Recommended Childhood and Adult Immunization Schedules - Minnesota, 2001

Transcription

1 MINNESOTA DEPARTMENT OF HEALTH D ISEASE C ONTROL N EWSLETTER Volume 29, Number 1 (pages 1-8) January/February 2001 Recommended Childhood and Adult Immunization Schedules - Minnesota, 2001 The Recommended Childhood Immunization Schedule, Minnesota, 2001 and a revised Recommended Adult Immunization Schedule appear on pages 3-6. These schedules reflect recommendations of national advisory bodies, such as the Advisory Committee on Immunization Practices (ACIP), the American Academy of Pediatrics (AAP), the American Academy of Family Physicians, and the American College of Physicians. The Minnesota Department of Health (MDH) Immunization Practices Task Force reviews the schedules and suggests modifications which are incorporated in the Minnesota schedules as appropriate for populations in this state. The childhood schedule is issued annually to incorporate changes as new vaccines are licensed, products change, and recommendations for their use are modified. Recommendations for adult immunization change less frequently; the 2001 adult schedule represents the first modification since Changes and/or modifications in the 2001 childhood schedule include: The addition of pneumococcal conjugate vaccine () for routine vaccination of infants 2-23 months of age and children months of age who are at moderate or high risk of infection; An alternate 2-dose hepatitis B schedule for adolescents. Presently, this applies only to the Merck product which is licensed for adolescents 11 up to 16 years of age as ml (10 µg, adult formulation) doses given at least 6 months apart. Adolescents who began a 3-dose series (0.5 ml dose) may not switch to the higher 1.0 ml, 2-dose schedule. Likewise, an adolescent who begins the 1.0 ml schedule but fails to receive the second dose before 16 years of age must finish on the 0.5 ml, 3-dose schedule. Because it will be difficult to know whether an adolescent is on a 2-dose or a 3- dose schedule, t documentation would default to the 3-dose series unless noted specifically as HBV 2-dose adolescent ; The number of doses needed in a mixed polio vaccine series (i.e., OPV/IPV) is clarified for catch-up scheduling. While a total of 3 doses completes a schedule for children who received their third dose after their fourth birthday in an all-ipv or all-opv sequence, 4 doses are indicated if that child received any combination of OPV and IPV. The Recommended Adult Immunization Schedule has been revised to include: Modification of the chart to separate vaccines that are routinely recommended for all persons in the age categories from those based on risk factors. As with the childhood schedule, this distinction is indicated by a broken line; The addition of recommendations for meningococcal vaccine which is indicated for adults with medical conditions and certain international travelers. In June 2000, the ACIP recommended that during routine medical care, physicians should inform college freshman (particularly those living in dormitories) of their slightly increased risk of disease and the benefits of vaccination; The addition of Lyme disease vaccine recommendations for persons who live, work, or play in areas where they have frequent or prolonged exposure to tick habitat. The chart on page 6 displays minimum intervals between doses. Consolidating immunization recommendations onto a 2-sided, 8½ inch by 11 inch placard is difficult. Recommendations of ACIP can be more than 50 pages, and some must be read in conjunction with supplemental recommendations published later. Since providers may not have time to carefully read these lengthy documents, we ve tried to succinctly present the t important rules to consider when administering a particular vaccine. However, please be aware of the following points: The chart(s) and guideline(s) must be read together. Refer to the complete ACIP statement for circumstances continued... Inside: Recommendations on Tuberculosis Screening of School Students in Minnesota... 2

