Immunizations 101 Best Practices in Vaccine Administration Handbook

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2 Table of Contents VACCINE STORAGE & HANDLING PAGE: Office Vaccine Management Plan 6 Vaccine Coordinator 7 Vaccine Cold Chain 8 Vaccine Expiration Guide 11 Refrigerator Prep/Setup 12 Freezer Prep/Setup 14 Monthly Care of Storage Units 16 Safeguard Your Power Supply 17 Refrigerator/Freezer Action Guide 18 Contact Info for Manufacturer/Distributors 20 Vaccine Acronyms/Abbreviations 21 Procedures in the Event of a Power Failure 22 Transporting Refrigerated Vaccine 23 Don't Be Guilty of These Preventable Errors 24 BEFORE YOU VACCINATE Children/Teen Vaccine Schedule 28 Vaccine-Preventable Disease/Vaccines that Prevent Them 29 Binational Tool for Vaccines given in Mexico 30 Screening Checklist for Children/Teens 32 Overview of Recommended Vaccines for Adults 34 Pneumococcal Vaccine Timing -For Adults 37 Screening Checklist for Adults 38 Guide to Containdications/Precautions 40 Vaccine Ingredients 42 Latex in Vaccine Packaging 46 Minimum Ages and Intervals Between Doses 48 Vaccine Information Statements (VISs) 50 Vaccine For Children Program (VFC) 52 HOW TO ADMINISTER VACCINES Six Rights/General Rules/Missed Opportunities 54 Preparing Your Work Area 55 Administering Vaccines: Dose,Route,Site,Needles 56 Preparing Liquid Vaccines 57 Vaccines with Diluents 58 Preparing Reconstituted Vaccines 59 Tdap or DTaP 60 DTaP, Tdap, Td Catch-up Vaccination 61 Administering Injectable Vaccines 62 Comforting Restraint 63 Immunization Site Maps 64 How to Administer Intradermal, Intranasal, Oral Vaccines 68 Nevada Web IZ 69 Skills Checklist for Immunization 70 VACCINE SAFETY & MEDICAL MANAGEMENT OF EVENTS Vaccine Adverse Event Reporting System (VAERS) 74 VAERS Table of Reportable Events 75 Medical management of Children and Teens 76 Initial Office Mangement of Anaphylaxis 79 TOOLS FOR TALKING WITH PARENTS Ten Reasons to Protect Your Child by Vaccinating 83 Cocooning Protects Babies 84 Be There for Your Child During Shots 85 Tips for a Less Stressful Shot Visit 86 After the Shots… 88 Vaccine Safety: 10 Facts for Medical Assistants 90 Clear Answers & Smart Advice About Your Baby's Shots 93 Need help Responding to Vaccine-hesitant Parents? 99 VACCINES THROUGH THE LIFE SPAN Pregnancy: Recommended Vaccines 102 5 Facts about Tdap & Pregnancy 103 Pertussis Information for Pregnant Women 105 Pregnant Women Need a Flu Shot 107 Hepatitis B Birth Dose: Hep B Fact Sheet 109 Medical Errors Lead to Hep B Infection 110 Testing for Hep B During Pregnancy 111 Prenatal Care to Prevent Hep B 112 Interpretation of Hep B Serologic Tests 113 Hospital Guidance to Prevent Hep B 114 Children/Tweens/Teens: 2016 CDC Schedule Age 0 to 18 Years 117 Adults: 2016 CDC Recommended Schedules Age 19 and Older 126

VACCINE STORAGE & HANDLING

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OFFICE VACCINE MANAGEMENT PLAN TEMPLATE

This plan has been developed to assure the proper handling and storage of vaccines administered by this clinic. Vaccines are temperature and light sensitive and must be stored correctly to maintain their effectiveness. The following personnel are responsible for vaccine management:

Vaccine Coordinator ______

Home phone number ______

Cell phone number ______

Back Up Vaccine Coordinator ______

Home phone number ______

Cell phone number ______

VACCINE ORDERING

To request state supplied vaccine, follow instructions in the Vaccines for Children Program Protocol (pages 8- 10).

To order privately supplied vaccine, refer to ______.

VACCINE RECEIVING

When vaccine is received by the front desk personnel, the vaccine coordinator or back-up will be notified immediately. All staff will be trained in vaccine receipt. The box will be taken to the vaccine storage area and unpacked in the following manner within 2 hours of receipt:

REFRIGERATED VACCINE

1. Upon opening the box, verify that the cold chain has been maintained. First, check the temperature indicator to determine if the vaccines were exposed to temperatures above 46϶F. Follow the instructions on the card. Second, inspect the temperature indicator for evidence that the vaccines were frozen. Follow the instructions on the card. Examine the shipping container and contents for signs of damage. If damage to the contents or cold chain failure is noted, then call the Nevada State Immunization Program (775-684-5900). Finally, check the interval between shipment from the supplier and arrival of the product at the office. If more than 48 hours has elapsed, call the Nevada State Immunization Program. The vaccine shipment must be inspected within 2 hours of arrival. If problems are discovered two hours after arrival of the vaccine, then McKesson is not responsible for replacement of the compromised vaccine. 2. Check the contents of the shipment against the shipping invoice. Compare quantities, lot numbers, and expiration dates carefully. Log in the date, name of the vaccine, lot number, manufacturer, expiration date, arrival condition and quantity received in your log book. Any discrepancies must be reported immediately to the Nevada State Immunization Program (775-684-5900). 3. File the shipping invoice in your Immunization Program binder. 4. Place the new vaccines in the refrigerator with the shortest expiration dates in the front of the pack. Make sure to separate the VFC vaccines from the private supply by ______.

Reviewed: 8/2011; 12/2012; 2/2013; 3/2013; 7/2013; 2/2014; 8/2014; 12/2014; 1/2015 Page 1 of 12 6 Vaccine Coordinator

The Role of the Vaccine Coordinator

Vaccines are expensive and sensitive to temperature. Careful vaccine management is essential to protecting your vaccine supply.

VFC requires providers to designate a fully trained Vaccine Coordinator and a Backup Vaccine Coordinator to implement routine and emergency vaccine management plans. Their names and contact information must be reported to the VFC Program through MyVFCVaccines.org. In many practices, the Vaccine Coordinator is a medical assistant. In other practices, the Vaccine Coordinator is an LVN, RN, office manager, or other staff person.

Responsibilities of the Vaccine Coordinator

The Vaccine Coordinator’s responsibilities vary depending on the amount of vaccine the practice gives and practice protocols. In some practices, the Vaccine Coordinator is responsible for all vaccine management activities, including training other (especially new) staff. In other practices, a different person may have one or more vaccine management responsibilities, such as ordering vaccines. Below is a list of essential responsibilities.

Receiving vaccines • Be present when vaccine is delivered and immediately process it into inventory. • Ensure that acceptable temperature ranges have been maintained.

Storing vaccines • Rotate the vaccine inventory so that vaccines with shorter expiration dates are used first. • Ensure that there are no expired vaccines in the refrigerator or freezer. • Keep VFC vaccine separate from private vaccine stock. • Perform routine cleaning on vaccine storage units.

Monitoring vaccine temperatures • Use a certified calibrated thermometer to review refrigerator and freezer temperatures. • Record minimum, current, and maximum temperatures on a VFC-supplied log twice a day. • Take immediate action if temperatures are outside acceptable ranges. • Implement the emergency vaccine management plan, if necessary. • Review vaccine temperature logs weekly. • Retain temperature logs for three years.

Ordering vaccines • Perform a physical inventory of all vaccines in stock. • Account for doses of returned or transferred vaccines since the last order. • Complete and submit the VFC vaccine order at MyVFCVaccines.org.

www.eziz.org

California Department of Public Health, Immunization Branch IMM-968 (7/13) 7 Vaccine Cold Chain

Key Messages: Cold Chain Flow Chart

The vaccine cold chain is a temperature-controlled environment used to maintain and distribute vaccines in optimal condition. Manufacturer Vaccine Responsibility Manufacturer Monitor the temperature of your storage unit(s) regularly to assure that appropriate conditions are maintained. Manufacturer/Distributor Vaccine Take immediate corrective action when a storage Responsibility Distribution unit temperature is outside the recommended range (Troubleshooting).

Call the vaccine manufacturer for guidance. Provider Vaccine Arrival Responsibility at Provider If you are a VFC provider or have other vaccines Facility purchased with public funds, contact your immunization program . Vaccine Storage Vaccine appearance is NOT a reliable indicator and Handling at Provider that vaccines have been stored under appropriate Facility conditions.

Vaccine exposed to inappropriate temperatures that Vaccine is inadvertently administered generally should be Administration repeated. Contact your immunization program , vaccine manufacturer(s), or both for guidance.

What is the Vaccine Cold Chain?

The vaccine cold chain is a temperature-controlled environment used to maintain and distribute vaccines in optimal condition. The cold chain relies on three main elements:

੠Well-trained personnel ੠Reliable transportation and storage equipment ੠Efficient management procedures

The cold chain begins with the cold storage unit at the manufacturing plant, extends through transport of vaccine(s) to the distributor, then delivery and storage at the provider facility, and ends with administration of vaccine to the patient. Appropriate storage conditions must be maintained at every link in the cold chain.

11 8 Vaccine Cold Chain

Importance of Maintaining the Vaccine Cold Chain Vaccine Potency Vaccine Appearance after Exposure to Inappropriate Storage Conditions Excessive heat, cold, or light exposure can Some vaccines may damage vaccines, show physical evidence resulting in reduced that potency has been potency. Once potency reduced when exposed is lost, it cannot be to inappropriate storage restored. Each time conditions. This may appear as vaccines are exposed clumping in the solution that to improper conditions, does not go away when the VACCINE potency is reduced vial is shaken. Other vaccines further. Eventually, if the may look normal when cold chain is not properly exposed to inappropriate maintained, potency will storage conditions (see be lost, and the vaccines become useless. photos below). For example, inactivated vaccines exposed to freezing temperatures (i.e., 32°F [0°C] While exposure to any inappropriate conditions or colder) may not appear frozen and give no can affect potency of refrigerated vaccines, a indication of reduced or lost potency. Vaccine single exposure to freezing temperatures will appearance is NOT a reliable indicator that destroy some. Liquid vaccines that contain an vaccines have been stored under appropriate aluminum adjuvant* can permanently lose conditions. potency when exposed to freezing temperatures. Monitor the temperature of your storage unit(s) regularly.

Take immediate corrective action when a storage unit temperature reading is outside the Can you spot recommended range (temperature excursion). the difference? Call your immunization program and/ or the vaccine manufacturer for guidance (Troubleshooting). Properly stored Improperly stored vaccine vaccine If you are a VFC provider or have other Full Potency Diminished Potency vaccines purchased with public funds, contact Vaccine appearance is NOT a reliable indicator that vaccines your immunization program . have been stored under appropriate conditions.

*Adacel, Boostrix, Cervarix, Comvax, Daptacel, Decavac, Engerix-B, Gardasil, Havrix, Infanrix, Kinrix, Pediarix, PedvaxHIB, Pentacel, Prevnar 13, Recombivax HB, Tenivac, Twinrix, and Vaqta contain an aluminum adjuvant, which boosts the immune response to the vaccine.

12 9 Vaccine Cold Chain

Store in Refrigerator Between 35°F and 46°F (2°C and 8°C)

MMR†§ HepA HepB HepA-HepB Hib† Hib-HepB Human papillomavirus (HPV2 and HPV4†) Influenza (LAIV, IIV,† RIV†) † Store in Freezer IPV Between -58°F and +5°F (-50°C and -15°C) Meningococcal-containing (Hib-MenCY,† MCV4,† MPSV4) VAR† Pneumococcal (PCV13 and PPSV23) HZV† Rotavirus† (RV1 and RV5) MMRV† Diphtheria toxoid-, Tetanus toxoid-, MMR†§ and Pertussis-containing (DT, DTaP, DTaP-HepB-IPV, DTaP-IPV, DTaP-IPV/Hib, Tdap, Td, TT)

†Protect the following vaccines from light: Varivax, Zostavax, ProQuad, M-M-R II, Hiberix, Gardasil, Afluria, Agriflu, Fluarix, Flublok, Flucelvax, FluLaval, Fluvirin, IPOL, MenHibrix, Menveo, Rotarix, and RotaTeq. §Unreconstituted lyophilized (freeze-dried) MMR may be frozen or refrigerated.

13 10 Vaccine Inventory Management

Vaccine Expiration Date: Vaccine Expiration Date: 08/16/15 08/15 Note: Use through Note: Use through August 16, 2015. August 31, 2015. Do NOT use on or after Do NOT use on or after August 17, 2015. September 1, 2015.

Vaccine may be used up to and including the expiration date. Exceptions to Expiration Dates on Labels (Beyond Use Date)

There are 3 instances when vaccines must be used prior to the expiration date printed on the label. 1. Reconstitution 3. Manufacturer shortened expiration date Once a lyophilized (freeze-dried) vaccine If vaccine has been exposed to is mixed with a diluent (liquid) and inappropriate storage conditions, its reconstituted into a liquid form, there is potency may be reduced before the a limited time frame in which the vaccine expiration date printed on the label. can be used. This time frame is indicated A manufacturer may determine that in the manufacturer’s package insert the vaccine can be used, but with a . Also see Reconstitution and IAC’s shortened expiration date. Contact Vaccines with Diluents: How to Use your immunization program and/ Them . or the vaccine manufacturer(s) per 2. Multidose vials your protocol for further guidance in Most multidose vials may be used until the determining if the vaccine can be used expiration date printed on the vial unless with a shortened expiration date or if it contaminated or compromised in some should be discarded. way. However, some multidose vials have a When vaccines must be used prior to the specified time frame for use once the vial expiration date on the label, this is referred to is entered with a needle (package insert) as the “beyond use date” or “BUD” noted in the . Also see Multidose Vials. package insert . For reconstituted vaccines, this may be a date and/or time after which the vaccine cannot be used. The “BUD” (date and/ or time) should be noted on the label along with the initials of the person changing the date/time.

60 11 Preparing Refrigerators for Vaccine Storage

1 Remove all drawers 2 Fill the refrigerator oor and bins. with water bottles. Put 2 2 water bottles in the door, Vaccine should not be on the top shelf stored in refrigerator (underneath the cold air doors, drawers, or bins. vent). Do not block air vents.

2

H2 O

3 Use a VFC-compliant

MIN MAX

thermometer to ensure 2 2 accurate temperatures.

MIN MAX For more information about thermometer requirements, Place the probe in the go to EZIZ.org. center of the refrigerator. Have a back-up VFC-compliant thermometer handy in case 2 there’s a problem with the one in the refrigerator.

4 5 Attach the digital display Plug in the refrigerator. to the outside of the Secure with plug guard/cover. WARNING! Do Not Unplug refrigerator, either on the Post “Do Not Unplug” sign. door or on the side. Set the modes on the

MIN MAX display so that it shows MIN and MAX temperatures.

6 7 temp Set the refrigerator temperature. Once the temperature has display stabilized, record CURRENT,

If the refrigerator has a MIN MAX MIN, and MAX tempera- thermostat, set it at 40ºF. tures on the log twice a 5 If it has a dial with a range of day. Set the alarm on the Fº Refrigerator Temperature Log Month/Year 1 (Days 1-8) Normal Refrigerator location Record CURRENT, MIN, and MAX temperatures twice a day. Complete steps 1–4. VFC PIN settings, set it to the middle of thermometer. Step 1 Write your initials and the time of day. 1 Sta Initials 10 example Day of Month 1 2 3 4 5 6 7 8

Time am am pm am pm am pm am pm am pm am pm am pm am pm

Warmer Colder the range. Step 2 Write CURRENT, MIN, and MAX temperatures. Circle any temperatures that are in DANGER Zone 1 or 2. Then go to step 3 (even if CURRENT temp is OK). If ALL temperatures are OK, go to step 4.

example Do not store vaccine in the CURRENT MIN

MAX

27º & lower 29º28º30º 31º 32º 34º33º 35º 36º 37º 38º 40º39º41º 42º 43º 44º 46º45º 48º47º49º 50º 51º 52º 53º 54º & higher The next morning, check the refrigerator until the DANGER Zone 1 These temperatures are OK. Go to step 4. DANGER Zone 2 Too cold! Go to Step 3! Too warm! Go to step 3!

