Volume 16 – Number 4 October 2012 (Content current VACCINATE ADULTS!as of October 16) from the Action Coalition — www.immunize.org

What’s In This Issue HPV : How Can We Do Better? HPV Vaccination: How Can We Do Better?...... 1 Recently released data on vaccination coverage of administered each time a clinician gave Tdap or teen girls and boys age 13–17 shows the rate of MCV4, coverage could jump to more than 80%.” Ask the Experts: CDC answers questions...... 1 HPV vaccination lags way behind rates of Tdap In a recent letter addressed to CDC grantees and Peek at the Redesign of IAC’s Website for the and meningococcal conjugate (MCV4) vaccina- partners, Dr. Anne Schuchat, director, CDC’s Na- Public, www.vaccineinformation.org...... 2 tion. Since 2006–07, when the Centers for Disease tional Center for Immunization and Respiratory Highlights: Recommendations, Control and Prevention (CDC) recommended the Diseases, outlines a call to action that involves schedules, and more...... 4 three for use in adolescents, coverage promoting HPV vaccination to physician audiences, IAC Welcomes Dr. William Atkinson as Associ- with Tdap and MCV4 has increased steadily. But immunization providers, and parents of preteen and ate Director for Immunization Education...... 5 HPV coverage has plateaued. Vaccination cover- teen girls and boys. To that end, CDC has developed age of teens in 2011 for the three vaccines follows: several new HPV resources, as have other respected Influenza Education Materials for Patients partner organizations. A selection of them follows. & Staff...... 6 • Coverage with 1 or more doses of Tdap vaccine was 78.2%. HPV Resources Screening for Contraindications...... 7 • Coverage with 1 or more doses of MCV4 was • CDC’s HPV web section: www.cdc.gov/hpv 70.5%. • 19-minute Medscape video, “HPV Vaccine: A Standing Orders for Administering • Coverage with 1 or more doses of HPV among Shot of Cancer Prevention,” Anne Schuchat, Influenza Vaccine to Adults...... 8 teenage girls was 53.0%, and coverage with 3 or MD; Lauri E. Markowitz, MD; Mona Saraiya, Standing Orders for Administering more doses was 34.8%. MD, MPH. Released: 08/10/2012; valid for Pneumococcal (PPSV23 and PCV13) credit through 08/10/2013: www.medscape.org/ Cervical Cancer Prevention Vaccine to Adults...... 9 viewarticle/768633 Annually in the United States, 12,000 new cases First Do No Harm: Mandatory Influenza of cervical cancer are diagnosed and 4000 cervi- • CDC parent education sheet: www.cdc.gov/ Vaccination Policies for Healthcare cal cancer deaths occur. HPV vaccine, which pre- vaccines/vpd-vac/hpv/downloads/dis-HPV- Personnel Help Protect Patients...... 10 vents that cause about 70% of cervical color-office.pdf Influenza Vaccine Products for 2012–2013...... 12 cancers, holds the prospect of being an incredible • IAC’s HPV web section: www.immunize.org/ Poster: No More Excuses: There Are Many cancer-prevention tool for an entire generation of resources/dis_hpv.asp Places to Get Your Flu Vaccine...... 13 women. Tragically, that prospect is not now being • IAC’s HPV video collection: www.immunize. org/votw/hpv-videos.asp New! Influenza Vaccination of People with a fully realized—but healthcare professionals have History of Egg ...... 14 the opportunity to turn the tide. • Four videos for parents on Children’s Hospital An article in the September 2012 issue of AAP of Philadelphia’s HPV web section: www.chop. Poster: Protect Your Baby from Serious Diseases....16 News states that a “pediatrician’s strong recom- edu/service/vaccine-education-center/prevent- New! Cocooning Protects Babies...... 17 mendation is the key to helping parents with hpv/index.html IAC’s Immunization Resources Order Form...... 18 their decision” to vaccinate their child with HPV • Heather’s story: www.youtube.com/user/ vaccine and that “if a dose of HPV vaccine were immunizationaction

Ask the Influenza vaccine What is the latest CDC guidance on influenza FEDERAL and Experts vaccination and egg allergy? MILITARY People who have experienced a serious systemic IAC extends thanks to our experts, medical epi- or anaphylactic reaction (e.g., hives, swelling of EMPLOYEES demiologist Andrew T. Kroger, MD, MPH; nurse the lips or tongue, acute respiratory distress, or educator Donna L. Weaver, RN, MN; and medical collapse) after eating eggs should consult a special- Make the officer Iyabode Akinsanya-Beysolow, MD, MPH. ist for appropriate evaluation to help determine if Immunization Action Coalition All are with the National Center for Immunization vaccine should be administered. and Respiratory Diseases, Centers for Disease your charity of choice for the A previous severe allergic reaction to influenza Control and Prevention (CDC). vaccine, regardless of the component suspected to Combined Federal Campaign. be responsible for the reaction, is a contraindication Use agency code to future receipt of the vaccine. Immunization questions? People who have documented immunoglobulin E #10612 (IgE)-mediated hypersensitivity to eggs, including The Immunization Action Coalition • Call the CDC-INFO Contact Center at those who have had occupational asthma or other (800) 232-4636 or (800) CDC-INFO allergic responses to egg protein, might also be at is a 501(c)(3) charitable organization • Email [email protected] increased risk for allergic reactions to influenza and your contribution is tax-deductible • Call your state health dept. (phone numbers vaccine. Protocols have been published for safely to the fullest extent of the law. at www.immunize.org/coordinators) administering influenza vaccine to people with (continued on page 5) Vaccinate Adults! Peek at the Redesign of IAC’s Website for the online at www.immunize.org/va Immunization Action Coalition Public, www.vaccineinformation.org! 1573 Selby Avenue, Suite 234 St. Paul, MN 55104 Phone: (651) 647-9009 Before the end of 2012, the Immunization Action • Resources Fax: (651) 647-9131 Coalition (IAC) will be launching a major redesign of Frequently updated listing of helpful resources for Email: [email protected] its website for the public, www.vaccineinformation.org. Websites: www.immunize.org people in all age groups who seek information about www.vaccineinformation.org Offering information about vaccination for the entire vaccines www.izcoalitions.org lifespan, the newly designed website will be organized Vaccinate Adults is a publication of the by age group—Infants & Children, Preteens, Teens, and • Vaccine-Preventable Diseases Immunization Action Coalition (IAC) writ- Adults. It will offer your patients accurate information ten for health professionals. Content is re- Information and resources for all vaccine-preventable and valuable resources from trusted organizations. viewed by the Centers for Disease Control­ diseases, including those associated with internation- and Prevention (CDC) for technical accuracy. This publication is supported by CDC Grant SNEAK PEEK AT THE CONTENT al travel No. U38IP000589. The content is solely the responsibility of IAC and does not neces- • Schedules • The Basics sarily represent the official views of CDC. ISSN 1526-1824. Detailed information about the immunization sched- Basic and helpful information on vaccines, ranging from “How to Pay for Vaccines” to “How Vaccines Publication Staff ules broken down by age group— infants and chil- Editor: Deborah L. Wexler, MD dren, preteens, teens, and adults Work” Associate Editor: Diane C. Peterson IAC will announce the launch of the redesigned vac- Managing Editor: Dale Thompson, MA cineinformation.org, in IAC Express, our free weekly Edit./Opr. Asst.: Janelle T. Anderson, MA • Personal Testimonies Consultants: Teresa A. Anderson, DDS, MPH Stories of suffering and loss from vaccine-preventable email news service. If you would like to start receiv- Linda A. Moyer, RN, and Mary Quirk diseases ing weekly email announcements about important Layout: Kathy Cohen developments related to immunization, as well as the Website Design: Sarah Joy • Videos future notification of the redesign launch, we urge you IAC Staff to complete the sign-up form at www.immunize.org/ Assoc. Director for Immunization Education: Collection of hundreds of videos and public service subscribe. William L. Atkinson, MD, MPH announcements about vaccine-preventable diseases Associate Director for Research: Sharon G. Humiston, MD, MPH and the importance of vaccination Coordinator for Public Health: Laurel Wood, MPA Asst. to the Director: Julie Murphy, MA Operations Manager: Robin VanOss Associate Operations Manager: Casey Pauly IAC publishes a free email news ser- vice (IAC Express) and two free periodi- cals (Needle Tips and Vaccinate Adults). To subscribe to any or all of them, go to www.immunize.org/subscribe. IAC, a 501(c)(3) charitable organization, pub- lishes practical immunization information for health professionals to help increase immuniza- tion rates and prevent disease. The Immunization Action Coalition is also supported by Merck Sharp & Dohme Corp. GlaxoSmithKline • Novartis Vaccines sanofi pasteur • Pfizer Inc. MedImmune, Inc. • CSL Biotherapies Ortho Clinical Diagnostics, Inc. American Pharmacists Association Mark and Muriel Wexler Foundation Anonymous Many other generous donors IAC maintains strict editorial independence in its publications. IAC Board of Directors Stephanie L. Jakim, MD Olmsted Medical Center James P. McCord, MD Children’s Hospital at Legacy Emanuel DISCLAIMER: Vaccinate Adults! is available to all readers free of charge. Some of the information in this issue is supplied to us by the Sheila M. Specker, MD Centers for Disease Control and Prevention in Atlanta, Georgia, and some information is supplied by third-party sources. The Immuniza- University of Minnesota tion Action Coalition (IAC) has used its best efforts to accurately publish all of this information, but IAC cannot guarantee that the original Debra A. Strodthoff, MD information as supplied by others is correct or complete, or that it has been accurately published. Some of the information in this issue is Amery Regional Medical Center created or compiled by IAC. All of the information in this issue is of a time-critical nature, and we cannot guarantee that some of the in- formation is not now outdated, inaccurate, or incomplete. IAC cannot guarantee that reliance on the information in this issue will cause no Deborah L. Wexler, MD injury. Before you rely on the information in this issue, you should first independently verify its current accuracy and completeness. IAC is Immunization Action Coalition not licensed to practice medicine or pharmacology, and the providing of the information in this issue does not constitute such practice. Any claim against IAC must be submitted to binding arbitration under the auspices of the American Arbitration Association in St. Paul, Minnesota.

2 Vaccinate Adults! • October 2012 • Immunization Action Coalition • (651) 647-9009 • www.immunize.org • www.vaccineinformation.org Advisory Board Wallet-sized immunization record cards for all ages: Liaisons from Organizations Bernadette A. Albanese, MD, MPH For adults, children & teens, and for a lifetime! Council of State & Territorial Epidemiologists Stephen L. Cochi, MD, MPH Now you can give any patient a permanent vaccination record Nat’l Ctr. for Immun. & Resp. Diseases, CDC card designed specifically for their age group: adult, child & teen, or Paul Etkind, DrPH, MPH Nat’l. Assn. of County & City Health Officials lifetime. These brightly colored cards are printed on durable rip-, Stanley A. Gall, MD smudge-, and water-proof paper. To view the cards or for more Amer. College of Obstetricians & Gynecologists Bruce Gellin, MD, MPH details, go to www.immunize.org/shop and click on the images. National Vaccine Program Office, DHHS Neal A. Halsey, MD Buy 1 box (250 cards) for $45 (first order of a 250-card box comes Institute for Vaccine Safety, Johns Hopkins Univ. Claire Hannan, MPH with a 30-day, money-back guarantee). Discounts for larger orders: Association of Immunization Managers 2 boxes $40 each; 3 boxes $37.50 each; 4 boxes $34.50 each Carol E. Hayes, CNM, MN, MPH American College of Nurse-Midwives To order, visit www.immunize.org/shop, or use the order form on page 18. Gregory James, DO, MPH, FACOFP American Osteopathic Association To receive sample cards, contact us: [email protected] Samuel L. Katz, MD Pediatric Infectious Diseases Society Elyse Olshen Kharbanda, MD, MPH Society for Adolescent Health and Medicine Marie-Michele Leger, MPH, PA-C American Academy of Physician Assistants Harold S. Margolis, MD "Immunization Techniques — Best Practices Nat’l Ctr. for Emerg. & Zoonotic Inf. Diseases, CDC Martin G. Myers, MD National Network for Immunization Information with Infants, Children, and Adults" Kathleen M. Neuzil, MD, MPH American College of Physicians The California Department of Public Health, Immunization Branch, Paul A. Offit, MD Vaccine Education Ctr., Children’s Hosp. of Phila. updated its award-winning training video, “Immunization Tech- Walter A. Orenstein, MD niques: Best Practices with Infants, Children, and Adults.” The Emory Vaccine Center, Emory University Mitchel C. Rothholz, RPh, MBA 25-minute DVD can be used to train new employees and to American Pharmacists Association Thomas N. Saari, MD refresh the skills of experienced staff on administering injectable, American Academy of Pediatrics oral, and nasal-spray vaccines to children, teens, and adults. William Schaffner, MD Infectious Diseases Society of America Make sure your healthcare setting has the 2010 edition! Anne Schuchat, MD Nat’l Ctr. for Immun. & Resp. Diseases, CDC The cost is $17 each for 1–9 copies; $10.25 each for 10–24 Thomas E. Stenvig, RN, PhD American Nurses Association copies; $7 each for 25–49 copies; $5.75 each for 50–99 copies. Kathryn L. Talkington, MPAff Assn. of State & Territorial Health Officials Litjen Tan, PhD To order, visit www.immunize.org/shop, or use the order form on page 18. American Medical Association For 100 or more copies, contact us for discount pricing: [email protected] Ann S. Taub, MA, CPNP National Assn. of Pediatric Nurse Practitioners For healthcare settings in California, contact your local health department immunization program for a free copy. John W. Ward, MD Division of Viral Hepatitis, NCHHSTP, CDC Patricia N. Whitley-Williams, MD, MPH National Medical Association Walter W. Williams, MD, MPH Nat’l Ctr. for Immun. & Resp. Diseases, CDC