2 beyond the guidance in the MDH schedule. Other resources include the AAP Red Book, the Minnesota Immunization Hotline (612/ or 800/ ), the Centers for Disease Control and Prevention (CDC) hotline (800/ ), and the vaccine manufacturers help-lines and package inserts. All clinics, hospitals, public health agencies, and health plans received a colored version of the schedules in February. To order colored copies of either immunization schedule, call the Minnesota Immunization Hotline or e- mail MDH at immunize@health.state.mn.us. Both schedules are accessible on our web site at immunize; scroll down to Schedules and Recommendations. New Vaccine Information Statements (VISs) Available Camera-ready copies of current versions of the federally required VISs for (dated 7/18/00-interim) and hepatitis B vaccine (dated 8/9/00- interim) were mailed to providers in February. These VISs, and one for DTaP, are being revised with final publication expected in the early part of this year. Use of the VIS and VISs for all other vaccines governed by the National Childhood Vaccine Injury Act is mandatory for all providers. The final versions and other VISs will be available on the MDH web site ( the CDC web site ( publications/vis/), or by calling the Minnesota Immunization Hotline. Translations of t of the VISs also are available in 23 languages on the MDH web site. Optional VISs for anthrax and meningococcal vaccines also have been developed by CDC within the past year and are available on the CDC web site. Recommendations on Tuberculosis Screening of School Students in Minnesota Background The practice of screening students for tuberculosis (TB) using Mantoux tuberculin skin testing originated in the 1950s after isoniazid became available to prevent the development of active TB disease in infected persons. Such screening initially was practiced alt universally nationwide but was discontinued in many areas as the incidence of TB fell dramatically in subsequent decades. Due to changing epidemiologic factors and deteriorating infrastructure for TB prevention and control activities, a resurgence of TB occurred in the United States during the mid-1980s and early 1990s. In 1994, national guidelines recommended routine tuberculin skin testing of children at 1 year of age and periodic screening of high-risk children; these recommendations also suggested that decisions about population-based screening should be based on the local epidemiology of TB. With renewed TB prevention and control efforts, the incidence of TB in the U.S. has declined since In 1996, the American Academy of Pediatrics issued updated recommendations for TB screening targeted to high-risk children, including those born, or whose parents were born, in high-prevalence regions of the world. In Minnesota, TB screening of students was practiced widely until the 1970s, when such screening was discontinued as the prevalence of latent TB infection (LTBI) among students fell below 1% (0% in many schools). Subsequent to a resurgence of TB in the U.S. and Minnesota, school-based TB screening projects were conducted in the St. Paul Public Schools and the Minneapolis Public Schools during 1992 and 1993, involving 7,596 secondary school students and 752 eighth-graders, respectively. Foreign-born students were more likely to have LTBI than those born in the U.S. In both studies, 1% of students born in the U.S. had reactive Mantoux tests. Among foreignborn students, 16% of St. Paul students and 14% of Minneapolis students had reactive Mantoux tests. In contrast to the decreasing incidence of TB in many areas of the U.S., Minnesota is experiencing a different trend. In 1999, 201 cases of TB disease were reported statewide, which is the largest number of cases reported annually since Most notably, a large and increasing percentage of TB cases in Minnesota occur among foreign-born persons, growing from 50% in 1995 to 82% in Of 832 TB cases reported from 1996 to 2000, 107 (13%) were less than 19 years of age; 79 (74%) of these children were foreign-born. Data from targeted TB screening of newly arrived refugees indicate that 49% of those who arrived in Minnesota during 1999 and were screened for TB had LTBI. The changing epidemiology of TB in Minnesota reflects trends in the state s population demographics. In particular, the number of refugees and immigrants arriving from countries where TB is endemic has increased notably; accordingly, the number of foreign-born students in schools statewide also has increased. Recommendations of the Minnesota Department of Health (MDH) Due to the increasing incidence and changing epidemiology of TB in Minnesota, the MDH TB Prevention and Control Program has received questions from parents, school nurses, teachers, and others inquiring whether TB screening of students is indicated. In response to these concerns, MDH convened a multi-disciplinary workgroup consisting of school nurses; public health professionals; clinicians from public TB clinics, private health care facilities, and Student Health Services at post-secondary schools; and others. The purpose of this workgroup was to discuss whether the school setting may be an appropriate means to access high-risk populations for whom targeted TB screening is indicated and, if so, how such screening should be implemented. In collaboration with the workgroup, MDH developed the following guidelines regarding TB screening of students: Elementary/Secondary Schools: Universal TB screening (i.e., Mantoux tuberculin skin testing) of all students in school settings is not recommended. This is continued on page