Step 3 If any CURRENT, MIN, or MAX temperature is in Danger Zone 1 (below 35ºF) If any CURRENT, MIN, or MAX temperature is in Danger Zone 2 (above 46ºF): even for a short time: • Alert your supervisor immediately. • Put a “Do Not Use Vaccine” sign on the refrigerator. • Do not adjust the thermostat. Press the MEMORY CLEAR/RESET button(s). • Alert your supervisor immediately. • Check temperatures again in 1 hour. If temps are still in DANGER Zone 2, • Call the VFC Call Center (1-877-243-8832) to report the incident. call the VFC Call Center (1-877-243-8832). temperature and adjust it until it temperature is stable at Document the date and actions you take:

Step 4 Press the MEMORY CLEAR/RESET button(s) on the thermometer every time you nish logging temperatures. If you press the MODE/ALARM button by mistake, LO and HI will display. Press it again to see MIN and MAX. IN

Example of MIN MAX stabilizes at approximately 40ºF. around 40ºF for 3–5 days. At the end of the month le this log and keep it for 3 years. thermometer MIN-RESET MAX-RESET www.eziz.org display IMM-1125 (3/14) MODE 1-877-243-8832

www.eziz.org

California Department of Public Health, Immunization Branch IMM-962 (8/14) 12 Refrigerator Setup for Vaccine Storage

A carefully organized refrigerator helps protect vaccine and facilitates vaccine inventory management. Refrigerate all vaccines except MMRV, Varicella, and Zoster. MMR vaccine can be stored in a refrigerator or freezer.

Refrigerator-only Unit

Usable space for vaccine is inside dashed lines.

Separate VFC vaccine from privately purchased vaccine and label them Do not block clearly. air vents.

2 2 DTaP Hep B Hib IPV Place vaccine boxes in No vaccine in solid breathable plastic mesh plastic trays or baskets or directly on VFC Vaccine containers. shelves. Label baskets or shelves by type of vaccine. PCV Rota Rota Hep A

VFC Vaccine No vaccine in doors. Always keep vaccine in its original box. Do not MCV Tdap HPV Flu open the box until you are ready to use the vaccine. VFC Vaccine No food in refrigerator. DTaP Hep B Hib IPV Group vaccine by pediatric and adolescent Privately purchased vaccine 2 types. No vaccine in drawers or on floor of refrigerator.

Keep baskets 2-3 inches from walls and other baskets.

Store only vaccine and Keep vaccine with the earliest expira- other medication in vaccine tion dates to front of shelf. Keep temperatures between storage units. If you have vaccine 35ºF and 46ºF. that will expire in Expires in 3–6 months that 9 months Below 35ºF Above 46ºF you will not be able is too cold! is too warm! to use, notify the Expires in Call VFC. Call VFC. VFC Program. 3 months

If you have any problems with your refrigerator, keep the refrigerator door shut and notify the Nevada VFC Reporting at 775-684-5939. VFC Field Rep. www.eziz.org

California Department of Public Health, Immunization Branch IMM-963 (11/14) 13 Preparing Freezers for Vaccine Storage

1 In an upright freezer, put a few cold packs in areas where vaccine Cold Pack Cold Pack Cold Pack Cold Pack cannot be stored, like the door, Cold Pack Cold Pack top shelf, and oor. Cold Pack

In a chest freezer, put a few cold Cold Pack Cold Pack

packs in the basket at the top or Cold Pack Cold Pack Cold Pack Cold Pack Cold Pack on the oor. Cold Pack Cold Pack Cold Pack Cold Pack Cold Pack Cold Pack Cold Pack Cold Pack Cold Pack

Upright freezer Chest freezer

2 Use a VFC-compliant thermometer to ensure accurate temperatures.

MIN MAX MIN MAX For more information about Cold Pack Cold Pack Cold Pack thermometer requirements, go to Cold Pack Cold Pack EZIZ.org.

Have a back-up VFC-compliant Cold Pack Cold Pack thermometer handy in case there’s Cold Pack Cold Pack Cold Pack Cold Pack a problem with the one in the Cold Pack Cold Pack Cold Pack Cold Pack freezer. Cold Pack Cold Pack Cold Pack Place the thermometer probe in Cold Pack Cold Pack Cold Pack the center of the freezer.

3 4 Plug in the freezer. Attach the digital display to the WARNING! Secure with plug guard/cover. Do Not Unplug outside of the freezer, either on Post “Do Not Unplug” sign. the door or on the side. Set the modes on the display so

MIN MAX that it shows MIN and MAX temperatures.

5 If the freezer has a thermostat, set 6 Once the temperature has temp display it below 0ºF. stabilized, record CURRENT, MIN MAX MIN, and MAX temperatures If it has a dial with a range of on the log twice a day. Set the

Fº Freezer Temperature Log Month/Year settings, set it to the coldest. 1 (Days 1–8) Normal Record CURRENT, MIN, and MAX temperatures twice a day. Complete steps 1–4. Freezer location alarm on the thermometer. Step 1 Write your initials and the time of day. example Sta Initials Day of Month 1 2 3 4 5 6 7 8 Time Cold Colder am am pm am pm am pm am pm am pm am pm am pm am pm Check the temperature the next Step 2 Read the thermometer display. (See example at bottom right.) Write the temperatures below. • Circle all temperatures that are in DANGER. (See zones below.) Then go to step 3. • If ALL temperatures are OK, go to step 4.

Do not store vaccine in the CURRENT MIN morning. Adjust the thermostat MAX

-20sº & lower -10sº -9º -8º -7º -6º -5º -4º -3º -1º-2º 0º 1º 2º 3º 5º4º 7º6º8º 9º 10º 11º 12º 13º 14º 15º 16º 17º 18º & higher These temperatures are OK. Go to Step 4. DANGER Zone freezer until the temperature Too warm! Go to Step 3! Step 3 If you ever see temps in the Danger Zone (above 5ºF), even for a short time: • Alert your supervisor immediately. • Press the MEMORY CLEAR button. Check the temperatures again, in 1 hour. If temps are still in the until the temperature stabilizes DANGER Zone, call the VFC Call Center (1-877-243-8832). stays below 0ºF for 3–5 days. Document the date and actions you take: Step 4 Press the MEMORY CLEAR button on the thermometer every time you nish logging temperatures. Example of If you press the MODE button by mistake, LO and HI will display. Press it again to see MIN and MAX. thermometer display below 0ºF. At the end of the month, le this log and keep it for 3 years. MIN MAX MEMORY MODE ALARM www.eziz.org Memory CLEAR IMM-1126 (10/13) Clear 1-877-243-8832

www.eziz.org

California Department of Public Health, Immunization Branch IMM-965 (8/14) 14 Freezer Setup for Vaccine Storage

A carefully organized freezer helps protect vaccine and facilitates vaccine inventory management. Freeze MMRV, Varicella and Zoster vaccines. MMR vaccine can be stored in the refrigerator or freezer.

Upright freezer

Place vaccine in breathable plastic mesh Do not block air vents. baskets and clearly label baskets by type of Cold Pack Cold Pack Cold Pack Cold Pack vaccine. Cold Pack

MMR MMR MMRV Varicella Always keep vaccine in its original box. Cold Pack Cold Pack Do not open the box until you are ready to VFC Vaccine use the vaccine.

MMR MMR MMRV Varicella Cold Pack Cold Pack Privately purchased vaccine Separate the VFC vaccine supply from privately purchased vaccine and label Cold Pack Cold Pack Cold Pack them clearly. Cold Pack Cold Pack Cold Pack Cold Pack

Keep vaccine with the earliest expiration dates to front of shelf. If you have vaccine Chest freezer that will expire in Expires in 3–6 months that you 9 months will not be able to use, notify the VFC Program. Expires in 3 months

Keep temperatures 5ºF or colder. Cold Pack VFC vaccine Aim for 0º F MMR Varicella Cold Pack Cold Pack earliest earliest Cold Pack and colder dated dated Cold Pack Cold Pack Above 5ºF is too warm! Call VFC.

If you have any problems with your freezer, keep the freezer door shut and notify the Nevada VFC Reporting at 775-684-5939. VFC Field Rep. eziz.org

California Department of Public Health, Immunization Branch IMM-966 (11/14) 15 Monthly Care of Vaccine Storage Units

A small amount of regular maintenance is necessary to help ensure that vaccine refrigerators and freezers work properly. Follow the steps below to keep household and commercial refrigerators and freezers clean. If you have a pharmaceutical/laboratory grade unit, follow the manufacturer’s maintenance schedule and other recommendations.

1. Clean the inside of the storage units

Cleaning the inside of the refrigerator and freezer will

2 2 help prevent the growth of bacteria and fungus. DTaP Hep B Hib IPV

VFC Vaccine

You do not need to remove the vaccine from the unit PCV Rota Rota Hep A

to clean it. Just move the trays of vaccine as you clean. VFC Vaccine

Do not unplug the unit. MCV Tdap HPV Flu VFC Vaccine

• Clean any spills. DTaP Hep B Hib IPV

• Wipe the inside of the compartment and the shelves Privately purchased vaccine 2 with disinfectant or antibacterial wipes. Let it dry. • Put the trays of vaccine back where they were.

2. Check the door seals

Refrigerators and freezers have flexible door seals that prevent cold air from escaping when doors are closed. If the seals do not seal completely, cold air escapes. This can cause temperatures to fluctuate in the unit.

Do not unplug the unit.

1. Locate the seals. 2. Examine the seals. • They should not be torn or brittle. • When the unit is closed, there should be no gaps between the seals and the body of the unit. 3. If you suspect a problem with the seals, tell your supervisor.

3. Clean the coils

If the coils are easy to reach, use a duster to remove any visible dust.

California Department of Public Health, Immunization Branch IMM-970 (8/14) 16 Safeguard Your Power Supply

Protect plug and outlet

WARNING! Do Not Unplug

Plug in vaccine storage Secure plug with a guard/cover. Post “Do Not Unplug” signs unit to a nearby outlet. near outlet.

Always avoid disruption of power

Do not use extension cords or power Do not plug more than one appliance Never unplug the vaccine refrigerator strips with an ON/OFF switch. into an outlet. This will prevent or freezer. tripping of circuit breakers.

Warning! Alert Vaccine Coordinator Jenny 555-5555

RESET vaccine fridge & freezer

heater

room 1

Do not use outlets that are Do not use outlets that have built-in Label fuses and circuit breakers. Post a controlled by wall switches. circuit switches (they have red reset sign to alert the Vaccine Coordinator buttons). any time the power goes out.

VFC Field Rep. www.eziz.org

California Department of Public Health, Immunization Branch IMM-967 (8/14) 17 Refrigerator Action Guide – When To Call VFC (ºF)

Action steps are di erent because vaccines respond di erently to WARM and COLD temperatures and the amount of time at these temperatures. Post this guide on the refrigerator to help you take the correct actions.

MIN TOO COLD MAX TOO WARM 28º & colder 29º 30º 31º 32º 33º 34º 34.9º 46.1º 47º 48º 49º 50º 51º 52º 53º 54º & warmer

1. Press MEMORY CLEAR/RESET button(s) 1. Press MEMORY CLEAR/RESET button(s) after recording temperatures. after recording temperatures. 2. Post “Do Not Use Vaccine” sign. 2. Post “Do Not Use Vaccine” sign. 3. Alert your supervisor. 3. Alert your supervisor.

Call VFC Reporting! A.M. P.M. 775-684-5939 recording recording

Press MEMORY CLEAR/RESET button(s). Call VFC Wait 1 hour Reporting! & check 775-684-5939 temperatures again. Document all actions taken.

CURRENT CURRENT TOO WARM OK CURRENT, MIN, and MAX are all OK. Call VFC No need 35.0º 36º 37º 38º 39º 40º 41º 42 43º 44º 45º 46.0º Reporting! to call VFC 775-684-5939 (unless this happens daily). 1. Press MEMORY CLEAR/RESET button(s). Done. No need to call VFC. Press MEMORY CLEAR/RESET button(s).

MIN MAX Make sure that MIN and Document all actions taken. MAX show on the display

MIN-RESET MAX-RESET and not alarm settings (LO and HI).

If you are not sure if there is a problem, call: Call Nevada VFC Reporting at 775-684-5939

IMM-1147 (12/14) 18 Freezer Action Guide – When To Call VFC (ºF)

Action steps are di erent because whether vaccines can be used or not depends on the amount of time at TOO WARM temperatures. Post this guide on the freezer to help you take the correct actions.

CURRENT, MIN, and MAX are all OK. MAX TOO WARM

-5º & colder -4º -3º -2º -1º 0º 1º 2º 3º 4º 5.0º 5.1º 6º 7º 8º 9º 10º 11º 12º 13º 14º 15º & warmer

1. Press MEMORY CLEAR/RESET button(s) 1. Press MEMORY CLEAR/RESET button(s) after recording temperatures. after recording temperatures. Done. 2. Post “Do Not Use Vaccine” sign. 3. Alert your supervisor.

A.M. P.M. recording recording MIN MAX

MIN-RESET MAX-RESET Call VFC Wait 1 hour Reporting! & check Make sure that MIN and MAX show on the 775-684-5939 temperatures again. display and not alarm settings (LO and HI).

CURRENT TOO CURRENT WARM OK -58ºF and colder

Call VFC No need Reporting! to call VFC Most freezers do not reach temperatures 775-684-5939 (unless this happens daily). below -58ºF, but if you see temperatures this low, call the VFC Call Center.

Press MEMORY CLEAR/RESET button(s).

Document all actions taken.

If you are not sure if there is a problem, call: Call Nevada VFC Reporting at 775-684-5939

IMM-1148 (12/14) 19

Contact Information: Phone Number Selected Vaccine Manufacturers & Products Distributors Manufacturer/Website

Centers for Disease Control & Prevention Distributor for diphtheria www.cdc.gov/ncidod/srp/drugs/drug-service.htm. 404-639-3670 antitoxin, VIG, smallpox www.cdc.gov/laboratory/drugsevice/index.html vaccine

Infanrix, Kinrix, Pediarix, Havrix, Engerix-B, Twinrix, www.gskvaccines.com GlaxoSmithKline 866-475-8222 Hiberix, Cervarix, Fluarix, FluLaval, Rotarix, Boostrix

Massachusetts Biological Labs 617-474-3000 IGIM, Td, TT www.umassmed.edu/massbiolabs/index.aspx

MedImmune, Inc. www.medimmune.com 877-633-4411 FluMist PedvaxHIB, Comvax, Vaqta, Recombivax-HB, Gardasil, M- Merck & Co., Inc. www.merckvaccines.com 800-637-2590 M-R II, ProQuad, Afluria, Pneumovax 23, RotaTeq, Varivax, Zostavax, Td

Biotest Pharmaceuticals 800-458-4244 HBIG www.biotestpharma.com/products/nabiHB.html

Fluvirin, Agriflu, Menveo, RabAvert (distributer for Ixiaro) Novartis Vaccines 877-683-4732 www.novartisvaccines.com/us/index.shtml

Pfizer (Wyeth Vaccines) www.pfizerpro.com/ 800-438-1985 Prevnar 13 Daptacel, Tripedia, Pentacel, ActHIB, Fluzone, Menomune, sanofi Pasteur www.vaccineshoppe.com 800-822-2463 Menactra, IPOL, Imovax, Decavac, Tenivac, Adacel, Typhim Vi, YF-Vax

Talecris Biotherapeutics www.talecris.com/talecris-biotherapeutics-us- 800-520-2807 HBIG, IGIM, RIG, TIG home.htm

Reviewed: 8/2011; 12/2012; 2/2013; 3/2013; 7/2013; 2/2014; 8/2014; 12/2014; 1/2015 Page 11 of 12 20 Vaccine Acronyms & Abbreviations

