MPSV4 for people age 55yrs and younger; use MPSV4 ONLY if age 56yrs or older or if there is a permanent contraindication/precaution to MCV4. For first year college students age 19 21yrs living in residence halls, give 1 initial dose if unvaccinated and give booster dose if most recent dose was given when younger than age 16yrs. Contraindication Previous anaphylactic reaction to this vaccine or to any of its components. Precautions Moderate or severe acute illness. Pregnancy. Contraindication Previous anaphylactic reaction to this vaccine or to any of its components. Precaution Moderate or severe acute illness. Tdap, Td (Tetanus, diphtheria, acellular pertussis) Give Using tetanus toxoid (TT) instead of Tdap or Td is not recommended. For people through age 18 years, consult Summary of Recommendations for Child/Teen Immunization at catg.d/p2010.pdf. All people who lack written documentation of a primary series consisting of at least 3 doses of tetanus- and diphtheria-toxoidcontaining vaccine. A booster dose of Td or Tdap may be needed for wound management, so consult ACIP recommendations.* For Tdap only: Adults who have not already received Tdap. Healthcare personnel of all ages. Give Tdap to pregnant women during each pregnancy (preferred during weeks gestation), regardless of number of years since prior Td or Tdap. For people who are unvaccinated or behind, complete the primary Td series (spaced at 0, 1 2m, 6 12m intervals); substitute a one-time dose of Tdap for one of the doses in the series, preferably the first. Give Td booster every 10yrs after the primary series has been completed. Tdap should be given regardless of interval since previous Td. Contraindications Previous anaphylactic reaction to this vaccine or to any of its components. For Tdap only, history of encephalopathy not attributable to an identifiable cause, within 7d following DTP/DTaP, or Tdap. Precautions Moderate or severe acute illness. Guillain-Barré syndrome within 6wks following previous dose of tetanus toxoid-containing vaccine. History of arthus reaction following a prior dose of tetanus- or diphtheria toxoid-containing vaccine (including MCV4); defer vaccination until at least 10yrs have elapsed since the last tetanus toxoid-containing vaccine. For Tdap only, progressive or unstable neurologic disorder, uncontrolled seizures, or progressive encephalopathy until a treatment regimen has been established and the condition has stabilized. February

45 Guide to Contraindications 1 and Precautions 1 to Commonly Used Vaccines*, (Page 1 of 2) Vaccine Contraindications 1 Precautions 1 Hepatitis B (HepB) Rotavirus (RV5 [RotaTeq], RV1 [Rotarix]) Diphtheria, tetanus, pertussis (DTaP) Tetanus, diphtheria, pertussis (Tdap) Tetanus, diphtheria (DT, Td) Haemophilus influenzae type b (Hib) Inactivated poliovirus vaccine (IPV) Pneumococcal (PCV13 or PPSV23) Measles, mumps, rubella (MMR) 4 Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component Severe combined immunodeficiency (SCID) History of intussusception or of uncorrected congenital malformation of the gastrointestinal tract that would predispose the infant to intussusception Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component Encephalopathy (e.g., coma, decreased level of consciousness, prolonged seizures) not attributable to another identifiable cause within 7 days of administration of previous dose of DTP or DTaP (for DTaP); or of previous dose of DTP, DTaP, or Tdap (for Tdap) Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component Age younger than 6 weeks Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component For PCV13, severe allergic reaction (e.g., anaphylaxis) after a previous dose of PCV7 or PCV13 or to a vaccine component, including to any vaccine containing diphtheria toxoid For PPSV23, severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component Known severe immunodeficiency (e.g., from hematologic and solid tumors, receipt of chemotherapy, congenital immunodeficiency, or long-term immunosuppressive therapy 5 or patients with human immunodeficiency virus [HIV] infection who are severely immunocompromised) 6 Pregnancy Moderate or severe acute illness with or without fever Infant weighing less than 2000 grams (4 lbs, 6.4 oz) 2 Moderate or severe acute illness with or without fever Altered immunocompetence other than SCID Chronic gastrointestinal disease 3 Spina bifida or bladder exstrophy 3 Moderate or severe acute illness with or without fever Guillain-Barré syndrome (GBS) within 6 weeks after a previous dose of tetanus toxoid-containing vaccine History of arthus-type hypersensitivity reactions after a previous dose of tetanus or diphtheria toxoid-containing vaccine; defer vaccination until at least 10 years have elapsed since the last tetanustoxoid containing vaccine Progressive or unstable neurologic disorder (including infantile spasms for DTaP), uncontrolled seizures, or progressive encephalopathy until a treatment regimen has been established and the condition has stabilized For DTaP only: Temperature of 105 F or higher (40.5 C or higher) within 48 hours after vaccination with a previous dose of DTP/DTaP Collapse or shock-like state (i.e., hypotonic hyporesponsive episode) within 48 hours after receiving a previous dose of DTP/DTaP Seizure within 3 days after receiving a previous dose of DTP/DTaP Persistent, inconsolable crying lasting 3 or more hours within 48 hours after receiving a previous dose of DTP/DTaP Moderate or severe acute illness with or without fever GBS within 6 weeks after a previous dose of tetanus toxoid-containing vaccine History of arthus-type hypersensitivity reactions after a previous dose of tetanus or diphtheria toxoid-containing vaccine; defer vaccination until at least 10 years have elapsed since the last tetanustoxoid containing vaccine Moderate or severe acute illness with or without fever Moderate or severe acute illness with or without fever Pregnancy Moderate or severe acute illness with or without fever Moderate or severe acute illness with or without fever Recent (within 11 months) receipt of antibody-containing blood product (specific interval depends on product) 7 History of thrombocytopenia or thrombocytopenic purpura Need for tuberculin skin testing 8 (continued on page 2) Technical content reviewed by the Centers for Disease Control and Prevention Item #P3072a (3/13) Immunization Action Coalition 1573 Selby Ave. St. Paul, MN (651)

46 Guide to Contraindications 1 and Precautions 1 to Commonly Used Vaccines*, (continued) (Page 2 of 2) Vaccine Contraindications 1 Precautions 1 Varicella (Var) 4 Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component Known severe immunodeficiency (e.g., from hematologic Moderate or severe acute illness with or without fever Recent (within 11 months) receipt of antibody-containing blood product (specific interval depends on product) 7 and solid tumors, receipt of chemotherapy, primary or Receipt of specific antivirals (i.e., acyclovir, famciclovir, or valacyclovir) 24 hours before vaccination; avoid use of these antiviral drugs acquired immunodeficiency, or long-term immunosuppressive therapy 5 or patients with HIV infection who are for 14 days after vaccination. severely immunocompromised) 6 Pregnancy Hepatitis A (HepA) Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component Moderate or severe acute illness with or without fever Influenza, inactivated injectable (IIV) Influenza, live attenuated (LAIV) 4 Human papillomavirus (HPV) Meningococcal: conjugate (MCV4), polysaccharide (MPSV4) Zoster (HZV) Severe allergic reaction (e.g., anaphylaxis) after a previous dose of any influenza vaccine or to a vaccine component, including egg protein Severe allergic reaction (e.g., anaphylaxis) after a previous dose of any influenza vaccine or to a vaccine component, including egg protein Conditions for which the ACIP recommends against use, but which are not contraindications in vaccine package insert: immune suppression, certain chronic medical conditions such as asthma, diabetes, heart or kidney disease, and pregnancy 9 Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component Severe allergic reaction (e.g., anaphylaxis) to a vaccine component Known severe immunodeficiency (e.g., from hematologic and solid tumors, receipt of chemotherapy, or long-term immunosuppressive therapy 5 or patients with HIV infection who are severely immunocompromised). Pregnancy Moderate or severe acute illness with or without fever History of GBS within 6 weeks of previous influenza vaccination Persons who experience only hives with exposure to eggs should receive IIV with additional safety precautions found in the ACIP influenza recommendations, pages at mmwr/pdf/wk/mm6132.pdf. Moderate or severe acute illness with or without fever History of GBS within 6 weeks of previous influenza vaccination Receipt of specific antivirals (i.e., amantadine, rimantadine, zanamivir, or oseltamivir) 48 hours before vaccination. Avoid use of these antiviral drugs for 14 days after vaccination. Moderate or severe acute illness with or without fever Pregnancy Moderate or severe acute illness with or without fever Moderate or severe acute illness with or without fever Receipt of specific antivirals (i.e., acyclovir, famciclovir, or valacyclovir) 24 hours before vaccination; avoid use of these antiviral drugs for 14 days after vaccination. Footnotes 1. Vaccine package inserts and the full ACIP recommendations for these vaccines should be consulted for additional information on vaccine-related contraindications and precautions and for more information on vaccine excipients. Events or conditions listed as precautions should be reviewed carefully. Benefits of and risks for administering a specific vaccine to a person under these circumstances should be considered. If the risk from the vaccine is believed to outweigh the benefit, the vaccine should not be administered. If the benefit of vaccination is believed to outweigh the risk, the vaccine should be administered. Whether and when to administer DTaP to children with proven or suspected underlying neurologic disorders should be decided on a case-by-case basis. 2. Hepatitis B vaccination should be deferred for preterm infants and infants weighing less than 2000 g if the mother is documented to be hepatitis B surface antigen (HBsAg)-negative at the time of the infant s birth. Vaccination can commence at chronological age 1 month or at hospital discharge. For infants born to women who are HBsAg-positive, hepatitis B immunoglobulin and hepatitis B vaccine should be administered within 12 hours of birth, regardless of weight. 3. For details, see CDC. Prevention of Rotavirus Gastroenteritis among Infants and Children: Recommendations of the Advisory Committee on Immunization Practices. (ACIP) MMWR 2009;58(No. RR 2), available at 4. LAIV, MMR, and varicella vaccines can be administered on the same day. If not administered on the same day, these vaccines should be separated by at least 28 days. 5. Immunosuppressive steroid dose is considered to be 2 or more weeks of daily receipt of 20 mg prednisone or equivalent. Vaccination should be deferred for at least 1 month after discontinuation of such therapy. Providers should consult ACIP recommendations for complete information on the use of specific live vaccines among persons on immune-suppressing medications or with immune suppression because of other reasons. 6. HIV-infected children may receive varicella and measles vaccine if CD4+ T-lymphocyte count is >15%. (Source: Adapted from American Academy of Pediatrics. Immunization in Special Clinical Circumstances. In: Pickering LK, ed. Red Book: 2012 Report of the Committee on Infectious Diseases. 29th ed. Elk Grove Village, IL: American Academy of Pediatrics: 2012.) 7. Vaccine should be deferred for the appropriate interval if replacement immune globulin products are being administered (see Table 5 in CDC. General Recommendations on Immunization: Recommendations of the Advisory Committee on Immunization Practices (ACIP) at 8. Measles vaccination might suppress tuberculin reactivity temporarily. Measles-containing vaccine can be administered on the same day as tuberculin skin testing. If testing cannot be performed until after the day of MMR vaccination, the test should be postponed for at least 4 weeks after the vaccination. If an urgent need exists to skin test, do so with the understanding that reactivity might be reduced by the vaccine. 9. For a complete list of conditions that CDC considers to be reasons to avoid getting LAIV, see CDC Prevention and Control of Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices (ACIP), MMWR 2010;59(No. RR-8), available at * Adapted from Table 6. Contraindications and Precautions to Commonly Used Vaccines found in: CDC. General Recommendations on Immunization: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2011; 60(No. RR-2), p , and from Atkinson W, Wolfe S, Hamborsky J, eds. Appendix A. Epidemiology and Prevention of Vaccine-Preventable Diseases ( Regarding latex allergy: some types of prefilled syringes contain natural rubber latex or dry natural latex rubber. Consult the package insert for any vaccine given. 46

47 Medical Management of Vaccine Reactions in Adult Patients All vaccines have the potential to cause an adverse reaction. In order to minimize adverse reactions, patients should be carefully screened for precautions and contraindications before vaccine is administered. Even with careful screening, reactions may occur. These reactions can vary from trivial and inconvenient (e.g., soreness, itching) to severe and life threatening (e.g., anaphylaxis). If reactions occur, staff should be prepared with procedures for their management. The table below describes procedures to follow if various reactions occur. Reaction Symptoms Management Localized Psychological fright and syncope (fainting) Anaphylaxis Soreness, redness, itching, or swelling at the injection site Slight bleeding Continuous bleeding Fright before injection is given Extreme paleness, sweating, coldness of the hands and feet, nausea, light-headedness, dizziness, weakness, or visual disturbances Fall, without loss of consciousness Loss of consciousness Sudden or gradual onset of generalized itching, erythema (redness), or urticaria (hives); angioedema (swelling of the lips, face, or throat); severe bronchospasm (wheezing); shortness of breath; shock; abdominal cramping; or cardiovascular collapse. Apply a cold compress to the injection site. Consider giving an analgesic (pain reliever) or antipruritic (anti-itch) medication. Apply an adhesive compress over the injection site. Place thick layer of gauze pads over site and maintain direct and firm pressure; raise the bleeding injection site (e.g., arm) above the level of the patient s heart. Have patient sit or lie down for the vaccination. Have patient lie flat or sit with head between knees for several minutes. Loosen any tight clothing and maintain an open airway. Apply cool, damp cloths to patient s face and neck. Examine the patient to determine if injury is present before attempting to move the patient. Place patient flat on back with feet elevated. Check the patient to determine if injury is present before attempting to move the patient. Place patient flat on back with feet elevated. Call 911 if patient does not recover immediately. See Emergency Medical Protocol for Management of Anaphylactic Reactions in Adults on the next page for detailed steps to follow in treating anaphylaxis. (continued on page 2) Technical content reviewed by the Centers for Disease Control and Prevention, April Item #P3082 (4/11) Immunization Action Coalition 1573 Selby Ave. St. Paul, MN (651)