3 Vaccine Recommended Childhood Immunization Schedule, Minnesota, 2001 **Chart must be used with guidelines below** z Hepatitis B 1 Age range of acceptable ages catch-up vaccination need for assessment Birth 1 mo Hepatitis B Hepatitis B - 2 Hepatitis B yrs yrs Hepatitis B 1 series yrs Diphtheria, Tetanus, Pertussis 2 Haemophilus influenzae type b 3 Polio 4 DTaP DTaP DTaP DTaP Td 2 DTaP 2 Hib Hib Hib 3 Hib 3 IPV IPV IPV 4 IPV Measles, Mumps, Rubella 5 MMR - 1 MMR-2 5 MMR-2 5 Varicella 6 Varicella Varicella Pneumococcal 7 Hepatitis A 8 Vaccines below line are for selected populations PPV Hepatitis A Influenza 9 Influenza (yearly) 1. Hepatitis B (HBV): Infants born to HBsAg-negative mothers should receive HBV- 1 by age 2. Give HBV-2 >4 wks after HBV-1 and HBV-3 >8 wks after HBV-2 (provided it is >4 since HBV-1 and infant is no younger than 6 of age). Infants born to HBsAg-positive mothers should receive 0.5 ml hepatitis B immune globulin (HBIG) within 12 hrs of birth, and HBV-1 at a separate site. HBV-2 is recommended at 1 mo of age and HBV-3 at 6 of age. Infants born to mothers whose HBsAg status is unknown should receive HBV-1 within 12 hours of birth. Maternal blood should be drawn at the time of delivery to determine the mother s HBsAg status; if the HBsAg test is positive, the infant should receive 0.5 ml of HBIG as soon as possible (no later than 1 wk of age). HBV-2 is recommended at 1 mo of age and HBV-3 at 6 of age. Children and adolescents who have not previously received all 3 doses of hepatitis B vaccine should complete the series with minimum intervals of 4 wks between HBV-1 and HBV-2, and 8 wks between HBV-2 and HBV-3 (and 4 between HBV-1 and HBV-3). Refer to vaccine package insert for alternate licensed 2-dose schedules for adolescents. 2. Diphtheria, tetanus, and acellular pertussis (DTaP): DTaP-4 may be given as early as 12 of age if at least 6 have passed since DTaP-3, and if the child is considered unlikely to return at of age. Td (tetanus and diphtheria toxoids, adsorbed, for adult use) is recommended at years of age if at least 5 yrs have passed since the last dose of DTP, DTaP, or DT. Subsequent routine Td boosters are recommended every 10 yrs. 3. Haemophilus influenzae type b (Hib): Three Hib conjugate vaccines are licensed for infant use. If PRP-OMP (PedvaxHIB or Comvax) is given at 2 and 4 of age, a dose at 6 is not required. DTaP/Hib combination products should not be used for the first 3 doses (primary series). Any Hib conjugate vaccine may be used as a booster. 4. Polio: A 4-dose schedule of inactivated polio vaccine (IPV) is recommended for routine vaccination of children. Oral poliovirus vaccine (OPV) is no longer available in the U.S. 5. Measles, mumps, rubella (MMR): MMR-2 is recommended at 4-6 yrs, but may be given during any visit, provided >4 wks have elapsed since MMR-1 and both doses are given >12 of age. 6. Varicella: Administer varicella vaccine to all susceptible children at of age. Unvaccinated children >18 who lack a reliable history of chickenpox should also be vaccinated. Children <12 yrs should receive 1 dose; those >13 yrs should receive 2 doses 4-8 wks apart. 7. Pneumococcal: Administer pneumococcal conjugate vaccine () to all healthy children <24 of age and others <60 with high risk conditions (SCD; asplenia; HIV infection; chronic cardiac, pulmonary or renal disease; CSF leaks; on immunosuppressive or radiation therapy; transplantation; diabetes mellitus). Consider giving to children at moderate risk (all children 24-35, those who are attending out-of-home child care, or are of Native American or African American descent). Give pneumococcal polysaccharide vaccine (PPV), in addition to, to children >2 yrs of age at increased risk of acquiring systemic pneumococcal infections or increased risk of serious disease if they become infected. The minimum interval between and PPV is 8 wks. Give a 2nd dose of PPV to children at highest risk of serious pneumococcal infection, as defined by ACIP*. For those <10 yrs of age, give 2nd dose >3 yrs from 1st PPV; for those >10 yrs of age, give 2nd dose >5 yrs from 1st PPV. 8. Hepatitis A: Give hepatitis A vaccine to children and adolescents