2012! Laminated adult and child immunization schedules Individuals Hie-Won L. Hann, MD Order one of each for every exam room Jefferson Medical College, Philadelphia, PA Mark A. Kane, MD, MPH Here are the ACIP/AAFP/ACP/ACOG/ACNM-approved Consultant, Seattle, WA Edgar K. Marcuse, MD, MPH schedule for adults and the ACIP/AAP/AAFP-approved University of Washington School of Medicine immunization schedule for people ages 0 through 18 years. Brian J. McMahon, MD Alaska Native Medical Center, Anchorage, AK Both are laminated and washable for heavy-duty use, Stanley A. Plotkin, MD Vaxconsult.com complete with essential footnotes, and printed in color for Gregory A. Poland, MD easy reading. The cost is $7.50 for each schedule and only Mayo Clinic, Rochester, MN Sarah Jane Schwarzenberg, MD $5.50 each for five or more copies. University of Minnesota Coleman I. Smith, MD To order, visit www.immunize.org/shop, or use the order form on page 18. Minnesota Gastroenterology, Minneapolis, MN Richard K. Zimmerman, MD, MPH For 20 or more copies, contact us for discount pricing: [email protected] University of Pittsburgh

Vaccinate Adults! • October 2012 • Immunization Action Coalition • (651) 647-9009 • www.immunize.org • www.vaccineinformation.org Vaccinate Adults! • October 2012 • Immunization Action Coalition • (651) 647-9009 • www.immunize.org • www.vaccineinformation.org 3 Vaccine Highlights Recommendations, schedules, and more Subscribe to IAC Express! www.immunize.org/subscribe Editor's note: The information in Vaccine High- Adults with the conditions specified below who lights is current as of October 16, 2012. are eligible for should be Get weekly vaccinated with 13-valent pneumococcal conjugate The next ACIP meetings vaccine (PCV13; Prevnar 13; Pfizer) during their updates next pneumococcal vaccination opportunity. A committee of 15 national experts, the Advisory on vaccine Committee on Immunization Practices (ACIP) For pneumococcal vaccine-naïve people advises CDC on the appropriate use of vaccines. ACIP recommends that adults age 19 years and information ACIP meets three times a year in Atlanta; meet- older with immunocompromising conditions, ings are open to the public. The next two meetings functional or anatomic asplenia, CSF leaks, or co- while it’s will be held on Oct. 24–25, 2012, and Feb. 20–21, chlear implants, who have not previously received 2013. For more information, visit www.cdc.gov/ PCV13 or 23-valent pneumococcal polysaccha- still news! vaccines/acip/index.html. ride vaccine (PPSV23; Pneumovax 23; Merck), ACIP periodically issues recommendations on the receive a dose of PCV13 first, followed by a dose All the news we publish in use of vaccines. Clinicians who vaccinate should have of PPSV23 at least 8 weeks later. Subsequent “Vaccine Highlights” will be a current set for reference. Published in the Morbidity doses of PPSV23 should follow current PPSV23 and Mortality Weekly Report (MMWR), ACIP recom- recommendations for adults at high risk. Specifi- sent by email to you mendations are easily available. Here are sources: cally, a second PPSV23 dose is recommended 5 every Tuesday. Free! • Download them from links on IAC’s website: years after the first PPSV23 dose for adults age To sign up, visit www.immunize.org/acip. 19 through 64 years with functional or anatomic • Download them from CDC’s website: www. cdc. asplenia and for people with immunocompromis- www.immunize.org/subscribe gov/vaccines/pubs/acip-list.htm. ing conditions. Additionally, those who received PPSV23 before age 65 years for any indication At the same time, you’ll be able Influenza vaccine news should receive another dose of the vaccine at age 65 years, or later if at least 5 years have elapsed to sign up to receive other On August 17, CDC published ACIP’s 2012 influ- since their previous PPSV23 dose. free IAC publications! enza recommendations, “Prevention and Control of Influenza with Vaccines—United States, 2012–13 For people previously vaccinated with PPSV23 Influenza Season.” The recommendations discuss Adults age 19 years and older with immunocom- the for children age 6 months promising conditions, functional or anatomic as- New and updated VISs through 8 years; febrile seizures associated with plenia, CSF leaks, or cochlear implants, who pre- administration of influenza and 13-valent pneu- viously have received 1 or more doses of PPSV23 The use of most Vaccine Information mococcal conjugate (PCV-13) vaccines; and vac- should be given a PCV13 dose 1 or more years af- Statements (VISs) is mandated by federal law. cination recommendations for people with a history ter the last PPSV23 dose was received. For those Listed below are the dates of the most current of egg allergy. For a copy, see pages 613–618 of who require additional doses of PPSV23, the first VISs. Check your stock of VISs against this www.cdc.gov/mmwr/pdf/wk/mm6132.pdf. such dose should be given no sooner than 8 weeks list. If you have outdated VISs, print current after PCV13 and at least 5 years after the most ones from IAC’s website at www.immunize. On August 3, CDC’s Health Alert Network recent dose of PPSV23. org/vis. You’ll find VISs in more than (HAN) issued an official CDC Health Advisory 30 languages. titled “Increase in Influenza A H3N2v In- To access the CDC recommendations, see pages DTaP/DT/DTP..... 5/17/07 MMRV...... 5/21/10 fections in Three U.S. States.” The HAN docu- 816–819 of MMWR at www.cdc.gov/mmwr/pdf/ Hepatitis A...... 10/25/11 PCV13...... 4/16/10 ment reports between July 12 and August 3, 2012, wk/mm6140.pdf. Or for the web text version, Hepatitis B ...... 2/2/12 PPSV ...... 10/6/09 16 cases of H3N2v were reported and confirmed go to www.cdc.gov/mmwr/preview/mmwrhtml/ Hib ...... 12/16/98 Polio ...... 11/8/11 by CDC. Each of the 16 cases involved contact mm6140a4.htm. with swine prior to illness onset. The advisory HPV ()...... 5/3/11 Rabies ...... 10/6/09 includes interim recommendations for the public HPV ().....2/22/12 Rotavirus...... 12/6/10 and healthcare providers, and access to resources. Vaccine coverage 2011–2012 Influenza (LAIV)...... 7/2/12 Shingles...... 10/6/09 To access the HAN document, go to www.bt.cdc. On Aug. 31, CDC published “National and State Influenza (TIV)...... 7/2/12 Td/Tdap ...... 1/24/12 gov/HAN/han00325.asp. Vaccination Coverage Among Adolescents Aged Japan. enceph...12/7/11 Typhoid...... 5/29/12 13–17 Years—United States, 2011.” The National Meningococcal. 10/14/11 Varicella ...... 3/13/08 Immunization Survey-Teen (NIS-Teen) provides MMR...... 4/20/12 Yellow fever ..... 3/30/11 Pneumococcal vaccine news vaccination coverage estimates for teens age 13–17 Multi-vaccine VIS ...... 9/18/08 On Oct. 12, CDC published ACIP recommen- years in the 50 states, District of Columbia, seven (for 6 vaccines given to infants/children: DTaP, IPV, Hib, HepB, PCV, RV) dations titled “Use of 13-Valent Pneumococcal selected local areas, and U.S. Virgin Islands. Ac- cess NIS-Teen on pages 671–677 of www.cdc.gov/  and 23-Valent Pneumococcal For a ready-to-print version of this table for posting mmwr/pdf/wk/mm6134.pdf or go to www.cdc.gov/ Polysaccharide Vaccine for Adults with Immuno- in your practice, go to www.immunize.org/catg.d/ compromising Conditions.” The recommendations mmwr/preview/mmwrhtml/mm6134a3.htm. p2029.pdf. follow:

4 Vaccinate Adults! • October 2012 • Immunization Action Coalition • (651) 647-9009 • www.immunize.org • www.vaccineinformation.org Ask the Experts . . . continued from page 1

egg . haven’t had a one-time dose of Tdap yet? personnel includes (1) documentation of 2 doses Some people who report allergy to egg might not Yes. Exposure to a person with pertussis is not a of given at least 28 days apart, be egg allergic. If a person can eat lightly cooked reason to avoid Tdap vaccination. All adolescents (2) history of varicella or herpes zoster based on eggs (e.g., scrambled eggs), they are unlikely to and adults who haven’t had a one-time dose of physician diagnosis, (3) laboratory evidence of im- have an egg allergy. However, people who can Tdap should receive a dose as soon as possible. munity, or (4) laboratory confirmation of disease. If tolerate egg in baked products (e.g., cake) might Should a person who received 2 doses of a healthcare employee has already received a dose still have an egg allergy. If the person develops varicella vaccine be vaccinated with zoster of but has no evidence of hives only after ingesting eggs, CDC recommends vaccine when they turn 60? to varicella, the zoster dose can be considered the (1) they receive TIV (not LAIV), (2) the vaccine No. CDC does not currently recommend zoster first dose of the 2-dose varicella series. be administered by a healthcare provider familiar vaccine for people who received 2 doses of vari- I work in employee health. Several hospi- with the potential manifestations of egg allergy, cella vaccine. However, healthcare providers do tal employees have told me they have had and (3) the vaccine recipient be observed for at not need to inquire about varicella vaccination (continued on page 15) least 30 minutes after receipt of the vaccine for history before administering zoster vaccine be- signs of a reaction. cause virtually all people currently or soon to be For more details about giving influenza vaccine in the recommended age group have not received Stay current with FREE subscriptions to people with a history of egg allergy, see “In- varicella vaccine. For details, see page 19 of the fluenza Vaccination of People with a History of CDC recommendations Prevention of Herpes The Immunization Action Coalition’s Egg Allergy” on page 14 of this issue of Vaccinate Zoster available at www.cdc.gov/mmwr/PDF/rr/ 2 periodicals, Vaccinate Adults and Adults or visit www.immunize.org/catg.d/p3094. rr5705.pdf. Needle Tips, and our email news pdf. You can also consult pages 616–617 of “Pre- service, IAC Express, are packed Can we accept receipt of a single documented with up-to-date information. vention and Control of Influenza with Vaccines: dose of zoster vaccine as proof of varicella Recommendations of the ACIP—U.S., 2012–13 immunity in a healthcare employee who has Subscribe to all 3 free publications in Influenza Season” at www.cdc.gov/mmwr/pdf/wk/ no other evidence of immunity? one place. It’s simple! Go to mm6132.pdf. No. Receipt of zoster vaccine is not proof of prior www.immunize.org/subscribe Which formulations of influenza vaccines (i.e., varicella disease. According to CDC, acceptable nasal spray, intradermal, injectable high-dose, evidence of varicella immunity in healthcare and injectable standard-dose) are recommend- ed for various age groups? Six manufacturers are producing influenza vac- cines for the U.S. market for the 2012–13 season. IAC Welcomes Dr. William Atkinson as Associate Page 12 of this issue of Vaccinate Adults has a table titled “Influenza Vaccine Products for the Director for Immunization Education 2012–2013 Influenza Season.” It summarizes the vaccine products and age groups for which they William L. Atkinson, MD, Prevention of Vaccine-Preventable Diseases (aka are licensed. MPH, recently joined the the Pink Book). The book is now in its twelfth Immunization Action Co- edition, and more than 400,000 copies have been In recommending influenza vaccination for alition as associate director distributed. He is the author or coauthor of 52 pub- people age 65 and older, does CDC prefer that lications and book chapters primarily relating to healthcare professionals administer high-dose for immunization educa- influenza vaccine or standard-dose influenza tion. In July, Dr. Atkinson measles and other vaccine-preventable diseases. vaccine? retired from the Centers for He contributed to several editions of the American William L. Atkinson, Academy of Pediatrics Red Book and to Vaccines, CDC has no preference. CDC stresses that vac- Disease Control and Preven- MD, MPH cination is the first and most important step in tion (CDC) after 25 years of the highly regarded textbook edited by Stanley A. protecting against influenza. service. At the time of his retirement, he was Plotkin, MD, Walter A. Orenstein, MD, and Paul medical epidemiologist and training team lead, A. Offit, MD. If a patient received a dose of influenza vac- Immunization Services Division, National Cen- Since 1989, he has been a member of multiple cine in June (e.g., for international travel), how work groups for the Advisory Committee on Im- long should the patient wait before getting ter for Immunization and Respiratory Diseases vaccinated with the next season’s flu vaccine? (NCIRD), a position he held for 17 years. In munization Practices (ACIP), and is currently a There should be a minimum of 4 weeks between that role, he pioneered the use of satellite and member of work groups responsible for developing the doses in such situations. broadcast technology to bring immunization ed- CDC’s harmonized child and adolescent immuniza- ucation to thousands of immunization providers tion schedule, general immunization recommen- Other vaccines simultaneously. During his tenure at CDC, he dations, meningococcal recommendations, and produced, wrote, and/or appeared in more than pertussis recommendations. Can adolescents and adults who have been 100 broadcasts and webcasts that were viewed Dr. Atkinson was the first recipient of CDC’s exposed to pertussis be vaccinated if they by more than 300,000 healthcare providers. He highest immunization honor, the Phil Horne Award. also gave more than 600 invited lectures and He was also the 2001 recipient of the Bill Watson taught more than 100 two-day training courses Medal of Excellence, the highest award given to a Vaccinate Adults correction policy across the United States, addressing more than CDC employee, and the 2003 Excellence in Dis- If you find an error, please notify us immediately by 150,000 attendees. tance Training Award of the United States Distance sending an email message to [email protected]. Dr. Atkinson’s skill as a communicator is not Learning Association. He was a recipient of the We publish notification of significant errors in IAC Superhero Award in 2001. our email announcement service, IAC Express. limited to his speaking prowess. He excels as a writer, as well. In 1995, he conceived, developed, Dr. Atkinson’s photograph has been added Be sure you’re signed up for this service. To to IAC’s staff web page at www.immunize.org/ subscribe, visit www.immunize.org/subscribe. and took the lead in writing one of CDC's most widely sought-after books, and aboutus/iacstaff.asp.

Vaccinate Adults! • October 2012 • Immunization Action Coalition • (651) 647-9009 • www.immunize.org • www.vaccineinformation.org 5 Influenza Education Materials for Patients & Staff Free and CDC-reviewed, they’re ready for you to download, copy, and use!