48 Medical Management of Vaccine Reactions in Adults (continued) (page 2 of 2) Supplies you may need at a community immunization clinic First-line treatment: Aqueous epinephrine 1:1000 (i.e., 1 mg/ml) dilution, in ampules, vials of solution, or prefilled syringes, including epinephrine autoinjectors (e.g., EpiPen). If EpiPens are stocked, at least three adult EpiPens (0.30 mg) should be available. Secondary treatment option: Diphenhydramine (Benadryl) injectable (50 mg/ml solution) or oral (12.5 mg/5 ml liquid, 25 or 50 mg capsules/tablets) Syringes: 1 and 3 cc, 22 and 25g, 1, 1½, and 2 needles for epinephrine and diphenhydramine (Benadryl) Alcohol wipes Tourniquet Adult airways (small, medium, and large) Adult size pocket mask with one-way valve Oxygen (if available) Stethoscope Sphygmomanometer (blood pressure measuring device) with adult-size and extra-large cuffs Tongue depressors Flashlight with extra batteries (for examination of the mouth and throat) Wristwatch with ability to count seconds Cell phone or access to onsite phone Emergency medical protocol for management of anaphylactic reactions in adults 1. If itching and swelling are confined to the injection site where the vaccination was given, observe patient closely for the development of generalized symptoms. 2. If symptoms are generalized, activate the emergency medical system (EMS; e.g., call 911) and notify the oncall physician. This should be done by a second person, while the primary nurse assesses the airway, breathing, circulation, and level of consciousness of the patient. 3. Drug Dosing Information: a. First-line treatment: Administer aqueous epinephrine 1:1000 dilution intramuscularly, 0.01 ml/kg/dose (adult dose ranges from 0.3 ml to 0.5 ml, with maximum single dose of 0.5 ml). b. Secondary treatment option: For hives or itching, you may also administer diphenhydramine either orally or by intramuscular injection; the standard dose is 1 2 mg/kg, up to 50 mg maximum single dose. 4. Monitor the patient closely until EMS arrives. Perform cardiopulmonary resuscitation (CPR), if necessary, and maintain airway. Keep patient in supine position (flat on back) unless he or she is having breathing difficulty. If breathing is difficult, patient s head may be elevated, provided blood pressure is adequate to prevent loss of consciousness. If blood pressure is low, elevate legs. Monitor blood pressure and pulse every 5 minutes. 5. If EMS has not arrived and symptoms are still present, repeat dose of epinephrine every 5 15 minutes for up to 3 doses, depending on patient s response. 6. Record all vital signs, medications administered to the patient, including the time, dosage, response, and the name of the medical personnel who administered the medication, and other relevant clinical information. 7. Notify the patient s primary care physician. Sources Boyce JA, Assa ad A, Burks AW, et al. Guidelines for the Diagnosis and Management of Food Allergy in the United States: Report of the NIAID- Sponsored Expert Panel. Allergy Clin Immunol 2010; 126(6):S1 S57. Simons FE, Camargo CA. Anaphylaxis: Rapid recognition and treatment. In: UpToDate, Bochnew BS (Ed). UpToDate: Waltham, MA, American Pharmacists Association, Grabenstein, JD, Pharmacy-Based Immunization Delivery, These standing orders for the medical management of vaccine reactions in adult patients shall remain in effect for patients of the_ until rescinded or until-. name of clinic date Medical Director s signature Effective date Item #P3082 (4/11) Immunization Action Coalition 1573 Selby Ave. St. Paul, MN (651)

49 Before you vaccinate adults, consider their H-A-L-O! What is H-A-L-O? As shown below, it s an easy-to-use chart that can help you make an initial decision about vaccinating a patient based on four factors the patient s Health condition, Age, Lifestyle, and Occupation. In some situations, though, you can vaccinate a patient without considering these factors. For example, all adults need a Td booster every 10 years, and any adult who wants protection against influenza, hepatitis A, or hepatitis B can be vaccinated. Note that not all patients who mention one or more H-A-L-O factors will need to be vaccinated. Before you make a definitive decision about vaccinating your patient, it s important that you refer to the more detailed information found in the Immunization Action Coalition s Summary of Recommendations for Adult Immunization, located at or the complete recommendations from the CDC s Advisory Committee on Immunization Practices at pubs/acip-list.htm. How do I use H-A-L-O? Though some factors can be easily determined (e.g., age, pregnancy), you will need to ask your patient about the presence or absence of others. Once you determine which of the H-A-L-O factors apply, scan down each column of the chart to see at a glance which vaccinations are possibly indicated (they are shown with a check mark). H-A-L-O checklist of factors that indicate a possible need for adult vaccination Health factors Age factors Lifestyle factors Occupational or other factors Tdap HPV Varicella Zoster MMR Influenza Pneumococcal HepA HepB Vaccine Meningococcal Chronic disease!!!!! Pregnant!! History of STD Immunosuppressed (including HIV)!!!! Cochlear implant candidate/recipient! Age equal to or younger than 26 2, 49 3, or ! 2!? * Vaccination may be indicated depending on degree of immunosuppression.? *? * Age equal to or older than 50 5, 60 4, or 65 6 Born outside the U.S.! 3!!!! 4 5 6! Men who have sex with men Not in a long-term, mutually monogamous relationship User of injection or noninjection street drugs!!!!! International traveler!!! College student!!!!!!!! Parent or caregiver of a young child!!!! Healthcare worker!!!!! Certain lab workers!! Adults in institutional settings (e.g., chronic care, correctional)!!!! Technical content reviewed by the Centers for Disease Control and Prevention, July Item #P3070 (7/08) Immunization Action Coalition 1573 Selby Avenue St. Paul, MN (651)

50 Pocket guides for Tdap, influenza, and zoster also available at immunize.org 50

51 Administering Vaccines: Dose, Route, Site, and Needle Size Vaccine Dose Route Diphtheria, Tetanus, Pertussis (DTaP, DT, Tdap, Td) 0.5 ml Haemophilus influenzae type b (Hib) 0.5 ml Hepatitis A (HepA) <18 yrs; 0.5 ml >19 yrs; 1.0 ml Hepatitis B (HepB) <19yrs: 0.5 ml >20 yrs: 1.0 ml *Persons yrs may be given Recombivax HB (Merck) 1.0 ml adult formulation on a 2-dose schedule. Human papillomavirus (HPV) 0.5 ml Influenza, live attenuated (LAIV) 0.2 ml Intranasal spray Influenza, trivalent inactivated (TIV) 6-35 mos: 0.25 ml >3 yrs: 0.5 ml TIV: Fluzone intradermal (18 64 yrs) 0.1 ml ID Measles, Mumps, Rubella (MMR) 0.5 ml SC Meningococcal conjugate (MCV) 0.5 ml Meningococcal polysaccharide (MPSV) 0.5 ml SC Pneumococcal conjugate (PCV) 0.5 ml Pneumococcal polysaccharide (PPSV) 0.5 ml or SC Polio, inactivated (IPV) 0.5 ml or SC Rotavirus (RV) Rotarix: 1.0 ml Rotateq: 2.0 ml Oral Varicella (Var) 0.5 ml SC Zoster (Zos) 0.65 ml SC Combination Vaccines DTaP-HepB-IPV (Pediarix) DTaP-IPV/Hib (Pentacel) DTaP-IPV (Kinrix) 0.5 ml Hib-HepB (Comvax) MMRV (ProQuad) <12 yrs: 0.5 ml SC HepA-HepB (Twinrix) >18 yrs: 1.0 ml Injection Site and Needle Size Subcutaneous (SC) injection Use a gauge needle. Choose the injection site that is appropriate to the person s age and body mass. Age Infants (1 12 mos) Children 12 mos or older, adolescents, and adults Newborns (1 st 28 days) Infants (1 12 mos) Toddlers (1 2 yrs) Anterolateral thigh muscle Anterolateral thigh muscle Anterolateral thigh muscle or deltoid muscle of arm Children & teens 5 8 1"* Deltoid muscle of arm or (3 18 years) 1" 1¼" anterolateral thigh muscle Adults 19 yrs or older Male or female less than 130 lbs Female lbs Male lbs Female 200+ lbs Male 260+ lbs Needle Length Needle Length 1" 1 1¼" 1"* 1"* 1 1½" 1½" Injection Site Fatty tissue over anterolateral thigh muscle Fatty tissue over anterolateral thigh muscle or fatty tissue over triceps Intramuscular () injection Use a gauge needle. Choose the injection site and needle length appropriate to the person s age and body mass. Age 5 8"* " 5 8 " Injection Site Deltoid muscle of arm Deltoid muscle of arm Deltoid muscle of arm *A 5 /8" needle may be used for patients weighing less than 130 lbs (<60 kg) for injection in the deltoid muscle only if the skin is stretched tight, the subcutaneous tissue is not bunched, and the injection is made at a 90-degree angle. Intramuscular () injection Subcutaneous (SC) injection Intradermal (ID) administration of Fluzone ID vaccine Intranasal (IN) administration of FluMist (LAIV) vaccine 90 angle skin 90 angle 45 angle skin Administer in area of deltoid subcutaneous tissue muscle subcutaneous tissue muscle Please note: Always refer to the package insert included with each biologic for complete vaccine administration information. CDC s Advisory Committee on Immunization Practices (ACIP) recommendations for the particular vaccine should be reviewed as well (see Technical content reviewed by the Centers for Disease Control and Prevention Item #P3085 (7/12) Immunization Action Coalition 1573 Selby Ave. St. Paul, MN (651)

52 Administering Vaccines to Adults: Dose, Route, Site, and Needle Size Hepatitis A (HepA) Hepatitis B HepB) Vaccine Dose Route <18 yrs: 0.5 ml >19 yrs: 1.0 ml <19 yrs: 0.5 ml >20 yrs: 1.0 ml HepA-HepB (Twinrix) >18 yrs: 1.0 ml Human papillomavirus (HPV) 0.5 ml Influenza, live attenuated (LAIV) 0.2 ml (0.1 ml into each nostril) Intranasal spray Influenza, trivalent inactivated (TIV), including Fluzone High-Dose 0.5 ml Influenza (TIV) Fluzone Intradermal, for ages 18 through 64 years 0.1 ml Intradermal Measles, Mumps, Rubella (MMR) 0.5 ml SC Meningococcal, conjugate (MCV4) 0.5 ml Meningococcal, polysaccharide (MPSV4) 0.5 ml SC Pneumococcal, conjugate (PCV13) 0.5 ml Pneumococcal, polysaccharide (PPSV) 0.5 ml SC Tetanus, Diphtheria (Td) with Pertussis (Tdap) 0.5 ml Varicella (VAR) 0.5 ml SC Zoster (Zos) 0.65 ml SC Injection Site and Needle Size Subcutaneous (SC) injection Use a gauge, 5 8 ", needle. Inject in fatty tissue over triceps. Intramuscular () injection Use a gauge needle. Inject in deltoid muscle of arm. Choose the needle length as indicated below: Gender/Weight Needle Length Male or female less than 130 lbs 5 8 "* 1" Female lbs 1 1½" Male lbs Female 200+ lbs 1½" Male 260+ lbs *A 5 /8" needle may be used for patients weighing less than 130 lbs (<60 kg) for injection in the deltoid muscle only if the subcutaneous tissue is not bunched and the injection is made at a 90-degree angle. Intramuscular () injection Subcutaneous (SC) injection Intradermal (ID) administration of Fluzone ID vaccine Intranasal (IN) administration of FluMist (LAIV) vaccine 90 angle skin 90 angle 45 angle skin Administer in area of deltoid subcutaneous tissue muscle subcutaneous tissue muscle Note: Always refer to the package insert included with each biologic for complete vaccine administration information. CDC s Advisory Committee on Immunization Practices (ACIP) recommendations for the particular vaccine should be reviewed as well. Access the ACIP recommendations at Technical content reviewed by the Centers for Disease Control and Prevention Item #P3084 (7/12) Immunization Action Coalition 1573 Selby Ave. St. Paul, MN (651)