who are at increased risk of infection, as defined by ACIP*, and consider for all others >2 yrs of age wishing to obtain immunity. Give a booster >6 after the initial dose. 9. Influenza: Administer influenza vaccine annually to children >6 of age who have specific risk factors, as defined by ACIP*, and consider for all others wishing to obtain immunity. Children <12 yrs should receive split virus vaccine in a dosage appropriate for their age (0.25 ml if 6-35 of age or 0.5 ml if >3 yrs). Children <9 yrs of age who are receiving influenza vaccine for the first time should receive 2 doses separated by at least 4 wks. Based on recommendations of the Advisory Committee on Immunization Practices (ACIP), the American Academy of Pediatrics (AAP), and the American Academy of Family Physicians (AAFP), and endorsed by the Immunization Practices Task Force of the Minnesota Department of Health (MDH). *Questions or need current ACIP recommendations? Web site: Call the Minnesota Immunization Hotline at (612) or toll-free (800) Minnesota Department of Health, January 2001 IC#

4 For Children Who Start Late or Who Are >1 Month Behind For any vaccine given in a series, it is not necessary to start over. Refer to the tables below for recommended catch-up schedule and minimum intervals between doses. Determine the number of previous doses of each vaccine received, find that number in the first column, and read across to the appropriate column for the next dose(s) and minimum interval(s). Table 1. Catch-up schedule for children 4 months through 6 years - must be used with guidelines below Number of previous doses of each vaccine Doses to be given and minimum intervals from previous dose First dose Second dose Third dose Fourth dose Fifth dose None One DTaP IPV HBV Hib 1 MMR 2 Varicella 3 1,4 DTaP: 4 weeks IPV: 4 weeks HBV: 4 weeks Hib: 4 wks, if 1st dose given at <12 of age; 8 wks (as final dose) if 1st dose given at of age; no more are needed if 1st dose given >15 of age. MMR 2 : 4 weeks 4 : 4 wks, if 1st dose given at <12 of age & child is <24 of age; 8 wks (as final dose) if 1st dose given >12 of age or child is now of age. DTaP: 4 weeks IPV: 4 weeks HBV: 8 weeks, and 4 months after 1st dose. Hib: If current age <12, 4 wks after 2nd dose (exception: see #6 below). If current age 12 to <5 yrs & 2nd dose given either (a) <12 of age, give final dose 8 wks after 2nd dose or (b) >12 of age, no more are needed. 4 : 4 wks if child is <12 of age; 8 wks (as final dose) if child is >12 of age. DTaP: 6 months IPV 5 : 4 weeks Hib 6 : Only necessary for children age 12 months to <5 years who received 3 doses <12 months of age. 4 : 8 wks (as final dose) if 3rd dose given at <12 of age. DTaP 7 : 6 months Two Three Four Table 2. Catch-up schedule for children age 7 through 18 years - must be used with guidelines below Number of previous doses of each vaccine Doses to be given and minimum intervals from previous dose First dose Second dose Third dose Booster dose None One Two Three Td IPV 8 HBV MMR Varicella 3 Td: 4 weeks IPV: 4 weeks HBV: 4 weeks MMR: 4 weeks Varicella 3 : 4 weeks Td: IPV: 6 months 4 weeks HBV: 8 weeks, and 4 months after 1st dose. Td: 6 months if 3rd dose given <7 years of age and current age 7-10 years; 5 years if 3rd dose given <7 years and current age >11 years; 10 years if 3rd dose given >7 years IPV 5 1. Hib and/or : Vaccine is not generally recommended for children >5 years. 2. MMR: Do not administer MMR vaccine before 12 months of age. Administer 2nd dose of MMR routinely at 4-6 years or earlier, if desired. 3. Varicella: Do not administer varicella vaccine before 12 months of age. Give 2-dose series to all susceptible adolescents >13 years of age. 4. : Table 1 should be used in determining catch-up scheduling of children at high risk of infection, as defined in guideline #7 on reverse side, as well as healthy children <60 months who have begun, but not completed, a schedule of. Unvaccinated children months of age, at moderate risk of infection, as defined in guideline #7 on reverse side, need only one dose. Consider giving one dose to unvaccinated children months of age who are not at moderate or high risk of infection, yet wish to obtain immunity. 5. Polio: The 4th dose is not necessary in an all-ipv or all-opv schedule if the 3rd dose was given after the 4th birthday. If both OPV and IPV were given as part of the series, a total of 4 doses should be given, regardless of the child s current age. 6. Hib: If PRP-OMP was given for the first 2 doses, no more than 3 doses are needed, with the final dose given at months and at least 8 weeks after the previous dose. If a 3rd dose of HbOC or PRP-T is given >12 months of age, a 4th dose is not needed. 