Patient name: Date of birth: (mo.) (day) (yr.) Declination of Influenza Vaccination Screening Checklist for Contraindications to My employer or affiliated health facility, ______, has recommended Inactivated Injectable Influenza Vaccination that I receive influenza vaccination to protect the patients I serve. INACTIVATED Patient name: Date of birth: I acknowledge that I am aware of the following facts: (mo.) (day) (yr.)  Influenza is a serious respiratory disease that kills thousands of people in the United States For adult patients as well as parents of children to be vaccinated: The following questions INFLUENZA each year. will help us determine if there is any reason we should not give you or your child inactivated injectable VACCINE Influenza vaccination is recommended for me and all other healthcare workers to protect Sinfluenzacreening vaccination Checklisttoday. If you answer for “yes” toContraindications any question, it does not necessarily tomean you (or  W H A Tthis Y facility’s O U patientsN E E from D influenza, T O K its Ncomplications, O W and death. your child) should not be vaccinated. It just means additional questions must be asked. If a question is 2011-12 Live Attenuated Intranasal Influenza Vaccination Many If IVaccine contract Information influenza, Statements I can are available shed the in Spanish virus and for other 24 languages.hours before See www.immunize.org/vis influenza symptoms appear. not clear, please ask your healthcare provider to explain it. Don’t LIVE, INTRANASALHojas de Informacián Sobre Vacunas están disponibles en español y en muchos otros idiomas. Visite www.immunize.org/vis Yes No Know My shedding the virus can spread influenza to patients in this facility. For use with people ages 2 through 49 years: The following questions will help us determine if there is Some inactivated infl uenza vaccine contains a preservative 1 Why get If Ivaccinated? become infected with influenza, I can spread severe illness to others even when my any reason we should not give you or your child live attenuated intranasal influenza vaccine (FluMist) today. If you  called thimerosal. Thimerosal-free infl uenza vaccine is    INFLUENZA symptoms are mild or non-existent. available. Ask your doctor for more information. Standinganswer Orders1. “yes”Is the forto person any Administering question, to be vaccinated it does Influenza not sick necessarily today? Vaccines mean you to (orChildren your child) and should Adolescents not be vaccinated. It just Infl uenza (“fl u”) is a contagious disease. VACCINE means additional questions must be asked. If a question is not clear, please ask your It is caused by  the Iin understandfl uenza virus, that which the can strains be spread of virus by that cause influenza change almost every year Don’t W H A T Y O and,U evenN E if Ethey D don’t T O change, K N my O immunity W declinesWho should over time. get This inactivated is why vaccination Purpose: Tohealthcare reduce2. morbidityDoes provider the and personto mortality explain to beit.from vaccinated influenza have by vaccinating an allergy allto childreneggs or and adolescents who meetYes the No Know copy this for youcoughing,r patient ssneezing, or nasal secretions. 3 criteria established by the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices.   against influenza is recommended each year. 2011-12infl uenza vaccine and when? to a component of the vaccine? Vaccine Information Statements are available in Spanish and many other languages. See www.immunize.org/vis Standing Orders for Administering Influenza Vaccine to Adults AnyoneHojas de can Informacián get infl uenza,Sobre Vacunas but rates están of disponibles infection en are español highest y en muchos otros idiomas. Visite www.immunize.org/vis Policy: Under1. theseIs the standing person toorders, be vaccinated eligible nurses sick today?and other healthcare professionals (e.g., pharmacists), where allowed by  among children.  For I understand most people, that symptoms I cannot last get only influenza a WHO from the influenza vaccine. state law, may vaccinate children and adolescents who meet any of the criteria below. Don’t takWhyfewe cdays. getha They nvaccinated? c include:eThes wconsequencesith you ofr my refusing3 to beWhoAll vaccinated people can 6receive months could haveof LAIV? age life-threatening and older should consequencesget fl u Purpose: To reduce morbidity3. andHas mortality the person from to influenza be vaccinated by vaccinating ever had all a seriousadults who reaction meet to the criteria 1  Procedure:2. Does the person to be vaccinated have an allergy to eggs or to a component of    • fever/chills • sore throat • muscle aches • fatigue vaccine. established by the Centers for Disease influenza Control vaccine and Prevention’s in the past? Advisory Committee on Immunization Practices. Infl uenza (“fl u”) is a contagious to my disease. health and the health of LAIVthose is with recommended whom I for have healthy contact, people including2 through 49 years 1. Identify children and adolescents ages 6 months and older who have not completed their influenza vaccination(s) for the  • cough • headache • runny or stuffy nose Guides for determining the influenza the vaccine? number of doses of influenza vaccine family’s health – m • alla kpatientse su inr thise y healthcareou alofl facility age, whoVaccination are not pregnant is especially and do not important have certain for health people at higher Policy: Under current these influenzastanding orders,season. eligible nurses and other healthcare professionals (e.g., pharmacists), where It is caused by the infl uenza virus, which can be spread by coughing,Other sneezing, illnesses or nasal can secretions. • myhave thecoworkers same symptoms and are oftenconditions risk(see #4,of severe below). in fl uenza and their close contacts, to giveallowed to by state2.children Screen law, mayall patients vaccinate ages4. for Has contraindicationspatients6 monthsthe person who meet to and be throughany precautionsvaccinated of the criteria everto 8 influenza years below.had Guillain-Barré vaccine: during syndrome? the    get vaccinated against influenza 3. Has the person to be vaccinated ever had a serious reaction to intranasal copy this for your patientmistakens for in fl uenza. • my family including healthcare personnel and close contacts of Procedure: a. Contraindications: a serious systemic or anaphylactic reaction after ingesting eggs, after receiving a previous dose  Anyone can get infl uenza, but rates of infection are highest 2012–2013 influenza influenza season vaccine (FluMist) in the past? Young children, people • my 65 community and older, pregnant women, and Somechildren people younger thanshould 6 months. not receive 1. Identify adults ofwith influenza no history vaccine, of influenza or to an influenzavaccination vaccine for the component. current influenza For a list season. of vaccine components, go to www.cdc.gov/ among children. For most people, symptoms last only a few 4 “ Prevention and Control of Influenza every yeapeopler! with certain health conditions – such as heart, lung LAIV InfluenzaV accination vaccines/pubs/pinkbook/downloads/appendices/B/excipient-table-2.pdf. of People Do not give live attenuated influenza vac- days. They include: WHEN 2. Screen all patients for4. contraindications Does the person and to precautions be vaccinatedwith to influenza haveVaccines: a long-term vaccine: Recommendations health proble ofm the with heart or kidney disease,Despite or a weakened these facts, immune I am system choosing – can getLAIV to decline is not recommended influenza vaccination for everyone. Theright following now for the following algorithm cine guide (LAIV; nasal spray)Form tocompleted people with by: a history______of hypersensitivity to eggs, either anaphylactic or non-anaphylac- Date: ______Seek eme•r fever/chillsgenc y m • soree throatdic al • cmuscleare aches if y • ofatigueu or a. Contraindications: adisease, serious systemiclung disease, or anaphylactic asthma, AkidneyC IreactionP–U.S., disease, 2after01 2neurologic– ingesting13 Influenza oreggs, ne Season.” uromuscularafter receiving disease, a previous    much sicker. Flureasons: can cause ______high fever and pneumonia, andpeople shouldGet getthe the vaccine inactivated as soon vaccine as it is(fl uavailable. shot) instead: This should with a History oftic; Egg pregnant Allergyadolescents; children youngerM thanMWR age, August 2 yrs; children17, 2012/Vol age 2 6 through1/No 32/ 4 yrs who have experienced wheez- Here’s• coughhow infl •u headacheenza ca • nrunny hu orr stuffyt yo noseur family. . . provide protection if the fl u season comes early. You can dose of influenza vaccine,liver disease,or to an influenzametabolic vaccine disease component.(e.g., diabetes), For aor list anemia of vaccine or another components, blood disorder? go to a family memmakebe rexisting sho medicalws conditionsthe s worse.ign Its can cause diarrhea• Adults 50 years of age and older or children from 6 The entire article is available at www.cdc.gov/mmwr/pdf/wk/mm6132.pdf, ing or asthma within Form the pages past reviewed 61 312–61 mos,8. by: based ______Pages on a 6healthcare13–618. provider’s statement; or children or adolescents Date: with ______get the vaccine as long as illness is occurring in your www.cdc.gov/vaccines/pubs/pinkbook/downloads/appendices/B/excipient-table-2.pdf. Do not give live Other illnessesand seizures can have in thechildren. same symptoms Each year and thousands are often of people throughdie 23 months of age. (Children younger than 6 chronic pulmonary (including asthma), cardiovascular (excluding hypertension), renal, hepatic, neurologic/neuromus- community. attenuated influenza vaccine (LAIV; nasal spray) to an adult with a history of hypersensitivity to eggs, either from infl uenza______and even more require hospitalization.coPY tmonthshis FOR should YOUR not PATIENTS get either infl uenza vaccine.) cular, 5.hematologic, If the person or metabolic to be vaccinated (e.g., diabetes) is a child disorders; age 2 through , 4 years, in the including past 12 thatmonths, caused by medications below – a mistakenlife c foro inufl uenza.ld be at risk! Severe allergic and anaphylactic anaphylatic reactions or can non-anaphylactic; occur in response whofigure is pregnant, 2 is age 50 years or older, or who has chronic pulmonary (includ-    Infl uenza can occur at any time, but most infl uenza occurs Has the orchild HIV; long-term has a healthcare aspirin therapy provider (applies ever to told a child you orthat adolescent he or she age had 6 mos whee throughzing or 18 asthma? yrs). InfluenzaYoung can mchildren,Byak egetting yo peopleu, fl u 65Ivaccine understand and older, youInfl pregnantcanu ethatn protectza uI women, scanua yourselflly change c oandme froms o myn su •mindd Childrendenl yat. S yanyyoungermp ttimeom sthan candan 5 i n yearsacceptclud withe h iinfluenzag asthmah fever ,or onevaccination, or more if vaccine to a number of influenza vaccineing asthma), components, cardiovascular but such reac (excluding- Recommendations hypertension), renal, regarding hepatic, influenza neurologic/neuromuscular, vaccination for hematologic, or from October through May. In recent seasons, most tions are rare. All currently everavailable received influenzab. Precautions: vaccines moderateare pre- orpersons severe acute who reportillness allergywith or to without eggs – fever;ACIP, historyUnited ofStates, Guillain-Barré syndrome within Keep youryou rkids childpeopleren safe, owithrin yflo certainuenzaur p—a andhealthren mayis tgets conditionsstill also available. avoidcthemh i–ll ssuch ,spreading he aasd aheart,c hvaccinatede ins ,lungfl e uenzaxh aus ttoio nothers., sepisodesore thro aoft, wheezingcough, a nwithind all-o theve rpast bod year.y ach es. First Do No Harm: metabolic Mandatory (including diabetes) influenza disorders;no immunosuppression, vaccination including policies that caused by medications or HIV. It’s a fact – every year, people of all ages in the infections have occurred in January and February. Getting pared by means of of virus into6 weeks chicken6. of Doeseggs. a previous The the person influenza201 2to– 1bevaccination;3 influenza vaccinated forseason have TIV cancer, only, allergic leukemia, reaction HIV/AID to eggsS, orconsisting any other of hives only (observe or kidney disease, or a weakened immuneSome p systemeople s–a cany, “I tget fe lt like a truck hit me!” Symptoms can also be mild. influenza / really sick. • Pregnantvaccinated women. in December, or even later, will still be for healthcareuse of influenza vaccines personnelb. forPrecautions: persons withpatient moderate a (HCP)history for immune30of or eggminutes severe help system followingacute protect problem; notillness vaccination); with or, orinpatients withoutthe for past LAIV fever;3 months, only, history close have ofcontact theyGuillain takewith Barrén an medications immunosuppressed syndrome that within person  when  much sicker.2 Flu canInactivated cause high feverR eing andaflr duenza lpneumonia,ess, whe vaccinen i nandflu enza strikes your family, the result is lost time from 6 weeks of a previous influenza vaccination; for TIV only, allergic reaction to eggs consisting of hives only (ob- everyU fall.S. d iore fr winter!om influenza aIn haved i treads c oandm fullyplic understandations. the• People information whobene havefi cial on long-term in this most declination healthyears. problems form. with: allergy has been reviewed recentlyvaccine? by ACIPthe (16). person For weakenrequiresthe 2011– protectivethe12 immune isolation, system, receipt such asof cortisone,influenza antivirals prednisone, (e.g., other amantadine, steroids, rimantadine, or zanamivir, or make existing medical conditions worse.work a Itn dcan sc hcauseool. diarrhea Refer to the positioninfluenza statements season, ofACIP the recommended leadingserve medicalpatient that organizationsfor persons at least with 30listed minutesegg below tofollowing helpCan you the persondevelop vaccination); eat and lightly implement for LAIVyes a mandator only, yclose influenza contact with an immunosup- and seizuresThere in children. are two Eachtypes year of in thousandsfl uenza vaccine: of people die - heart disease - kidney or liver disease oseltamivir) anticancer within the drugs; previous or have48 hours surethey or had possibility radiation of treatments? useAdminister within 14vaccine days per after vaccination - lung diseaseAdults and - older metabolic children disease, need such one asdose diabetes of infl uenza vaccination policyallergy at who your report healthcare only hives institution after eggor medical exposure setting. should Policy receive titles, publicationcooked dates,egg (e.g., links, scrambled and excerpts follow. from infl uenza and even more require hospitalization. pressed3. person Provide when all patients the person (or, requiresin the case protective of a minor, isolation, their parent receipt or of legal influenzausual representative) Giveprotocol. antivirals 2 doses with (e.g., a ofcopyamantadine, of the most riman- current federal Is influenza more serious 1. InactivatedInfants andSignature: young(killed) children vaccine, ______are the at a“ flgreater u shot,” risk is forgiven getting by- asthma seriouslyvaccine ill fromeach - anemia, year. But and some other Date:children blood ______disorders younger than 9 years TIV, with several additional safety measures, as described in this egg) without reaction?* tadine, zanamivir,Vaccine Information or oseltamivir) Statement within (VIS). the previous You must 48 documenthours or possibility in the patient’s of use medical within record 14 days or officeafter vaccination log, the publication date for kids? injectioninfluenza. with That’sa needle. why health experts recommend that all childrenof age 6 monthsneed two and doses to be protected. Ask your doctor. American Academydocument. of FamilyRecent Physiciansexamination (AAFP) of VAERS data 7.indicated Is the nofluenza person dis- vaccination to be vaccinated of all health receivingworkers as aantiviral precondition2 medication01 of 2employment–201s? 3 influenza    EmergIennflcuye nwzaaByr snp igettingnrega dssi flg eun avaccines ily fr oyouAmn cany c hprotectildA no riyourselfn tfecetned w frompheros osnh coawn ss ptrheea d•f o iAnyonenllflouweninz withag wehm certainene rthge ymusclen ccoyu gh or, s nnerveeeze disorders, or just (such 3. Provide all patients with a copy of the most currentno federal Vaccine Information Statement (VIS). You must docu- AAFP Mandatoryproportionate Influenza Vaccination reporting ofof allergyHealth y Careor eanaphylaxisof Personnels the VIS (6/11) afterand theinfluen dateand zathereafter it was givenon an annual to the basis, patient unless (parent/legal a medical contraindication representative). recog- Provide non-English speaking patients with infl uenza andolder may andalso allavoidName adults spreading (print): get vaccinated in ______fl uenza against to others. influenza eachas seizure fall or disorders winter. or cerebral palsy) that can lead to www.aafp.org/online/en/home/clinical/immunizationres/influenza/ nized in national guidelines is documented in the worker’s health record.” InfluenzaV accineperson to p Prersooductsn2.. Live, attenuatedw aforrnin (weakened)g tthesailkg nesa nr2 eointehfl0d euenzasr1s u. T2rgh vaccinee–yn ct2a mn0 ae islds1 oic 3saplr aeInfluenzaattde intIn tbiflyo uenzatno u–cht aivaccinenkge o trh sen maymee zSeasoni nbeg ogivenn an atob theject same time as other How to administervaccination intramuscular, during the 2ment011– 1in2 season the patient’sa copy(21). intradermal, Forof medicalthe the VIS 2012 inrecord–1 3their ornative officeand language, log, intranasal the if publication available and date influenza preferred; of thevaccine VIS these and can vaccines thethis be date found season it wasat www.immunize.org/vis. given to the for children or teens with mandatoryinfluenza.html 8. Is the child or teen to be vaccinated receiving aspirin therapy or aspirin-containing therapy?    sprayed into theto anostrils.n emteh raThisgt eson mvaccinecye ornoeo e misls edescribedo tro cuachlle 9s l-ina1t- ea1breathingr .. And, an or in swallowingfected pers problems.on doesn ’t have to feel patient. Provide non-English speakingAssociation patients for Professionals with a copy in ofInfection the VIS Control in their and native language, if available and vaccines, including pneumococcal vaccine. “The AAFP supportsinfluenza annual season, mandatory ACIP influenzarecommends immunization4. Administer the following: for health injectable trivalentAfter inactivated eating eggs vaccine or (TIV) intramuscularlyAdministerspaced TIV. in the at vastus least lateralis for infants (and toddlers Influenzai nvaccinefluenz amay save Live,separate attenuated VaccineDepartment: Information infl uenza ______Statement. Epidemiology (APIC) yes Most people with influenzasick to baree csickont aforgi oaboutus: th ea y week,caMercury•n Anyone sandpre athen d iwithn fltheyu ean weakenedfeelza t obetter. oth eimmune rs when system. they feel care personnel (HCP) except for religious preferred; or medical reasonstheselacking can(not personaladequatebe found deltoidat www.immunize.org/vis. mass)egg-containing or in the deltoid foods, muscledoes (for toddlers, children, and teens). Use a 22–25 g needle. Choose 2 • Fast breathing or trouble breathing 1. Persons with a history of egg allergy who have experienced only Observe reaction for at least vaccine - LAIV (nasal spray) Content Reference:Some CDC. Preventionpeople and shouldControl of Influenza not1 withget Vaccines— preferences). If HCP are not vaccinated, policies to adjust practice9. activi Is- theInfluenza person Vaccination to thebe personvaccinated Should experience Be pregnanta Condition orof Employmentcould she4 forbecome weeks Health- pre apart.gnant within Manufactureryour child’s life. Trade Name A “high-dose”But, someHow people, inactivated Supplied especiallywel lin –fl buenza youngefore vaccinet children,heir sym is ppregnant availabletoms ha vwomen, e even boldereAgegun people,. Group Product Code Intramuscular injectionhives after exposure 4. toAdminister egg should Intradermal influenzaneedlereceive influenzalength vaccine appropriate administrationvaccine, as follows: to the a) child’s For adults agesure and of allbody ages, mass:Intranasal give infants 0.530 minutesmL 6 throughadministration of after injectable vaccination. 