53 Administering Intradermal Trivalent Influenza Vaccine (TIV ID) Getting Started: Gently shake TIV ID and remove the needle cap from the manufacturer s prefilled syringe Do not place TIV ID in any other syringe! Some experts suggest having the patient sit with arm bent at the elbow, hand resting on hip to receive ID influenza vaccine. 1. Place the thumb and middle finger on the finger pads on the syringe. Ensure that the index finger remains free. Do not place any fingers on the windows of the syringe Hold the syringe over the deltoid muscle area of either upper arm. With the opposite hand, gently hold the arm as shown. Insert the needle rapidly and perpendicular to the skin in a short quick movement. 3. Once the needle is inserted, maintain light pressure on the surface of the skin. Using your index finger to inject, push on the plunger of the syringe to inject the vaccine. Do not aspirate. 4. Remove the syringe from the patient s arm. Direct the needle away from you and the patient. Use your thumb to depress the plunger firmly to activate the needle shield. (You will hear a click when the shield extends to cover the needle.) Put the used syringe in a sharps container Important Intradermal Influenza fact! The vaccine must be administered into the dermal (dermis) layer of the skin Do not give SC or Age Dosage Route Site TIV ID years 0.1 ml Intradermal (ID) Over deltoid muscle area of upper arm For more information or updates to this form: contact your local health department or visit MI Dept of Comm Health or CDC Refer to: Prevention and Control of Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2011 MMWR Vol.60/No.33/August 26, 2011 at The influenza vaccine recommendations should continue to be referenced for other information on influenza vaccines. September 13,

54 For Healthcare Providers Only. Administration Guidelines 1 XXXXXXX XXXXXXX 2 3 XXXX XXXX Check expiration date. Product must be used before the date on sprayer label. Remove rubber tip protector. Do not remove dose-divider clip at the other end of the sprayer. With the patient in an upright position, place the tip just inside the nostril to ensure FluMist is delivered into the nose With a single motion, depress plunger as rapidly as possible until the dosedivider clip prevents you from going further. Pinch and remove the dose-divider clip from plunger. Place the tip just inside the other nostril and with a single motion, depress plunger as rapidly as possible to deliver remaining vaccine. DO NOT INJECT. DO NOT USE A NEEDLE. Note: Active inhalation (i.e., sniffing) is not required by the patient during FluMist administration Important Safety Information FluMist is a vaccine indicated for active immunization of individuals 2-49 years of age against influenza disease caused by influenza virus subtypes A and type B contained in the vaccine. FluMist is contraindicated in individuals with history of hypersensitivity to eggs, egg proteins, gentamicin, gelatin or arginine or with life-threatening reactions to previous influenza vaccinations, and in children and adolescents receiving concomitant aspirin or aspirin-containing therapy. Do not administer FluMist to children <24 months of age due to an increased risk of hospitalization and wheezing that was observed in clinical trials. FluMist should not be administered to any individual with asthma and to children <5 years of age with recurrent wheezing unless the potential benefit outweighs the potential risk. Do not administer FluMist to individuals with severe asthma or active wheezing. (Continued on next page) 54 1

55 Supplies You May Need at a Community Immunization Clinic Frozen Vaccine options* Diphtheria, tetanus, and pertussis (DTaP) DTaP-HepB-IPV (Pediarix) DTaP-Hib (Trihibit) DTaP-Hib-IPV (Pentacel) DTaP-IPV (Kinrix) Haemophilus influenzae type b (Hib) Hepatitis A Hepatitis B Hep B-Hib (Comvax) Hep A-Hep B (Twinrix) Human papillomavirus (HPV) Influenza, trivalent injectable (TIV) (in season) Measles, mumps, rubella (MMR) Meningococcal Pneumococcal conjugate (PCV) Pneumococcal polysaccharide (PPSV) Polio, inactivated (IPV) Rotavirus (RV) Tetanus-diphtheria, adult (Td) Tetanus, diphtheria, and pertussis (Tdap) Influenza, live attenuated intranasal (LAIV) (in season) Measles, mumps, rubella, varicella (MMRV) Varicella Zoster (shingles) Note: do not place diluent in container with dry ice. For instructions on how to pack and transport vaccines, go to Immunization Clinic Documentation Immunization clinic standing orders and protocols Vaccination administration records (i.e., medical records) Billing forms Screening Questionnaire for Childhood Immunization Screening Questionnaire for Adult Immunization Summary of Recommendations for Childhood and Adolescent Immunization Summary of Recommendations for Adult Immunization Immunization record cards for patients Release of information forms Notification of Vaccination Letter (to send to primary clinic) Vaccine Adverse Events Reporting (VAERS) forms List of clinics, phone #s, and other referral sources Supplies You May Need at a Community Immunization Clinic (i.e., this form) Schedules including dates and times of future clinics Miscellaneous Office Supplies Calendar Stapler/staples Pens, black and red Rubber bands Files Tape Scissors Paper clips Pad of paper Technical content reviewed by the Centers for Disease Control and Prevention, May Vaccine Information Statements (VISs)* DTaP/DT/DTP Polio Hepatitis A PCV Hepatitis B PPSV HPV (Cervarix or Gardasil) Rotavirus Hib Td/Tdap Influenza (TIV) Varicella Influenza (LAIV) Zoster (shingles) MMR Multi-vaccine Meningococcal Emergency Supplies* Standing orders for medical emergencies Aqueous epinephrine USP (1:1000), in ampules, vials of solution, or prefilled syringes (including Epi-Pens) Diphenhydramine (e.g., Benadryl) injectable (50 mg/ml solution) and oral (12.5 mg/5 ml suspension) and 25 mg or 50 mg capsules or tablets 1 and 3 cc syringes with 1", 1½", and 2" needles for epinephrine or diphenhydramine Alcohol wipes Tourniquet Pediatric and adult airways (small, medium, and large) Pediatric & adult size pocket masks with one-way valve Oxygen (if available) Stethoscope Sphygmomanometer (child, adult & extra-large cuffs) Tongue depressors Flashlight & extra batteries (for examination of mouth & throat) Wrist watch with ability to count seconds Cell phone or access to an onsite phone Vaccine Supplies* 1 or 2 needle disposal containers 1 box of 3 cc syringes 22 25g needles e"; 1"; 1½"; 2" 1 box of medical gloves Alcohol wipes Spot bandaids Rectangular bandaids 1" gauze pads or cotton balls Thermometers along with probe covers Certified calibrated thermometer for vaccine cooler Paper towels Bleach solution in spray bottle * Always check the expiration dates of all vaccines, medications, and medical supplies before using! In addition, be sure to check that you have the most current versions of the VISs. To learn more about VISs, visit These materials are available at These materials may be purchased at Item #P3046 (5/10) Immunization Action Coalition 1573 Selby Ave. St. Paul, MN (651)

56 Vaccine product name Manufacturer Liquid diluent (may contain vaccine) Time allowed between reconstitution and use* Diluent storage environment ActHIB (Hib) sanofi pasteur Hib 0.4% sodium chloride 24 hrs Refrigerator Hiberix (Hib) GlaxoSmithKline Hib 0.9% sodium chloride 24 hrs Refrigerator or room temp Imovax (RAB HDCV ) sanofi pasteur Rabies virus Sterile water Immediately Refrigerator M-M-R II (MMR) Merck MMR Sterile water 8 hrs MenHibrix (Hib-MenCY) Menomune (MPSV4) GlaxoSmithKline Hib-MenCY 0.9% sodium chloride Immediately sanofi pasteur MPSV4 Distilled water 30 min (single-dose vial) 35 days (multidose vial) Refrigerator or room temp Refrigerator or room temp Refrigerator Menveo (MCV4) Novartis MenA MenCWY 8 hrs Refrigerator Pentacel (DTaP-IPV/Hib) sanofi pasteur Hib DTaP-IPV ProQuad (MMRV) Merck MMRV Sterile water 30 min Immediately (i.e., within 30 minutes or less) Refrigerator Refrigerator or room temp RabAvert (RAB PCECV ) Novartis Rabies virus Sterile water Immediately Refrigerator Rotarix (RV1) GlaxoSmithKline RV1 Sterile water, calcium carbonate, and xanthan Varivax (VAR) Merck VAR Sterile water 30 min YF-VAX (YF) sanofi pasteur YF 0.9% sodium chloride 60 min Zostavax (HZV) Merck HZV Sterile water 30 min 1. For single-dose vaccine products (exceptions are Menomune in the multidose vial and Rotarix ), select a syringe and a needle of proper length to be used for both reconstitution and administration of the vaccine. Following reconstitution, Menomune in a multidose vial will require a new needle and syringe for each dose of vaccine to be administered. For Rotarix, see the package insert. 2. Before reconstituting, check labels on both the lyophilized vaccine vial and the diluent to verify the following: that they are the correct two products to mix together that the diluent is the correct volume (especially for Menomune in the multidose vial) that neither vaccine nor diluent has expired 3. Reconstitute (i.e., mix) vaccine just prior to use by removing the protective caps and wiping each stopper with an alcohol swab inserting needle of syringe into diluent vial and withdrawing entire contents Vaccines with Diluents: How to Use Them The following vaccines must be reconstituted correctly before they are administered. Reconstitution means that the lyophilized (freeze-dried) vaccine powder or wafer in one vial must be reconstituted (mixed) with the diluent (liquid) in another. Only use the diluent provided by the manufacturer for that vaccine as indicated on the chart. ALWAYS check the expiration date on the diluent and vaccine. NEVER use expired diluent or vaccine. Lyophilized vaccine (powder) Always refer to package inserts for detailed instructions on reconstituting specific vaccines. In general, follow these steps: * If the reconstituted vaccine is not used within this time period, it must be discarded. MMRV contains seven times as much varicella component as does the single antigen VAR. Rotarix vaccine is administered by mouth using the applicator that contains the diluent. It is not administered as an injection. HZV contains fourteen times as much varicella component as does the single antigen VAR. 24 hrs Room temp Refrigerator or room temp Refrigerator or room temp Refrigerator or room temp injecting diluent into lyophilized vaccine vial and rotating or agitating to thoroughly dissolve the lyophilized powder 4. Check the appearance of the reconstituted vaccine. Reconstituted vaccine may be used if the color and appearance match the description on the package insert. If there is discoloration, extraneous particulate matter, obvious lack of resuspension, or cannot be thoroughly mixed, mark the vial as DO NOT USE, return it to proper storage conditions, and contact your state or local health department immunization program or the vaccine manufacturer. 5. If reconstituted vaccine is not used immediately or comes in a multidose vial (i.e., multi-dose Menomune), clearly mark the vial with the date and time the vaccine was reconstituted maintain the product at F (2 8 C); do not freeze protect reconstituted vaccines from light use only within the time indicated on chart above Technical content reviewed by the Centers for Disease Control and Prevention Item #P3040 (12/12) Immunization Action Coalition 1573 Selby Ave. St. Paul, MN (651)

57 HEALTH CARE AUTHORITY Olympia, Washington To: From: Pharmacists Managed Care Organizations Doug Porter, Director Health Care Authority # Memo: Issued: July 07, 2011 For further information, go to: Subject: Prescription Drug Program: Reimbursement for Flu and Pneumonia Vaccine Administrations Retroactive to dates of service on and after July 1, 2011, pharmacists who administer a flu or pneumonia vaccine to eligible clients may bill the Health Care Authority/Medicaid (the Agency) for vaccines and vaccine administration fees as described in this memo. When Does the Agency Pay Pharmacists for Administering Immunizations? To be paid for administering immunizations to Agency clients, pharmacists must have an immunization collaborative practice protocol on file with the Board of Pharmacy. How Do I Bill the Agency for a Vaccine Administration? When billing the Agency for the flu or pneumonia vaccine administration, use one of the following Healthcare Common Procedure Coding System (HCPCS) codes: HCPCS Code G0008 G0009 Description Administration of influenza virus vaccine Administration of pneumococcal vaccine Rate updates for HCPCS codes G0008 and G0009 are reflected under Current Procedural Terminology (CPT) code on the Physician-Related Services Fee Schedule. The Agency pays for administration codes only when billed with place of service 01 (pharmacy). CPT is a trademark of the American Medical Association CPT codes and descriptions only are copyright 2010 American Medical Association. 57