7. DTaP: The 5th dose is not necessary if the 4th dose was given after the 4th birthday. 8. Polio: Vaccine is not generally recommended for persons >18 years. Reporting Adverse Reactions Disease Reporting Report adverse reactions to vaccines through the federal Vaccine Adverse Event Reporting System. For information on reporting reactions following vaccines administered by private clinics, call the 24-hour national toll-free information line (800) Report reactions to vaccine administered in public clinics to the Minnesota Department of Health, (612) or toll-free (877) Report suspect cases of vaccine-preventable diseases to the local health department or to the Minnesota Department of Health, 717 Delaware Street S.E., P.O. Box 9441, Minneapolis, Minnesota , (612) or toll-free (877)

5 Recommended Adult Immunization Schedule **Chart must be used with guidelines below** Vaccine z Age years years years 65+ years Tetanus, Diphtheria 1 Measles, Mumps, Rubella 2 Vaccines below line are for selected populations Influenza 3 Pneumococcal 4 Hepatitis A 5 Hepatitis B 6 Lyme 7 Meningococcal 8 Varicella 9 Booster every 10 years 1-2 doses if born after 1956 Annually, if at risk or wishing immunity Annually 1-2 doses for those with risk factors 1-2 doses 2 doses for those at increased risk of HAV infection and others wishing immunity 3 doses for those with risk factors 3 doses for those with risk factors 1 or more doses for those with risk factors 2-dose series for selected groups 1. Tetanus and Diphtheria (Td): All adults should complete a 3-dose primary series of diphtheria and tetanus toxoids, with the first 2 doses given at least 4 weeks apart and the 3rd dose given 6-12 months after the 2nd. All adults for whom 10 years have elapsed since their primary series or since their last booster dose should receive a Td booster. 2. Measles, Mumps, Rubella: Adults born before 1957 are considered naturally immune. Adults born in 1957 or later should receive 1 dose of MMR vaccine. Some adults may need 2 doses given not less than 4 weeks apart, such as college students, those working in health care facilities, and international travelers. 3. Influenza: Administer influenza vaccine annually to all adults >50 years of age; residents of nursing homes and other long-term care facilities; younger adults with chronic cardiopulmonary disorders, chronic metabolic diseases (including diabetes), renal dysfunction, hemoglobinopathies, or immunosuppression; as well as to the household members, caregivers, and health care workers of the above. Other adults who wish to reduce their likelihood of becoming ill with influenza may also be vaccinated. 6. Hepatitis B: Adults at risk for HBV infection include: persons who may be exposed to blood or blood products in their work, clients and staff of institutions for the developmentally disabled, hemodialysis patients, recipients of factor VIII or IX concentrates, household or sexual contacts of persons identified as HBsAg-positive, persons who plan to travel or live in parts of the world where HBV infections are common, injecting drug users, sexually active hoexual or bisexual males, sexually active heterosexual persons with multiple partners or recent episode of an STD, inmates of long-term correctional facilities, and persons of Pacific Islander ethnicity or first generation immigrants/refugees from countries where HBV infection is of high/intermediate endemicity. Give a 3-dose series on a schedule of 0, 1, and 6 months. 7. Lyme: Consider giving Lyme disease vaccine to persons years who are at high risk for disease because they live, work, or play in areas that have infected deer ticks and have frequent or prolonged exposure to tick habitat from May through September. Give a 3-dose series on a schedule of 0, 1, and 12 months. Vaccinated persons should continue to practice personal preventive measures against ticks. 4. Pneumococcal: Give pneumococcal polysaccharide vaccine (PPV) to all adults >65 years and those <65 years with chronic cardiovascular disease, chronic pulmonary disease, diabetes mellitus, alcoholism, cirrhosis, CSF leaks, functional or anatomic asplenia, HIV infection, leukemia, lymphoma, Hodgkins disease, multiple myeloma, generalized malignancy, chronic renal failure, nephrotic syndrome, or if receiving immunosuppressive chemotherapy. Routine revaccination of immunocompetent persons previously vaccinated with 23-valent PPV is not recommended; however, revaccination is recommended if a person was vaccinated >5 years previously and either (1) was <65 when first vaccinated and is now >65 years or (2) is at highest risk for serious pneumococcal infection, as defined by ACIP,* or (3) is likely to have a rapid decline in pneumococcal antibody levels. 