Vaccine names are often abbreviated. Here are some common ones. California Immunization Registry (CAIR) codes may differ for certain vaccines. Use this chart as a reference.* CDC Abbreviation CAIR Code Vaccine Brand Name BCG BCG Bacillus Calmette-Guérin (Tuberculosis) DT DT Diphtheria & Tetanus DTaP DTaP Diphtheria, Tetanus & Acellular Pertussis DAPTACEL®, Infanrix®, Tripedia® DTaP-HepB-IPV DTaPHBIP Diphtheria, Tetanus & Acellular Pertussis, Pediarix® Hepatitis B, Polio DTaP-IPV DTaP-IPV Diphtheria, Tetanus & Acellular Pertussis Kinrix™, Quadracel™ Inactivated Polio DTaP-IPV/Hib DTaPIPHi Diphtheria, Tetanus & Acellular Pertussis, Pentacel ® Haemophilus influenzae type b, Polio HepA HAV Hepatitis A Virus Havrix®, VAQTA ® HepB HBV, HBV2dose Hepatitis B Virus ENGERIX B®, RECOMBIVAX® HepA-HepB HAV-HBV Hepatitis A and Hepatitis B Twinrix® ,Twinrix Junior® Hib-HepB HIB-HBV Hepatitis B and Haemophilus influenzae type b COMVAX® Hib HIB Haemophilus influenzae type b ACTHIB®, Hiberix® Hib HIBPEDVX Haemophilus influenzae type b PedvaxHIB® Hib-MenCY MenHibrx Haemophilus influenza type b & MenHibrix® bivalent Meningococcal Conjugate HPV2 HPV Human papillomavirus (bivalent) Cervarix® HPV4 HPV Human papillomavirus (quadravalent) Gardasil® HPV9 HPV Human papillomavirus (nine valent) Gardasil®9 IIV FLU Inactivated Influenza Vaccine IIV3 (TIV) Trivalent options Afluria®, Fluarix®, FluLaval®, Fluvirin®, Fluzone® variants ccIIV3 Trivalent options Flucelvax (ccIIV3) IIV4 (QIV) Quadrivalent options Fluarix®, FluLaval®, Fluzone® RIV3 Recombinant, non egg option Flublok® IPV IPV Inactivated Polio IPOL® LAIV, LAIV4 FLU-LAIV Live, Attenuated Influenza (nasal spray) FluMist® MenB BEXSERO Meningococcal Group B Bexsero® MenB TRUMENBA Meningococcal Group B Trumenba® MMR MMR Measles, Mumps & Rubella MMR-II® MMRV MMR-VZV Measles, Mumps, Rubella & Varicella ProQuad® MCV4 MCV4 Meningococcal Conjugate Menactra™ , Menveo® MPSV4 MENING Meningococcal Polysaccharide Menomune™ PCV7 PNUcon Pneumococcal Conjugate, 7-valent Prevnar® (discontinued in 2011) PCV13 PCV13 Pneumococcal Conjugate, 13-valent Prevnar13® PPSV23 PNUps Pneumococcal Polysaccharide, 23-valent Pneumovax® RV5 Rotaviru Rotavirus RotaTeq™ RV1 Rotarix Rotavirus Rotarix® Td Td Tetanus & Reduced Diphtheria DECAVAC ™ Tdap Tdap Tetanus, Reduced Diphtheria & ADACEL™, BOOSTRIX® Acellular Pertussis TT TT Tetanus Toxoid VAR VZV Varicella VARIVAX® ZOS Zoster Varicella Zoster Virus (Shingles) Zostavax® Note: You can find the most recent version of CDC’s list at www.cdc.gov/vaccines/acip/committee/guidance/vac-abbrev.pdf

www.eziz.org *Disclaimer: Abbreviations may vary across medical practices. California Department of Public Health, Immunization Branch IMM-895 (6/15) 21

PROCEDURES IN THE EVENT OF A POWER FAILURE OR MECHANICAL DIFFICULTY

SHORT TERM POWER OUTAGE

1. Record the time and temperatures of the room, refrigerator, and freezer using certified thermometers.

2. If you are sure that the power will only be off for several hours, then tape the freezer and refrigerator doors shut so no one inadvertently opens the doors and allows all the cold air to escape.

3. When the power resumes, record the time and the temperatures in the refrigerator and freezer. If temperatures are out of range, contact the manufacturer for instructions and do not use the vaccine until the manufacturer has been consulted. Notify the Nevada State Health Division, Immunization Program (775-684- 5900) if state supplied vaccines were involved.

LONG TERM POWER OUTAGE DUE TO A NATURAL OR MANMADE DISASTER: FACILITY WITH A GENERATOR

1. Record the time and temperatures of the room, refrigerator, and freezer using certified thermometers.

2. Make sure that the vaccine storage unit is plugged into an outlet that is supplied power by the generator. Once the generator is supplying power to the storage unit, record the temperatures in the freezer and refrigerator. If the generator is not functioning, then prepare to transfer the vaccine to a functioning unit.

LONG TERM POWER OUTAGE DUE TO A NATURAL OR MANMADE DISASTER: FACILITY WITHOUT A GENERATOR

1. Record the time and temperatures of the room, refrigerator, and freezer using certified thermometers.

2. Have the following items available in case of a disaster: flashlight with extra batteries, ice packs, bubble wrap and cardboard, coolers (Styrofoam or hard sided), and cold-weather gloves.

3. Complete the Vaccine Incident Report. (Page 10)

4. Place ice packs on the bottom of the cooler/box. Place a layer of bubble wrap and cardboard over top of the ice packs. Fill the cooler/box with refrigerated vaccine. Place a thermometer in the middle of the box, surrounded by the vaccine, with the display placed outside the box. Place a layer of bubble wrap and cardboard over top of the vaccine boxes. Place ice packs on top of bubble wrap and cardboard. Secure the lid of the cooler/box and the digital thermometer display.

5. Place freezer packs on the bottom and sides of a cooler. Remove varicella vaccine from the freezer and place in the cooler on top of the freezer packs. Surround vaccine with freezer packs. Place a thermometer in the middle of the cooler, surrounded by the vaccine, with the display placed outside the cooler. Secure the lid of the cooler and the digital thermometer display. Alternatively, a VaxiPac or AcuTemp unit can be used to transport frozen vaccine.

6. Transport vaccine immediately. Note the amount of time the vaccine is out of the vaccine storage unit and the temperature and call the manufacturer for instructions if appropriate temperatures are not maintained.

7. Transport the containers of vaccine in the cab of the vehicle – NOT IN THE TRUNK – to a vaccine storage unit that has been appropriately monitored. Transport the vaccine to:

Reviewed: 8/2011; 12/2012; 2/2013; 3/2013; 7/2013; 2/2014; 8/2014; 12/2014; 1/2015 Page 5 of 12 22 Transporting Refrigerated Vaccine

Guidelines for vaccine transport and short-term storage • This procedure will keep all vaccines except varicella and MMRV within the recommended temperature range for up to 12 hours during transport and/or storage outside the primary storage unit (e.g. in the building, inside a car, etc.). If the storage cooler is exposed to temperatures as low as -4ºF (e.g. inside a car trunk), this procedure will safeguard vaccines for up to 1 hour. • If the vaccine will be stored in refrigerators after transport, be sure those refrigerators have maintained temperatures between 35ºF and 46ºF for at least 3 to 5 days. Assemble packing supplies and documents 1. Cooler. Use a hard-sided cooler. Attach a “Vaccines: Do Not Freeze” label to the cooler. 2. “Conditioned” cold packs. Condition frozen gel packs by leaving them at room temperature for 1 to 2 hours until the edges have defrosted and packs look like they’ve been “sweating.” Cold packs that are not condi- tioned can freeze vaccine. Do not use dry ice. 3. Thermometer. Prepare a VFC-compliant thermometer by placing it in the refrigerator at least 2 hours before you pack the vaccine. If you nor- mally use a continuous-read monitoring system, you will need a portable thermometer for vaccine transport. 4. Packing material. Use two 2-inch layers of bubble wrap. Not using enough bubble wrap can cause the vaccine to freeze. 5. Transport Log. Complete a Refrigerated Vaccine Transport Log (IMM- 1132) to document the duration and temperature monitoring information. Pack vaccine and prepare for transport 1. Cold packs 4. Bubble wrap Spread conditioned cold packs Completely cover the vaccine with to cover only half of the bot- another 2-inch layer of bubble tom of the cooler. wrap.

2. Bubble wrap & Thermometer 5. Cold packs Completely cover the cold Spread “conditioned” cold packs to packs with a 2-inch layer of cover only half of the bubble wrap. bubble wrap. Make sure that the cold packs do Then, place the thermometer/ not touch the boxes of vaccine. probe on top of the bubble wrap directly above a cold pack. 3. Vaccine 6. Form & display Stack layers of vaccine boxes on Fill the cooler to the top with bub- the bubble wrap. Do not let the ble wrap. Place the thermometer’s boxes of vaccine touch the cold digital display and the Refrigerated packs. Vaccine Transport Log on top. It’s okay if temperatures go above 46ºF while packing. Unpack vaccine When you reach the destination site, record the temperature in the cooler on the Transport Log before removing the vaccine. If it is: • Between 35ºF and 46ºF (2ºC and 8ºC), unpack the vaccine and put it in the refrigerator. • Below 35ºF (2ºC) or above 46ºF (8ºC), call your VFC Representative or the VFC Program immediately at 877-243-8832. Then label the vaccine “Do Not Use” and place it in the refrigerator. www.eziz.org California Department of Public Health, Immunization Branch IMM-983 (9/14) 23 Don’t Be Guilty of These Preventable Errors in Vaccine Storage and Handling!

Do you see your clinic or practice making any of these error: Using the wrong type of equipment frequently reported errors in vaccine storage and handling? storage units Although some of these errors are much more serious than • CDC recommends storing vaccines in separate, self-contained others, none of them should occur. Be sure your healthcare units that only refrigerate or only freeze. If a combination setting is not making any of these preventable errors. refrigerator/freezer must be used, only refrigerated vaccines should be stored in the unit, and a separate stand-alone error: Designating only one person, rather than at least freezer should be used for frozen vaccines. two, to be responsible for storage and handling of vaccines • Never store vaccines in a “dormitory-style” unit (i.e., a small • Everyone in the office should know the basics of vaccine han- refrigerator-freezer unit with one exterior door and a freezer dling, including what to do when a shipment arrives and what compartment inside the refrigerator). These units cannot to do in the event of an equipment failure or power outage. maintain stable temperatures. • Train at least one back-up person. The back-up and primary thermometers persons should be equally familiar with all aspects of vaccine • storage and handling, including knowing how to handle Use only calibrated thermometers that have a Certificate of vaccines when they arrive, properly record refrigerator and Traceability and Calibration Testing. Ideally, you should use a freezer temperatures, what to do when an out-of-range “continuous read” thermometer that records temperatures temperature occurs, and how to appropriately respond to an all day and all night. equipment problem or power outage. • Place the thermometer’s temperature probe in glycol so that you are not just measuring air temperature, which is subject error: Storing vaccine inappropriately to fluctuation when you open the door. • Be sure all office staff (especially persons involved in receiving For more detailed information, see the Vaccine Storage Equip- vaccine shipments) understand the importance of properly ment section of CDC’s Vaccine Storage and Handling Toolkit storing vaccines immediately after they arrive. (www.cdc. gov/vaccines/recs/storage/toolkit). • Know which vaccines should be refrigerated and which should be frozen. Storage information is found in the package error: Inadvertently leaving the refrigerator or freezer insert. For quick reference, post IAC’s Vaccine Handling Tips door open or having inadequate seals (www.immunize. org/catg.d/p3048.pdf) on the refrigerator • Unfortunately, too much vaccine is lost every year because and freezer. storage unit doors were left open. Remind staff tocompletely • Always store vaccines (and thermometers) in the body of close the door every time they open the refrigerator or freezer. the refrigerator – not in the vegetable bins, on the floor, next • Check the seals on the doors on a regular schedule, such to the walls, in the door, or near the cold air outlet from the as when you’re taking inventory. If there is any indication freezer. The temperature in these areas may differ significantly the door seal may be cracked or not sealing properly, have from the temperature in the body of the unit. it replaced. (This is much less costly than replacing a box of • Don’t over-pack the unit. Place the vaccine packages in such pneumococcal conjugate or varicella vaccine!) a way that air can circulate around the compartment. error: Storing food and drinks in the vaccine refrigerator • Always store vaccines in their original packaging. • Frequent opening of the refrigerator door to retrieve food items can adversely affect the internal temperature of the unit and damage vaccines. Store only vaccines in the designated units. continued on the next page �

immunization action coalition Technical content reviewed by the Centers for Disease Control and Prevention Saint Paul, Minnesota • 651-647-9009 • www.immunize.org • www.vaccineinformation.org www.immunize.org/catg.d/p3036.pdf • Item #P3036 (7/14) IimmAunize.orgC

24 Don’t Be Guilty of These Preventable Errors in Vaccine Storage and Handling (continued) page 2 of 2 error: Inadvertently cutting the power supply to the error: Discarding temperature logs too soon storage units Keep your temperature logs for at least 3 years. Why? • Be sure everyone in your office, including the janitorial staff, • You can track recurring problems as the storage unit ages. understands that very expensive and fragile vaccines are being stored in the refrigerator and freezer. • If out-of-range temperatures have been documented, you can determine how long and how often this has been occurring. • Post a Do Not Unplug sign (www.immunize.org/catg.d/ p2090.pdf) next to electrical outlets for the refrigerator and • This can be a great way to demonstrate why you need a new freezer, and a Do Not Stop Power warning label (www.immunize. refrigerator or freezer! org/catg.d/p2091.pdf) by the circuit breaker for the electrical outlets. error: Not using vaccine with the soonest expiration date first error: Recording temperatures only once per day When unloading a new shipment of vaccine: • Refrigerator and freezer temperatures should be checked at • Move vaccine with the shortest expiration date to the front of the beginning and end of each workday. the unit, making it easier for staff to access this vaccine first. • Record the temperatures you observed on an appropriate log. • Mark the “older” vaccine to be used first. IAC has temperature logs (www.immunize.org/handouts/ temperature-logs.asp) available in both Fahrenheit and Cel- error: Dealing inappropriately with expired vaccines sius formats. • Carefully monitor your usage to ensure viable vaccines don’t • Record temperatures for ALL units being used to store vaccine. expire! As discussed above, place vaccines with the shortest Don’t forget to check temperatures for both the refrigerator expiration dates at the front of the unit. and freezer. • If you discover expired vaccines, immediately remove them error: Documenting out-of-range temperatures on from the unit so that they are not inadvertently administered. vaccine temperature logs but not taking action error: Discarding multidose vials prematurely • If you find out-of-range temperatures...do something! The viability of your vaccine – and the protection of your patients • Almost all multidose vials of vaccines contain a preservative – is at stake. and can be used until the expiration date on the vial, unless there is actual contamination or the vials are not stored • Guidance on what to do may be found on IAC’s temperature under appropriate conditions. However, multidose vials of logs (www.immunize.org/handouts/temperature-logs.asp) reconstituted vaccine (e.g., meningococcal polysaccharide and Vaccine Storage Troubleshooting Record (www.immunize. and yellow fever) must be used within a defined period after org/catg.d/p3041.pdf). reconstitution. Refer to the package inserts for information. • Have an Emergency Response Plan and trained staff in place • The Joint Commission has clarified that vaccines are an before a problem occurs. For help in developing a plan, see exception to its usual “28-day rule” for use of medications the Checklist of Resources for the Emergency Vaccine Retrieval in multidose vials. Providers are directed to follow guidance and Storage Plan in CDC’s Vaccine Storage and Handling from CDC and vaccine manufacturers. Toolkit (www.cdc.gov/vaccines/recs/storage/toolkit).

immunization action coalition Technical content reviewed by the Centers for Disease Control and Prevention Saint Paul, Minnesota • 651-647-9009 • www.immunize.org • www.vaccineinformation.org www.immunize.org/catg.d/p3036.pdf • Item #P3036 (7/14) IimmAunize.orgC

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BEFORE YOU VACCINATE: Schedules Screening VIS

27

child than Flu ✔ Influenza fall or winter to all people ages 6 mos and older. Some children younger than age 9 years may need 2 doses; ask your child’s healthcare pro - vider if your 1 dose.) needs more (One dose each

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or missing, get your child caught up as soon as possible. If your child has not completed a series of vaccinations on time, he or she will need only the remainder of the vaccinations in series. There’s no need to start over. If your child’s vaccinations are overdue