58 # Memo July 07, 2011 Page 2 Coverage Changes Effective for dates of services on and after July 1, 2011, the Agency will make the following coverage changes for vaccines: Change the following procedure codes from covered to free from Department of Health Code Description Comments Hib vaccine prp-omp im Free from DOH, 0-18 years of age Hep b vacc adol 2 dose im Free from DOH, 0-18 years of age Change the following procedure codes from noncovered to covered: Code Description Comments Hpv vaccine 2 valent im Free from DOH, 0-18 years of age Flu vaccine 3 yrs im Free from DOH, 0-18 years of age Rotavirus vacc 2 dose oral Free from DOH, 0-18 years of age Dtap-ipv vacc 4-6 yr im Free from DOH, 0-18 years of age Hep b/hib vaccine im Free from DOH, 0-18 years of age Additional Limits and Clarifications. Effective for dates of services on and after July 1, 2011, the Agency will make the following coverage changes, limitations and clarifications: Change the following procedure codes from noncovered to covered without PA or EPA: Use these for clients 19 years of age and older only. Refer to the EPSDT Billing Instructions for clients 18 years of age and younger. Code Description Comments Q2035 Afluria vacc, 3 yrs & >, im clients 19 years of age and older Q2036 Flulaval vacc, 3 yrs & >, im clients 19 years of age and older Q2037 Fluvirin vacc, 3 yrs & >, im clients 19 years of age and older Q2038 Fluzone vacc, 3 yrs & >, im clients 19 years of age and older Q2039 NOS flu vacc, 3 yrs & >, im clients 19 years of age and older 58

59 # Memo July 07, 2011 Page 3 Bill the Agency for the vaccine administration using an approved HIPAA-compliant (837-P), Direct Data Entry (DDE) professional or paper CMS-1500 claim form. Note: The Agency encourages providers to bill electronically for the most efficient distribution of payment. Bill the Agency using your National Provider Identification (NPI) number in the appropriate field on the claim. Continue to bill through the Point-of-Sale (POS) system using national drug codes (NDCs) for flu and pneumonia vaccines for clients 19 years of age and older. Note: The Agency does not reimburse for drugs available at no charge from the Department of Health (DOH) through the Vaccines for Children Program. The Agency pays providers only for the administration fees when the vaccines are available at no cost from the Department of Health (DOH) through the Universal Vaccine Distribution program and the Federal Vaccines for Children program for children 0-18 years of age. Note: Managed care plans are responsible for immunizations for their enrollees. How Can I Get the Agency Provider Documents? To download and print the Agency provider numbered memos and billing instructions, go to the Agency website at (click the Billing Instructions and Numbered Memorandum link). 59

60 THIS PAGE INTENTIONALLY LEFT BLANK 60

61 QUICK REFERENCE INFORMATION: MEDICARE MUNIZATION BILLING (Seasonal Influenza Virus, Pneumococcal, and Hepatitis B) Immunization Procedure Codes & Descriptors ADMINISTRATION & DIAGNOSIS CODES Seasonal Influenza Virus Vaccine Administration Code: G0008 Diagnosis Code: V04.81 VACCINE CODES & DESCRIPTORS Influenza virus vaccine, split virus, preservative free, when administered to children 6-35 months of age, for intramuscular use Influenza virus vaccine, split virus, preservative free, when administered to individuals 3 years and older, for intramuscular use Influenza virus vaccine, split virus, when administered to children 6-35 months of age, for intramuscular use until 12/31/2010 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use Q2035 beginning 1/1/2011 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Afluria) Q2036 beginning 1/1/2011 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Flulaval) Q2037 beginning 1/1/2011 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Fluvirun) Q2038 beginning 1/1/2011 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Fluzone) Q2039 beginning 1/1/2011 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Not Otherwise Specified) FREQUENCY OF ADMINISTRATION Once per influenza season in the fall or winter Medicare may cover additional seasonal influenza virus vaccinations if medically necessary What s New? Effective for dates of service on or after October 1, 2010, Healthcare Common Procedure Coding System (HCPCS) codes Q2035, Q2036, Q2037, Q2038, and Q2039 will replace the Current Procedural Terminology (CPT) code (Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use) for Medicare payment purposes during the influenza season; however, these HCPCS codes will not be recognized by the Medicare claims processing systems until January 1, 2011, when CPT code will no longer be recognized. Since Medicare reimbursement rates change periodically, providers are encouraged to enroll in a relevant CMS electronic mailing list at AboutWebsite/20_ Updates.asp for the latest updates. Institutional Providers: Additional Billing Information FACILITY TYPE OF BILL Hospitals, other than Indian Health Service (IHS) Hospitals and Critical Access Hospitals (CAHs) CAHs: Method I and II and IHS CAHs IHS Hospitals Skilled Nursing Facilities (SNFs) 12X, 13X 85X 12X, 13X 22X, 23X Influenza virus vaccine, live, for intranasal use Home Health Agencies (HHAs) 34X Pneumococcal Vaccine Administration Code: G0009 Diagnosis Code: V03.82 Pneumococcal and Seasonal Influenza Virus Vaccines received during the same visit Administration Codes: G0008: Influenza Virus G0009: Pneumococcal Diagnosis Code: V06.6 Hepatitis B Vaccine Administration Code: G0010 Diagnosis Code: V Influenza virus vaccine, split virus, preservative free, enhanced immunogenicity via increased antigen content, for intramuscular use Pneumococcal conjugate vaccine, polyvalent, when administered to children younger than 5 years, for intramuscular use Pneumococcal conjugate vaccine, 13 valent, for intramuscular use Pneumococcal polysaccharide vaccine, 23-valent, adult or immunosuppressed patient dosage, when administered to individuals 2 years or older, for subcutaneous or intramuscular use Use seasonal influenza virus and pneumococcal vaccine codes Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (3 dose schedule), for intramuscular use Hepatitis B vaccine, adolescent (2 dose schedule), for intramuscular use Hepatitis B vaccine, pediatric/adolescent dosage (3 dose schedule), for intramuscular use Hepatitis B vaccine, adult dosage, for intramuscular use Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (4 dose schedule), for intramuscular use CPT only copyright 2010 American Medical Association. All rights reserved. Once in a lifetime/ Medicare may cover additional vaccinations based on risk Follow administration guidelines for seasonal influenza virus and pneumococcal vaccines Scheduled doses required Comprehensive Outpatient Rehabilitation Facilities (CORFs) Independent and Hospital-Based Renal Dialysis Facilities Revenue Codes: 0636 vaccine 0771 administration Special Information for Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs)* FACILITY TYPE OF BILL Rural Health Clinics (RHCs) Federally Qualified Health Centers (FQHCs) 75X 72X 71X 73X (for dates of service prior to April 1, 2010) 77X (for dates of service on or after April 1, 2010) * Seasonal influenza virus, pneumococcal, and hepatitis B vaccines are covered when given by RHCs and FQHCs when they meet all program requirements, but no line items specifically for vaccines are billed on Type of Bill (TOB) 71X and 73X/77X claims. Beginning with dates of service on or after January 1, 2011, when billing for the pneumococcal, seasonal influenza virus, and hepatitis B vaccine and their administration on TOB 77X, the services should be reported separately with the appropriate HCPCS code and revenue codes. The cost of the seasonal influenza virus and pneumococcal vaccines and the vaccine administration is reported separately on the RHC s and FQHC s cost report for reimbursement purposes. 61

62 Frequently Asked Questions Does a Part B deductible or coinsurance apply to adult immunizations covered by Medicare? Neither a Part B deductible nor coinsurance applies to the seasonal influenza virus or pneumococcal vaccines and their administration. The Part B deductible, plus the 20 percent Medicare coinsurance amount, applies to the hepatitis B vaccine for all dates of service prior to January 1, 2011, but will not apply for services on or after January 1, If a beneficiary receives a seasonal influenza virus vaccination more than once in a 12-month period, will Medicare still pay for it? Yes. Medicare pays for one seasonal influenza virus vaccination per influenza season; however, a beneficiary could receive the seasonal influenza virus vaccine twice in a calendar year for two different influenza seasons and the provider would be reimbursed for each. For example, a beneficiary could receive a seasonal influenza virus vaccination in January 2011 for the influenza season and another seasonal influenza virus vaccination in November 2011 for the influenza season and Medicare would pay for both vaccinations. Are HCPCS codes Q2035 and Q2039 payable by Medicare? Effective for claims with dates of service on or after October 1, 2010, Q2035 and Q2039 are payable by Medicare. However, the codes will not be recognized by the Medicare claims processing systems until January 1, Since no national payment limits are available for Q2035 or Q2039, payment limits will be determined by the local claims processing contractor. Will Medicare pay for the pneumococcal vaccination if a beneficiary is uncertain of his or her vaccination history? Yes. If a beneficiary is uncertain about his or her vaccination history in the past five years, the vaccine should be given and Medicare will cover the revaccination. If a beneficiary is certain that more than five years have passed, revaccination is not appropriate unless the beneficiary is at highest risk. Does Medicare cover the hepatitis B vaccine for all Medicare beneficiaries? No. Medicare provides coverage for certain beneficiaries at intermediate to high risk for the hepatitis B virus (HBV). These individuals include workers in health care professions who have frequent contact with blood or blood-derived body fluids during routine work, those with End-Stage Renal Disease (ESRD), and persons who live in the same household as an HBV carrier. There are other situations that could qualify a beneficiary as being at intermediate or high risk of contracting HBV. When a beneficiary receives both the seasonal influenza virus and pneumococcal vaccines on the same visit, would a provider continue to report separate administration codes for each type of vaccine? Yes. Although the provider would use diagnosis code V06.6 when an individual receives both vaccines, separate administration codes for the seasonal influenza virus (G0008) and pneumococcal (G0009) vaccines should be reported. Medicare will pay both administration fees if a beneficiary receives both the seasonal influenza virus and the pneumococcal vaccines on the same day. Can the seasonal influenza virus, pneumococcal, and hepatitis B vaccines all be roster billed? No. Only the seasonal influenza virus and pneumococcal vaccines are eligible for roster billing. Roster billing does not apply to the hepatitis B vaccine. What is a mass immunizer? A mass immunizer offers seasonal influenza virus and/or pneumococcal vaccinations to a large number of individuals and may be a traditional Medicare provider or supplier or a nontraditional provider or supplier (such as a senior citizens center, a public health clinic, or a community pharmacy). Mass immunizers must submit claims for immunizations on roster bills and must take assignment on both the vaccine and its administration. A mass immunizer should enroll with the Medicare Contractor prior to influenza season. Please see the next question for more enrollment information. Do providers that only provide immunizations need to enroll in the Medicare Program? Yes. Providers must enroll in the Medicare Program even if immunizations are the only service they will provide to beneficiaries. They should enroll as provider specialty type 73, Mass Immunization Roster Biller, by completing Form CMS-855I for individuals or Form CMS-855B for a group. Visit MedicareProviderSupEnroll to locate these forms. New providers must also first receive a National Provider Identifier (NPI) prior to enrollment. Visit hhs.gov for NPI enrollment information. May a single roster claim be submitted containing information for both the pneumococcal and seasonal influenza virus vaccines when the vaccines are administered on the same visit? No. A separate roster claim needs to be prepared for the pneumococcal vaccine and the seasonal influenza virus vaccine. However, a provider may file an individual claim containing information for both types of vaccines. Quick Facts! Enrolled providers may roster bill for seasonal influenza virus and pneumococcal vaccinations even if they are not a mass immunizer. All physicians, non-physician practitioners, and suppliers who administer the seasonal influenza virus and the pneumococcal vaccines must accept assignment on the claims for the vaccines. Seasonal influenza virus, pneumococcal, and hepatitis B vaccines and their administration are covered Part B benefits and are NOT covered Part D benefits. Resources Influenza (Flu) Season Educational Products and Resources flu_products.pdf Immunizers Question & Answer Guide to Medicare Part B & Medicaid Coverage of Seasonal Influenza and Pneumococcal Vaccinations loads/ immunizersguide.pdf CMS Website Adult Immunization Web Page Centers for Disease Control and Prevention (CDC) Vaccines & Immunizations Food and Drug Administration (FDA) Influenza Season Vaccine Questions and Answers GuidanceComplianceRegulatoryInformation/Post- MarketActivities/LotReleases/ucm htm For beneficiary-related information MEDICARE ( ) TTY users ( ) This educational tool was current at the time it was published or uploaded onto the web. Medicare policy changes frequently so links to the source documents have been provided within the document for your reference. This educational tool was prepared as a service to the public and is not intended to grant rights or impose obligations. This educational tool may contain references to links or statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations, and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2010 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS\DFARS Restrictions Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The International Classification of Diseases, 9 th Revision, Clinical Modification (ICD-9-CM) is published by the United States Government. A CD-ROM, which may be purchased through the Government Printing Office, is the only official Federal government version of the ICD-9-CM. ICD-9-CM is an official Health Insurance Portability and Accountability Act standard. The Medicare Learning Network (MLN), a registered trademark of CMS, is the brand name for official CMS educational products and information for Medicare Fee-For-Service Providers. For additional information, visit the MLN s web page at MLNGenInfo on the CMS website. February 2011 ICN