5. Hepatitis A: Give 2 doses of hepatitis A vaccine, 6-12 apart, to persons who are at increased risk for infection with hepatitis A virus (HAV) as well as to food handlers and others wishing to obtain immunity. Populations at increased risk include: persons traveling to or working in countries with high rates of HAV, men who have sex with men, persons who use street drugs, persons with chronic liver disease, persons who work with HAV-infected primates or with HAV in a research setting, and persons with clotting factor disorders. 8. Meningococcal: Give quadrivalent polysaccharide meningococcal vaccine (A/C/Y/W-135) to adults with terminal complement component deficiencies, those with anatomic or functional asplenia, and travelers to countries where meningococcal disease is epidemic (e.g., the meningitis belt of sub-saharan Africa) or to Mecca, Saudi Arabia, for the annual Hajj. Consider revaccination within 3-5 years for persons who continue to be at high risk of infection (e.g., persons remaining in areas where disease is epidemic). Providers may consider vaccination of college freshman who live in dormitories to reduce their slightly increased risk of disease. 9. Varicella: Administer varicella vaccine to susceptible persons who will have close contact with persons at high risk for serious complications (i.e., health care workers and family contacts of immunocompromised persons). Consider vaccinating susceptible persons who are at high risk of exposure, such as those with occupational risk (i.e., teachers of young children, day care workers, and residents and staff in institutional settings); college students; inmates and staff of correctional institutions; military personnel; non-pregnant women of childbearing age; and international travelers. Vaccination for adults consists of 2 doses given 4-8 weeks apart. Based on recommendations of the Advisory Committee on Immunization Practices (ACIP), the American College of Physicians, and endorsed by the Immunization Practices Task Force of the Minnesota Department of Health (MDH). *Questions or need current ACIP recommendations? Web site: Call the Minnesota Immunization Hotline at (612) or toll-free (800) Minnesota Department of Health, 2001 IC#

6 Catch-Up Schedule and Minimum Intervals for Adults For any vaccine given in a series, it is not necesary to start over. Refer to the table below for recommended catch-up schedule and minimum intervals between doses. Determine the number of previous doses of each vaccine received, find that number in the first column, and read across to the appropriate column for the next dose(s) and minimum interval(s). Number of previous doses of each vaccine Doses to be given and minimum intervals from previous dose for adults >19 years First dose Second dose Third dose Booster dose Td MMR Td: 4 weeks after 1st dose MMR: 4 weeks after 1st dose Td: 6 months after 2nd dose Td: 10 years after completion of the primary series or since last booster dose None Pneumococcal (PPV) Hepatitis A (HAV) PPV: 5 years after 1st dose for those who received 1st dose at <65 years or who are at highest risk for pneumococcal infection HAV: 6 months after 1st dose One Hepatitis B (HBV) Lyme disease (LYM) Varicella HBV: 4 weeks after 1st dose LYM: 4 weeks after 1st dose Varicella: 4 weeks after 1st dose HBV: 8 weeks after 2nd dose and 4 months after 1st dose LYM: 12 months after 1st dose Two Three Guidelines for Patients with an Incomplete or Non-existent Vaccine History This catch-up schedule must be used together with the guidelines printed on the reverse side. Use all opportunities to assess the vaccination status of adult patients. At age 50, give a Td (unless a dose has been given in the previous 10 years) and evaluate for risk factors for pneumococcal and other vaccine-preventable diseases. If patient has started a series (e.g., HBV) but not completed it, continue where he/she left off. Never restart a series of any vaccine (exception: oral typhoid vaccine in some situations). MMR and varicella vaccines can be given at the same visit. If not given simultaneously, they must be separated by at least 4 weeks. Patients do not need measles, mumps, and/or rubella vaccine if they were born before 1957, have lab evidence of immunity, or (for measles/mumps only) have physician-diagnosed disease history. Consider vaccinating women born before 1957 who may