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28 Last updated on 02/01/2012 • CS229912-B Last updated Disease complications Infected blisters, bleeding disorders, encephalitis (brain (brain encephalitis bleeding disorders, Infected blisters, pneumonia (infectionswelling), in the lungs) of the heart heartcoma, Swelling muscle, failure, death paralysis, the brain around Meningitis (infection of the covering epiglottis (life­ retardation, mental and spinal cord), infection can block the windpipe and that threatening and pneumonia problems) serious breathing lead to (infection in the lungs), death failure Liver cancer liver infection, failure, liver liver Chronic (infectionPneumonia in the lungs) pneumonia (infection swelling), in (brain Encephalitis the lungs), death the brain around Meningitis (infection of the covering inflam­ swelling), (brain , encephalitis and spinal cord) deafness or ovaries, of testicles mation (infectionPneumonia in the lungs), death death Paralysis, (blood infection),Bacteremia meningitis (infection of death and spinal cord), the brain around the covering diarrhea, dehydration Severe miscar­ women—can lead to serious in pregnant Very and birth defects delivery, stillbirth,riage, premature death difficulty, breathing bones, Broken Disease symptoms Rash, tiredness, headache, fever fever headache, Rash, tiredness, swollen weakness, mild fever, throat, Sore glands in neck unless bacteria be no symptoms May the blood enter pain, stomach fever, be no symptoms, May jaundice vomiting, fatigue, loss of appetite, dark urine and eyes), of skin (yellowing headache, fever, be no symptoms, May of (yellowing jaundice vomiting, weakness, pain joint and eyes), skin cough, throat, muscle pain, sore Fever, fatigue extreme pinkeye nose, runny cough, Rash, fever, salivary fever, glands (under the jaw), Swollen muscle pain tiredness, headache, apnea (a pause in nose, runny cough, Severe in infants) breathing fever, throat, sore be no symptoms, May nausea, headache pneumonia (infection be no symptoms, May in the lungs) vomiting Diarrhea, fever, infected with rubella virus sometimes Children lymph nodes. and swollen fever, a rash, have in neck and abdominal muscles, Stiffness fever muscle spasms, difficultyswallowing, Disease spread by Disease by spread Air, direct contact Air, direct contact Air, direct contact Air, contact, Personal food or water contaminated with blood or Contact body fluids direct contact Air, direct contact Air, direct contact Air, direct contact Air, the mouth Through direct contact Air, the mouth Through direct contact Air, cuts in skin through Exposure Vaccine Vaccine Varicella vaccine protects against chickenpox. against chickenpox. protects vaccine Varicella against diphtheria. protects vaccine DTaP* against Haemophilus protects Hib vaccine type influenzae b. A. against hepatitis protects vaccine HepA B. against hepatitis protects vaccine HepB against influenza. protects vaccine Flu against measles. protects MMR** vaccine against mumps. protects MMR**vaccine against pertussis protects vaccine DTaP* (whooping cough). against polio. protects IPV vaccine against pneumococcus. protects PCV vaccine against rotavirus. protects RV vaccine against rubella. protects MMR** vaccine against tetanus. protects vaccine DTaP* Disease Chickenpox Chickenpox Diphtheria Hib HepA HepB Flu Measles Mumps Pertussis Polio Pneumococcal Rotavirus Rubella Tetanus Them Prevent that Vaccines Diseases and the Vaccine-Preventable DTaP is a combination vaccine that protects against diphtheria, tetanus, and pertussis. tetanus, against diphtheria, protects that vaccine is a combination * DTaP and rubella. mumps, against measles, protects that vaccine ** MMR is a combination

29 6 years 6 years Kinrix Kinrix Revised January 2014 4 through 4 through = Hib-MenCY = MMRV = DTaP-IPV/Hib = DTaP-IPV/Hib 18 months 18 months 18 months = DTaP-HepB-IPV = DTaP-HepB-IPV = Hib-HepB FOOTNOTES FOOTNOTES 2, 4, 6, 2, 4, 6, Pentacel Pentacel or a listing of Tdap requirements requirements Tdap or a listing of Comvax Vaccination Combinations Combinations Vaccination Pediarix MenHibrix ProQuad Pentacel Kinrix = DTaP-IPV for secondary visit http:// for schools, . www.immunize.org/laws/tdap.asp lapsed who were Some children at Tdap a dose of received have may 10 years. ages 7 through Depending on which Hibis vaccine not need the dose a child may used, of age. 6 months at Two doses given at least four weeks weeks least four at doses given Two children for apart recommended are of 8 years through aged 6 months vaccine getting a flu age who are the first time or who did not for ­ previ doses of vaccine two receive least one of which a dose at ously, the containing of seasonal vaccine 2009(H1N1) strain. 15 through 15 through 15 through * ** F § Pediarix Pediarix Pediarix (high-risk) HibMenCY HibMenCY 2, 4, 6 months 2, 4, 6 months 2, 4, 6 months 2 through 15 months 15 months 2 through USA USA Through 18 Years Through 18 Years DOSES RECOMMENDED BY AGE AGE BY RECOMMENDED DOSES risk) Tdap MMRV MMRV PPSV23 PPSV23 Comvax Comvax 15 months, 15 months, 12 through 12 through 15 months 15 months (required in (required many states for for states many 2, 4, 12 through 2, 4, 12 through 4 through 6 years 6 years 4 through 7th grade entry)**7th grade 11 through 12 years years 12 through 11 2 through 18 years (high 18 years 2 through or 2, 4 months 2, 4 months 2, 4, 6 months 2, 4, 6 months Hib IPV HPV years years MMR DTaP DTaP HepA HepB MCV4 months months months months PCV13 PCV13 months, months, months, months, , 12 through 15 , 12 through (3 doses) Varicella Varicella § 12, 18 months 12, 18 months 2, 4, 6 through 18 2, 4, 6 through 4 through 6 years 6 years 4 through 4 through 6 years 6 years 4 through 4 through 6 years 6 years 4 through 4 through 6 years 6 years 4 through 6 months or older 6 months 2 months through through 2 months 2 months through through 2 months 10 years (high-risk) 10 years 18 years (high-risk) 18 years 11 through 18 years 18 years 11 through 2, 4, 6, 12 through 18 2, 4, 6, 12 through Rotarix Rotarix birth, 18 2, 6 through Influenza* (yearly) Influenza* (yearly) 2, 4, 6 12 through 15 months, 15 months, 12 through 15 months, 12 through 11 through 12 years, 16 12 years, 11 through RotaTeq RotaTeq type b Influenza Rotavirus Rotavirus DISEASES Hepatitis B Hepatitis Hepatitis A Hepatitis Tuberculosis Tuberculosis Meningococcal Tétanos / Tetanus Tetanus / Tétanos Rubéola / Rubella / Rubéola Varicela / Varicella Varicella / Varicela (Not offered in theU.S.) Poliomielitis / Polio Polio Poliomielitis / H. influenzaeH. Parotiditis / Mumps Mumps / Parotiditis Tosferina / Pertussis / Tosferina Difteria / Diphtheria / Difteria Sarampión / Measles / Sarampión Human Papillomavirus Papillomavirus Human (Private sector only in Mexico) Virus del Papiloma Humano / Humano Papiloma del Virus Neumococo / Pneumococcal / Neumococo

. § § Vaccines for Infants and Adolescents Infants and for Vaccines 2 See back for immunization tool protocol and translation of common terms terms of common and translation protocol tool immunization See back for 1 2 BCG at birthat Rotateq Rotateq Varicela Varicela 12 months 2, 4 months 2, 4 months 9 through 12 years 12 years 9 through 2, 4, 6 months 2, 4, 6 months 2, 4, 6, 18 months 2, 4, 6, 18 months 2, 4, 6, 18 months Antihepatitis A Antihepatitis B Neumocóccica Triple Viral Viral SRP Triple 12 months, 6 years 6 years 12 months, (3 doses) (girls only) (3 doses) (girls Influenza (yearly) Influenza (yearly) at birth,at 2, 6 months 12 months, 4-6 years 4-6 years 12 months, 9 years (high risk only) 9 years 12 through 15 months 15 months 12 through Conjugada (PCV13) Conjugada (PCV13) HPV Pentavalente Acelular Pentavalente Acelular Pentavalente 6 through 59 months, 60 months through through 60 months 59 months, 6 through , 3 SR DPT Weeks) Weeks) 11 years 11 years Sabin (OPV) 6 to 59 months of age 59 months 6 to 4 through 6 years 6 years 4 through 2 doses per year 2 doses per year from from Binational Immunization Resource Tool for Children from Birth from Children for Tool Resource Immunization Binational (administered duringHealth National (administered DOSES RECOMMENDED BY AGE AGE BY RECOMMENDED DOSES MEXICO MEXICO 2014 2014 IPV+Hib = DTaP+ = DTaP+ Td = MMR = DPT + Hib + HepB 10-12 years 10-12 years FOOTNOTES FOOTNOTES

http://www.cdc.gov/vaccines/schedules/downloads/child/mmwr-child-schedule.pdf Pentavalente Acelular Acelular Pentavalente present) 2007 to (August ffered to high-risk groups only groups to high-risk ffered (Prior to July 2007) to (Prior Pentavalente Pentavalente Vacunas Combinadas/ Combinadas/ Vacunas Combinations Vaccination Viral SRP Triple § dministered after least 2 doses of at dministered For those who have not had the full those who have For doses two give age 11 years, series by apart1 month 11 years at O IPV (Pentavalente) IPV (Pentavalente) A 1 2 3

Vaccine doses administered in Mexico may be counted as valid in the United States (including vaccines not licensed for use in the U.S.) if the dose or doses are documented in writing (including the date of in writing (including the date documented if the dose or doses are use in the U.S.) for not licensed (including vaccines States in the United as valid be counted may in Mexico doses administered Vaccine on Immunization Practices. the Advisory by Committee with the minimum intervals and minimum ages as recommended and comply administration) See

30 CS245366-C FECHA DE VACUNACIÓN DE VACUNACIÓN AD Y 1 A Ñ O 6 A Ñ OS ED 6 MESES 7 MESES 2 MESES 4 MESES 12 MESES ). FRECUENCIA LOS 59 MESES LOS ANUAL HASTA HASTA ANUAL ADICIONALES ADICIONALES DOSIS PRIMERA PRIMERA SEGUNDA SEGUNDA SEGUNDA SEGUNDA REFUERZO REFUERZO ADICIONALES ADICIONALES REVACUNANCIÓN REVACUNANCIÓN RUBÉOLA ESQUEMA DE VACUNACIÓN ESQUEMA DE VACUNACIÓN POR SARAMPIÓN Y POLIOMIELITIS PREVINE DAD QUE DAD ENFERME­ RUBÉOLA Y INFLUENZA INFLUENZA PAROTIDITIS PAROTIDITIS SARAMPIÓN, INFECCIONES INFECCIONES NEUMOCOCO NEUMOCOCO SR SRP SABIN OTRAS OTRAS VACUNA VACUNA VACUNAS VACUNAS INFLUENZA INFLUENZA CONJUGADA CONJUGADA NEUMOCÓCICA NEUMOCÓCICA OGRAFÍA F M TIVA TIVA CIÓN FOT Date of BirthDate 20 4 2011 DÍA MES AÑO DÍA MES AÑO SEXO: SEXO: ENTIDAD FEDERA ENTIDAD TIVA TIVA MUNICIPIO O DELEGA CALLE Y NÚMERO Robles Ramos Maria GPO SANGUÍNEO Y RH: GPO SANGUÍNEO http://www.cdc.gov/vaccines/schedules/downloads/child/0-6yrs-schedule-pr.pdf C.P. C.P. LOCALIDAD LOCALIDAD LOCALIDAD COLONIA / LOCALIDAD / LOCALIDAD COLONIA AFILIACIÓN / MATRÍCULA / EXPEDIENTE: / MATRÍCULA AFILIACIÓN MEDICA: UNIDAD NO. CONSULTORIO DOMICILIO: Y FECHA DE NACIMIENTO: LUGAR CIVIL: Y FECHA DE REGISTRO LUGAR MUNICIPIO O DELEGACIÓN / ENTIDAD FEDERATIVA FEDERATIVA / ENTIDAD MUNICIPIO O DELEGACIÓN MUNICIPIO O DELEGACIÓN / ENTIDAD FEDERA / ENTIDAD MUNICIPIO O DELEGACIÓN APELLIDOS Y NOMBRE: IDENTIFICACIÓN: IDENTIFICACIÓN: GENERALES: DATOS No. de Certificado No. de Nacimiento CURP: CURP:

ing te is always recorded in pencil. in pencil. recorded is always te Demographic Information Information Demographic ScheduleBasic Immunization Private Sector Vaccines Next due da Clinic stamp or signature of person administer Clinic stamp or signature in pen. recorded are administration of vaccine Dates and second last name)" or paternal and maternal last and maternal last name)" or paternal and second respectively. names, 20/1/2008 is Jan 20, 2008. instance, For año). FECHA DE VACUNACIÓN (Date of Vaccine Administration) Administration) Vaccine of (Date VACUNACIÓN FECHA DE • • • • Name Section includes a "primer y segundo apellido (first (día/mes/ Day/Month/Year written are in Mexico • Dates - The first sec tion on the inside of this document contains contains first sec tion on the inside of this document The information. demographic 1 - VACUNA ( Vaccine) Vaccine) ( VACUNA 1 - Disease) QUE PREVIENE (Preventable 2 - ENFERMEDAD 3 - DOSIS (Dose) & Frequency) Y FREQUENCIA (Age 4 - EDAD 5 The second part of the document contains information on part second information The contains of the document outlined in 5 schedule, the basic childhood immunization columns: in recorded sector are in the private administered Vaccines (other vaccines) VACUNAS section: OTRAS the gray Spanish Enero Febrero Marzo Abril Mayo Junio Julio Agosto Septiembre Octubre Noviembre Diciembre Mes(es) Año(s) nacer Al Próxima Próxima

ember English January February March April May June July August Sept October November December Month(s) Years(s) birthAt Next Encourage patient to obtain available medical records from all clinicians and healthcare providers in the future and continue to document vaccinations received. Patient Patient received. vaccinations document to and continue in the future providers all clinicians and healthcare from medical records obtain available to patient Encourage visits. healthcare subsequent any to take these records to should be encouraged Match Mexican records with left side of guide (Mexico Doses Recommended by Age). with left Age). Doses by side of guide (Mexico Recommended Mexican records Match States. obtained in the United records immunization Review any Age). with right side of guide (USA Doses by Recommended records the U.S. Match which includes vaccine, is a combination Acelular Pentavalente in Mexico, example, For vaccines. important about combination as they contain information Check footnotes, and Hib. IPV, DTaP, chart,considered vaccination can be for EITHER side of the the child/adolescent disease is fulfilled particular for preventable vaccine recommendation vaccination If a given disease. against that vaccinated due or need are that vaccinations any administer Then, questions with the parent. VIS), and discuss any ( Statement Information Vaccine provide contraindications, Check for up. be caught to given. are that vaccinations any record personal medical Document in official chartpatient’s and Review the child’s Mexican immunization record, which is part (Cartilla Nacional de Salud). Health Card of the National record, Mexican immunization Review the child’s birth 10 through from age 9, and the other is for children through One is for of the Health Cards. versions two are There 19. The and other health information. immunization record to Mexico used throughout the official documents are These birth and on pages from 9 years the children through for on pages 10-11 of the Health Cards located are records vaccine the pre-teens (ages 10-19). and teens 7-8 for Determine what immunizations are needed for the child based on his or her age and the United States’ Recommended Immunization Recommended Schedule ( States’ the child based on his or her age and United needed for are immunizations Determine what The table below provides translations of terms that may may that of terms translations provides table below The and the immunization on the Health Cards be found sections of those cards. records Binational Tool Protocol Tool Binational 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

31 Patient name: Date of birth: (mo.) (day) (yr.) Screening Checklist for Contraindications to Vaccines for Children and Teens For parents/guardians: The following questions will help us determine which vaccines your child may be given today. If you answer “yes” to any question, it does not necessarily mean your child should not be vaccinated. It just means additional questions must be asked. If a question is not Don’t clear, please ask your healthcare provider to explain it. Yes No Know

1. Is the child sick today?   

2. Does the child have allergies to medications, food, a vaccine component, or latex?   

3. Has the child had a serious reaction to a vaccine in the past?   

4. Has the child had a health problem with lung, heart, kidney or metabolic disease    (e.g., diabetes), asthma, or a blood disorder? Is he/she on long-term aspirin therapy?

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

6. If your child is a baby, have you ever been told he or she has had intussusception?   

7. Has the child, a sibling, or a parent had a seizure; has the child had brain or other    nervous system problems?

8. Does the child have cancer, leukemia, HIV/AIDS, or any other immune system problem?   

9. In the past 3 months, has the child taken medications that weaken their immune system, such as cortisone, prednisone, other steroids, or anticancer drugs, or had    radiation treatments?

10. In the past year, has the child received a transfusion of blood or blood products,    or been given immune (gamma) globulin or an antiviral drug?