63 Vaccine Handling Tips Outdated or improperly stored vaccines won t protect patients! Freezer MMR* MMRV Varicella Zoster Maintain refrigerator temperature between 35 and 46 F (2 and 8 C) Refrigerator DTaP, Tdap, Td, DT Hib Hepatitis A Hepatitis B Human papillomavirus Influenza (TIV/LAIV) Polio (IPV) MMR* Meningococcal (MCV4 & MPSV4) Pneumococcal (PPSV & PCV13) Rotavirus Maintain freezer temperature between -58 and 5 F (-50 and -15 C) Manage vaccine inventories. Inventory your vaccine supplies at least monthly and before placing an order. Expired vaccine must never be used and is money wasted! Always use the vaccine with the soonest expiration date first. Move vaccine with the soonest expiration date to the front of the storage unit and mark it to be used first. Keep vaccine vials in their original boxes. Store vaccine appropriately. Place vaccines in refrigerator or freezer immediately upon receiving shipment. Keep vaccine vials in their original packaging. Place vaccine in clearly labeled wire baskets or other open containers with a 2 3" separation between baskets and from wall of unit. Separate vaccines that have been supplied from your state s Vaccines for Children program from vaccines that are privately purchased. Do not store vaccines in the door or on the floor of the unit. Stabilize temperatures. Store ice packs in the freezer and large jugs of water in the refrigerator along with the vaccines. This will help maintain a stable, cold temperature in case of a power failure or if the refrigerator or freezer doors are opened frequently or left open. Frequent opening of either the refrigerator or freezer door can lead to temperature variations inside, which could affect vaccine efficacy. For this reason you should not store food or beverages in the refrigerator or freezer. Safeguard the electrical supply to the refrigerator. Make sure the refrigerator and freezer are plugged into outlets in a protected area where they cannot be disconnected accidentally. Label the refrigerator, freezer, electrical outlets, fuses, and circuit breakers on the power circuit with information that clearly identifies the perishable nature of vaccines and the immediate steps to be taken in case of interruption of power. If your building has auxiliary power, use the outlet supplied by that system. *MMR may be stored in either the freezer or the refrigerator. Refer to package insert for specific instructions on the storage of each vaccine. If you have questions about the condition of the vaccine upon arrival, you should immediately place the vaccine in recommended storage, mark it do not use, and then call your state health department or the vaccine manufacturer(s) to determine whether the potency of the vaccine(s) has been affected. For other questions, call the immunization program at your state or local health department. Record your health department s phone number here: Technical content reviewed by the Centers for Disease Control and Prevention, December Item #P3048 (12/11) Immunization Action Coalition 1573 Selby Ave. St. Paul, MN (651)

64 THIS PAGE INTENTIONALLY LEFT BLANK 64

65 Checklist for Safe Vaccine Storage and Handling Here are the most important things you can do to safeguard your vaccine supply. Are you doing them all? Review this list to see where you might make improvements in your vaccine management practices. Fill in each box with either YES or NO. Establish Storage and Handling Policies YES YES YES YES NO NO NO NO 1. We have designated a primary vaccine coordinator and at least one back-up coordinator to be in charge of vaccine storage and handling at our facility. 2. Both the primary and back-up vaccine coordinator(s) have completely reviewed either CDC's online vaccine storage and handling guidance or equivalent training materials offered by our state health department's immunization program. 3. We have detailed, up-to-date, written policies for general vaccine management, including policies for routine activities and an emergency vaccine-retrieval-and-storage plan for power outages and other problems. Our policies are based on CDC's vaccine storage and handling guidance and/or on instruction from our state or local health department's immunization program. 4. We review these policies with all staff annually and with new staff, including temporary staff, when they are hired. Log In New Vaccine Shipments YES YES YES YES YES NO NO 5. We maintain a vaccine inventory log that we use to document the following: a. Vaccine name and number of doses received b. Date we received the vaccine c. Condition of vaccine when we received it d. Vaccine manufacturer and lot number e. Vaccine expiration date Use Proper Storage Equipment YES YES YES NO NO NO NO NO NO 6. We store vaccines in refrigerator and freezer units designed specifically for storing biologics, including vaccines. Alternatively, we keep frozen and refrigerated vaccines in separate, free-standing freezer and refrigerator units. At a minimum, we use a household-style unit with a separate exterior door for the freezer and separate thermostats for the freezer and refrigerator. We do NOT use a dormitory-style unit (a small combination freezer-refrigerator unit with a freezer compartment inside the refrigerator). 7. We use only calibrated thermometers with a Certificate of Traceability and Calibration* that are recalibrated as recommended by the manufacturer. 8. We have planned back-up storage unit(s) in the event of a power failure or other unforeseen event. We perform regular maintenance to assure optimal functioning. Ensure Optimal Operation of Storage Units YES YES NO NO 9. We have a "Do Not Unplug" sign next to the electrical outlets for the refrigerator and freezer and a "Do Not Stop Power" warning label by the circuit breaker for the electrical outlets. Both include emergency contact information. 10. We keep the storage unit clean, dusting the coils and cleaning beneath it every 3 6 months. Maintain Correct Temperatures YES NO 11. We always keep at least one accurate calibrated thermometer (+/-1ºC [+/-2ºF]) with the vaccines in the refrigerator; YES NO ideally, we have a continuous-temperature logger and/or temperature-sensitive alarm system. 12. We maintain the refrigerator temperature at 35 46ºF (2 8ºC), and we aim for 40ºF (5ºC). (Maintain Correct Temperatures continued on page 2) *Certificate of Traceability and Calibration with calibration measurements traceable to a testing laboratory accredited by the International Organization of Standardization, to the standards of the National Institute of Standards and Technology, or to another internationally recognized standards agency. Technical content reviewed by the Centers for Disease Control and Prevention, July Item #P3035 (7/11) Immunization Action Coalition 1573 Selby Ave. St. Paul, MN (651)

66 Checklist for Safe Vaccine Storage and Handling (continued) (page 2 of 2) (Maintain Correct Temperatures continued from page 1) YES YES YES YES NO NO NO NO 13. We keep extra containers of water in the refrigerator (e.g., in the door, on the floor of the unit where the vegetable bins were located) to help maintain cool temperatures. 14. We always keep at least one accurate calibrated thermometer (+/-1ºC [+/-2ºF]) with vaccines in the freezer. 15. We maintain the average temperature in the freezer at +5ºF (-15ºC), preferably colder but no colder than -58ºF (-50ºC). 16. We keep ice packs or ice-filled containers in the freezer to help maintain cold temperatures. Store Vaccines Correctly YES YES YES YES YES YES YES NO NO NO NO NO NO NO 17. We post signs on the doors of the refrigerator and freezer that indicate which vaccines should be stored in the refrigerator and which in the freezer. 18. We do NOT store any food or drink in any vaccine storage unit. 19. We store vaccines in the middle of the refrigerator or freezer (never in the doors), with room for air to circulate. 20. We have removed all vegetable and deli bins from the storage unit. 21. If we are using a combination refrigerator-freezer unit, we do not store vaccines in front of the cold air outlet that leads from the freezer to the refrigerator (often near the top shelf). 22. We check vaccine expiration dates and rotate our supply of each type of vaccine so that we use the vaccines that will expire soonest. 23. We store vaccines in their original packaging in clearly labeled uncovered containers with slotted sides that allow air to circulate. Maintain Daily Temperature Logs YES YES YES YES YES YES YES NO NO NO NO NO NO NO 24. On days when our practice is open, we document refrigerator and freezer temperatures on the daily log twice a day first thing in the morning and right before our facility closes. 25. We consistently record temperatures on the log in either Fahrenheit or Celsius. We NEVER mix in any way how we record our temperatures. For example, if the log prompts us to insert an "x" by the temperature that's preprinted on the log, we do not attempt to write in the actual temperature. 26. The logs show whom to call if the temperature in the storage unit goes out of range. 27. When we change the thermostat setting, we document it in the daily log sheet's note section. 28. If out-of-range temperatures occur in the unit, we document in the daily log sheet's note section who responded and when. 29. Trained staff (other than staff designated to record the temperatures) review the logs weekly. 30. We keep the temperature logs on file for at least 3 years. Take Emergency Action As Needed YES YES YES YES YES NO NO NO NO NO 31. In the event that vaccines are exposed to improper storage conditions, we take the following steps: a. We restore proper storage conditions as quickly as possible; if necessary, we move the vaccine to our planned back-up storage unit. We address the storage unit s mechanical or electrical problems according to guidance from the manufacturer or repair service. b. In responding to improper storage conditions, we do NOT make frequent or large changes in thermostat settings. After changing the setting, we give the unit at least a day to stabilize its temperature. c. We temporarily label exposed vaccines Do not use and keep them separate from any unexposed vaccines. We do not use exposed vaccines until our state health department s immunization program or the vaccine manufacturer gives us approval. d. We document exactly what happened, noting the temperature in the storage unit and the amount of time the vaccines were out of proper storage conditions. We contact our state health department s immunization program or the vaccine manufacturer to determine how to handle the exposed vaccines. e. We follow the health department or manufacturer s instructions and keep a record detailing the event. Where applicable, we mark the exposed vials with a revised expiration date provided by the manufacturer. If we answer YES to all of the above, we give ourselves a pat on the back! If not, we assign someone to implement needed changes! Immunization Action Coalition Item #P3035 (7/11) 66

67 Temperature Log for Refrigerator and Freezer Celsius Completing this temperature log: Check the temperatures in both the freezer and the refrigerator compartments of your vaccine storage units at least twice each working day. Place an X in the box that corresponds with the temperature and record the ambient (room) temperature, the time of the temperature readings, and your initials. Once the month has ended, save each month s completed form for 3 years, unless state or local jurisdictions require a longer time period. If the recorded temperature is in the shaded zone: This represents an unacceptable Month/Year: Days 1 15 temperature range. Follow these steps: 1. Store the vaccine under proper conditions as quickly as possible. 2. Temporarily mark exposed vaccine do not use until you have verified whether or not the vaccine may be used. 3. Call the immunization program at your state or local health department and/ or the vaccine manufacturer to determine whether the vaccine is still usable: ( ). 4. Document the action taken on the reverse side of this log. Aim for 5 Too warm* Too cold* Day of Month Staff Initials Room Temp. Exact Time o C Temp am pm am pm am pm am pm am pm am pm am pm am pm am pm am pm am pm am pm am pm am pm am pm >11 o 10 o Take immediate corrective action if temperature is in shaded section* 9 o 8 o 7 o 6 o 5 o 4 o 3 o 2 o 1 o 0 o Take immediate corrective action if temperature is in shaded section* <-1 o Refrigerator temperature Too warm* Freezer temp >-12 o -13 o -14 o -15 o -16 o <-17 o Take immediate corrective action if temperature is in shaded section* Some frozen vaccines must not be stored colder than -50 o C. Check the Prescribing Information on the vaccine manufacturer s website for specific storage temperature instructions. Adapted by the Immunization Action Coalition courtesy of the Michigan Department of Community Health and the California Department of Health Services. Technical content reviewed by the Centers for Disease Control and Prevention, August Item #P3039C (8/11) Distributed by the Immunization Action Coalition (651) admin@immunize.org

68 Vaccine Storage Troubleshooting Record Use this page to record the details of the vaccine storage incident, including the date and time of the last known temperature within the appropriate vaccine storage range. Date Time Storage Unit Temp Room Temp Incident Action Taken Results Initials 68

69 Aim for 5 Temperature Log for Refrigerator and Freezer Celsius Completing this temperature log: Check the temperatures in both the freezer and the refrigerator compartments of your vaccine storage units at least twice each working day. Place an X in the box that corresponds with the temperature and record the ambient (room) temperature, the time of the temperature readings, and your initials. Once the month has ended, save each month s completed form for 3 years, unless state or local jurisdictions require a longer time period. If the recorded temperature is in the shaded zone: This represents an unacceptable Too warm* Too cold* Too warm* Month/Year: Days Day of Month Staff Initials Room Temp. Exact Time o C Temp am pm am pm am pm am pm am pm am pm am pm am pm am pm am pm am pm am pm am pm am pm am pm am pm >11 o 10 o Take immediate corrective action if temperature is in shaded section* 9 o 8 o 7 o 6 o 5 o 4 o 3 o 2 o 1 o 0 o Take immediate corrective action if temperature is in shaded section* <-1 o Freezer temp Refrigerator temperature >-12 o -13 o -14 o -15 o -16 o <-17 o Some frozen vaccines must not be stored colder than -50 o C. Check the Prescribing Information on the vaccine manufacturer s website for specific storage temperature instructions. temperature range. Follow these steps: 1. Store the vaccine under proper conditions as quickly as possible. 2. Temporarily mark exposed vaccine do not use until you have verified whether or not the vaccine may be used. 3. Call the immunization program at your state or local health department and/ or the vaccine manufacturer to determine whether the vaccine is still usable: ( ). 4. Document the action taken on the reverse side of this log. Take immediate corrective action if temperature is in shaded section* Adapted by the Immunization Action Coalition courtesy of the Michigan Department of Community Health and the California Department of Health Services. Technical content reviewed by the Centers for Disease Control and Prevention, August Item #P3039C (8/11) Distributed by the Immunization Action Coalition (651) admin@immunize.org