11 mos: trivalent 1"; 1 through inactivated 2 yrs: in-1–1 3"; 3yrs   • Bluish skin color (μg• AnyoneHg/0.5mL) in closeRecommendations contact with of someoneACIP at www.cdc.gov/flu/professionals/acip/index.htm whose immune ties during flu season are appropriate (e.g. wear masks, refrain from direct care Personnel,only Unless hives? Medically Contraindicated (2/1/11) and people with chronic health problems can get very sick. Some4 even inactivateddie. A infl uenza vaccine or Trivalent Inactivated Influenzawith the Vaccines following (TIV) Didadditional the safety childTrivalentand measures older: receive Inactivated (Figure 1–1½".the 2):next GiveInfluenza month? 0.25 VaccinemL to children (TIV) 6–35 mosLive and Attenuated 0.5 mL for Influenza all others Vaccine age 3 yrs (LAIV) and older. (Note: A e" There are fortwo people types of 65 in yearsfl uenza of vaccine: age and older. Ask your doctor forsystem is so weak they require care in a protected patient care).” fluenza vaccine (TIV-IM) intramuscularlywww.apic.org/Resource_/TinyMceFileManager/Advocacy-PDFs/APIC_In (22–25g,no 1–1½" needle) in the deltoid muscle.- (Note: A e" needle may Technical0.5• contentN mLot reviewed w(single-doseak byi ntheg Centers up for o Disease rsyringe) n oControlt in andte Prevention,racti nOctoberg 02011. should wait www.immunize.org/catg.d/p4068.pdf90656 • Item #P4068 (10/11) needle may be usedfluenza_Immunization_of_HCP_12711.PDF for patients weighingnot less that 130 “As lbs a profession(<60kg) thatfor reliesinjection on in the deltoid muscle only if the skin moreyearly information. vaccination against influenza is the best way toenvironment protect your (such child asfrom a bone marrow transplant unit). Close a) Because studies published be2 usedor more tofor date adults involved doses weighing use of lessTIV, thanTIV 130 lbs/ (<60 kg) for injection in the deltoid muscle only if the skin is stretched 1. Live,2 attenuated infl uenza vaccine (LAIV) contains live 3 Technicalevidence content reviewed to guide by the Centersour decisions for Disease Control and aactions,nd Prevention we can no longer afford to ig- www.immunize.org/catg.d/p4066.pdf • Item#P4066 (10/12) CSL Biotherapies Afluria (TIV) this serious• disease. It is recommended for everyone 6contacts months of and other9 years older. people & olde withr a weakened 1. Use a needleAmerican long enough Academy to reach of Pediatrics deep into (AAP) the 1. isGently stretched shake10. tight, theHas microinjection subcutaneousthe person system to tissue be beforevaccinated is not bunched, ever 1.had and FluMist Guillain-Barréthe injection(LAIV) is foris syndrom madeintranasal at ae? administration 90-degree angle.) only. Alternatively,   Influenza and its compliImmunizationcatioBnesing ActionsoE aircr hCoalitioni tyaebalre, mth •oa r1573te t thhea Selby nc h2i0l dAve.0 ,d0o0 •e0 s St.p ne Paul,otp lwe MN aanr•et 55104tTellhoo sbp eyouri t•ha el(651)ilz ddoctored 647-9009in th ife youU. S• . havewww.immunize.orgfr9om0 658any severe (life-threatening) • www.vaccineinformation.org rather than LAIV shouldtight, besubcutaneous used (22); tissue is notnore bunched, the compelling and evidence the injection that supports is made requiring at a influenza 90 degree vaccine angle; for or b) For healthy adults but attenuatedInfl uenza (weakened) viruses5.0 mL arein fl(multi-dose uenzaalways virus. changing, vial)It is sprayed so annual into 24.5 muscle. InfantsPolicy Statement—Recommendationage 6 through 11 mos: 1"; of for seasonalMandatory Influenzaadministering influenza Immuniza the- vaccine. noDoes the person experience Do not injectRefer toFluMist. a physician with (such as those allergies, with HIV) including may receive a severe QLAIV.2 allergy035 Healthcare (Medicare) to eggs. A severe younger than healthy age 50 children years, give ageHCP. 20.2 yrs This mL and is notof older onlyintranasal a may patient be LAIV;safety given imperative, 0.10.2 mLyes but ofis issprayedintranasal a moral and into LAIV; ethical each 0.1 nostril mL iswhile sprayed the intopatient each nostril while can be so stheer nostrils.iouvaccinations that the yis• crecommended.Nanot drininkflinuge n eEachznao aung dyearh i tflsu cscientistsiodms plicat itryon sto. B etween 3,000 and 50,000 die, which shows 1 throughtion 2 yrs: of All 1–1 Health3 "; b) children Care Vaccine Personnel and should adults (10/1/10) be administered by a health-care provider who other symptoms such as tableexpertise guide in management personnel in allergy neonatal to any intensive vaccine care component units or oncology may be a reason not to http://pediatrics.aappublications.org/cgi/content/abstract/peds.2010-2376v1 2. theHold patient the 11.system is Doesin byan placingobligation uprightthe person the position.to those to who be Children placevaccinated their age trust live6 in mos our with care.”through or expectof allergic8 yrs toshould conditions have receivecl osefor contact a second with dose 4 wks or more after GlaxoSmithKline Fluarix (TIV) matchInfluenza, the viruses0.5 or mL“flu,” in (single-dose the ish vaccineoanw uinfectionnpr etosyringe)d ithosec tofa bthele most i nnose,flu elikelyn zthroat,a 0c toan bande. Tlungs.he pe 3oIt pyears lcane m oeasily&s tolder l ikely to be ho9s0p656italized 3 yrs and older: 1–1½". is familiar with the ispotential in anvaccine uprightmanifestations position; of egg or allergy; c) For and adults ages• Cardiovascular 18 through changes 64 years, 2. Remove give 0.1 rubber ml tipTIV-ID protector. intradermally Do not remove by dose- inserting What is influenza?put you, y2.oInactivatedur childre (killed)n, or in•fl Nuenzaot u rvaccine,inating theor n“flo u t shot,”ears w ish en cryingclinics may receive LAIV. “The implementation of mandatory annual influenza theimmunizationthumb first and dose middle pro if- they finger are on receiving influenza vaccine for the firstfurther time evaluation. or if they did not receive at least 1 dose of vaccine get the vaccine. Allergic reactions to infl uenza vaccine the needle of the microinjectiona personInfectious system whose at Diseases aimmune 90(e.g., degree hypotension) Society system angle of America isin severely the deltoid divider(IDSA) compromised clipmuscle; at the orother d) and Forend who adultsof the mu sprayer. agesst be 65 in years and    causespreadfl u thatfrom year. person Flu to avaccinen person.d die awillre i nnotfan tprevents, youn gdisease childre n, older adults, and people of all ages who ID Biomedical Corp of given by injection with• a needle. This vaccine is described are rare. 2. With yourgrams left hand*, for HCP bunch nationwidec) Vaccine up the is muscle.recipients long overdue. sinceshould For thebe July observedprevention inthe 1 the, finger 2for and 2010–20110 at 10?control pads;least 30the minutesImmunization vaccinationIDSAindex Policyfinger Action on season.• Mandatory Respiratory Coalition Immunization distress • 1573 Selby of Ave.Health • CareSt. Paul, Workers MN 55104Against • (651) 647-9009 • www.immunize.org • www.vaccineinformation.org your parents in the hospital S–e vere or persistent vomiting • Children or adolescents on long-term 9aspirin0658 treatment. older, give 0.5 mL of high-doseprotective TIV-IM isolation intramuscularly (e.g., anNumber isolation (22–25g, of room3. doses With 1–1½" of the of a bonepatient needle) marrow in an in upright Numberthe transplant deltoid position of dosesmuscle. unit)? Quebec, a subsidiary FluLaval (TIV) from other ,5.0 mL including(multi-dosehave c ofl nu d vial)virusesitions s unotch containedas hear<25t o rin lu ng disea18se . yearsBut r e&m olderember, it’s not only the of influenza, now isfor the signstime to of put a thereaction health afterand safety administration ofshould the patient remain of first.” each free. vaccine (e.g., wheezing)? in a separate Vaccine Information Statement. Q2036 (Medicare) 3. With your right hand*, insert the needle at a 5. Document each patient’sSeasonal vaccineand Pandemic administration Influenzainfluenza (rev. 7/28/10)information vaccine received* abbreviationand follow uprecommended in the following for places:the or lead to death. • Influenza-like symptoms improve but then return with fever and • (i.e., head not tilted back), place the of GlaxoSmithKline the vaccine. youngest, oldest, or sickest whTello d iyoure: Ev doctore•r yTell yea if ryour iyounflu doctorhaveenza anyk iiflls severeyou peo everpl e(life-threatening) w hadho wae severere reaction after a dose (22). 5. Document each patient’s vaccinewww.idsociety.org/HCW_Policy administration Gastrointestinal information and follow* TIV =up trivalent in the inactivated following vaccine places: • Influenza shots can be given to children 6 months and older. 90° angleAmerican to the skin College with a quick of Physicians thrust. (ACP) 3. a.Insert Medical the needle chart: perpendicular Record the to date the skin,the vaccine since was July administered, 1,tip 20 just10 inside the the manufacturer nostril2 to012 –1 and3 season lot number, the vaccination site What types of vaccine areIn fl uenza viruses are alwayswo changing,rse coug hso annual vaccination dose of infl uenza vaccine. 12. Has the“Physicians person and to (e.g.,other be vaccinated nausea/vomiting)?health care providers received must any have other two special vaccination objec- s in the past 4 weeks?    MedImmune FluMist (LAIV)2 0.2 mL (single-useotherwis nasale hea lspray)thy. 0allergies, including2 through a severe 49 allergyyears to eggs.90660 A severe allergy ACP Policy on1. Influenza Other measures, Vaccination such ofa. Health asMedical dividing Carey Workers e andchart:ins theadministering (9/1/10) region Record of the the the deltoid, datevac- the in a vaccineshort, quick was administered,ensure the* Personsmanufacturer LAIV with is delivered egg allergy and might lot number, the vaccina- is recommended.It takes• A nasal-spray Each up to year 2 weeks scientistsvaccine for can protectiontry beto matchgiven to tothe develop healthy viruses afterchildren the 2 years and older. 4. Push down on the plunger and inject the entire and route, and thetives name in view and when• title Reaction treating of the requiring patients, person namely, administering ‘to do good orthe to vaccine.do no harm’ If vaccine was not given, record the available for children? to any vaccine component may be a reason not to get the www.acponline.org/clinical_information/resources/adult_immunization/flu_hcw.pdfcine by a two-step approach tion and site skin andmovement. testing route, with and vaccine, the name are and titleepinephrine? of the person administeringinto thetolerate nose. the egg vaccine. The in baked patient products If vaccine was not given, in the vaccineshot. to Protection those most lasts likely about to cause a year. fl u that year. Flu < • Tell your doctor if you ever90 656had Guillain-Barré contents of the syringe. There is no need to aspi- reason(s) for non-receipt(Hippocratic of Corpus the vaccine in Epidemics: (e.g.,none Bk. medical or I, unknownSect. 5,contraindication, trans.(e.g., Adams), bread or andcake). havepatient Tolerance refusal). to2 • Children0.5 younger mL (single-dose than 5 years syringe)who have had wheezing–vaccine.1 in the Allergic past year—or reactions an toy infl uenza vaccine are rare. “Vaccinating HCWsnot necessary[healthcare (22). workers] against influenza represents a • Reaction requiring emer- should breathe normally. rate. record the4. b.Once reasons(s) Personal the needle immunizationfor hasnon-receiptan been ethical andrecord of moral the card: vaccineobligation Record (e.g.,to prevent the medical datetransmission of contraindication, egg-containingvaccination of infectious foods and dis does the -patient notname/location refusal). of the administering clinic. Novartis Vaccines Fluvirin vaccine(TIV) will not prevent disease from other viruses, including duty of care, and a standard of quality care, so it should be reasonable Form that completed by: ______gency medical attention? Date: ______child with chronic health problems—should get the injectable vaccine4 years (a & shot), older 90658 b. Personal inserted,immunization maintain recordlighteases pressure to card:their patients.” Record the date of vaccination4. 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Dispose of the applicator in a sharpsimmunoglobulin con- E antibodiesremaining to egg proteins. vaccine. • Sudden dizziness 90658 American Medical3. All vaccines Directors should Association be administered (AMDA) in settings in which personworker- influenza vaccinationany of the policies following: from 1)AAP, 2 or IDSA more anddoses SHEA. of seasonal Mean- influenza vaccine since cinated, they5.0 mL rely (multi-dose on those around vial) them to get vaccinated.25 3 years & older Medical Director’sImmunizationtainer. signature: Action Coalition • 1573 Selby Ave. • St. Paul, MN 55104 Effective • (651) date: 647-9009 • www.immunize.org • www.vaccineinformation.org Q2038 (Medicare) Mandatory Immunizationnel and equipmentfor Long Term for Care rapid Workers recognition (3/ 11) and treatment ingfulof ana increases- 5. A inprevious healthcareJuly 1 severe, 2 0worker10; allergic2) atimmunization least 7.reaction Dispose2 doses ratesto ofinfluenza areseasonalthe essentialapplicator vaccine,vaccine to in givenaregard sharps before- container. July 1, • Wash your• handsInflue noftenzBa-el iandk es su coverymrept oyourymos ucoughsimrp rpova ander beu sneezes.tn thtesn gr eIt’steu trbestn v wa itothc usefcevi enar antded,too! www.amda.com/governance/resolutions/J11.cfmphylaxis are available. ACIP recommends that all vaccinationpatient safety, aless hallmark of 2the010 of component andour healthcareat least suspected1 dose system.” of monovalent to be responsible 2009 H1N1 for the vaccine; or 3) at least Fluzone High-Dose (TIV) 0.5w mLors (single-dosee cough syringe) 0 65 years & older 90662 “Therefore be it resolved, AMDA - Dedicated to Long-Term Care Medicine tissue and quickly throw it away. If you don’t have a tissue, you should cough providers should beTechnical familiar content reviewed with by the Centers office for Disease emergency Control and Prevention, planNational August (1 1).2011. Patientreaction, Safety1 dose isFoundation a contraindicationof seasonal (NPSF) vaccine to given future before receiptwww.immunize.org/catg.d/p3074.pdf July of 1 ,the 2010 vaccine. and at least 1 dose • Item of #P3074 (8/11) supports a mandatory annual influenza vaccination for every long-term or sneeze0.1 into mL your (single-dose upper sleeve, micro not injection your hands. This will prevent the spread 90° angle NPSF Supports Mandatoryseasonal Flu vaccine since for Healthcare July 1, 2 0Workers10. (11/18/09) Fluzone Intradermal (TIV) Technical content reviewed by the Centers for Disease Control and Prevention,9 N0ov654ember 2010. health care worker who has direct patient contact unless a medical contra- 0 18 through 64 years Immunization Action Coalition • 1573 Selbywww.npsf.org/updates-news-press/press/media-alert-npsf-supports-mandatory- Ave. • St. Paul, MN 55104 • (651) 647-9009 • www.immunize.org • www.vaccineinformation.org of germs.system) indication or religiousreferences objection exists.” Immunization Action Coalition 1573 Selby Avenue • St. Paul, MN 55104 • 651 647-9009 • www.vaccineinformation.org • www.immunize.org skin flu-vaccinations-for-healthcare-workers Keep this handy! Post it on your refrigerator or another place where it will be easy to find! note: Reference numbers on this sheet are taken from the complete article found at itoring. Presented at the Advisory Committee on Immunization Practices meeting, Atlanta, • Tell your children to “NPSF recognizes vaccine-preventable diseasesTechnical ascontent a matter reviewed of patient by the Centers safe- for Disease Control and Prevention footnotes www.immunize.org/catg.d/p4069.pdf • Item #P4069 (11/10) American Pharmacistswww.cdc.gov/mmwr/pdf/wk/mm6132.pdf, Association (APhA) pages 613–618. GA; June 2012. Available at www.cdc.gov/vaccines/recs/acip/downloads/ subcutaneous11. CDC. General tissue recommendations on immunization: recommendations of the Advisoryty and supportsmtg-slides-jun12/03-influenza-shimabukuro.pdf. mandatory influenza vaccination of healthAccessed care August workers 10, 201 2.to 1. Effective for claims with dates of service on or after 1/1/2–01 Stay1, CPT away (Current from Procedural people who are3. On sick, August 6, 2010, ACIP recommended that Afluria not be used in children younger Requiring Influenza VaccinationImmunization for All Pharmacy Action Personnel Coalition (4/11) 1573 Selby Avenue • St. Paul, MN 55104 • 651-647-9009 • www.immunize.org • www.vaccineinformation.org Committee on Immunization Practices (ACIP). MMWR 2011;60(No. RR-2). protect the 22.health Kelso of JM, patients, Greenhawt health MJ, Li JT.care Adverse workers, reactions and to thevaccines community.” practice parameter 2012 Terminology) code 90658 is no longer payable for Medicare;– rather,Wash theirHCPCS hands (Healthcare often, than age 9 years. If no other age-appropriate TIV is available, Afluria may be considered www.ashp.org/DocLibrary/BestPractices/HRPositions.aspx16. CDC. Prevention and control of influenza with vaccines: recommendations of the Advisory update. J Allergy Clin Immunol 2012;130:25–43. muscle www.immunize.org/catg.d/p3093.pdf • Item #P3093 (8/12) Committee on Immunization Practices (ACIP), 2011. MMWR 2011;60:1128–32. 23. Erlewyn-Lajeunesse M, Brathwaite N, Lucas JS, Warner JO. Recommendations for the Common Procedure Coding System) Q codes, as indicated above, should be submitted for a child age 5 through 8 years at high risk for influenza complications, after risks and “APhA supports an annual influenza vaccination as a condition of employ- – Keep their hands away from their face, and Adapted from the Centers for Disease Control and Prevention 21. Advisory Committee on Immunization Practices. Update on influenza vaccine safetySociety mon -for Healthcareadministration Epidemiology of influenza vaccine of inAmerica children allergic(SHEA) to egg. BMJ 2009;339:912–5. ment, training, or volunteering, within an organization that provides phar- for Medicare payment purposes. benefits have been discussed with the parent or guardian. Afluria should not be used in Influenza Vaccination of Healthcare Personnel (rev. 8/31/10) – Cover coughs and sneezesTe ctohn icprotectal content rothers.eviewed by the Centers for Disease Control and Prevention, August 2010. macy services or operates a pharmacy or pharmacy department (unless a 2. TIV is the abbreviation for trivalent inactivated influenza vaccine (injectable); LAIV is the children younger than age 5 years. This recommendation continues for the 2012–2013 www.journals.uchicago.edu/doi/full/10.1086/656558 Immunization Action Coalition 1573 Selby Avenue • St. Paul, MN 55104 • 651 647-9009 • www.vaccineinformation.org • www.immunize.org valid medical or religious reason precludes vaccination).” Technical content reviewed by the Centers for Disease Control and Prevention abbreviation for live attenuated influenza vaccine (nasal spray). influenza season. Technical content reviewed by the Centers for Disease Control and Prevention, October 2011. “SHEA views influenza vaccination of HCP as a core www.immunize.org/catg.d/p2024.pdfpatient and HCP • Item #P2024 (10/11) Immunization Action Coalition 1573 Selby Avenue • St. Paul, MN 55104 • 651-647-9009 • www.immunize.org • www.vaccineinformation.org www.immunize.org/catg.d/p4073.pdf • Item #P4073 (8/10) safety practice with which noncompliance should not be tolerated.” What are signs of influenza? Influenza comes on suddenly. Most people with influenza feel extremely Technical content reviewed by the Centers for Disease Control and Prevention American Public Health Association (APHA) • • • • / / Immunization Action Coalition 1573 Selby Avenue St. Paul, MN 55104 651-647-9009 www.immunize.org www.vaccineinformation.org www.immunize.org/catg.d/p4072.pdf • Item #P4072 (9 12) Immunization AnnualAction CoalitionInfluenza Vaccination • 1573 Selby Requirements Avenue for • Health Saint Paul,Workers MN (11/55104 9/10) • (651) 647-9009 • www.immunize.orgwww.immunize.org/catg.d/p • www.vaccineinformation.org3094.pdf • Item #P 3•094 [email protected](9 12) fatigued and have a high fever, headache, dry cough, sore throat, runny or www.apha.org/advocacy/policy/policysearch/default.htm?id=1410 continued on page 2 stuffy nose, and sore muscles. The cough can last two or more weeks. Some “Encourages institutional, employer, and public health policy to require in- www.immunize.org/catg.d/p2014.pdf • Item #P2014 (10/12) people, especially children, may also have stomach problems and diarrhea. page 1 of 2 Immunization Action Coalition • 1573 Selby Ave. • St. Paul, MN 55104 • (651) 647-9009 • www.immunize.org • www.vaccineinformation.org