11. Is the child/teen pregnant or is there a chance she could become pregnant during    the next month?

12. Has the child received vaccinations in the past 4 weeks?   

Form completed by: ______Date:______

Form reviewed by: ______Date:______Did you bring your child’s immunization record card with you? yes  no  It is important to have a personal record of your child’s vaccinations. If you don’t have one, ask the child’s healthcare provider to give you one with all your child’s vaccinations on it. Keep it in a safe place and bring it with you every time you seek medical care for your child. Your child will need this document to enter day care or school, for employment, or for international travel.

Technical content reviewed by the Centers for Disease Control and Prevention Immunization Action Coalition Saint Paul, Minnesota • 651-647-9009 • www.immunize.org • www.vaccineinformation.org www.immunize.org/catg.d/p4060.pdf • Item #P4060 (1/15)

32 Information for Health Professionals about the Screening Checklist for Contraindications (Children & Teens) Are you interested in knowing why we included a certain question on the screening checklist? If so, read the information below. If you want to find out even more, consult the references listed at the bottom of this page.

1. Is the child sick today? [all vaccines] 8. Does the child have cancer, leukemia, HIV/AIDS, or any There is no evidence that acute illness reduces vaccine efficacy or increases vaccine other immune system problem? [LAIV, MMR, MMRV, RV, VAR] adverse events (1, 2). However, as a precaution with moderate or severe acute ill- Live virus vaccines (e.g., MMR, MMRV, varicella, rotavirus, and the intranasal live, at- ness, all vaccines should be delayed until the illness has improved. Mild illnesses (such tenuated influenza vaccine [LAIV]) are usually contraindicated in immunocompromised as otitis media, upper respiratory infections, and diarrhea) are NOT contraindications children. However, there are exceptions. For example, MMR is recommended for to vaccination. Do not withhold vaccination if a person is taking antibiotics. asymptomatic HIV-infected children who do not have evidence of severe immunosup- 2. Does the child have allergies to medications, food, a pression. Likewise, varicella vaccine should be considered for HIV-infected children with age-specific CD4+ T-lymphocyte percentage at 15% or greater and may be con- vaccine component, or latex? [all vaccines] sidered for children age 8 years and older with CD4+ T-lymphocyte counts of greater If a person has anaphylaxis after eating gelatin, do not administer MMR, MMRV, or than or equal to 200 cells/µL. Immunosuppressed children should not receive LAIV. varicella vaccine. A local reaction following a prior vaccine dose is not a contraindica- Infants who have been diagnosed with severe combined immunodeficiency (SCID) tion to a subsequent dose. For a table of vaccines supplied in vials or syringes that should not be given a live virus vaccine, including rotavirus (RV) vaccine. Other forms of contain latex, go to www.cdc.gov/vaccines/pubs/pinkbook/downloads/appendices/B/ immunosuppression are a precaution, not a contraindication, to rotavirus vaccine. For latex-table.pdf. For an extensive list of vaccine components, see reference 3. An egg- details, consult the ACIP recommendations (1, 5, 6). free recombinant influenza vaccine (RIV3) may be used in people age 18years and older with egg allergy of any severity who have no other contraindications. Children 9. In the past 3 months, has the child taken medications that and teens younger than age 18 years who have experienced a serious systemic or weaken their immune system, such as cortisone, prednisone, anaphylactic reaction (e.g., hives, swelling of the lips or tongue, acute respiratory dis- other steroids, or anticancer drugs, or had radiation treat- tress, or collapse) after eating eggs can usually be vaccinated with inactivated influenza ments? [LAIV, MMR, MMRV, VAR] vaccine (IIV); consult ACIP recommendations (see reference 4). Live virus vaccines (e.g., MMR, MMRV, varicella, LAIV) should be postponed until after 3. Has the child had a serious reaction to a vaccine in the past? chemotherapy or long-term high-dose steroid therapy has ended. For details and length [all vaccines] History of anaphylactic reaction (see question 2) to a previous dose of of time to postpone, consult the ACIP statement (1). To find specific vaccination schedules vaccine or vaccine component is a contraindication for subsequent doses (1). His- for stem cell transplant (bone marrow transplant) patients, see reference 7. LAIV can be tory of encephalopathy within 7 days following DTP/DTaP is a contraindication for given only to healthy non-pregnant individuals age 2 through 49 years. further doses of pertussis-containing vaccine. Precautions to DTaP (not Tdap) include the following: (a) seizure within 3 days of a dose, (b) pale or limp episode or collapse 10. In the past year, has the child received a transfusion of within 48 hours of a dose, (c) continuous crying for 3 or more hours within 48 hours blood or blood products, or been given immune (gamma) of a dose, and (d) fever of 105°F (40°C) within 48 hours of a previous dose. There globulin or an antiviral drug? [LAIV, MMR, MMRV, VAR] are other adverse events that might have occurred following vaccination that constitute Certain live virus vaccines (e.g., LAIV, MMR, MMRV, varicella) may need to be deferred, contraindications or precautions to future doses. Under normal circumstances, vac- depending on several variables. Consult the most current ACIP recommendations or the cur- cines are deferred when a precaution is present. However, situations may arise when rent Red Book for the most current information on intervals between antiviral drugs, immune the benefit outweighs the risk (e.g., during a community pertussis outbreak). globulin or blood product administration and live virus vaccines (1, 2). 4. Has the child had a health problem with lung, heart, kid- 11. Is the child/teen pregnant or is there a chance she could ney, or metabolic disease (e.g., diabetes), asthma, or a blood become pregnant during the next month? [LAIV, MMR, MMRV, VAR] disorder? Is he/she on long-term aspirin therapy? [LAIV] Live virus vaccines (e.g., MMR, MMRV, varicella, LAIV) are contraindicated one month The safety of LAIV in children and teens with lung, heart, kidney, or metabolic disease before and during pregnancy because of the theoretical risk of virus transmission to (e.g., diabetes), or a blood disorder has not been established. These conditions, in- the fetus (1, 3). Sexually active young women who receive a live virus vaccine should cluding asthma in children ages 5 years and older, should be considered precautions be instructed to practice careful contraception for one month following receipt of the for the use of LAIV. Children on long-term aspirin therapy should not be given LAIV; vaccine (6, 8). On theoretical grounds, inactivated poliovirus vaccine should not be instead, they should be given IIV. given during pregnancy; however, it may be given if risk of exposure is imminent (e.g., travel to endemic areas) and immediate protection is needed. Use of Td or Tdap is not 5. If the child to be vaccinated is 2 through 4 years of age, has contraindicated in pregnancy. At the provider’s discretion, either vaccine may be admin- a healthcare provider told you that the child had wheezing or istered during the 2nd or 3rd trimester (9). asthma in the past 12 months? [LAIV] 12. Has the child received vaccinations in the past 4 weeks? Children ages 2 through 4 years who have had a wheezing episode within the past 12 [LAIV, MMR, MMRV, VAR, yellow fever] months should not be given LAIV. Instead, these children should be given IIV. Children who were given either LAIV or an injectable live virus vaccine (e.g., MMR, 6. If your child is a baby, have you ever been told that he or MMRV, varicella, yellow fever) should wait 28 days before receiving another vaccina- she has had intussusception? [Rotavirus] tion of this type. Inactivated vaccines may be given at the same time or at any spacing Infants who have a history of intussusception (i.e., the telescoping of one portion of the interval. intestine into another) should not be given rotavirus vaccine. References: 7. Has the child, a sibling, or a parent had a seizure; has the 1. CDC. General recommendations on immunization, at www.cdc.gov/vaccines/pubs/acip-list.htm. child had brain or other nervous system problem? [DTaP, Td, Tdap, 2. AAP. Red Book: Report of the Committee on Infectious Diseases at www.aapredbook.org. IIV, LAIV, MMRV] DTaP and Tdap are contraindicated in children who have a history of 3. Table of Vaccine Components: www.cdc.gov/vaccines/pubs/pinkbook/downloads/ encephalopathy within 7 days following DTP/DTaP. An unstable progressive neuro- appendices/B/excipient-table-2.pdf. 4. CDC. Prevention and control of seasonal influenza with vaccines: Recommendations of the logic problem is a precaution to the use of DTaP and Tdap. For children with stable ACIP—2014–2015 Influenza Season at www.cdc.gov/mmwr/pdf/wk/mm6332.pdf, pages 691–7. neurologic disorders (including seizures) unrelated to vaccination, or for children with 5. CDC. Measles, mumps, and rubella—vaccine use and strategies for elimination of measles, a family history of seizures, vaccinate as usual (exception: children with a personal or rubella, and congenital rubella syndrome and control of mumps. MMWR 1998; 47 (RR-8). family [i.e., parent or sibling] history of seizures generally should not be vaccinated with 6. CDC. Prevention of varicella: Recommendations of the Advisory Committee on Immunization MMRV; they should receive separate MMR and VAR vaccines). A history of Guillain- Practices. MMWR 2007; 56 (RR-4). Barré syndrome (GBS) is a consideration with the following: 1) Td/Tdap: if GBS has 7. Tomblyn M, Einsele H, et al. Guidelines for preventing infectious complications among hemato- poietic stem cell transplant recipients: a global perspective. Biol Blood Marrow Transplant 15:1143– occurred within 6 weeks of a tetanus-containing vaccine and decision is made to con- 1238; 2009 at www.cdc.gov/vaccines/pubs/hemato-cell-transplts.htm. tinue vaccination, give age-appropriate Tdap instead of Td if no history of prior Tdap, 8. CDC. Notice to readers: Revised ACIP recommendation for avoiding pregnancy after receiving to improve pertussis protection; 2) Influenza vaccine (IIV or LAIV): if GBS has occurred a rubella-containing vaccine. MMWR 2001; 50 (49). within 6 weeks of a prior influenza vaccination, vaccinate with IIV if at high risk for se- 9. CDC. Prevention of pertussis, tetanus, and diphtheria among pregnant and postpartum women and their infants: Recommendations of the ACIP. MMWR 2008; 57 (RR-4). vere influenza complications.

Immunization Action Coalition • Item #P4060 • p. 2 33 Immunizing Adult Patients: New Standards for Practice

Your patients trust you to give them the best advice on how to protect their health. Vaccine- preventable diseases can result in serious illness, hospitalization, and even death. Make adult vaccination a standard of care in your practice.

Your patients have probably not Make Immunization a Standard of received all the vaccines they need. Patient Care In Your Practice: Even though most insurance plans cover the cost of 1. ASSESS the immunization status of all your patients at recommended vaccines, adult vaccination rates in the U.S. are every clinical encounter. extremely low. Each year, tens of thousands of adults needlessly • Stay informed about the latest CDC recommendations suffer, are hospitalized, and even die as a result for immunization of adults. of diseases that could be prevented by • Implement protocols in your office to ensure that patients’ vaccines. vaccine needs are routinely reviewed and patients get reminders about vaccines they need. Your patients may 2. Strongly RECOMMEND vaccines that your patients need. not even realize that • Address patient questions and concerns in clear and they need vaccines. understandable language. A recent national survey showed that • Highlight positive experiences with vaccination (personal most adults are not aware that they need or in your practice). vaccines throughout their lives to protect 3. ADMINISTER needed vaccines or REFER your patients against diseases like shingles, pertussis, to a vaccination provider. and hepatitis. Many also report not • For vaccines that you stock, make vaccination services receiving vaccine recommendations as convenient as possible for your patients. from their healthcare professional. • For vaccines that you don’t stock, refer patients to providers in the area that offer vaccination services. You can make a difference. 4. DOCUMENT vaccines received by your patients. • Participate in your state’s immunization registry to Clinicians are the most help your office, your patients, and your patients’ other valued and trusted source providers know which vaccines your patients have had. of health information for • Follow up to confirm that patients received recommended adults. Research shows that vaccines that you referred them to get from other most adults believe vaccines immunization providers. are important and that a recommendation from their healthcare professional is a key predictor of patients getting needed vaccines.

NEW Standards for Adult Immunization Practice emphasize the role of ALL healthcare professionals whether they provide immunization services or not in ensuring that adult patients are fully immunized. These standards are published by the National Vaccine Advisory Committee and supported by the Centers for Disease Control and Prevention as well as a number of U.S. Department of Health and Human Services national medical associations. Centers for Disease Control and Prevention

34 Overview A Series on Standards for Adult Immunization Practice

In 2013, the National Vaccine Advisory Committee updated the 2012 U.S. Adult Vaccination Rates Standards for Adult Immunization Practice to reflect the critical need for ALL healthcare professionals—whether they provide Only 14% of adults 19 years or older had received immunization services or not—to take steps to ensure that adult Tdap vaccination. Over 48,000 cases of pertussis were reported in 2012—and many more cases may patients get the vaccines they need. have gone unreported. About five in 100 adults with pertussis are hospitalized and others may have complications, which could include pneumonia. Patients trust you to give them the best Adults can also spread pertussis to infants, who are at most risk for severe illness and death from advice on how to protect their health. this disease.

Make adult vaccination a standard of care Only 20% of adults 60 years or older had in your practice. received zoster (shingles) vaccination. Nearly 1 million Americans experience the condition each year, and about half of all cases occur in adults 60 years or older. Older adults are also most likely to Why should adult immunization experience severe pain from the disease and have be a priority for your practice? postherpetic neuralgia. 1. Your patients are probably not getting the vaccines they Only 20% of adults 19 to 64 years at high risk need. Even though most private insurance plans cover the had received pneumococcal vaccination. While cost of recommended vaccines, adult vaccination rates in the coverage among adults 65 years or older is better, United States are extremely low. Each year, tens of thousands there are still many adults left unprotected. There of adults needlessly suffer, are hospitalized, and even die as a were approximately 32,000 cases of invasive result of diseases that could be prevented by vaccines. pneumococcal disease in 2012, and about 3,000 of those resulted in death. 2. Your patients are likely not aware that they need vaccines. Only 41% of adults 18 years or older had Although adults do believe immunization is important, received flu vaccination during the 2012-2013 a recent national survey showed that most adults are not flu season. Each year, more than 200,000 aware that they need vaccines throughout their lives to people are hospitalized from seasonal protect against diseases like shingles, pertussis, and hepatitis. flu-related complications. Many also report not receiving vaccine recommendations Sources: NHIS 2012 and BRFSS 2012-2013 from their healthcare professional.

3. You play a critical role in ensuring that your patients are fully immunized. Clinicians are the most valued and trusted source of health information for adults. Your patients rely on you to inform them about the vaccines they need. Research shows that a recommendation from their healthcare professional is the top predictor of patients getting vaccinated.

U.S. Department of Health and Human Services Centers for Disease Information Series for Healthcare Professionals Control and Prevention www.cdc.gov/vaccines/adultstandards

35 Overview of Recommended Vaccines for Adults*

VACCINE WHO NEEDS IT NUMBER OF DOSES Seasonal ALL Adults 1 dose every year Influenza Tdap ALL Adults who have not received a dose since age 11 or older 1 dose (All) Women should receive during every pregnancy 1 dose each pregnancy Td ALL Adults 1 dose every 10 years

Zoster Adults 60 years or older 1 dose

Pneumococcal Adults 65 years or older 1 dose (if not Conjugate previously received) Adults 64 years or younger with certain medical conditions (HIV, asplenia, sickle cell 1 dose (if not disease, cerebrospinal fluid leaks, cochlear implants, or conditions that cause weakening previously received) of the immune system) Pneumococcal Adults 65 years or older 1 dose Polysaccharide Adults 64 years or younger with certain medical conditions and who are at higher risk 1 or 2 doses of infection HPV Adults 26 years or younger who have not started or finished the vaccine series 3 doses

Meningococcal Adults who have not had the vaccine and are at risk for exposure or have 1 or more doses damaged spleen

MMR Adults born during or after 1957 who have not had the vaccine or do not have 1 or 2 doses documented evidence of immunity

Varicella Adults who have not had chickenpox or do not have documented evidence of immunity 2 doses

Hep A Adults who are at risk and have not had the vaccine series 2 doses

Hep B Adults who have not had the vaccine series and who are at risk, including adults with 3 doses diabetes, end-stage kidney disease, chronic liver disease, or behaviors that increase risk

Hib Adults with special health conditions (sickle cell disease, HIV/AIDS, removal of 1 dose the spleen, bone marrow transplant, or cancer treatment with drugs) who have not already had the vaccine

*Visit www.cdc.gov/vaccines/schedules/ for a detailed schedule of recommended vaccines and guidelines for administration.