70 Vaccine Storage Troubleshooting Record Use this page to record the details of the vaccine storage incident, including the date and time of the last known temperature within the appropriate vaccine storage range. Date Time Storage Unit Temp Room Temp Incident Action Taken Results Initials 70

71 Follow these procedures: 1. Close the door tightly and/or plug in the refrigerator/freezer. 2. Ensure the vaccine is kept at appropriate temperatures. Make sure the refrigerator/freezer is working properly or move the vaccines to a unit that is. Do not discard the affected vaccines. Mark the vaccines so that the potentially compromised vaccines can be easily identified. 3. Notify the local or state health department or call the manufacturer (see manufacturers phone numbers below). 4. Record action taken. Emergency Response Worksheet What to do in case of a power failure or another event that results in vaccine storage outside of the recommended temperature range Record this information*: 1. Temperature of refrigerator: current max. min. 2. Temperature of freezer: current max. min. 3. Air temperature of room where refrigerator is located: 4. Estimated amount of time the unit s temperature was outside normal range: refrigerator freezer 5. Vaccines in the refrigerator/freezer during the event (use the table below) * Using a recording thermometer is the most effective method of tracking the refrigerator and freezer temperatures over time. Visually checking thermometers twice a day is an effective method to identify inconsistent or fluctuating temperatures in a refrigerator and freezer. Vaccines Stored in Refrigerator Vaccine, manufacturer, and lot # Expiration date # of doses # of affected vials Action taken Vaccines Stored in Freezer Vaccine, manufacturer, and lot # Expiration date # of doses # of affected vials Action taken Other Conditions 1. Prior to this event, was the vaccine exposed to temperatures outside the recommended range? Y N 2. Were water bottles in the refrigerator and ice packs in the freezer at the time of this event? Y N 3. Other: Manufacturers Crucell Vaccines Inc. (800) CSL Biotherapies, Inc. (888) GlaxoSmithKline (888) MedImmune, Inc. (877) Merck & Co., Inc. (800) Novartis Vaccines (800) Pfizer Inc. (800) sanofi pasteur (800) Other Resources Local health department phone number State health department phone number Adapted by the Immunization Action Coalition, courtesy of the Michigan Department of Community Health Technical content reviewed by the Centers for Disease Control and Prevention, October Item #P3051 (10/10) Immunization Action Coalition 1573 Selby Ave. St. Paul, MN (651)

72 THIS PAGE INTENTIONALLY LEFT BLANK 72

73 Vaccine Administration Record Patient Name: Date of Birth: Clinic Name and Address *VFC Status 1 (Patient's Vaccines For Children Program status) A = American Indian / N = No Insurance Alaska Native U = Underinsured M = Medicaid P = Private Insurance I have read or have had explained to me, information about the diseases and the vaccines listed below. I have had the chance to ask questions that were answered to my satisfaction. I believe I understand the benefits and risks of the vaccines cited, and ask that the vaccine(s) listed below be given to me or to the person named above (for whom I am authorized to make this request). [Sign in the signature column for each vaccine row below.] Vaccine document combos under each vaccine 2 Hep B - 1 Hep B - 2 Hep B - 3 Hep B DTaP - 1 DTaP - 2 DTaP - 3 DTaP - 4 DTaP - 5 Hib - 1 Hib - 2 Hib - 3 Hib - 4 Polio - 1 Polio - 2 Polio - 3 Polio - 4 MMR - 1 MMR - 2 Varicella - 1 Varicella - 2 Influenza Influenza Influenza Route SQ / SQ / SQ / SQ / SQ SQ SQ SQ / IN / IN / IN (See other side for additional influenza rows) Hep A - 1 Hep A - 2 Hep A Rotavirus - 1 Rotavirus - 2 Rotavirus - 3 Other: PO PO PO Date Administered (mm/dd/yy) Dosage Vaccine Manufacturer & Vaccine Lot # Site VIS Materials Publication Date Date Given Initials of Person Administering Vaccine Signature of Parent or Guardian VFC Status* Initials & Signatures of Persons Administering Vaccine 1 If using this form to record VFC status: Keep this form in the child s medical record; Complete the VFC Status column for every vaccination given to every child less than 19 years of age. Parent, guardian or legal representative, or health care provider may provide VFC status information. This form must be made available on request for a site review. 2 For combination vaccines, fill in a row for each separate antigen in the combination. DOH (REV. 1/2009) 73

74 Vaccine Administration Record, page 2 Patient Name: Date of Birth: Clinic Name and Address *VFC Status 1 (Patient's Vaccines For Children Program status) A = American Indian / N = No Insurance Alaska Native U = Underinsured M = Medicaid P = Private Insurance I have read or have had explained to me, information about the diseases and the vaccines listed below. I have had the chance to ask questions that were answered to my satisfaction. I believe I understand the benefits and risks of the vaccines cited, and ask that the vaccine(s) listed below be given to me or to the person named above (for whom I am authorized to make this request). [Sign in the signature column for each vaccine row below.] Vaccine document combos under each vaccine 2 Tdap - 1 Td - 1 Td - 2 Td - 3 Td - 4 MCV4-1 MCV4 MPSV4-1 MPSV4 PCV - 1 PCV - 2 PCV - 3 PCV - 4 PPV - 1 PPV - 2 HPV - 1 HPV - 2 HPV - 3 Herpes Zoster Influenza Influenza Influenza Influenza Influenza Influenza Influenza Influenza Influenza Influenza Influenza Other: Route SQ SQ SQ / SQ / SQ / IN / IN / IN / IN / IN / IN / IN / IN / IN / IN / IN Date Administered (mm/dd/yy) Dosage Vaccine Manufacturer & Vaccine Lot # Site VIS Materials Publication Date Given Date Initials of Person Administering Vaccine Signature of Parent or Guardian VFC Status* Initials & Signatures of Persons Administering Vaccine 1 If using this form to record VFC status: Keep this form in the child s medical record; Complete the VFC Status column for every vaccination given to every child less than 19 years of age. Parent, guardian or legal representative, or health care provider may provide VFC status information. This form must be made available on request for a site review. 2 For combination vaccines, fill in a row for each separate antigen in the combination. DOH (REV. 1/2009) 74

75 Washington State Immunization Information System Frequently Asked Questions about the Name Change What is the Washington State Immunization Information System? The Immunization Information System is a secure, Web-based tool that helps healthcare providers keep track of the immunizations they give to patients of all ages in their practice. The old name implied that the system was just for kids, but it s a lifetime registry with records for people of all ages. These immunization records remain available when families move or change providers within our state. What is the new name of the immunization registry? The new name is the Washington State Immunization Information System. For short, we sometimes call it the Immunization Information System or simply the system. Occasionally, we also call it the IIS (pronouncing each letter, like Eye-Eye-Ess ). Why did you change the name of the registry? We changed the name because the system outgrew the name the old name implied a system only for kids. The new name better reflects that our system is (and always has been) a lifetime registry that keeps track of immunization records for people of all ages. 95% of Washington State providers use the registry as a key tool in their services. It is important that providers and the public are aware of what the registry provides for individuals of all ages in our state. Most other registries in our country have Immunization Information System in their names. We also chose this name because it is the national standard. What does the Immunization Information System provide? Reliable data. The Immunization Information System helps ensure that people of all ages get the right vaccines at the right time. Healthcare providers can record vaccinations in the registry which helps them know when their patients need which vaccines. Healthier communities. The Immunization Information System is critical for doctors, nurses, public health staff, health educators, and more. The System helps providers give the right vaccines and acts as a state resource to protect the public during outbreaks of vaccine-preventable disease. This leads to safer and healthier communities across the state. Powerful tools. Not only are up-to-date immunization records readily available for people to give to schools, child care, camps, colleges, employers, and more, but schools can verify records and providers can order vaccine too. Why do I still hear people talking about Child Profile if you changed the name? The Department of Health has two programs that work together to help providers and parents make informed decisions about immunizations. One is the Immunization Information System. The other is the Child Profile Health Promotion System, sometimes called Child Profile. Before, both systems used the name Child Profile. Now, only the health promotion system is called Child Profile. Get 75 August 2012

76 Washington State Immunization Information System Frequently Asked Questions about the Name Change more information about Child Profile Health Promotion at See below for a graphic that outlines benefits of both systems. How can I get more information? To get your questions answered: Visit the our Web site, and search for Immunizations: Call the Immunization Information System Help Desk at August 2012

77 Notification of Vaccination Letter Dear Doctor or Nurse at : Patient s primary care clinic We have recently provided vaccination services to one of your patients. A personal immunization record card was filled out and given to the patient. We want to make certain that you, too, have this information so that you can update your patient s medical record. Please contact us if you have any questions about this information. Patient s name: Patient s birthdate: (For a child, parent s name: Parent s birthdate: ) The vaccines that were given on are checked below. Date Vaccine Vaccine G Hepatitis B ( ml) G DTaP G DTaP-HepB-IPV (Pediarix) G DTaP-IPV (Kinrix) G DTaP-IPV/Hib (Pentacel) G DT G Tdap G Td G Hib (G ACTHIB; G Hiberix; G PedvaxHIB) G Hib-HepB (Comvax) G Pneumococcal conjugate (PCV13) G Pneumococcal polysaccharide (PPSV) G IPV (Polio) G Rotavirus (G RV1 [Rotarix]; G RV5 [RotaTeq]) G MMR G Varicella G MMRV (ProQuad) G Hepatitis A G HepA-HepB (Twinrix) G Human papillomavirus (HPV) (G HPV2 [Cervarix]; G HPV4 [Gardasil]) G Meningococcal conjugate (MCV4) G Meningococcal polysaccharide (MPSV4) G Influenza (injectable) G Influenza (intranasal) G Zoster (shingles) G Other Name of clinic providing services Address City, State, Zip Contact Person address Phone number Technical content reviewed by the Centers for Disease Control and Prevention, January Item #P3060 (1/11) Distributed by the Immunization Action Coalition (651) admin@immunize.org 77

78 THIS PAGE INTENTIONALLY LEFT BLANK 78

79 It s Federal Law! You must give your patients current Vaccine Information Statements (VISs) To obtain current VISs in more than 30 languages, visit the Immunization Action Coalition s website at As healthcare professionals understand, the risks of serious consequences following vaccination are many hundreds or thousands of times less likely than the risks associated with the diseases that the vaccines protect against. Most adverse reactions from vaccines are mild and self-limited. Serious complications are rare, but they can have a devastating effect on the recipient, family members, and the providers involved with the care of the patient. We must continue the efforts to make vaccines as safe as possible. Equally important is the need to furnish vaccine recipients (or the parents/legal representatives of minors) with objective information on vaccine safety and the diseases that the vaccines protect against, so that they are actively involved in making decisions affecting their health or the health of their children. When people are not informed about vaccine adverse events, even common, mild events, they can lose their trust in healthcare providers and vaccines. Vaccine Information Statements (VISs) provide a standardized way to present objective information about vaccine benefits and adverse events. What are VISs? VISs are developed by the staff of the Centers for Disease Control and Prevention (CDC) and undergo intense scrutiny by panels of experts for accuracy. Each VIS provides information to properly inform the adult vaccine recipient or the minor child s parent or legal representative about the risks and benefits of each vaccine. VISs are not meant to replace interactions with healthcare providers, who should answer According to CDC, every time one of these vaccines is given regardless of what combination vaccine it is given in regardless of whether it is given by a public health clinic or a private provider regardless of how the vaccine was purchased and regardless of the age of the recipient the appropriate VIS must be given out prior to the vaccination. Source: questions and address concerns that the recipient or the parent/legal representative may have. Use of the VIS is mandatory! Before a healthcare provider vaccinates a child or an adult with a dose of any vaccine containing diphtheria, tetanus, pertussis, measles, mumps, rubella, polio, hepatitis A, hepatitis B, Haemophilus influenzae type b (Hib), influenza, pneumococcal conjugate, meningococcal, rotavirus, human papillomavirus (HPV), or varicella (chickenpox) vaccine, the provider is required by the National Childhood Vaccine Injury Act (NCVIA) to provide a copy of the VIS to either the adult recipient or to the child s parent/legal representative. How to get VISs All available VISs can be downloaded from the website of the Immunization Action Coalition at or from CDC s website at Ready-to-copy versions may also be available from your state or local health department. You can find VISs in more than 30 languages on the Immunization Action Coalition website at To find VISs in alternative formats (e.g., audio, web-video), go to: Most current versions of VISs As of November 16, 2012, the most recent versions of the VISs are as follows: DTaP/DT...5/17/07 Hepatitis A...10/25/11 Hepatitis B...2/2/12 Hib...12/16/98 HPV (H. papillomavirus)... Cervarix...5/3/11 Gardasil...2/22/12 Influenza (inactive)...7/2/12 Influenza (live)...7/2/12 Japanese encephalitis...12/7/11 MMR...4/20/12 MMRV...5/21/10 PCV13...4/16/10 PPSV...10/6/09 Polio...11/8/11 Rabies...10/6/09 Rotavirus...12/6/10 Shingles...10/6/09 Td/Tdap...1/24/12 Typhoid...5/29/12 Varicella (chickenpox)...3/13/08 Meningococcal... 10/14/11 Yellow fever...3/30/11 Multi-vaccine VIS... 11/16/12 (for 6 vaccines given to infants/children: DTaP, IPV, Hib, Hep B, PCV, RV) (Page 1 of 2) Item #P2027 (11/12) Immunization Action Coalition 1573 Selby Ave. St. Paul, MN (651)