Technical content reviewed by the Centers for Disease Control and Prevention, October 2011

Immunization Action Coalition 1573 Selby Avenue n St. Paul, Minnesota 55104 n www.vaccineinformation.org n www.immunize.org For 8-1/2" x 11" copies of the pieces above, visit IAC's website: www.immunize.orgwww.immunize.org/catg.d/p4070.pdf n Item #P4070 (10/11) 1. Screening checklist for contraindications to inactivated injectable influenza vaccination: www.immunize.org/catg.d/p4066.pdf 2. Screening checklist for contraindications to live attenuated intranasal influenza vaccination: www.immunize.org/catg.d/p4067.pdf 3. Standing orders for administering influenza vaccines to children and adolescents: www.immunize.org/catg.d/p3074a.pdf 4. Standing orders for administering influenza vaccine to adults: www.immunize.org/catg.d/p3074.pdf 5. Guides for determining number of doses of influenza vaccine for children 6 months through 8 years: www.immunize.org/catg.d/p3093.pdf 6. Influenza vaccination of people with a history of egg allergy: www.immunize.org/catg.d/p3094.pdf 7. First do no harm: Mandatory influenza vaccination policies for HCP help protect patients: www.immunize.org/catg.d/p2014.pdf 8. How to administer intramuscular, intradermal, and intranasal influenza vaccines: www.immunize.org/catg.d/p2024.pdf 9. Declination of influenza vaccination (for healthcare personnel refusal): www.immunize.org/catg.d/p4068.pdf 10. Federally required Vaccine Information Statements in English and other languages: www.immunize.org/vis - Inactivated Influenza Vaccine: www.immunize.org/vis/flu_inactive.pdf - Live, Intranasal Influenza Vaccine: www.immunize.org/vis/flu_live.pdf 11. Don’t take chances with your family’s health—make sure you all get vaccinated against influenza: www.immunize.org/catg.d/p4069.pdf 12. Seek emergency medical care if you or a family member shows the signs below: www.immunize.org/catg.d/p4073.pdf 13. Keep your kids safe—get them vaccinated every fall or winter! www.immunize.org/catg.d/p4070.pdf 14. Influenza vaccine products for the 2012–13 influenza season: www.immunize.org/catg.d/p4072.pdf

6 Vaccinate Adults! • October 2012 • Immunization Action Coalition • (651) 647-9009 • www.immunize.org • www.vaccineinformation.org Screening for Influenza Vaccine Contraindications Save time — have patients fill these out while waiting to be seen

Patient name: Date of birth: (mo.) (day) (yr.) These checklists will

Screening Checklist for Contraindications to help you quickly identify Inactivated Injectable Influenza Vaccination contraindications — screen

For adult patients as well as parents of children to be vaccinated: The following questions will help us determine if there is any reason we should not give you or your child inactivated injectable every time you vaccinate! influenza vaccination today. If you answer “yes” to any question, it does not necessarily mean you (or 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. Don’t Yes No Know Patient name: Date of birth: 1. Is the person to be vaccinated sick today?    (mo.) (day) (yr.)