Coverage of Adult Vaccines In 2012: Most private health insurance plans cover the cost of recommended vaccines. If your patients do not currently have health insurance, refer them to www.HealthCare.gov to learn more about • Only 14% of adults 19 years or older had received health coverage options. Tdap vaccine. For patients 65 years or older enrolled in Medicare, Medicare Part B covers the cost of influenza • Only 20% of adults 60 and pneumococcal vaccines as well as Hep B vaccine for persons at increased risk of hepatitis. years or older had received Those with a Medicare Prescription Drug Plan (Part D) or enrolled in a Medicare Advantage Plan zoster vaccine. (Part C) that offers Medicare prescription drug coverage may also have coverage for additional • Only 20% of adults 19 to vaccines like zoster, MMR, and Tdap. Visit www.Medicare.gov for more information. 64 years at high risk had received pneumococcal Vaccine coverage for Medicaid beneficiaries varies by state. Contact your State Medicaid vaccine. Agency for more information. Source: National Health Interview Survey, 2012.

For additional information on adult immunization and resources for patient education, visit: www.cdc.gov/vaccines/hcp/adults.

Last Updated February 5, 2014

36 Pneumococcal Vaccine Timing–For Adults

DO NOT administer PCV13 and PPSV23 at the same visit.

Age 65 Years or Older

• If PCV13 was given before age 65 years, no additional PCV13 is needed.

No history of PCV PPSV pneumococcal 1 year (8 weeks for groups B & C as defined below) vaccine 13 23 Prevnar 13® Pneumovax® 23

Received PCV 1 year PPSV PPSV23 1 year (8 weeks for groups B & C as defined below) before age 65 13 and 5 years after prior dose of PPSV23 23

Received PCV PPSV23 at 1 year age 65 or older 13

Age 19-64 Years With Underlying Condition(s)

• Prior doses count towards doses recommended below and do not need to be repeated. • If PPSV23 given previously – wait one year before giving PCV13 – for group B, wait at least five years before giving a second dose of PPSV23. • No more than two doses of PPSV23 recommended before 65th birthday and one dose thereafter.

A. Smoker, Long-term facility resident, or PPSV Chronic conditions: • heart disease (excluding hypertension) • diabetes • lung disease (including asthma) • alcoholism 23 • liver disease (including cirrhosis)

B. Immunocompromised (including HIV infection), PCV PPSV PPSV Chronic renal failure, 8 weeks 5 years Nephrotic syndrome, or 13 23 23 Asplenia

C. CSF leaks or PCV PPSV Cochlear implants 13 8 weeks 23

For further details, see: www.cdc.gov/vaccines/hcp/acip-recs/vacc-speci c/pneumo.html California Department of Public Health, Immunization Branch www.EZIZ.org This publication was supported by Grant Number H23/CCH922507 from the Centers for Disease Control and Prevention (CDC) IMM-1152 (9/15)

37 Patient name: Date of birth: (mo.) (day) (yr.)

Screening Checklist for Contraindications to Vaccines for Adults For patients: The following questions will help us determine which vaccines you may be given today. If you answer “yes” to any question, it does not necessarily mean you should not be vaccinated. It just means additional questions must be asked. If a question is not clear, please ask your healthcare provider to explain it. Don’t Yes No Know

1. Are you sick today?   

2. Do you have allergies to medications, food, a vaccine component, or latex?   

3. Have you ever had a serious reaction after receiving a vaccination?   

4. Do you have a long-term health problem with heart disease, lung disease, asthma,    kidney disease, metabolic disease (e.g., diabetes), anemia, or other blood disorder?

5. Do you have cancer, leukemia, HIV/AIDS, or any other immune system problem?   

6. In the past 3 months, have you taken medications that weaken your immune system, such as cortisone, prednisone, other steroids, or anticancer drugs, or have you had    radiation treatments?

7. Have you had a seizure or a brain or other nervous system problem?   

8. During the past year, have you received a transfusion of blood or blood products,    or been given immune (gamma) globulin or an antiviral drug?

9. For women: Are you pregnant or is there a chance you could become pregnant    during the next month?

10. Have you received any vaccinations in the past 4 weeks?   

Form completed by: ______Date:______

Form reviewed by: ______Date:______

Did you bring your immunization record card with you? yes  no  It is important for you to have a personal record of your vaccinations. If you don’t have a personal record, ask your healthcare provider to give you one. Keep this record in a safe place and bring it with you every time you seek medical care. Make sure your healthcare provider records all your vaccinations on it.

Technical content reviewed by the Centers for Disease Control and Prevention Immunization Action Coalition Saint Paul, Minnesota • 651-647-9009 • www.immunize.org • www.vaccineinformation.org www.immunize.org/catg.d/p4065.pdf • Item #P4065 (1/15)

38 Information for Health Professionals about the Screening Checklist for Contraindications To Vaccines for Adults Are you interested in knowing why we included a certain question on the screening checklist? If so, read the information below. If you want to find out even more, consult the references listed at the bottom of this page.

1. Are you sick today? [all vaccines] 7. Have you had a seizure or a brain or other nervous system There is no evidence that acute illness reduces vaccine efficacy or increases problem? [influenza, Td/Tdap] vaccine adverse events (1). However, as a precaution with moderate or se- Tdap is contraindicated in people who have a history of encephalopathy within vere acute illness, all vaccines should be delayed until the illness has improved. 7 days following DTP/DTaP given before age 7 years. An unstable progressive Mild illnesses (such as upper respiratory infections or diarrhea) are NOT neurologic problem is a precaution to the use of Tdap. For people with stable contraindications to vaccination. Do not withhold vaccination if a person is taking neurologic disorders (including seizures) unrelated to vaccination, or for people antibiotics. with a family history of seizure, vaccinate as usual. A history of Guillain-Barré syndrome (GBS) is a consideration with the following: 1) Td/Tdap: if GBS has 2. Do you have allergies to medications, food, a vaccine component, occurred within 6 weeks of a tetanus-containing vaccine and decision is made or latex? [all vaccines] to continue vaccination, give Tdap instead of Td if no history of prior Tdap; 2) If a person has anaphylaxis after eating gelatin, do not administer MMR or Influenza vaccine (IIV/LAIV): if GBS has occurred within 6 weeks of a priorin - varicella vaccine. A local reaction to a prior vaccine dose or vaccine compo- fluenza vaccine, vaccinate with IIV if at high risk for severe influenza complications. nents (e.g., latex) is not a contraindication to a subsequent dose or vaccine 8. During the past year, have you received a transfusion of blood containing that component. For a table of vaccines supplied in vials or syringes that contain latex, go to www.cdc.gov/vaccines/pubs/pinkbook/downloads/ or blood products, or been given immune (gamma) globulin or an appendices/B/latex-table.pdf. For an extensive list of vaccine components, see antiviral drug? [LAIV, MMR, VAR] reference 2. Certain live virus vaccines (e.g., LAIV, MMR, VAR, ZOS) may need to be An egg-free recombinant influenza vaccine (RIV3) may be used in people deferred, depending on several variables. Consult the most current ACIP age 18 years and older with egg allergy of any severity who have no other recommendations for current information on intervals between antiviral drugs, contraindications. People younger than age 18 years who have experienced immune globulin or blood product administration and live virus vaccines. (1) a serious systemic or anaphylactic reaction (e.g., hives, swelling of the lips or 9. For women: Are you pregnant or is there a chance you could tongue, acute respiratory distress, or collapse) after eating eggs can usually be become pregnant during the next month? [MMR, LAIV, VAR, ZOS] vaccinated with inactivated influenza vaccine (IIV); consult ACIP recommenda- Live virus vaccines (e.g., MMR, VAR, ZOS, LAIV) are contraindicated one tions (see reference 3). month before and during pregnancy because of the theoretical risk of virus 3. Have you ever had a serious reaction after receiving a transmission to the fetus. Sexually active women in their childbearing years vaccination? [all vaccines] who receive live virus vaccines should be instructed to practice careful con- History of anaphylactic reaction (see question 2) to a previous dose of vaccine traception for one month following receipt of the vaccine. On theoretical or vaccine component is a contraindication for subsequent doses (1). Under grounds, inactivated poliovirus vaccine should not be given during pregnancy; normal circumstances, vaccines are deferred when a precaution is present. however, it may be given if risk of exposure is imminent and immediate pro- However, situations may arise when the benefit outweighs the risk (e.g., during tection is needed (e.g., travel to endemic areas). Use of Td or Tdap is not a community pertussis outbreak). contraindicated in pregnancy. At the provider’s discretion, either vaccine may be administered during the 2nd or 3rd trimester. (1, 3, 4, 5, 7, 8) 4. Do you have a long-term health problem with heart disease, lung disease, asthma, kidney disease, metabolic disease (e.g., 10. Have you received any vaccinations in the past 4 weeks? diabetes), anemia, or other blood disorder? [LAIV] [LAIV, MMR, VAR, yellow fever] People who were given either LAIV or an in- The safety of intranasal live attenuated influenza vaccine (LAIV) in people with jectable live virus vaccine (e.g., MMR, VAR, ZOS, yellow fever) should wait 28 these conditions has not been established. These conditions, including asthma days before receiving another vaccination of this type. Inactivated vaccines may in adults, should be considered precautions for the use of LAIV. be given at any spacing interval if they are not administered simultaneously.

5. Do you have cancer, leukemia, HIV/AIDS, or any other im- References: mune system problem? [LAIV, MMR, VAR, ZOS] 1. CDC. General recommendations on immunization, at www.cdc.gov/vaccines/ Live virus vaccines (e.g., LAIV, measles-mumps-rubella [MMR], varicella [VAR], pubs/acip-list.htm zoster [ZOS]) are usually contraindicated in immunocompromised people. 2. Table of Vaccine Components: www.cdc.gov/vaccines/pubs/pinkbook/downloads/ However, there are exceptions. For example, MMR vaccine is recommended appendices/B/excipient-table-2.pdf. and varicella vaccine should be considered for adults with CD4+ T-lympho- 3. CDC. Prevention and control of seasonal influenza with vaccines: Recommenda- cyte counts of greater than or equal to 200 cells/µL. Immunosuppressed people tions of the ACIP—2014–2015 Influenza Season at www.cdc.gov/mmwr/pdf/wk/ should not receive LAIV. For details, consult the ACIP recommendations (1, 4, 5). mm6332.pdf, pages 691–7. 4. CDC. Measles, mumps, and rubella—vaccine use and strategies for elimination 6. In the past 3 months, have you taken medications that of measles, rubella, and congenital rubella syndrome and control of mumps. weaken your immune system, such as cortisone, prednisone, MMWR 1998; 47 (RR-8). other steroids, or anticancer drugs, or have you had radiation 5. CDC. Prevention of varicella: Recommendations of the Advisory Committee on Im- treatments? [LAIV, MMR, VAR, ZOS] munization Practices. MMWR 2007; 56 (RR-4). Live virus vaccines (e.g., LAIV, MMR, VAR, ZOS) should be postponed until 6. Tomblyn M, Einsele H, et al. Guidelines for preventing infectious complications after chemotherapy or long-term high-dose steroid therapy has ended. For among hematopoietic stem cell transplant recipients: a global perspective. Biol Blood details and length of time to postpone, consult the ACIP statement (1, 3). To Marrow Transplant 15:1143–1238; 2009 at www.cdc.gov/vaccines/pubs/hemato- find specific vaccination schedules for stem cell transplant (bone marrow trans- cell-transplts.htm. plant) patients, see reference 6. LAIV can be given only to healthy non-pregnant 7. CDC. Notice to readers: Revised ACIP recommendation for avoiding pregnancy people younger than age 50 years. after receiving a rubella-containing vaccine. MMWR 2001; 50 (49). 8. CDC. Prevention of pertussis, tetanus, and diphtheria among pregnant and postpar- tum women and their infants: Recommendations of the ACIP. MMWR 2008; 57 (RR-4).

Immunization Action Coalition • Item #P4065 • p. 2 39 Guide to Contraindications and Precautions to Commonly Used Vaccines1,*,† (page 1 of 2)

Vaccine Contraindications Precautions

Hepatitis B (HepB) • Severe allergic reaction (e.g., anaphylaxis) after a previous • Moderate or severe acute illness with or without fever dose or to a vaccine component • Infant weighing less than 2000 grams (4 lbs, 6.4 oz)2 Rotavirus • Severe allergic reaction (e.g., anaphylaxis) after a previous • Moderate or severe acute illness with or without fever (RV5 [RotaTeq], dose or to a vaccine component • Altered immunocompetence other than SCID RV1 [Rotarix]) • Severe combined immunodeficiency (SCID) • Chronic gastrointestinal disease3 • History of intussusception • Spina bifida or bladder exstrophy3 Diphtheria, tetanus, • Severe allergic reaction (e.g., anaphylaxis) after a previous • Moderate or severe acute illness with or without fever pertussis (DTaP) dose or to a vaccine component • Guillain-Barré syndrome (GBS) within 6 weeks after a previous • For pertussis-containing vaccines: encephalopathy (e.g., dose of tetanus toxoid-containing vaccine Tetanus, diphtheria, coma, decreased level of consciousness, prolonged sei- • History of Arthus-type hypersensitivity reactions after a previous pertussis (Tdap) zures) not attributable to another identifiable cause within 7 dose of tetanus or diphtheria toxoid-containing vaccine; defer days of administration of a previous dose of DTP or DTaP vaccination until at least 10 years have elapsed since the last Tetanus, diphtheria (for DTaP); or of previous dose of DTP, DTaP, or Tdap (for tetanus-toxoid containing vaccine (DT, Td) Tdap) • For pertussis-containing vaccines: progressive or unstable neuro- logic disorder (including infantile spasms for DTaP), uncontrolled seizures, or progressive encephalopathy until a treatment regimen has been established and the condition has stabilized For DTaP only: • Temperature of 105° F or higher (40.5° C or higher) within 48 hours after vaccination with a previous dose of DTP/DTaP • Collapse or shock-like state (i.e., hypotonic hyporesponsive episode) within 48 hours after receiving a previous dose of DTP/ DTaP • Seizure within 3 days after receiving a previous dose of DTP/DTaP • Persistent, inconsolable crying lasting 3 or more hours within 48 hours after receiving a previous dose of DTP/DTaP Haemophilus influen- • Severe allergic reaction (e.g., anaphylaxis) after a previous • Moderate or severe acute illness with or without fever zae type b (Hib) dose or to a vaccine component • Age younger than 6 weeks Inactivated poliovirus • Severe allergic reaction (e.g., anaphylaxis) after a previous • Moderate or severe acute illness with or without fever vaccine (IPV) dose or to a vaccine component • Pregnancy Pneumococcal • Severe allergic reaction (e.g., anaphylaxis) after a previous • Moderate or severe acute illness with or without fever (PCV13 or PPSV23) dose or to a vaccine component (including, for PCV13, to any diphtheria toxoid-containing vaccine) Measles, mumps, • Severe allergic reaction (e.g., anaphylaxis) after a previous • Moderate or severe acute illness with or without fever rubella (MMR)4 dose or to a vaccine component • Recent (within 11 months) receipt of antibody-containing blood • Known severe immunodeficiency (e.g., from hematologic product (specific interval depends on product)7 and solid tumors, receipt of chemotherapy, congenital im- • History of thrombocytopenia or thrombocytopenic purpura 5 munodeficiency, or long-term immunosuppressive therapy • Need for tuberculin skin testing8 or patients with human immunodeficiency virus [HIV] infec- tion who are severely immunocompromised)6 • Pregnancy Varicella (Var)4 • Severe allergic reaction (e.g., anaphylaxis) after a previous • Moderate or severe acute illness with or without fever dose or to a vaccine component • Recent (within 11 months) receipt of antibody-containing blood • Known severe immunodeficiency (e.g., from hematologic product (specific interval depends on product)7 and solid tumors, receipt of chemotherapy, congenital • Receipt of specific antivirals (i.e., acyclovir, famciclovir, or vala- immunodeficiency, or long-term immunosuppressive cyclovir) 24 hours before vaccination; avoid use of these antiviral therapy5 or patients with HIV infection who are severely drugs for 14 days after vaccination. immunocompromised)6 • Pregnancy Hepatitis A (HepA) • Severe allergic reaction (e.g., anaphylaxis) after a previous • Moderate or severe acute illness with or without fever dose or to a vaccine component (continued on page 2)

Technical content reviewed by the Centers for Disease Control and Prevention Immunization Action Coalition Saint Paul, Minnesota • 651-647-9009 • www.immunize.org • www.vaccineinformation.org www.immunize.org/catg.d/p3072a.pdf • Item #P3072a (3/15)