80 It s Federal Law... you must give your patients current VISs Page 2 of 2 Top 10 Facts about VISs Fact 1 It s federal law! Federal law requires that VISs must be used for the following vaccines when vaccinating patients of ALL ages: DTaP (includes DT) Td/Tdap Hib hepatitis A hepatitis B HPV influenza (inactivated and live vaccines) MMR and MMRV meningococcal pneumococcal conjugate polio rotavirus varicella According to CDC, every time one of these vaccines is given regardless of what combination vaccine it is given in regardless of whether it is given by a public health clinic or a private provider regardless of how the vaccine was purchased and regardless of the age of the recipient the appropriate VIS must be given out prior to the vaccination. There are also VISs for vaccines not covered by NCVIA: anthrax, Japanese encephalitis, pneumococcal polysaccharide, rabies, shingles, smallpox, typhoid, and yellow fever. CDC recommends the use of VISs whenever these vaccines are given. The VIS must always be used if vaccine was purchased under CDC contract. By using the VISs with your patients, you are helping to develop a better educated patient population and you are doing the right thing. coccal (PCV), polio (IPV), or rotavirus (RV). The multi-vaccine VIS can also be used when giving combination vaccines (e.g., Pediarix, Pentacel, Comvax) or when giving two or more routine vaccines at other pediatric visits (e.g., months, 4 6 years). However, when giving combination vaccines for which no VIS exist (e.g., Twinrix), give out all relevant single VISs. For example, before administering Twinrix give your patient the VISs for both hepatitis A and hepatitis B vaccines. Fact 6 VISs are available in other formats, including more than 30 languages You may use laminated copies of VISs for patients and parents to read and return before leaving the clinic, but you must also offer the patient (parent/legal representative) a printed copy of the VIS to take home. If they prefer to download the VIS onto a mobile device, direct them to CDC s VIS Mobile Downloads web page: To download VISs in other languages, visit Fact 7 Federal law does not require signed consent in order for a person to be vaccinated Signed consent is not required by federal law (although some states may require them). Fact 2 VISs are required for both public and private sectors Federal law requires use of VISs in both the public and private sector settings and regardless of the source of payment for the vaccine. Fact 3 VIS must be provided before vaccine is administered to the patient The VIS provides information about the disease and the vaccine and should be given to the patient before vaccine is administered. It is also acceptable to hand out the VIS well before administering vaccines (e.g., at a prenatal visit or at birth for vaccines an infant will receive during infancy), as long as you still provide the VIS right before administering vaccines. Fact 4 You must provide a current VIS for each dose of vaccine The most current VIS must be provided before each dose of vaccine is given, including vaccines given as a series of doses. If five doses of a single vaccine are required, the patient (parent/legal representative) must have the opportunity to read the information on the VIS before each dose is given. Fact 5 You must provide VISs for combination vaccines too There is a VIS available for MMRV (ProQuad). An alternative VIS the multi-vaccine VIS is an option to providing singlevaccine VISs when administering one or more of these routine birth-through-6-month vaccines: DTaP, hepatitis B, Hib, pneumo- Fact 8 To verify that a VIS was given, providers must record in the patient s chart (or permanent office log or file) the following information: The published date of the VIS The date the VIS is given to the patient Name, address (office address), and title of the person who administers the vaccine The date the vaccine is administered The vaccine manufacturer and lot number of each dose administered Fact 9 VISs should not be altered before giving them to patients Providers should not change a VIS or write their own VISs. It is permissible to add a practice s name, address, or phone number to an existing VIS. Providers are encouraged to supplement the VIS with additional patient-education materials. Fact 10 Provide VISs to all patients For patients who don t read or speak English, the law requires that providers ensure all patients (parent/legal representatives) receive a VIS, regardless of their ability to read English. If available, provide a translation of the VIS in the patient s language. Translations of VISs in more than 30 languages are available from IAC. Go to for VISs in multiple languages as well as in other formats. Immunization Action Coalition 1573 Selby Ave. St. Paul, MN (651)

81 Influenza Vaccine Inactivated What You Need to Know 1 Why get vaccinated? Influenza ( flu ) is a contagious disease. It is caused by the influenza virus, which can be spread by coughing, sneezing, or nasal secretions. Anyone can get influenza, but rates of infection are highest among children. For most people, symptoms last only a few days. They include: fever/chills sore throat muscle aches fatigue cough headache runny or stuffy nose Other illnesses can have the same symptoms and are often mistaken for influenza. Young children, people 65 and older, pregnant women, and people with certain health conditions such as heart, lung or kidney disease, or a weakened immune system can get much sicker. Flu can cause high fever and pneumonia, and make existing medical conditions worse. It can cause diarrhea and seizures in children. Each year thousands of people die from influenza and even more require hospitalization. By getting flu vaccine you can protect yourself from influenza and may also avoid spreading influenza to others. 2 Inactivated influenza vaccine There are two types of influenza vaccine: 1. Inactivated (killed) vaccine, the flu shot, is given by injection with a needle. 2. Live, attenuated (weakened) influenza vaccine is sprayed into the nostrils. This vaccine is described in a separate Vaccine Information Statement. A high-dose inactivated influenza vaccine is available for people 65 years of age and older. Ask your doctor for more information. Influenza viruses are always changing, so annual vaccination is recommended. Each year scientists try to match the viruses in the vaccine to those most likely to cause flu that year. Flu vaccine will not prevent disease from other viruses, including flu viruses not contained in the vaccine. It takes up to 2 weeks for protection to develop after the shot. Protection lasts about a year. VACCINE INFORMATION STATEMENT Many Vaccine Information Statements are available in Spanish and other languages. See Hojas de Informacián Sobre Vacunas están disponibles en Español y en muchos otros idiomas. Visite Some inactivated influenza vaccine contains a preservative called thimerosal. Thimerosal-free influenza vaccine is available. Ask your doctor for more information. 3 WHO Who should get inactivated influenza vaccine and when? All people 6 months of age and older should get flu vaccine. Vaccination is especially important for people at higher risk of severe influenza and their close contacts, including healthcare personnel and close contacts of children younger than 6 months. WHEN Get the vaccine as soon as it is available. This should provide protection if the flu season comes early. You can get the vaccine as long as illness is occurring in your community. Influenza can occur at any time, but most influenza occurs from October through May. In recent seasons, most infections have occurred in January and February. Getting vaccinated in December, or even later, will still be beneficial in most years. Adults and older children need one dose of influenza vaccine each year. But some children younger than 9 years of age need two doses to be protected. Ask your doctor. Influenza vaccine may be given at the same time as other vaccines, including pneumococcal vaccine. 4 Some people should not get inactivated influenza vaccine or should wait. Tell your doctor if you have any severe (lifethreatening) allergies, including a severe allergy to eggs. A severe allergy to any vaccine component may be a reason not to get the vaccine. Allergic reactions to influenza vaccine are rare.

82 Tell your doctor if you ever had a severe reaction after a dose of influenza vaccine. Tell your doctor if you ever had Guillain-Barré Syndrome (a severe paralytic illness, also called GBS). Your doctor will help you decide whether the vaccine is recommended for you. People who are moderately or severely ill should usually wait until they recover before getting flu vaccine. If you are ill, talk to your doctor about whether to reschedule the vaccination. People with a mild illness can usually get the vaccine. 5 What are the risks from inactivated influenza vaccine? A vaccine, like any medicine, could possibly cause serious problems, such as severe allergic reactions. The risk of a vaccine causing serious harm, or death, is extremely small. Serious problems from inactivated influenza vaccine are very rare. The viruses in inactivated influenza vaccine have been killed, so you cannot get influenza from the vaccine. Mild problems: soreness, redness, or swelling where the shot was given hoarseness; sore, red or itchy eyes; cough fever aches headache itching fatigue If these problems occur, they usually begin soon after the shot and last 1-2 days. Moderate problems: Young children who get inactivated flu vaccine and pneumococcal vaccine (PCV13) at the same time appear to be at increased risk for seizures caused by fever. Ask your doctor for more information. Tell your doctor if a child who is getting flu vaccine has ever had a seizure. Severe problems: Life-threatening allergic reactions from vaccines are very rare. If they do occur, it is usually within a few minutes to a few hours after the shot. In 1976, a type of inactivated influenza (swine flu) vaccine was associated with Guillain-Barré Syndrome (GBS). Since then, flu vaccines have not been clearly linked to GBS. However, if there is a risk of GBS from current flu vaccines, it would be no more than 1 or 2 cases per million people vaccinated. This is much lower than the risk of severe influenza, which can be prevented by vaccination. The safety of vaccines is always being monitored. For more information, visit: and 6 One brand of inactivated flu vaccine, called Afluria, should not be given to children 8 years of age or younger, except in special circumstances. A related vaccine was associated with fevers and fever-related seizures in young children in Australia. Your doctor can give you more information. What if there is a severe reaction? What should I look for? Any unusual condition, such as a high fever or unusual behavior. Signs of a serious allergic reaction can include difficulty breathing, hoarseness or wheezing, hives, paleness, weakness, a fast heart beat or dizziness. What should I do? Call a doctor, or get the person to a doctor right away. Tell your doctor what happened, the date and time it happened, and when the vaccination was given. Ask your doctor, nurse, or health department to report the reaction by filing a Vaccine Adverse Event Reporting System (VAERS) form. Or you can file this report through the VAERS web site at or by calling VAERS does not provide medical advice. 7 The National Vaccine Injury Compensation Program The National Vaccine Injury Compensation Program (VICP) was created in People who believe they may have been injured by a vaccine can learn about the program and about filing a claim by calling or visiting the VICP website at 8 How can I learn more? Ask your doctor. They can give you the vaccine package insert or suggest other sources of information. Call your local or state health department. Contact the Centers for Disease Control and Prevention (CDC): - Call (1-800-CDC-INFO) or - Visit CDC s website at Vaccine Information Statement (Interim) Influenza Vaccine (Inactivated) 7/2/ U.S.C. 300aa-26 Office Use Only 82

83 your name date of birth / / today s date / / Do I Need Any Vaccinations Today? Influenza vaccination This questionnaire will help you and your healthcare provider determine if you need any vaccinations today. Please check the boxes that apply to you. n I haven t had my annual influenza vaccination yet this season so I need it now. Pneumococcal vaccination (PPSV23, PCV13) month day year month day year n I am 65 or older. I either never received a pneumococcal shot or I don t remember receiving a shot. n I am 65 or older and received 1 or 2 doses of pneumococcal vaccine when I was younger than 65. It has either been 5 years or more since my last shot or I don t remember how long it has been. n I am younger than 65. I have not been vaccinated against pneumococcal disease, and I am in one of the following risk groups: n I smoke cigarettes. n I have heart, lung (including asthma), liver, kidney, or sickle cell disease; diabetes; or alcoholism. n I have a weakened immune system due to cancer, Hodgkin s disease, leukemia, lymphoma, multiple myeloma, kidney failure, HIV/AIDS; or I am receiving radiation therapy; or I am on medication that suppresses my immune system. n I had an organ or bone marrow transplant. n I had my spleen removed, had or will have a cochlear implant, or have leaking spinal fluid. n I live in a nursing home or other long-term care facility, and I have never had a pneumococcal shot. Tetanus-, diphtheria-, and pertussis (whooping cough)-containing vaccination (e.g., DTP, DTaP, Tdap, or Td) n I either never received a dose of Tdap vaccine or I don t remember if I have. n I have not yet received at least 3 tetanus- and diphtheria- containing shots. n I have received at least 3 tetanus- and diphtheria-containing shots in my lifetime, but I believe it s been 10 years or more since I received my last shot. n I am in my late second or third trimester of my pregnancy and haven t had a dose of Tdap vaccine during this pregnancy. Measles-Mumps-Rubella (MMR) vaccination n I was born in 1957 or later and either never received an MMR shot or I don t remember receiving a shot. n I am a woman thinking about a future pregnancy and do not know if I m immune to rubella. n I am a healthcare worker, and I have no laboratory evidence of immunity to measles, mumps, or rubella. I received 1 dose of MMR vaccine, but I don t remember receiving 2 doses. n I was born in 1957 or later. I received only 1 MMR shot, and I am in one of the following groups: n I am entering college or a post-high school educational institution. n I am planning to travel internationally. continued on page 2 immunization action coalition IAC immunize.org Technical content reviewed by the Centers for Disease Control and Prevention 1573 Selby Avenue Saint Paul, Minnesota Item #P4036 (1/13) 83