become pregnant and do not have lab evidence of immunity or physician-diagnosed disease. Reporting Adverse Reactions Report adverse reactions to vaccines through the federal Vaccine Adverse Event Reporting System. For information on reporting reactions following vaccines administered by private clinics, call the 24-hour national toll-free information line (800) Report reactions to vaccine administered in public clinics to the Minnesota Department of Health, (612) or toll-free (877) For adult patients who are refugees or immigrants, provide vaccinations as you would for any other adult patient. Translations of foreign vaccine terms and vaccine products can be found in the MDH Provider s Guide to Immunizations or on the MDH web site: Patients 18 years of age or older, including foreign-born adults, do not need polio vaccination unless they are traveling to a country where wild poliovirus still exists (see MDH Recommended Immunizations for International Travel). A mantoux test can be administered simultaneously with any live or inactivated vaccine. If the patient already received MMR, the mantoux test must be delayed for at least 4 weeks after the MMR; if the mantoux was applied first, MMR or any other vaccine can be given at any time. Count only vaccinations that are well documented (i.e., including month, year and, preferably, day of vaccination). If no documentation exists, assume the patient is unvaccinated. It is always better to vaccinate when in doubt, rather than miss an opportunity to provide protection. Disease Reporting Report suspect cases of vaccine-preventable diseases to the local health department or to the Minnesota Department of Health, 717 Delaware Street S.E., P.O. Box 9441, Minneapolis, Minnesota , (612) or toll-free (877)

7 consistent with national guidelines. Decisions to conduct screening should be based on an assessment of trends in the local epidemiology of TB and pertinent population demographics (e.g., immigration trends) in the community. The local public health department, in consultation with MDH, should assess the community s incidence and prevalence of TB, identify high-risk groups based on local epidemiology and population demographics, and ascertain convenient sites to access group(s) to which screening should be targeted (e.g., school, work site, homeless shelter, etc.). On an annual basis, MDH will provide local health agencies with an individualized summary of local epidemiologic TB data to assist in this assessment. Population-based screening for TB in community settings (including schools), when indicated, is primarily the responsibility of local public health departments. When the school setting is determined to be a convenient site to access a highrisk group, the local public health department should work with school nursing staff and school administrators to coordinate any school-based TB screening program. However, local public health agencies should be responsible for overseeing the screening program, ensuring linkages with essential clinical services and financial resources, and ensuring initiation and completion of therapy for LTBI, as indicated. Decisions regarding implementation of a school-based TB screening program should be made jointly by local public health professionals in collaboration with school nurses and school administrators. MDH also is available for consultation, as needed. A decision to conduct TB screening is a decision to treat LTBI, if identified. Targeted screening of persons at high risk for LTBI or TB disease must be accompanied by a plan for providing necessary follow-up. This plan must include resources for providing a follow-up chest x- ray, medical evaluation, treatment for LTBI or TB disease, and clinical monitoring during such treatment, as indicated. A plan to address each of these criteria should be developed before screening is initiated. Systematic program evaluation is an integral part of any TB screening program. Programmatic indicators that should be evaluated include the number of students with history of prior TB disease or LTBI, the number of tuberculin skin tests administered, the number of tests read and the result of each in millimeters of induration, and rates of initiation and completion of treatment for LTBI (including reasons for discontinuation among those who fail to complete therapy). These data should be reviewed periodically to determine the yield and effectiveness of the screening program. If a low prevalence of TB disease or LTBI or suboptimal rates of completion of therapy are identified, decisions to continue the screening program should be