40 Guide to Contraindications and Precautions to Commonly Used Vaccines1,*,† (page 2 of 2)

Vaccine Contraindications Precautions Influenza, inactivated • Severe allergic reaction (e.g., anaphylaxis) after a previous • Moderate or severe acute illness with or without fever injectable (IIV)9 dose of any influenza vaccine or to a vaccine component, • History of GBS within 6 weeks of previous influenza vaccination including egg protein • Persons who experience only hives with exposure to eggs may • In addition, ACIP recommends that LAIV not be used in the receive RIV or, with additional safety precautions, IIV.9 following populations: pregnant women; immunosuppressed adults; adults with egg allergy of any severity; adults who have taken influenza antiviral medications (amantadine, rimantadine, zanamivir, or oseltamivir) within the previous 48 hours; avoid use of these antiviral durgs for 14 days after vaccination Influenza, recombinant • Severe allergic reaction (e.g., anaphylaxis) after a previous • Moderate or severe acute illness with or without fever (RIV)9 dose of RIV or to a vaccine component. RIV does not • History of GBS within 6 weeks of previous influenza vaccination contain any egg protein.9 Influenza, live • Severe allergic reaction (e.g., anaphylaxis) to any compo- • Moderate or severe acute illness with or without fever attenuated (LAIV)4,9 nent of the vaccine, or to a previous dose of any influenza • History of GBS within 6 weeks of previous influenza vaccination vaccine • Asthma in persons age 5 years and older • Concomitant use of aspirin or aspirin-containing medication • Other chronic medical conditions (e.g., other chronic lung dis- in children or adolescents eases, chronic cardiovascular disease [excluding isolated hyper- • In addition, ACIP recommends that LAIV not be used in the tension], diabetes, chronic renal or hepatic disease, hematologic following populations: pregnant women; immunosuppressed disease, neurologic disease, and metabolic disorders) adults; adults with egg allergy of any severity; adults who have taken influenza antiviral medications (amantadine, rimantadine, zanamivir, or oseltamivir) within the previous 48 hours; avoid use of these antiviral durgs for 14 days after vaccination Human papillomavirus • Severe allergic reaction (e.g., anaphylaxis) after a previous • Moderate or severe acute illness with or without fever (HPV) dose or to a vaccine component • Pregnancy Meningococcal: • Severe allergic reaction (e.g., anaphylaxis) after a previous • Moderate or severe acute illness with or without fever conjugate (MenACWY), dose or to a vaccine component polysaccharide (MPSV4) Zoster (HZV)4 • Severe allergic reaction (e.g., anaphylaxis) to a vaccine • Moderate or severe acute illness with or without fever component • Receipt of specific antivirals (i.e., acyclovir, famciclovir, or vala- • Known severe immunodeficiency (e.g., from hematologic cyclovir) 24 hours before vaccination; avoid use of these antiviral and solid tumors, receipt of chemotherapy, or long-term drugs for 14 days after vaccination. immunosuppressive therapy5 or patients with HIV infection who are severely immunocompromised). • Pregnancy

FOOTNOTES 1. Vaccine package inserts and the full ACIP recommendations for these vaccines should be consulted 6. HIV-infected children may receive varicella and measles vaccine if CD4+ T-lymphocyte count is >15%. for additional information on vaccine-related contraindications and precautions and for more infor- (Source: Adapted from American Academy of Pediatrics. Immunization in Special Clinical Circum- mation on vaccine excipients. Events or conditions listed as precautions should be reviewed carefully. stances. In: Pickering LK, ed. Red Book: 2012 Report of the Committee on Infectious Diseases. 29th ed. Benefits of and risks for administering a specific vaccine to a person under these circumstances should Elk Grove Village, IL: American Academy of Pediatrics: 2012.) be considered. If the risk from the vaccine is believed to outweigh the benefit, the vaccine should 7. Vaccine should be deferred for the appropriate interval if replacement immune globulin products not be administered. If the benefit of vaccination is believed to outweigh the risk, the vaccine should be are being administered (see “General Recommendations on Immunization: Recommendations of the administered. A contraindication increases the chance of a serious adverse reaction. Therefore, a vac- Advisory Committee on Immunization Practices (ACIP)” MMWR 2011;60(No. RR-2) available at www. cine should not be administered when a contraindication is present. Whether and when to administer cdc.gov/vaccines/hcp/acip-recs/index.html.) DTaP to children with proven or suspected underlying neuro-logic disorders should be decided on a 8. Measles vaccination might suppress tuberculin reactivity temporarily. Measles-containing vaccine case-by-case basis. may be administered on the same day as tuberculin skin testing. If testing cannot be performed until 2. Hepatitis B vaccination should be deferred for preterm infants and infants weighing less than 2000 g if after the day of MMR vaccination, the test should be postponed for at least 4 weeks after the vaccina- the mother is documented to be hepatitis B surface antigen (HBsAg)-negative at the time of the infant’s tion. If an urgent need exists to skin test, do so with the understanding that reactivity might be reduced birth. Vaccination can commence at chronological age 1 month or at hospital discharge. For infants by the vaccine. born to women who are HBsAg-positive, hepatitis B immunoglobulin and hepatitis B vaccine should 9. For more information on use of influenza vaccines among persons with egg allergies and a complete be administered within 12 hours of birth, regardless of weight. list of conditions that CDC considers to be reasons to avoid getting LAIV, see CDC. “Prevention and 3. For details, see CDC. “Prevention of Rotavirus Gastroenteritis among Infants and Children: Recom- Control of Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization mendations of the Advisory Committee on Immunization Practices. (ACIP)” MMWR 2009;58(No. Practices (ACIP) – United States, 2014–15” MMWR 2014;63(32):691–97. RR–2), available at www.cdc.gov/vaccines/hcp/acip-recs/index.html. 4. LAIV, MMR, varicella, or zoster vaccines can be administered on the same day. If not administered on the same day, these live vaccines should be separated by at least 28 days. * Adapted from “Table 6. Contraindications and Precautions to Commonly Used Vaccines” found in: 5. Immunosuppressive steroid dose is considered to be 2 or more weeks of daily receipt of 20 mg CDC. “General Recommendations on Immunization: Recommendations of the Advisory Committee on prednisone or equivalent. Vaccination should be deferred for at least 1 month after discontinuation of Immunization Practices (ACIP).” MMWR 2011; 60(No. RR-2), p. 40–41, and from Atkinson W, Wolfe S, such therapy. Providers should consult ACIP recommendations for complete information on the use of Hamborsky J, eds. Appendix A. Epidemiology and Prevention of Vaccine-Preventable Diseases.12th ed. specific live vaccines among persons on immune-suppressing medications or with immune suppres- † Regarding latex allergy, consult the package insert for any vaccine administered. sion because of other reasons. Technical content reviewed by the Centers for Disease Control and Prevention Immunization Action Coalition Saint Paul, Minnesota • 651-647-9009 • www.immunize.org • www.vaccineinformation.org www.immunize.org/catg.d/p3072a.pdf • Item #P3072a (3/15)

41 Appendix B

Vaccine Excipient & Media Summary Excipients Included in U.S. Vaccines, by Vaccine

This table includes not only vaccine ingredients (e.g., adjuvants and preservatives), but also substances used during the manufacturing process, including vaccine-production media, that are removed from the final product and present only in trace quantities. In addition to the substances listed, most vaccines contain Sodium Chloride (table salt).

Last Updated February 2015 All reasonable efforts have been made to ensure the accuracy of this information, but manufacturers may change product contents before that information is reflected here. If in doubt, check the manufacturer’s package insert.

Source: Vaccine Contains Manufacturer’s P.I. Dated sucrose, D-mannose, D-fructose, dextrose, potassium phosphate, plasdone C, anhydrous lactose, micro crystalline cellulose, polacrilin potassium, magnesium stearate, cellulose acetate phthalate, alcohol, acetone, castor Adenovirus March 2011 oil, FD&C Yellow #6 aluminum lake dye, human serum albumin, fetal bovine serum, sodium bicarbonate, human-diploid fibroblast cell cultures (WI-38), Dulbecco’s Modified Eagle’s Medium, monosodium glutamate aluminum hydroxide, benzethonium chloride, formaldehyde, amino acids, Anthrax (Biothrax) May 2012 vitamins, inorganic salts and sugars glycerin, asparagine, citric acid, potassium phosphate, magnesium sulfate, BCG (Tice) February 2009 Iron ammonium citrate, lactose aluminum potassium sulfate, peptone, bovine extract, formaldehyde, DT (Sanofi) thimerosal (trace), modified Mueller and Miller medium, ammonium December 2005 sulfate aluminum phosphate, formaldehyde, glutaraldehyde, 2-Phenoxyethanol, Stainer-Scholte medium, modified Mueller’s growth medium, modified DTaP (Daptacel) October 2013 Mueller-Miller casamino acid medium (without beef heart infusion), dimethyl 1-beta-cyclodextrin, ammonium sulfate formaldehyde, glutaraldehyde, aluminum hydroxide, polysorbate 80, DTaP (Infanrix) Fenton medium (containing bovine extract), modified Latham medium November 2013 (derived from bovine casein), modified Stainer-Scholte liquid medium formaldehyde, glutaraldehyde, aluminum hydroxide, Vero (monkey kidney) cells, calf serum, lactalbumin hydrolysate, polysorbate 80, DTaP-IPV (Kinrix) neomycin sulfate, polymyxin B, Fenton medium (containing bovine November 2013 extract), modified Latham medium (derived from bovine casein), modified Stainer-Scholte liquid medium formaldehyde, gluteraldehyde, aluminum hydroxide, aluminum phosphate, lactalbumin hydrolysate, polysorbate 80, neomycin sulfate, DTaP-HepB-IPV (Pediarix) polymyxin B, yeast protein, calf serum, Fenton medium (containing November 2013 bovine extract), modified Latham medium (derived from bovine casein), modified Stainer-Scholte liquid medium, Vero (monkey kidney) cells aluminum phosphate, polysorbate 80, formaldehyde, sucrose, gutaraldehyde, bovine serum albumin, 2-phenoxethanol, neomycin, polymyxin B sulfate, Mueller’s Growth Medium, Mueller-Miller DTaP-IPV/Hib (Pentacel) casamino acid medium (without beef heart infusion), Stainer-Scholte October 2013 medium (modified by the addition of casamino acids and dimethyl-beta- cyclodextrin), MRC-5 (human diploid) cells, CMRL 1969 medium (supplemented with calf serum), ammonium sulfate, and medium 199 B ammonium sulfate, formalin, sucrose, Modified Mueller and Miller Hib (ActHIB) January 2014 medium Hib (Hiberix) formaldehyde, lactose, semi-synthetic medium March 2012 aluminum hydroxphosphate sulfate, ethanol, enzymes, phenol, detergent, Hib (PedvaxHIB) December 2010 complex fermentation medium

Centers for Disease Control and Prevention Epidemiology and Prevention of Vaccine-Preventable Diseases, 13th Edition April, 2015

Appendix B-7

42 Appendix B

Source: Vaccine Contains Manufacturer’s P.I. Dated yeast (vaccine contains no detectable yeast DNA), nicotinamide adenine dinucleotide, hemin chloride, soy peptone, dextrose, mineral salts, amino Hib/Hep B (Comvax) acids, formaldehyde, potassium aluminum sulfate, amorphous aluminum December 2010 hydroxyphosphate sulfate, sodium borate, phenol, ethanol, enzymes, detergent tris (trometamol)-HCl, sucrose, formaldehyde, synthetic medium, semi- Hib/Mening. CY (MenHibrix) 2012 synthetic medium aluminum hydroxide, amino acid supplement, polysorbate 20, formalin, Hep A (Havrix) December 2013 neomycin sulfate, MRC-5 cellular proteins amorphous aluminum hydroxyphosphate sulfate, bovine albumin, Hep A (Vaqta) February 2014 formaldehyde, neomycin, sodium borate, MRC-5 (human diploid) cells aluminum hydroxide, yeast protein, phosphate buffers, sodium Hep B (Engerix-B) December 2013 dihydrogen phosphate dihydrate yeast protein, soy peptone, dextrose, amino acids, mineral salts, potassium Hep B (Recombivax) aluminum sulfate, amorphous aluminum hydroxyphosphate sulfate, May 2014 formaldehyde, phosphate buffer formalin, yeast protein, aluminum phosphate, aluminum hydroxide, amino Hep A/Hep B (Twinrix) acids, phosphate buffer, polysorbate 20, neomycin sulfate, MRC-5 human August 2012 diploid cells vitamins, amino acids, lipids, mineral salts, aluminum hydroxide, sodium Human Papillomavirus dihydrogen phosphate dehydrate, 3-O-desacyl-4’ Monophosphoryl lipid November 2013 (HPV) (Cerverix) A, insect cell, bacterial, and viral protein yeast protein, vitamins, amino acids, mineral salts, carbohydrates, Human Papillomavirus amorphous aluminum hydroxyphosphate sulfate, L-histidine, polysorbate June 2014 (HPV) (Gardasil) 80, sodium borate yeast protein, vitamins, amino acids, mineral salts, carbohydrates, Human Papillomavirus amorphous aluminum hydroxyphosphate sulfate, L-histidine, polysorbate December 2014 (HPV) (Gardasil 9) 80, sodium borate beta-propiolactone, thimerosol (multi-dose vials only), monobasic sodium phosphate, dibasic sodium phosphate, monobasic potassium phosphate, Influenza (Afluria) December 2013 potassium chloride, calcium chloride, sodium taurodeoxycholate, neomycin sulfate, polymyxin B, egg protein, sucrose egg proteins, formaldehyde, polysorbate 80, cetyltrimethylammonium Influenza (Agriflu) 2013 bromide, neomycin sulfate, kanamycin, barium octoxynol-10 (Triton X- Į-tocopheryl hydrogen succinate, Influenza (Fluarix) Trivalent polysorbate 80 (Tween 80), hydrocortisone, gentamicin sulfate, June 2014 and Quadrivalent ovalbumin, formaldehyde, sodium deoxycholate, sucrose, phosphate buffer monobasic sodium phosphate, dibasic sodium phosphate, polysorbate 20, Influenza (Flublok) baculovirus and host cell proteins, baculovirus and cellular DNA, Triton March 2014 X-100, lipids, vitamins, amino acids, mineral salts Madin Darby Canine Kidney (MDCK) cell protein, MDCK cell DNA, Influenza (Flucelvax) SRO\VRUEDWHFHW\OWULPHWKO\DPPRQLXPEURPLGHȕ-propiolactone, March 2014 phosphate buffer nonylphenol ethoxylate, thimerosal (multidose vial–trace only in prefilled Influenza (Fluvirin) syringe), polymyxin, neomycin, beta-propiolactone, egg proteins, February 2014 B phosphate buffer Influenza (Flulaval) thimerosal, formaldehyde, sodium deoxycholate, egg proteins, phosphate February 2013 Trivalent and Quadrivalent buffer Influenza (Fluzone: formaldehyde, octylphenol ethoxylate (Triton X-100), gelatin (standard Standard (Trivalent and trivalent formulation only), thimerosal (multi-dose vial only) , egg 2014 Quadrivalent), High-Dose, protein, phosphate buffers, sucrose & Intradermal)

Centers for Disease Control and Prevention Epidemiology and Prevention of Vaccine-Preventable Diseases, 13th Edition April, 2015