2. Does the person to be vaccinated have an allergy to eggs or  Screening   Checklist for Contraindications to to a component of the vaccine? Live Attenuated Intranasal Influenza Vaccination 3. Has the person to be vaccinated ever had a serious reaction to For use with  people  ages 2 through 49 years: The following questions will help us determine if there is influenza vaccine in the past? any reason we should not give you or your child live attenuated intranasal influenza vaccine (FluMist) today. If you answer “yes” to any question, it does not necessarily mean you (or your child) should not be vaccinated. It just 4. Has the person to be vaccinated ever had Guillain-Barré syndrome?    means additional questions must be asked. If a question is not clear, please ask your Don’t healthcare provider to explain it. Yes No Know

1. Is the person to be vaccinated sick today?    Form completed by: ______Date: ______2. Does the person to be vaccinated have an allergy to eggs or to a component of Form reviewed by: ______Date: ______   the influenza vaccine?

3. Has the person to be vaccinated ever had a serious reaction to intranasal    influenza vaccine (FluMist) in the past?

4. Does the person to be vaccinated have a long-term health problem with heart disease, lung disease, asthma, kidney disease, neurologic or neuromuscular disease,    liver disease, metabolic disease (e.g., diabetes), or anemia or another blood disorder?

5. If the person to be vaccinated is a child age 2 through 4 years, in the past 12 months, has a healthcare provider ever told you that he or she had wheezing or asthma?   

6. Does the person to be vaccinated have cancer, leukemia, HIV/AIDS, or any other immune system problem; or, in the past 3 months, have they taken medications that    weaken the immune system, such as cortisone, prednisone, other steroids, or anticancer drugs; or have they had radiation treatments?

Technical content reviewed by the Centers for Disease Control and Prevention www.immunize.org/catg.d/p4066.pdf • Item#P4066 (10/12) 7. Is the person to be vaccinated receiving antiviral medications?   

8. Is the child or teen to be vaccinated receiving aspirin therapy or aspirin-containing therapy?    Immunization Action Coalition • 1573 Selby Ave. • St. Paul, MN 55104 • (651) 647-9009 • www.immunize.org • www.vaccineinformation.org 9. Is the person to be vaccinated pregnant or could she become pregnant within    the next month?

10. Has the person to be vaccinated ever had Guillain-Barré syndrome?   

11. Does the person to be vaccinated live with or expect to have close contact with a person whose immune system is severely compromised and who must be in    protective isolation (e.g., an isolation room of a bone marrow transplant unit)?

12. Has the person to be vaccinated received any other vaccinations in the past 4 weeks?   

Form completed by: ______Date: ______Form reviewed by: ______Date: ______

Technical content reviewed by the Centers for Disease Control and Prevention www.immunize.org/catg.d/p4067.pdf • Item #P4067 (10/12)

Immunization Action Coalition • 1573 Selby Ave. • St. Paul, MN 55104 • (651) 647-9009 • www.immunize.org • www.vaccineinformation.org

Screening checklist for contraindications to injectable influenza vaccination: www.immunize.org/catg.d/p4066.pdf

Screening checklist for contraindications to intranasal influenza vaccination: www.immunize.org/catg.d/p4067.pdf

Vaccinate Adults! • October 2012 • Immunization Action Coalition • (651) 647-9009 • www.immunize.org • www.vaccineinformation.org 7 Standing Orders for Administering Influenza Vaccine to Adults

Purpose: To reduce morbidity and mortality from influenza by vaccinating all adults who meet the criteria established by the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices. Policy: Under these standing orders, eligible nurses and other healthcare professionals (e.g., pharmacists), where allowed by state law, may vaccinate patients who meet any of the criteria below. Procedure: 1. Identify adults with no history of influenza vaccination for the current influenza season. 2. Screen all patients for contraindications and precautions to influenza vaccine: a. Contraindications: a serious systemic or anaphylactic reaction to a prior dose of the vaccine or to any of its compo- nents. For a list of vaccine components, go to www.cdc.gov/vaccines/pubs/pinkbook/downloads/appendices/B/ excipient-table-2.pdf. Do not give live attenuated influenza vaccine (LAIV; nasal spray) to a person who has a history of either an anaphylactic or non-anaphylactic hypersensitivity to eggs, ; who is pregnant, is age 50 years or older, or who has chronic pulmonary (including asthma), cardiovascular (excluding hypertension), renal, hepatic, neurologic/ neuromuscular, hematologic, or metabolic (including diabetes) disorders; immunosuppression, including that caused by medications or HIV. b. Precautions: moderate or severe acute illness with or without fever; history of Guillain Barré syndrome within 6 weeks of a previous influenza vaccination; for LAIV only, close contact with an immunosuppressed person when the person requires protective isolation, receipt of influenza antivirals (e.g., amantadine, rimantadine, zanamivir, or oselta- mivir) within the previous 48 hours or possibility of use within 14 days after vaccination. c. Other considerations: onset of hives only after ingesting eggs: healthcare providers familiar with the potential manifes- tations of egg allergy should administer TIV and observe patient for 30 minutes after receipt of the vaccine for signs of a reaction. 3. Provide all patients with a copy of the most current federal Vaccine Information Statement (VIS). You must document in the patient’s medical record or office log, the publication date of the VIS and the date it was given to the patient. Pro- vide non-English speaking patients with a copy of the VIS in their native language, if available and preferred; these can be found at www.immunize.org/vis. 4. Administer influenza vaccine as follows: a) For adults of all ages, give 0.5 mL of injectable trivalent inactivated influ- enza vaccine (TIV-IM) intramuscularly (22–25g, 1–1½" needle) in the deltoid muscle. (Note: A e" needle may be used for adults 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.) b) For healthy adults younger than age 50 years, give 0.2 mL of intranasal LAIV; 0.1 mL is sprayed into each nostril while the patient is in an upright position. c) For adults age 18 through 64 years, give 0.1 ml TIV-ID intradermally by inserting the needle of the microinjection system at a 90 degree angle in the deltoid muscle. d) For adults age 65 years and older, give 0.5 mL of high-dose TIV-IM intramuscularly (22–25g, 1–1½" needle) in the deltoid muscle. 5. Document each patient’s vaccine administration information and follow up in the following places: a. Medical chart: Record the date the vaccine was administered, the manufacturer and lot number, the vaccination site and route, and the name and title of the person administering the vaccine. If vaccine was not given, record the reasons(s) for non-receipt of the vaccine (e.g., medical contraindication, patient refusal). b. Personal immunization record card: Record the date of vaccination and the name/location of the administering clinic. 6. Be prepared for management of a medical emergency related to the administration of vaccine by having a written emergency medical protocol available, as well as equipment and medications. 7. Report all adverse reactions to influenza vaccine to the federal Reporting System (VAERS) at www.vaers.hhs.gov or (800) 822-7967. VAERS report forms are available at www.vaers.hhs.gov.

This policy and procedure shall remain in effect for all patients of the until rescinded or until (date). (name of practice or clinic)

Medical Director’s signature: Effective date:

Technical content reviewed by the Centers for Disease Control and Prevention www.immunize.org/catg.d/p3074.pdf • Item #P3074 (8/12)

8 VaccinateImmunization ActionAdults! Coalition • October • 1573 2012 Selby • Immunization Ave. • St. Paul, Action MN Coalition 55104 • • (651) (651) 647-9009 647-9009 • • www.immunize.org • www.vaccineinformation.orgwww.vaccineinformation.org Standing Orders for Administering Pneumococcal (PPSV23 and PCV13) Vaccine to Adults

Purpose: To reduce morbidity and mortality from pneumococcal disease by vaccinating all adults who meet the criteria established by the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices. Policy: Under these standing orders, eligible nurses and other healthcare professionals (e.g., pharmacists), where allowed by state law, may vaccinate adults who meet any of the criteria below. Procedure 1. Identify adults in need of vaccination with pneumococcal polysaccharide vaccine (PPSV23) based on the following criteria: a. Age 65 years or older with no or unknown history of prior receipt of PPSV b. Age 64 years or younger with no or unknown history of prior receipt of PPSV and any of the following conditions: i. cigarette smoker ii. chronic cardiovascular disease (e.g., congestive heart failure, cardiomyopathies) iii. chronic pulmonary disease (e.g., chronic obstructive pulmonary disease, emphysema, asthma) iv. diabetes mellitus, alcoholism or chronic liver disease (cirrhosis), v. candidate for or recipient of cochlear implant; cerebrospinal fluid leak vi. functional or anatomic asplenia (e.g., sickle cell disease, splenectomy) vii. immunocompromising condition (e.g., HIV infection, congenital , hematologic and solid tumors) viii. immunosuppressive therapy (e.g., alkylating agents, antimetabolites, long-term systemic corticosteroids, radiation therapy) ix. organ or bone marrow transplantation; chronic renal failure or nephrotic syndrome 2. Identify adults in need of an additional dose of PPSV23 if 5 or more years have elapsed since the previous dose of PPSV and the patient meets one of the following criteria: a. Age 65 years or older and received prior PPSV vaccination before age 65 years b. Age 64 years or younger and at highest risk for serious pneumococcal infection or likely to have a rapid decline in pneumococcal antibody levels (i.e., categories 1.vi.-ix. above) 3. Identify adults age 19 years and older in need of vaccination with pneumococcal conjugate vaccine (PCV13) who are at highest risk for serious pneumococcal infection or likely to have a rapid decline in pneumococcal antibody levels (i.e., categories 1.v.–1.ix. above). 4. Screen all patients for contraindications and precautions to pneumococcal vaccine: a. Contraindication: a history of a serious reaction (e.g., anaphylaxis) after a previous dose of pneumococcal vaccine (PPSV or PCV) or to a vaccine component. For a list of vaccine components, go to www.cdc.gov/vaccines/pubs/pinkbook/downloads/appendices/B/ excipient-table-2.pdf. b. Precaution: moderate or severe acute illness with or without fever 5. Provide all patients with a copy of the most current federal Vaccine Information Statement (VIS). Although not required by federal law, it is prudent to document in the patient’s medical record or office log, the publication date of the VIS and the date it was given to the patient. Provide non-English speaking patients with a copy of the VIS in their native language, if available; these can be found at www. immunize.org/vis. 6. Administer vaccine as follows: a. For adults identified in 1. and 2. above, administer 0.5 mL PPSV23 vaccine either intramuscularly (22–25g, 1–1½" needle) in the 5 deltoid muscle or subcutaneously (23–25g, /8" needle) in the posterolateral fat of the upper arm. b. For adults identified in 3. above, administer 0.5 mL PCV13 intramuscularly (22–25g, 1–1½" needle) in the deltoid muscle. For adults previously vaccinated with PPSV, give PCV13 at least 12 months following PPSV. If not previously vaccinated with PPSV, give PCV13 first, followed by PPSV23 in 8 weeks. 5 (Note: A /8" needle may be used for IM injection for patients who weigh less than 130 lbs [<60kg] for injection in the deltoid muscle, only if the subcutaneous tissue is not bunched and the injection is made at a 90-degree angle.) 7. Document each patient’s vaccine administration information and follow up in the following places: a. Medical chart: Record the date the vaccine was administered, the manufacturer and lot number, the vaccination site and route, and the name and title of the person administering the vaccine. If vaccine was not given, record the reason(s) for non-receipt of the vaccine (e.g., medical contraindication, patient refusal). b. Personal immunization record card: Record the date of vaccination and the name/location of the administering clinic. 8. Be prepared for management of a medical emergency related to the administration of vaccine by having a written emergency medical protocol available, as well as equipment and medications. 9. Report all adverse reactions to PPSV23 and PCV13 to the federal Vaccine Adverse Event Reporting System (VAERS) at www.vaers.hhs. gov or by calling (800) 822-7967. VAERS report forms are available at www.vaers.hhs.gov. This policy and procedure shall remain in effect for all patients of the______until rescinded or until ______(date). (name of practice or clinic) Medical Director’s signature: ______Effective date: ______For standing orders for other vaccines, go to www.immunize.org/standing-orders

Technical content reviewed by the Centers for Disease Control and Prevention,. www.immunize.org/catg.d/p3075.pdf • Item #P3075 (8/12)

VaccinateImmunization Adults! Action Coalition • October • 2012 1573 •Selby Immunization Ave. • St. Action Paul, MN Coalition 55104 • • (651) (651) 647-9009 647-9009 • www.immunize.org• www.immunize.org • www.vaccineinformation.org • www.vaccineinformation.org 9 First Do No Harm: Mandatory Influenza Vaccination Policies for Healthcare Personnel (HCP) Help Protect Patients

Refer to the position statements of the leading medical organizations listed below to help you develop and implement a mandatory influenza at your healthcare institution or medical setting. Policy titles, publication dates, links, and excerpts follow.