reevaluated. MDH is available for consultation on implementing a program evaluation system and evaluating resulting data. Post-Secondary Schools: While the feasibility of targeted TB screening in elementary or secondary schools often may be limited by lack of resources, appropriate infrastructure, or access to health care services for students identified with LTBI or TB disease, the workgroup identified postsecondary schools (i.e., colleges, universities, vocational/technical schools) as a setting in which such screening is indicated and practical. For example, t post-secondary students are 18 years of age or older; data indicate that the prevalence of LTBI increases with age, and adults with pulmonary TB disease are more likely than young children to be infectious. Post-secondary school students often live in congregate settings which may facilitate transmission of TB. Also, post-secondary students typically have access to student health services, thereby enabling them to obtain medical evaluation and treatment, if indicated. Therefore, with support of the workgroup, MDH developed the following recommendation: In post-secondary schools, targeted tuberculin skin testing is recommended for all international students originating from (and other students traveling to) countries where TB is endemic. In this context, international students are defined as students who travel to the U.S. for the purpose of studying at the given post-secondary institution. In addition, all students whose studies involve extensive international travel to areas where TB is endemic also are candidates for tuberculin skin testing prior to travel and weeks following their return to the U.S. Screening programs targeted to highrisk post-secondary school students also should reflect the general MDH guidelines for TB screening of elementary and secondary school students (described above). For example, a targeted screening program should be accompanied by a plan for providing necessary medical evaluation, followup, and treatment for students identified with LTBI or TB disease. Postsecondary schools at which not all students have access to centralized health care services should consider and identify other means to ensure appropriate follow-up services prior to implementing a targeted TB screening program. Also, programmatic indicators should be evaluated routinely and systematically to assess the effectiveness of the screening program. These recommendations regarding TB screening of elementary, secondary, and post-secondary school students are general public health guidelines focused on decisions about populationbased screening in the school setting. They are not intended to be clinical guidelines for determining whether screening is indicated for a specific patient. As indicated by current national guidelines, clinicians should continued... 7

8 carefully assess each patient s individual risk factors for TB when making decisions about TB screening, evaluation, and treatment for a given patient. Related Resources With input from the workgroup, MDH developed several practical tools for use by school staff and/or public health professionals following the diagnosis of a case of infectious TB disease in the school setting. These tools include fact sheets, prototype letters addressed to parents/guardians of students at the school and those students for whom TB screening is recommended, and a letter to notify local clinics about a schoolbased contact investigation so providers can anticipate calls from parents. MDH recommendations regarding TB screening of students and related resources are available on the MDH TB Program s web site ( Also, upon request of the prescribing clinician, the MDH TB Program provides TB medications at no cost for persons in Minnesota receiving treatment for LTBI or TB disease. TB medications, copies of current recommendations, and additional information can be obtained by calling the MDH TB Program at (612) or (877) Jan K. Malcolm Commissioner of Health Division of Infectious Disease Prevention and Control Harry F. Hull, M.D.... Division Director & State Epidemiologist Richard N. Danila, Ph.D., M.P.H.... Acute Disease Epi. Section Manager Kirk Smith, D.V.M., Ph.D....Editor Wendy Mills, M.P.H.... Assistant Editor Sheril Arndt... Production Editor CHANGING YOUR ADDRESS? Please correct the address below and send it to: DCN MAILING LIST Minnesota Dept. of Health 717 Delaware Street SE Minneapolis, MN The Disease Control Newsletter is available on the MDH Acute Disease Epidemiology Section web site at The Disease Control Newsletter toll-free telephone number is