84 Do I Need Any Vaccines Today? (Page 2 of 3 Human papillomavirus (HPV) vaccination n I am a woman 26 or younger and haven t completed a 3-dose series of HPV shots. n I am a man 21 or younger and haven t completed a series of HPV shots. n I am a man 22 through 26 years. I haven t completed a 3-dose series of HPV shots, and I am in one of the following groups: I want to be protected from HPV. I have a weakened immune system as a result of infection (including HIV), disease, or medications. I have sex with men. n I am older than 26 and although I started the HPV series when I was younger, I never completed it. Hepatitis A vaccination n I want to be vaccinated to avoid getting hepatitis A and spreading it to others. n I was vaccinated with hepatitis A vaccine in the past. I either never received the second shot or don t remember if I received it. n I might have been exposed to the hepatitis A virus in the past 2 weeks. n I am in one of the following risk groups, and I haven t completed the 2-dose series of hepatitis A shots: I travel or plan to travel in countries where hepatitis A is common. 1, 2 I have (or will have) contact with an adopted child within the first 60 days of the child s arrival from a country where hepatitis A is common. 2 I am a man who has sex with men. I use street drugs. I have chronic liver disease. I have a clotting factor disorder. I work with HAV-infected primates or with HAV in a research laboratory setting. Hepatitis B vaccination n I want to be vaccinated to avoid getting hepatitis B and spreading it to others. n I am 18 or younger and haven t completed the series of hepatitis B shots. n I was vaccinated with hepatitis B vaccine in the past. I either never completed the full series or don t remember if I completed the series. n I am in one of the following risk groups. I either haven t completed the series of hepatitis B shots or don t remember if I completed the series: I am sexually active and am not in a long-term, mutually monogamous relationship. I am a man who has sex with men. I am an immigrant, or my parents are immigrants, from an area of the world where hepatitis B is common, so I need testing and may need vaccination. 3, 4 I live with or am a sex partner of a person with hepatitis B. I have been diagnosed with a sexually transmitted disease. I have been diagnosed with HIV. I inject street drugs. I have chronic liver disease. I am or will be on kidney dialysis. I have diabetes and I am younger than 60 years and/or receiving assisted glucose monitoring. I am a healthcare or public safety worker who is exposed to blood or other body fluids. I provide direct services to people with developmental disabilities. I travel or plan to travel outside the U.S. 1, 3 continued on page 3 84

85 Do I Need Any Vaccines Today? (Page 3 of 3 Chickenpox (varicella) vaccination n I was born in 1980 or later. I neither had chickenpox nor received the vaccine, or I don t remember if I had the disease or received the vaccine. n I was born before I am either a healthcare worker or foreign born, and I am not sure if I ve had chickenpox or not. n I received one dose of varicella vaccine in the past but never got a second shot. Meningococcal vaccination n I am 18 or younger and haven t received a meningococcal shot. n I am 21 or younger. I haven t had a meningococcal shot since my 16th birthday, and I am (or will be) in college, living in a residence hall. n I am traveling to an area of the world where meningococcal disease is common. 1 n I have sickle cell disease, or my spleen isn t working or has been removed, or I have a persistent complement component deficiency. n I am a microbiologist routinely exposed to isolates of Neisseria meningitidis. n I was vaccinated 5 or more years ago and continue to be at risk for meningococcal disease because I am in one of the risk groups listed above. Note: this does not apply to students whose only risk factor is attending college. Shingles (zoster) vaccination n I am 60 or older and haven t had a shingles shot. Note: Adults who travel may need additional vaccinations, such as polio or others. Talk to your healthcare provider. footnotes 1. Call your local travel clinic to find out if additional vaccines are recommended. 2. Countries where hepatitis A is common include all countries other than the U.S., Western Europe, Canada, Japan, Australia, and New Zealand. 3. Areas with high rates of hepatitis B include Africa, China, Korea, Southeast Asia including Indonesia and the Philippines, South and Western Pacific Islands, interior Amazon Basin, certain parts of the Caribbean (i.e., Haiti and the Dominican Republic), and the Middle East except Israel. Areas with moderate rates include 1. South Central and Southwest Asia, Israel, Japan, Eastern and Southern Europe, Russia, and most of Central and South America. 4. Most adults from moderate- or high-risk areas of the world do not know their hepatitis B status. All patients from these areas need hepatitis B blood tests to determine if they have been previously infected. The first hepatitis B shot can be given during the same visit as the blood tests but only after the blood is drawn. 85

86 Immunization & Pregnancy Vaccines help keep a pregnant woman and her growing family healthy. Vaccine Before pregnancy During pregnancy After pregnancy Type of Vaccine Route Hepatitis A Yes, if at risk Yes, if at risk Yes, if at risk Inactivated Hepatitis B Yes, if at risk Yes, if at risk Yes, if at risk Inactivated Human Papillomavirus (HPV) Yes, if 9 through 26 years of age No, under study Yes, if 9 through 26 years of age Inactivated Influenza TIV Yes Yes Yes Inactivated Influenza LAIV MMR Meningococcal: polysaccharide conjugate Pneumococcal Polysaccharide Tetanus/Diphtheria Td Yes, if less than 50 years of age and healthy; avoid conception for 4 weeks Yes, avoid conception for 4 weeks No No If indicated If indicated If indicated Yes, if less than 50 years of age and healthy; avoid conception for 4 weeks Yes, give immediately postpartum if susceptible to rubella Live Live Inactivated Inactivated If indicated If indicated If indicated Inactivated Yes, Tdap preferred Yes, Tdap preferred if 20 weeks gestational age or more, ID (18-64 years) Nasal spray SC SC or SC Yes, Tdap preferred Toxoid Tdap, one dose only Yes, preferred Yes, preferred Yes, preferred Toxoid/ inactivated Varicella Yes, avoid conception for 4 weeks No Yes, give immediately postpartum if susceptible Live SC For information on all vaccines, including travel vaccines, use this table with Get an answer to your specific question by ing cdcinfo@cdc.gov or calling 800-CDC-INFO ( ) English or Spanish National Center for Immunization and Respiratory Diseases Immunization Services Division CS226523B 10/

87 Vaccinations for Adults You re NEVER too old to get immunized! Getting immunized is a lifelong, life-protecting job. Don t leave your healthcare provider s office without making sure you ve had all the vaccinations you need. Age Vaccine Influenza years years 65 years & older You need a dose every fall (or winter) for your protection and for the protection of others around you. Pneumococcal polysaccharide (PPSV) You need 1 2 doses if you smoke cigarettes or if you have certain chronic medical conditions.* You need 1 dose at age 65 (or older) if you ve never been vaccinated. Tetanus, diphtheria, pertussis (whooping cough) (Td, Tdap) Hepatitis B (HepB) Hepatitis A (HepA) Human papillomavirus (HPV) Measles, mumps, rubella (MMR) Varicella (Chickenpox) Meningococcal Zoster (shingles) Be sure to get a 1-time dose of Tdap vaccine (the adult whooping cough vaccine) if you are younger than age 65 years, are 65+ and have contact with an infant, are a healthcare worker, are pregnant, or simply want to be protected from whooping cough. After that, you need a Td booster dose every 10 years. Consult your healthcare provider if you haven t had at least 3 tetanus- and diphtheria-containing shots sometime in your life or have a deep or dirty wound. You need this vaccine if you have a specific risk factor for hepatitis B virus infection* or you simply wish to be protected from this disease. The vaccine is given in 3 doses, usually over 6 months. You need this vaccine if you have a specific risk factor for hepatitis A virus infection* or you simply wish to be protected from this disease. The vaccine is usually given as 2 doses, 6 18 months apart. You need this vaccine if you are a woman age 26 years or younger or a man age 21 years or younger. Men age 22 through 26 years with a risk condition* also need vaccination. Any other man age 22 through 26 years may receive it too. The vaccine is given in 3 doses over 6 months. You need at least 1 dose of MMR if you were born in 1957 or later. You may also need a 2nd dose.* If you ve never had chickenpox or you were vaccinated but received only 1 dose, talk to your healthcare provider to find out if you need this vaccine.* If you are age years and a first-year college student living in a residence hall, or have one of several medical conditions*, you need to get vaccinated against meningococcal disease. You may also need additional booster doses.* If you are age 60 years or older, you should get this vaccine now. * Consult your healthcare provider to determine your level of risk for infection and your need for this vaccine. Do you travel outside the United States? If so, you may need additional vaccines. The Centers for Disease Control and Prevention (CDC) provides information to assist travelers and their healthcare providers in deciding the vaccines, medications, and other measures necessary to prevent illness and injury during international travel. Visit CDC s website at or call (800) CDC-INFO ([800] ). You may also consult a travel clinic or your healthcare provider. Technical content reviewed by the Centers for Disease Control and Prevention, February Item #P4030 (2/12) Immunization Action Coalition 1573 Selby Ave. St. Paul, MN (651)

88 Reliable Sources of Immunization Information: Where to go to find answers! Websites American Academy of Pediatrics (AAP) AAP s childhood immunization website contains information for both parents and clinicians. Centers for Disease Control and Prevention (CDC) The information on this website ranges from official vaccine recommendations for healthcare professionals to information for the general public about vaccines. vaccine information Every Child by Two (ECBT) and ECBT, founded by Rosalynn Carter and Betty Bumpers, has created these two websites. Each contains a broad array of educational materials and information about vaccines, their safety, vaccine research and science, vaccine misperceptions, and many other topics to help clinicians and parents. Immunization Action Coalition (IAC) and IAC is a nonprofit organization that promotes immunization for all people against vaccine-preventable diseases. These websites offer educational materials, photos, and video clips for parents, healthcare professionals, the media, and the general public. National Network for Immunization Information (NNii) NNii provides current, sciencebased, extensively reviewed information to healthcare professionals, the media, policy makers, and the public. U.S. Dept of Health and Human Services (HHS) Vaccines.gov is the federal gateway to information on vaccines and immunizations for infants, children, teenagers, adults, and seniors. Vaccine Education Center (VEC) The goal of the VEC at Children s Hospital of Philadelphia is to accurately communicate the facts about each childhood vaccine. VEC publishes a monthly vaccine e-newsletter for parents titled Parents PACK. For more information or to subscribe, visit Phone Numbers CDC INFO Contact Center A toll-free number for consumers and healthcare professionals who have questions about immunization and vaccine-preventable diseases. Call (800) CDC-INFO or (800) The Center operates 24/7 in English & Spanish. TTY: (888) Books for Parents Vaccines Vaccinating Your Child VACCINES: What you should know Baby 411, 4th edition By Denise Fields and Ari Brown, MD, Windsor Peak Press, Written by a Harvardtrained pediatrician (Brown) and the author of the best-selling Baby Bargains (Fields), this book is the ultimate compilation of frequently asked questions for baby s first year. It includes a special section on vaccines. To purchase, visit your local bookstore or Do Vaccines Cause That?! A Guide for Evaluating Vaccine Safety, 1st edition By Martin Myers, MD, and Diego Pineda, MS. Published by Immunizations for Public Health, Get straight, science-based answers to parents questions about the safety of vaccines. To purchase, visit your local bookstore or Parents Guide to Childhood Immunization, 2010 This 68-page booklet from CDC introduces parents to 14 childhood diseases and the 10 vaccines that can protect children from them. Parents can order a free booklet or print their own copy by visiting Plain Talk About Childhood Immunization, 6th edition Washington State Department of Health, et al., This 54- page booklet provides parents with accurate information about immunizations and the diseases they prevent, vaccine safety, and other topics of interest to the public. The publication, available in English and Spanish, can be downloaded at plain-talk-about-childhood-immunizations in either low resolution (for printing on office copiers) or high resolution (for professional printing). Vaccines and Your Child, Separating Fact from Fiction, 2011 By Paul Offit, MD, and Charlotte Moser, Columbia University Press, This book answers questions about the science and safety of modern vaccines. In straightforward prose, Offit and Moser explain how vaccines work, how they are made, and how they are tested. Most important, they separate the real risks of vaccines from feared but unfounded risks. To purchase, visit your local bookstore or Videos Vaccines and Your Baby and Vaccines: Separating Fact from Fear Available for a nominal charge in English and Spanish in DVD format, these videos answer many questions that new parents have. Ordering information is available at vaccine-education-center/familyorder.cfm or parents can watch the videos online at Technical content reviewed by the Centers for Disease Control and Prevention, May Item #P4012 (5/11) Immunization Action Coalition 1573 Selby Ave. St. Paul, MN (651)