American Academy of Family Physicians (AAFP) “Encourages institutional, employer, and public health policy to require in- AAFP Mandatory Influenza Vaccination of Health Care Personnel (6/11) fluenza vaccination of all health workers as a precondition of employment www.aafp.org/online/en/home/clinical/immunizationres/influenza/ and thereafter on an annual basis, unless a medical contraindication recog- mandatoryinfluenza.html nized in national guidelines is documented in the worker’s health record.” “The AAFP supports annual mandatory influenza immunization for health care personnel (HCP) except for religious or medical reasons (not personal Association for Professionals in Infection Control and preferences). If HCP are not vaccinated, policies to adjust practice activi- Epidemiology (APIC) ties during flu season are appropriate (e.g. wear masks, refrain from direct Influenza Vaccination Should Be a Condition of Employment for Health- patient care).” care Personnel, Unless Medically Contraindicated (2/1/11) www.apic.org/Resource_/TinyMceFileManager/Advocacy-PDFs/APIC_In- American Academy of Pediatrics (AAP) fluenza_Immunization_of_HCP_12711.PDF “As a profession that relies on Policy Statement—Recommendation for Mandatory Influenza Immuniza- evidence to guide our decisions and actions, we can no longer afford to ig- tion of All Health Care Personnel (10/1/10) nore the compelling evidence that supports requiring influenza vaccine for http://pediatrics.aappublications.org/cgi/content/abstract/peds.2010-2376v1 HCP. This is not only a patient safety imperative, but is a moral and ethical “The implementation of mandatory annual influenza immunization pro- obligation to those who place their trust in our care.” grams for HCP nationwide is long overdue. For the prevention and control Infectious Diseases Society of America (IDSA) of influenza, now is the time to put the health and safety of the patient first.” IDSA Policy on Mandatory Immunization of Health Care Workers Against Seasonal and Pandemic Influenza (rev. 7/28/10) American College of Physicians (ACP) www.idsociety.org/HCW_Policy ACP Policy on Influenza Vaccination of Health Care Workers (9/1/10) “Physicians and other health care providers must have two special objec- www.acponline.org/clinical_information/resources/adult_immunization/flu_hcw.pdf tives in view when treating patients, namely, ‘to do good or to do no harm’ “Vaccinating HCWs [healthcare workers] against influenza represents a (Hippocratic Corpus in Epidemics: Bk. I, Sect. 5, trans. Adams), and have duty of care, and a standard of quality care, so it should be reasonable that an ethical and moral obligation to prevent transmission of infectious dis- this duty should supersede HCW personal preference.” eases to their patients.”

American Hospital Association (AHA) National Business Group on Health (NBGH) AHA Endorses Patient Safety Policies Requiring Influenza Vaccination of Hospitals Should Require Flu Vaccination for all Personnel to Protect Health Care Workers (7/22/11) Patients’ Health and Their Own Health (10/18/11) http://businessgrouphealth. www.aha.org/advocacy-issues/tools-resources/advisory/2011/110722- org/healthpolicy/statements.cfm quality-adv.pdf “Hospitals should require flu vaccination for all personnel to protect pa- “To protect the lives and welfare of patients and employees, AHA supports tients’ health and their own health.” mandatory patient safety policies that require either influenza vaccination or wearing a mask in the presence of patients across healthcare settings dur- National Foundation for Infectious Diseases (NFID) ing flu season. The aim is to achieve the highest possible level of protection.” Immunizing Healthcare Professionals Against Influenza (9/23/10) www.nfid. org/idinfo/influenza/influenza-info-hcps/hcp-immunization American Medical Directors Association (AMDA) “NFID supports the public statements supporting mandatory healthcare Mandatory Immunization for Long Term Care Workers (3/ 11) worker influenza vaccination policies from AAP, IDSA and SHEA. Mean- www.amda.com/governance/resolutions/J11.cfm ingful increases in healthcare worker immunization rates are essential to “Therefore be it resolved, AMDA - Dedicated to Long-Term Care Medicine patient safety, a hallmark of our healthcare system.” supports a mandatory annual influenza vaccination for every long-term National Patient Safety Foundation (NPSF) health care worker who has direct patient contact unless a medical contra- NPSF Supports Mandatory Flu Vaccinations for Healthcare Workers (11/18/09) indication or religious objection exists.” www.npsf.org/updates-news-press/press/media-alert-npsf-supports-mandatory- American Pharmacists Association (APhA) flu-vaccinations-for-healthcare-workers Requiring Influenza Vaccination for All Pharmacy Personnel (4/11) “NPSF recognizes vaccine-preventable diseases as a matter of patient safe- www.pharmacist.com/sites/default/files/files/2011ActionsoftheAPhAHoD- ty and supports mandatory influenza vaccination of health care workers to Public.pdf protect the health of patients, health care workers, and the community.” “APhA supports an annual influenza vaccination as a condition of employ- ment, training, or volunteering, within an organization that provides phar- Society for Healthcare Epidemiology of America (SHEA) macy services or operates a pharmacy or pharmacy department (unless a Influenza Vaccination of Healthcare Personnel (rev. 8/31/10) valid medical or religious reason precludes vaccination).” www.journals.uchicago.edu/doi/full/10.1086/656558 “SHEA views influenza vaccination of HCP as a core patient and HCP American Public Health Association (APHA) safety practice with which noncompliance should not be tolerated.” Annual Influenza Vaccination Requirements for Health Workers (11/ 9/10) www.apha.org/advocacy/policy/policysearch/default.htm?id=1410 continued on next page

www.immunize.org/catg.d/p2014.pdf • Item #P2014 (10/12)

10 Vaccinate Adults! • October 2012 • Immunization Action Coalition • (651) 647-9009 • www.immunize.org • www.vaccineinformation.org First Do No Harm: Mandatory Influenza Vaccination Policies for HCP Help Protect Patients

Practical Resources for Vaccinating HCP Against Influenza

American Nurses Association (ANA) Immunization Action Coalition (IAC) • Unite to Fight the Flu! tool kit provides a listing of links for staff and patient educational materials, posters, recommendations, and Visit the Immunization Action Coalition’s Honor Roll PSAs: www.anaimmunize.org/flutoolkit for Patient Safety to view stellar examples of influenza vaccination mandates in healthcare settings: www. • Nurse-to-Nurse Influenza Vaccinationvideo uses principles of risk communication to address the concerns of a nurse hesitant to re- immunize.org/honor-roll ceive influenza vaccine: www.anaimmunize.org/flu-video

Association for Professionals in Infection Get these IAC print materials online: Control and Epidemiology (APIC) • Access Influenza Vaccine Information Statements (VISs) in more Protect Your Patients. Protect Yourself tool kit features a variety of than 35 languages: www.immunize.org/vis helpful resource materials for healthcare institutions to implement or expand their healthcare worker immunization programs: http:// • How to Administer Intramuscular, Intradermal, and Intranasal Influ- utility.apic.org/Content/NavigationMenu/PracticeGuidance/Topics/ enza Vaccines: www.immunize.org/catg.d/p2024.pdf Influenza/toolkit_contents.htm • Influenza Vaccine Products for the 2012–13 Influenza Season: www. immunize.org/catg.d/p4072.pdf Centers for Disease Control and Prevention (CDC) • Read the joint HICPAC/ACIP Recommendations Influenza Vacci- nation of Health-Care Personnel (MMWR, 2/24/06): www.cdc.gov/ mmwr/PDF/rr/rr5502.pdf • For more recent guidance from CDC, see Immunization of Health- Care Personnel: Recommendations of the Advisory Committee on Immunization Practices (MMWR, 11/25/11): www.cdc.gov/mmwr/ pdf/rr/rr6007.pdf • Visit CDC’s Influenza web section: www.cdc.gov/flu

Department of Health and Human Services (HHS) See HHS’s Influenza Vaccination of Healthcare Personnel: Disease, vaccine, beliefs, barriers, and recommended strategies to improve vaccination: www.hhs.gov/ash/initiatives/vacctoolkit/presentation.html

Immunization Action Coalition of Washington Tool Kit Make the Case toolkit promotes influenza and Tdap immunization among healthcare providers: • Standing Orders for Administering Influenza Vaccine to Adults: www.immunizewa.org/healthcare_worker_toolkit www.immunize.org/catg.d/p3074.pdf • Screening Checklist for Contraindications to Inactivated Inject- The Joint Commission able Influenza Vaccination: Providing a Safer Environment for Health Care Personnel and Patients www.immunize.org/catg.d/p4066.pdf Through Influenza Vaccination monograph helps healthcare organi- • Screening Checklist for Contraindications to Live Attenuated zations of all types improve seasonal influenza vaccination rates in Intranasal Influenza Vaccination: healthcare personnel: www.immunize.org/catg.d/p4067.pdf www.jointcommission.org/assets/1/18/Flu_Monograph.pdf • Influenza Vaccination of People with a History of Egg Allergy: www.immunize.org/catg.d/p3094.pdf National Influenza Vaccine Summit (NIVS) Co-sponsored by the American Medical Association and CDC. • Declination of Influenza Vaccination (for healthcare worker refusal): www.immunize.org/catg.d/p4068.pdf Visit the summit website: www.preventinfluenza.org

Video Commentary Visit IAC’s Influenza web section: www.immunize.org/influenza Why Hospital Workers Should Be Forced to Get Flu Shots by Arthur

2012–13 Influenza Vaccine L. Caplan, PhD, New York University: Pocket Guide Who Should Be Vaccinated? Annual vaccination against influenza is recommended for all people age 6 mos and older who do not have a contraindication to the vaccine. Important Points for Healthcare Providers • Vaccination should begin as soon as vaccine becomes available in late summer and should continue through the spring months. Free! Order bulk quantities of Influenza Vaccine Pocket • Six manufacturers will produce approximately 150 million doses of www.medscape.com/viewarticle/770383 (log-in required) vaccine for the 2012–13 influenza vaccination season in the U.S.; five of the six will produce vaccine for use in children. • Vaccine recommendations have been updated to include revised information concerning the number of vaccine doses recommended for children age 6 mos through 8 yrs (see reverse side). • It is important that you and everyone in your healthcare setting be vaccinated to protect patients, other healthcare workers, their families Guides for distribution to healthcare professionals: —and to set the right example. Talking Points with Patients • Influenza is a serious respiratory disease caused by a virus. It is not the same as the common cold or an intestinal illness. • Influenza may be contagious for 24 hrs before any symptoms develop. Though everyday preventive actions (e.g., handwashing) can help prevent transmission of many types of germs, the best way to avoid www.immunize.org/pocketguides influenza infection is to get vaccinated. • Many places offer influenza vaccine to the public. If a physician prac- tice is not offering influenza vaccine, patients should be encouraged to seek vaccination in a health department clinic, pharmacy, retail store, community site, workplace, or school-based clinic. • Because influenza vaccine is recommended for almost everyone, it is covered by most health insurance plans; it is covered under Medicare Part B for those enrolled in Medicare. • It is important that everyone age 6 mos and older be vaccinated for their own protection, as well as the protection of those they love and those who are especially vulnerable to the serious and sometimes deadly complications of influenza. Influenza is a serious and unpredictable disease! Vaccinate everyone age 6 months and older. Created by the Immunization Action Coalition (www.immunize.org) in collaboration with the National Influenza Vaccine Summit (www.preventinfluenza.org) Item #R2202 (8/12)

www.immunize.org/catg.d/p2014.pdf • Item #P2014 (10/12)

Vaccinate Adults! • October 2012 • Immunization Action Coalition • (651) 647-9009 • www.immunize.org • www.vaccineinformation.org 11 12 Influenza Vaccine Products for the 2012–2013 Influenza Season Information about influenza vaccine products

Mercury Manufacturer Trade Name How Supplied Content Age Group Product Code1 (μg Hg/0.5mL) 0.5 mL (single-dose syringe) 0 90656 CSL Biotherapies Afluria (TIV)2 9 years & older3 5.0 mL (multi-dose vial) 24.5 90658 Q2035 (Medicare) GlaxoSmithKline Fluarix (TIV) 0.5 mL (single-dose syringe) 0 3 years & older 90656 ID Biomedical Corp of 90658 Quebec, a subsidiary FluLaval (TIV) 5.0 mL (multi-dose vial) <25 18 years & older Q2036 (Medicare) of GlaxoSmithKline MedImmune FluMist (LAIV)2 0.2 mL (single-use nasal spray) 0 2 through 49 years 90660 0.5 mL (single-dose syringe) <–1 90656 Novartis Vaccines Fluvirin (TIV) 4 years & older 90658 5.0 mL (multi-dose vial) 25 Q2037 (Medicare) 90658 Agriflu (TIV) 0.5 mL (single-dose syringe) 0 18 years & older Q2034 (Medicare) 0.25 mL (single-dose syringe) 0 6 through 35 months 90655 5.0 mL (multi-dose vial) 25 6 through 35 months 90657 0.5 mL (single-dose syringe) 0 3 years & older 90656 sanofi pasteur Fluzone (TIV) 0.5 mL (single-dose vial) 0 3 years & older 90656 90658 5.0 mL (multi-dose vial) 25 3 years & older Q2038 (Medicare) Fluzone High-Dose (TIV) 0.5 mL (single-dose syringe) 0 65 years & older 90662

Fluzone Intradermal (TIV) 0.1 mL (single-dose micro injection 90654 system) 0 18 through 64 years footnotes 1. Effective for claims with dates of service on or after 1/1/2011, CPT (Current Procedural 3. On August 6, 2010, ACIP recommended that Afluria not be used in children younger Terminology) code 90658 is no longer payable for Medicare; rather, HCPCS (Healthcare than age 9 years. If no other age-appropriate TIV is available, Afluria may be considered Common Procedure Coding System) Q codes, as indicated above, should be submitted for a child age 5 through 8 years at high risk for influenza complications, after risks and for Medicare payment purposes. benefits have been discussed with the parent or guardian. Afluria should not be used in 2. TIV is the abbreviation for trivalent inactivated influenza vaccine (injectable); LAIV is the children younger than age 5 years. This recommendation continues for the 2012–2013 abbreviation for live attenuated influenza vaccine (nasal spray). influenza season.

Technical content reviewed by the Centers for Disease Control and Prevention Immunization Action Coalition 1573 Selby Avenue • St. Paul, MN 55104 • 651-647-9009 • www.immunize.org • www.vaccineinformation.org www.immunize.org/catg.d/p4072.pdf • Item #P4072 (8/12) No More Excuses.

Anyone can get the flu, and it can be serious. Every year, protect yourself and those around THERE ARE MANY PLACES you by getting a TO GET YOUR FLU VACCINE. flu vaccine.

DOCTOR’S RETAIL OFFICE SCHOOLS PHARMACIES STORES

GROCERY PEDIATRICIAN’S HEALTH STORE OFFICE DEPARTMENT WORKPLACE

MEDICAL DRUG COMMUNITY CENTER STORE CLINICS CENTER For more information, visit http://www.cdc.gov/flu

U.S. Department of Health and Human Services Centers for Disease Control and Prevention

CS226285-B13 “ Prevention and Control of Influenza InfluenzaV accination of People with Vaccines: Recommendations of the ACIP–U.S., 2012–13 Influenza Season.” with a History of Egg Allergy MMWR, August 17, 2012/Vol. 61/No. 32, The entire article is available at www.cdc.gov/mmwr/pdf/wk/mm6132.pdf, pages 613–618. pages 613–618.

Severe allergic and anaphylactic reactions can occur in response figure 2 to a number of influenza vaccine components, but such reac- Recommendations regarding influenza vaccination for tions are rare. All currently available influenza vaccines are pre- persons who report allergy to eggs – ACIP, United States, pared by means of inoculation of virus into chicken eggs. The 2012–13 influenza season use of influenza vaccines for persons with a history of egg allergy has been reviewed recently by ACIP (16). For the 2011–12 influenza season, ACIP recommended that persons with egg Can the person eat lightly yes Administer vaccine per cooked egg (e.g., scrambled allergy who report only hives after egg exposure should receive usual protocol. TIV, with several additional safety measures, as described in this egg) without reaction?* document. Recent examination of VAERS data indicated no dis- proportionate reporting of allergy or anaphylaxis after influenza no vaccination during the 2011–12 season (21). For the 2012–13 influenza season, ACIP recommends the following: Administer TIV. After eating eggs or yes egg-containing foods, does 1. Persons with a history of egg allergy who have experienced only Observe for reaction for at the person experience least 30 minutes after hives after exposure to egg should receive influenza vaccine, only hives? vaccination. with the following additional safety measures (Figure 2): no a) Because studies published to date involved use of TIV, TIV rather than LAIV should be used (22); Does the person experience yes Refer to a physician with b) Vaccine should be administered by a health-care provider who other symptoms such as expertise in management is familiar with the potential manifestations of egg allergy; and • Cardiovascular changes of allergic conditions for (e.g., hypotension)? further evaluation. c) Vaccine recipients should be observed for at least 30 minutes • Respiratory distress for signs of a reaction after administration of each vaccine (e.g., wheezing)? * abbreviation • dose (22). Gastrointestinal * TIV = trivalent (e.g., nausea/vomiting)? 1. Other measures, such as dividing and administering the vac- • Reaction requiring * Persons with egg allergy might cine by a two-step approach and skin testing with vaccine, are epinephrine? tolerate egg in baked products • Reaction requiring emer- (e.g., bread or cake). Tolerance to not necessary (22). egg-containing foods does not gency medical attention? 2. Persons who report having had reactions to egg involving such exclude the possibility of egg allergy. symptoms as angioedema, respiratory distress, lightheaded- ness, or recurrent emesis; or who required epinephrine or 4. Some persons who report allergy to egg might not be egg-allergic. another emergency medical intervention, particularly those Those who are able to eat lightly cooked egg (e.g., scrambled that occurred immediately or within a short time (minutes to egg) without reaction are unlikely to be allergic. Egg-allergic hours) after egg exposure, are more likely to have a serious persons might tolerate egg in baked products (e.g., bread or systemic or anaphylactic reaction upon reexposure to egg pro- cake). Tolerance to egg-containing foods does not exclude the teins. Before receipt of vaccine, such persons should be possibility of egg allergy (23). Egg allergy can be confirmed referred to a physician with expertise in the management of by a consistent medical history of adverse reactions to eggs allergic conditions for further risk assessment (Figure 2). and egg-containing foods, plus skin and/or blood testing for immunoglobulin E antibodies to egg proteins. 3. All vaccines should be administered in settings in which person- nel and equipment for rapid recognition and treatment of ana- 5. A previous severe allergic reaction to influenza vaccine, regard- phylaxis are available. ACIP recommends that all vaccination less of the component suspected to be responsible for the providers should be familiar with the office emergency plan (11). reaction, is a contraindication to future receipt of the vaccine.

references note: Reference numbers on this sheet are taken from the complete article found at itoring. Presented at the Advisory Committee on Immunization Practices meeting, Atlanta, www.cdc.gov/mmwr/pdf/wk/mm6132.pdf, pages 613–618. GA; June 2012. Available at www.cdc.gov/vaccines/recs/acip/downloads/ 11. CDC. General recommendations on immunization: recommendations of the Advisory mtg-slides-jun12/03-influenza-shimabukuro.pdf. Accessed August 10, 2012. Committee on Immunization Practices (ACIP). MMWR 2011;60(No. RR-2). 22. Kelso JM, Greenhawt MJ, Li JT. Adverse reactions to vaccines practice parameter 2012 16. CDC. Prevention and control of influenza with vaccines: recommendations of the Advisory update. J Allergy Clin Immunol 2012;130:25–43. Committee on Immunization Practices (ACIP), 2011. MMWR 2011;60:1128–32. 23. Erlewyn-Lajeunesse M, Brathwaite N, Lucas JS, Warner JO. Recommendations for the 21. Advisory Committee on Immunization Practices. Update on influenza vaccine safety mon- administration of influenza vaccine in children allergic to egg. BMJ 2009;339:912–5.

Technical content reviewed by the Centers for Disease Control and Prevention

Immunization Action Coalition 1573 Selby Avenue • St. Paul, MN 55104 • 651-647-9009 • www.immunize.org • www.vaccineinformation.org

www.immunize.org/catg.d/p3094.pdf • Item #P3094 (9/12) 14 Ask the Experts . . . continued from page 5

IAC’s Now Available! 2012 Edition “Ask the The Vaccine Handbook: Experts” A Practical Guide for Clinicians team by Gary S. Marshall, MD from www.immunize.org/vaccine-handbook CDC

Andrew T. Kroger, MD, MPH Donna L. Weaver, RN, MN Iyabode Akinsanya-Beysolow, MD, MPH

chickenpox, but their titers show no antibod- many years ago—can you advise? ies. Should I offer varicella vaccination to All healthcare personnel (HCP) with risk of ex- them even though they insist they’ve had the posure to hepatitis B should be tested 1–2 months illness? after receiving the third dose of . If you cannot verify a healthcare employee’s his- CDC does not recommend testing healthcare per- tory of chickenpox, the employee should receive sonnel who were not tested within the 1–2 month 2 doses of varicella vaccine at least 4 weeks apart. postvaccination time frame. HCP who are exposed For details, refer to pages 16 and 26 of the CDC can be tested as part of postexposure management, recommendations Prevention of Varicella at www. if indicated. For more information, see “Hepatitis cdc.gov/mmwr/pdf/rr/rr5604.pdf. B and the Healthcare Worker” at www.immunize. Does the recommendation to administer org/catg.d/p2109.pdf. hepatitis B vaccine to diabetics younger than Should women who have not received HPV age 60 extend to women with gestational vaccine get Pap tests more often than women diabetes? who have received HPV vaccine? No. The 2011 CDC recommendations for hepatitis No. Receipt of HPV vaccine does not replace the B vaccination of people with diabetes pertain to need for cervical cancer screening. Women should those with type-1 and type-2 diabetes. They do consult their healthcare provider for recommenda- not apply to women with gestational diabetes. It tions regarding the frequency of cervical cancer is worth noting that pregnancy is not a contraindi- screening, which includes Pap testing and HPV cation to hepatitis B vaccination, and that women testing. with gestational diabetes are more likely to develop Now Available! 4th Edition Is it acceptable practice to administer MMR, type-1 or type-2 diabetes later in life. Diabetic American College of Physicians women who become pregnant can be vaccinated, Tdap, and influenza vaccines to a postpar- if indicated. The CDC recommendations "Use of tum mom at the same time as administering Guide to Adult Immunization: RhoGam? Hepatitis B Vaccination for Adults with Diabetes Yes. Receipt of RhoGam is not a reason to delay A Team-based Manual Mellitus" are available at www.cdc.gov/mmwr/pdf/ vaccination. See page 9 of CDC’s General Rec- wk/mm6050.pdf on pages 1709–11. (updated March 2012) ommendations on Immunization at www.cdc.gov/ I still am not clear about the need for testing if mmwr/pdf/rr/rr6002.pdf. http://immunization.acponline.org the hepatitis B vaccine series was completed

To receive “Ask the Experts” Q&As by email, subscribe to the Immunization Action Coalition’s news service, IAC Express. Special “Ask the Experts” issues are published five times per year. Subscribe at www.immunize.org/subscribe

To find more than a thousand “Ask the Experts” Q&As answered by CDC experts, go to www.immunize.org/askexperts

Vaccinate Adults! • October 2012 • Immunization Action Coalition • (651) 647-9009 • www.immunize.org • www.vaccineinformation.org 15 Protect Your Baby from Serious Diseases

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Flu and are very serious diseases, especially in infants. Many babies are too young to get certain vaccines. Vaccinate people around these babies to protect them from disease. People who should get flu and whooping cough vaccines are: p Pregnant women (protection is passed on from mother to baby) p Parents, grandparents, and household members including brothers and sisters p Babysitters and out-of-home caregivers including daycare workers p Health care personnel in hospitals and clinics p Any loved ones who visit your baby Be sure all the people around your baby get vaccinated!

16 Cocooning Protects Babies Everyone in a baby’s life needs to get vaccinated against whooping cough and flu!

What is cocooning? How can we protect babies against Babies younger than 6 months old are more likely to develop whooping cough? certain infectious diseases than older children are. Co- • All children should be vaccinated on schedule with cooning is a way to protect babies from catching diseases DTaP (the childhood whooping cough vaccine). from the people around them – people like their par- • All teenagers and adults need a one-time dose of Tdap ents, siblings, grandparents, friends, child-care providers, vaccine (the teen and adult whooping cough vaccine). babysitters, and healthcare providers. Once these people • Unvaccinated women who might become pregnant are vaccinated, they are less likely to spread these conta- should receive a Tdap vaccination. gious diseases to the baby. They surround the baby with a cocoon of protection against disease until he or she is old • Pregnant women who haven’t been vaccinated with enough to get all the doses of vaccine needed to be fully Tdap should receive a dose in the 2nd or 3rd trimester protected. of pregnancy. This will protect the pregnant woman as well as her baby! Why is cocooning important? Babies less than 6 months old are too young to have How can we protect babies against flu? received all the doses of vaccine that are needed to protect Everyone age 6 months and older needs to receive flu them from whooping cough (pertussis), flu (influenza), vaccine every year. and other dangerous diseases. To be fully protected, ba- information from trusted sources bies need to get all the vaccine doses in a series – not just the first dose. � Video: Surround Your Baby with Protection (about whooping cough) Unvaccinated adults and family members, including parents, www.preventpertussis.org/consumer/video.html are often the ones who unknowingly spread dangerous From the Texas Department of State Health Services

diseases to babies. � Diseases and the Vaccines That Prevent Them www.cdc.gov/vaccines/spec-grps/hcp/ Currently, towns and cities across the nation have had whoop- provider-resources-factsheets.html ing cough outbreaks. Influenza outbreaks happen every year. From the Centers for Disease Control and Prevention

� Vaccine Educational Materials for Parents How can we protect babies? www.chop.edu/service/vaccine-education-center/ Everyone has the opportunity to protect babies by getting order-educational-materials From the Vaccine Education Center, Children’s Hospital vaccinated themselves. Cocooning is an easy and effective of Philadelphia way that people can work together to prevent the spread � Vaccine Information Website of whooping cough and flu to babies. www.vaccineinformation.org From the Immunization Action Coalition

� Cocooning and Tdap Vaccination Web Section (cocooning information about whooping cough) www.immunize.org/cocooning From the Immunization Action Coalition

Technical content reviewed by the Centers for Disease Control and Prevention

Immunization Action Coalition 1573 Selby Avenue • St. Paul, MN 55104 • 651-647-9009 • www.immunize.org • www.vaccineinformation.org

www.immunize.org/catg.d/p4039.pdf • Item #P4039 (10/12) 17 Order Essential Immunization Resources from IAC Immunization record cards for all: for adults, for children & teens, for a lifetime! Immunization record cards offer healthcare professionals a way to mended for people in the age group. Sized to fit in a wallet, each is help patients maintain a permanent record of their vaccinations. brightly colored to stand out and is printed on durable rip-, smudge-, Patient-held cards are handy for patients when they enter daycare or and water-proof paper. school, change healthcare providers, or travel abroad. To order record cards or any of our other essential immunization We offer three record cards: adult, child & teen, and lifetime. Each resources, print out and mail or fax the form below, or place your is designed for a specific age group and lists all vaccines recom- order online at www.immunize.org/shop.

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Order Essential Immunization Resources How to Place an Order By Credit Card: Order easily online at our secure shopping cart at Patient Immunization Record Cards — www.immunize.org/shop. Qty. for adults, children & teens, and for a lifetime! Amt. (all are wallet-sized; details p. 3; call for discounts on bulk orders) By Check, Purchase Order, or Credit Card: Print out this page, fill 250 cards/box; 1 box–$45; 2 boxes–$40 each; 3 boxes–$37.50 each; 4 boxes–$34.50 each out the necessary information, and ��� R2005 Adult immunization record cards ...... $______Fax the page to: (651) 647-9131 or ��� R2003 Child/teen immunization record cards ...... $______��� R2004 Lifetime immunization record cards ...... $______Mail the page to: Immunization Action Coalition 1573 Selby Avenue, Suite 234 DVD – Immunization Techniques: Best Practices St. Paul, MN 55104 with Infants, Children, and Adults Our federal ID# is 41-1768237. (details p. 3; call for discounts on bulk orders) 1-9 copies–$17 each; 10-24 copies–$10.25 each; 25-49 copies–$7 each For Questions or International Orders: Contact us by phone at ��� D2021 Immunization Techniques: Best Practices with Children/Teens/Adults.....$______(651) 647-9009 or email [email protected] Thank you for your support of the Immunization Action Coalition. We Laminated 2012 U.S. Immunization Schedules depend on you! (details p. 3; call for discounts on bulk orders) ��� R2009 Adult schedule: 1-4 copies–$7.50 each; 5-19 copies–$5.50 each...... $______��� R2008 Child/teen schedule: 1-4 copies–$7.50 each; 5-19 copies–$5.50 each...... $______Method of payment: ❏ Check enclosed (payable to Immunization Action Coalition) ❏ Purchase order # ______Total for Purchases $

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18 Vaccinate Adults! • October 2012 • Immunization Action Coalition • (651) 647-9009 • www.immunize.org • www.vaccineinformation.org