Appendix B-8

43 Appendix B

Source: Vaccine Contains Manufacturer’s P.I. Dated ethylene diamine tetraacetic acid (EDTA), monosodium glutamate, Influenza (FluMist) hydrolyzed porcine gelatin, arginine, sucrose, dibasic potassium July 2013 Quadrivalent phosphate, monobasic potassium phosphate, gentamicin sulfate, egg protein Japanese Encephalitis aluminum hydroxide, Vero cells, protamine sulfate, formaldehyde, bovine May 2013 (Ixiaro) serum albumin, sodium metabisulphite, sucrose formaldehyde, phosphate buffers, Mueller Hinton agar, Watson Scherp Meningococcal (MCV4- media, Modified Mueller and Miller medium, detergent, alcohol, April 2013 Menactra) ammonium sulfate Meningococcal (MCV4- formaldehyde, amino acids, yeast extract, Franz complete medium, CY August 2013 Menveo) medium Meningococcal (MPSV4- thimerosal (multi-dose vial only), lactose, Mueller Hinton casein agar, April 2013 Menomune) Watson Scherp media, detergent, alcohol Meningococcal (MenB – aluminum hydroxide, E. coli, histidine, sucrose, deoxycholate, kanomycin 2015 Bexsero) Meningococcal (MenB – polysorbate 80, histodine, E. coli, fermentation growth media October 2015 Trumenba) Medium 199 (vitamins, amino acids, fetal bovine serum, sucrose, glutamate) , Minimum Essential Medium, phosphate, recombinant human MMR (MMR-II) June 2014 albumin, neomycin, sorbitol, hydrolyzed gelatin, chick embryo cell culture, WI-38 human diploid lung fibroblasts sucrose, hydrolyzed gelatin, sorbitol, monosodium L-glutamate, sodium phosphate dibasic, human albumin, sodium bicarbonate, potassium MMRV (ProQuad) phosphate monobasic, potassium chloride, potassium phosphate dibasic, March 2014 neomycin, bovine calf serum, chick embryo cell culture, WI-38 human diploid lung fibroblasts, MRC-5 cells Pneumococcal (PCV13 – casamino acids, yeast, ammonium sulfate, Polysorbate 80, succinate January 2014 Prevnar 13) buffer, aluminum phosphate, soy peptone broth Pneumococcal (PPSV-23 – phenol May 2014 Pneumovax) 2-phenoxyethanol, formaldehyde, neomycin, streptomycin, polymyxin B, Polio (IPV – Ipol) monkey kidney cells, Eagle MEM modified medium, calf serum protein, May 2013 Medium 199 Human albumin, neomycin sulfate, phenol red indicator, MRC-5 human Rabies (Imovax) April 2013 diploid cells, beta-propriolactone ȕ-propiolactone, potassium glutamate, chicken protein, egg protein, Rabies (RabAvert) neomycin, chlortetracycline, amphotericin B, human serum albumin, March 2012 polygeline (processed bovine gelatin), sodium EDTA, bovine serum sucrose, sodium citrate, sodium phosphate monobasic monohydrate, sodium hydroxide, polysorbate 80, cell culture media, fetal bovine serum, Rotavirus (RotaTeq) vero cells [DNA from porcine circoviruses (PCV) 1 and 2 has been June 2013 detected in RotaTeq. PCV-1 and PCV-2 are not known to cause disease in humans.] amino acids, dextran, sorbitol, sucrose, calcium carbonate, xanthan, Dulbecco’s Modified Eagle Medium (potassium chloride, magnesium sulfate, ferric (III) nitrate, sodium phosphate, sodium pyruvate, D- Rotavirus (Rotarix) glucose, concentrated vitamin solution, L-cystine, L-tyrosine, amino acids May 2014 B solution, L-glutamine, calcium chloride, sodium hydrogenocarbonate, and phenol red) [Porcine circovirus type 1 (PCV-1) is present in Rotarix. PCV-1 is not known to cause disease in humans.] Smallpox (Vaccinia – human serum albumin, mannitol, neomycin, glycerin, polymyxin B, September 2009 ACAM2000) phenol, Vero cells, HEPES

Centers for Disease Control and Prevention Epidemiology and Prevention of Vaccine-Preventable Diseases, 13th Edition April, 2015 Appendix B-9

44 Appendix B

Source: Vaccine Contains Manufacturer’s P.I. Dated aluminum potassium sulfate, peptone, formaldehyde, thimerosal, bovine Td (Decavac) muscle tissue (US sourced), Mueller and Miller medium, ammonium March 2011 sulfate aluminum phosphate, formaldehyde, modified Mueller-Miller casamino Td (Tenivac) April 2013 acid medium without beef heart infusion, ammonium sulfate aluminum phosphate, formaldehyde, thimerosal (trace), ammonium Td (Mass Biologics) February 2011 phosphate, modified Mueller’s media (containing bovine extracts) aluminum phosphate, formaldehyde, glutaraldehyde, 2-phenoxyethanol, ammonium sulfate, Stainer-Scholte medium, dimethyl-beta-cyclodextrin, Tdap (Adacel) March 2014 modified Mueller’s growth medium, Mueller-Miller casamino acid medium (without beef heart infusion) formaldehyde, glutaraldehyde, aluminum hydroxide, polysorbate 80 Tdap (Boostrix) (Tween 80), Latham medium derived from bovine casein, Fenton medium February 2013 containing a bovine extract, Stainer-Scholte liquid medium hexadecyltrimethylammonium bromide, formaldehyde, phenol, Typhoid (inactivated – polydimethylsiloxane, disodium phosphate, monosodium phosphate, March 2014 Typhim Vi) semi-synthetic medium yeast extract, casein, dextrose, galactose, sucrose, ascorbic acid, amino Typhoid (oral – Ty21a) September 2013 acids, lactose, magnesium stearate. gelatin sucrose, phosphate, glutamate, gelatin, monosodium L-glutamate, sodium phosphate dibasic, potassium phosphate monobasic, potassium chloride, sodium phosphate monobasic, potassium chloride, EDTA, residual Varicella (Varivax) March 2014 components of MRC-5 cells including DNA and protein, neomycin, fetal bovine serum, human diploid cell cultures (WI-38), embryonic guinea pig cell cultures, human embryonic lung cultures Yellow Fever (YF-Vax) sorbitol, gelatin, egg protein May 2013 sucrose, hydrolyzed porcine gelatin, monosodium L-glutamate, sodium Zoster (Shingles – phosphate dibasic, potassium phosphate monobasic, neomycin, potassium February 2014 Zostavax) chloride, residual components of MRC-5 cells including DNA and protein, bovine calf serum

A table listing vaccine excipients and media by excipient can be found in:

Grabenstein JD. ImmunoFacts: Vaccines and Immunologic Drugs – 2013 (38th revision). St Louis, MO: Wolters Kluwer Health, 2012.

B

Centers for Disease Control and Prevention Epidemiology and Prevention of Vaccine-Preventable Diseases, 13th Edition April, 2015 Appendix B-10

45 Appendix B

Latex in Vaccine Packaging

“If a person reports a severe (anaphylactic) allergy to latex, vaccines supplied in vials or syringes that contain natural rubber, or whose product information does not say “not made with natural rubber latex” should not be administered unless the benefit of vaccination outweighs the risk for a potential allergic reaction. In these cases, providers should be prepared to treat patients who are having an allergic reaction. For latex allergies other than anaphylactic allergies (e.g., a history of contact allergy to latex gloves), vaccines supplied in vials or syringes that contain dry natural rubber or rubber latex may be administered.” (ACIP General Recommendations on Immunization. 2011)

The following table is accurate, to the best of our knowledge, as of February 2015. If in doubt, check the package insert for the vaccine in question.

Source: Vaccine Latex? Manufacturer’s PI Dated: Adenovirus (Adenovirus Type 4 NO March 2011 and Type 7) Anthrax (Biothrax) YES – Vial May 2012 Comvax YES – Vial December 2010 Daptacel NO October 2013 DTaP YES – Syringe Infanrix November 2013 NO – Vial DT (Sanofi) YES December 2005 Hiberix YES – Syringe Tip Cap March 2012 PedvaxHIB YES – Vial December 2010 Hib YES – Diluent vial ActHIB January 2014 NO – Lyophilized vaccine vial YES – Syringe Havrix December 2013 NO – Vial Hepatitis A YES – Vial Vaqta February 2014 YES – Syringe YES – Syringe Engerix-B December 2013 NO – Vial Hepatitis B Recombivax YES – Vial May 2014 HB YES – Syringe Gardasil NO June 2014 HPV Gardasil 9 NO December 2014 Cervarix YES November 2013 Afluria NO December 2013 Agriflu YES – Syringe Tip Cap 2013 Fluarix NO June 2014 B Fluarix NO June 2014 Quadrivalent Flublok NO March 2014 Influenza Flucelvax YES – Syringe Tip Cap March 2014 FluLaval NO February 2013 FluMist NO July 2013 Quadrivalent YES – Syringe Tip Cap Fluvirin February 2014 NO– Vial Centers for Disease Control and Prevention April, 2015 Epidemiology and Prevention of Vaccine-Preventable Diseases, 13th Edition Appendix B-11

46 Appendix B

Source: Vaccine Latex? Manufacturer’s PI Dated: Fluzone NO 2014 Fluzone NO 2014 Influenza High-Dose Fluzone (cont’d) NO 2014 Intradermal Fluzone 2014 Quadrivalent NO Japanese Encephalitis (Ixiaro) NO May 2013 YES – Syringe Kinrix November 2013 NO – Vial MMR (M-M-R II) NO June 2014 MMRV (ProQuad) NO March 2014 Menomune YES April 2013 Menactra NO April 2013 Meningococcal Menveo NO August 2013 Bexsero YES – Syringe Tip Cap 2015 Trumenba NO October 2014 MenHibrix NO 2012 YES – Syringe Pediarix November 2013 NO – Vial Pentacel NO October 2013 Pneumovax 23 NO May 2014 Pneumococcal Prevnar 13 NO January 2014 Polio (IPOL) NO May 2013 Imovax Rabies NO April 2013 Rabies RabAvert NO March 2012 RotaTeq NO June 2013 Rotavirus Rotarix YES – Oral Applicator of Diluent May 2014 YES – Syringe Decavac March 2011 NO – Vial Td Tenivac NO April 2013 Mass Biologics NO February 2011 YES – Syringe Tip Cap Adacel March 2014 NO – Vial Tdap YES – Syringe Boostrix February 2014 NO – Vial YES – Syringe B Twinrix August 2012 NO – Vial Typhim Vi NO March 2014 Typhoid Vivotif Berna NO September 2013 Varicella (Varivax) NO March 2014 Vaccinia (Smallpox) NO September 2009 (ACAM2000) Yellow Fever (YF-Vax) YES – Vial May 2013 Zoster (Shingles) (Zostavax) NO February 2014 February 2015 Centers for Disease Control and Prevention Appendix B-12 Epidemiology and Prevention of Vaccine-Preventable Diseases, 13th Edition April, 2015

47 Appendix A

Recommended and Minimum Ages and Intervals Between Doses of Routinely Recommended Vaccines1,2,3,4 Recommended Minimum Recommended Minimum age Vaccine and dose number interval to next interval to next age for this dose for this dose dose dose Diphtheria-tetanus-acellular pertussis (DTaP)-15 2 months 6 weeks 8 weeks 4 weeks DTaP-2 4 months 10 weeks 8 weeks 4 weeks DTaP-3 6 months 14 weeks 6-12 months 6 months6 DTaP-4 15-18 months 15 months7 3 years 6 months DTaP-5 4-6 years 4 years — — Haemophilus influenzae type b (Hib)-16,8 2 months 6 weeks 8 weeks 4 weeks Hib-2 4 months 10 weeks 8 weeks 4 weeks Hib-39 6 months 14 weeks 6-9 months 8 weeks Hib-4 12-15 months 12 months — — Hepatitis A (HepA)-1 12-23 months 12 months 6-18 months 6 months HepA-2 >18 months 18 months — — Hepatitis B (HepB)-15 Birth Birth 4 weeks-4 months 4 weeks HepB-2 1-2 months 4 weeks 8 weeks-17 months 8 weeks HepB-310 6-18 months 24 weeks — — Herpes zoster (HZV)11 >60 years 60 years — — Human papillomavirus (HPV)-112 11-12 years 9 years 8 weeks 4 weeks HPV-2 11-12 years 9 years 4 months 12 weeks13 (+ 2 months) (+ 4 weeks) HPV-313 11-12 years 9 years — — (+ 6 months) (+24 weeks) Influenza, inactivated (IIV)14 >6 months 6 months15 4 weeks 4 weeks Influenza, live attenuated (LAIV)14 2-49 years 2 years 4 weeks 4 weeks Measles-mumps-rubella (MMR)-116 12-15 months 12 months 3-5 years 4 weeks MMR-216 4-6 years 13 months — — Meningococcal conjugate (MCV)-117 11-12 years 6 weeks18 4-5 years 8 weeks MCV-2 16 years 11 years — — (+ 8 weeks) Meningococcal polysaccharide (MPSV4)-117 — 2 years 5 years 5 years MPSV4-2 — 7 years — — Pneumococcal conjugate (PCV)-18 2 months 6 weeks 8 weeks 4 weeks PCV-2 4 months 10 weeks 8 weeks 4 weeks PCV-3 6 months 14 weeks 6 months 8 weeks PCV-4 12-15 months 12 months — — Pneumococcal polysaccharide (PPSV)-1 — 2 years 5 years 5 years PPSV-219 — 7 years — — Poliovirus, Inactivated (IPV)-15 2 months 6 weeks 8 weeks 4 weeks IPV-2 4 months 10 weeks 8 weeks-14 months 4 weeks A IPV-3 6-18 months 14 weeks 3-5 years 6 months IPV-420 4-6 years 4 years — — Rotavirus (RV)-121 2 months 6 weeks 8 weeks 4 weeks RV-2 4 months 10 weeks 8 weeks 4 weeks RV-322 6 months 14 weeks — — Tetanus-diphtheria (Td) 11-12 years 7 years 10 years 5 years Tetanus-diphtheria-acellular pertussis (Tdap)23 >11 years 7 years — — Varicella (Var)-116 12-15 months 12 months 3-5 years 12 weeks24 Var-216 4-6 years 15 months25 — —

Centers for Disease Control and Prevention Epidemiology and Prevention of Vaccine-Preventable Diseases, 13th Edition April, 2015

Appendix A-13 Appendix A

1 Combination vaccines are available. Use of licensed combination vaccines is generally preferred to separate injections of their equivalent component vaccines. When administering combination vaccines, the minimum age for administration is the oldest age for any of the individual components (exception: the minimum age for the first dose of MenHibrix is 6 weeks); the minimum interval between doses is equal to the greatest interval of any of the individual components.

2 Information on travel vaccines including typhoid, Japanese encephalitis, and yellow fever, is available at www.cdc.gov/travel. Information on other vaccines that are licensed in the US but not distributed, including anthrax and smallpox, is available at www.bt.cdc.gov.

3 Ages and intervals less than 4 months may be expressed in weeks. When the term “months” is used to express an age or interval, it means calendar months.

4 A hyphen used to express a range (as in “12-15 months”) means “through.”

5 Combination vaccines containing a hepatitis B component (Comvax, Pediarix, and Twinrix) are available. These vaccines should not be administered to infants younger than 6 weeks because of the other components (i.e., Hib, DTaP, HepA, and IPV).

6 The minimum recommended interval between DTaP-3 and DTaP-4 is 6 months. However, DTaP-4 need not be repeated if administered at least 4 months after DTaP-3. This is a special grace period (2 months long) that can be used while evaluating records retrospectively. An additional 4 days should not be added to this grace period.

7 A special grace period of 3 months, based on expert opinion, can be applied to the minimum age of 15 months when evaluating records retrospectively, which will result in an acceptable minimum age of 12 months. An additional 4 days should not be added to this grace period.

8 Children receiving the first dose of Hib or PCV vaccine at age 7 months or older require fewer doses to complete the series.

9 If PRP-OMP (Pedvax-Hib) was administered at ages 2 and 4 months, a dose at age 6 months is not required.

10 HepB-3 should be administered at least 8 weeks after HepB-2 and at least 16 weeks after HepB-1, and should not be administered before age 24 weeks.

11 Herpes zoster vaccine is recommended as a single dose for persons 60 years of age and older.

12 Bivalent HPV vaccine (Cervarix) is approved for females 9 through 25 years of age. Quadrivalent HPV vaccine (Gardasil) is approved for males and females 9 through 26 years of age.

13 The minimum age for HPV-3 is based on the baseline minimum age for the first dose (9 years) and the minimum interval of 24 weeks between the first and third doses. Dose 3 need not be repeated if it is given at least 16 weeks after the first dose (and if the intervals between doses 1 and 2 and doses 2 and 3 are maintained at 4 weeks and 12 weeks, respectively).

14 One dose of influenza vaccine per season is recommended for most people. Children younger than 9 years of age who are receiving Influenza vaccine for the first time should receive 2 doses this season. See current influenza recommendations for other factors affecting the decision to administer one vs. two doses to children younger than 9 years.

15 The minimum age for inactivated influenza vaccine varies by vaccine manufacturer and formulation. See package inserts for vaccine-specific minimum ages.

16 Combination measles-mumps-rubella-varicella (MMRV) vaccine can be used for children aged 12 months through 12 years. (See CDC. General Recommendations on Immunization: recommendations of the ACIP. MMWR 2011;60[No. RR-2],7.)

17 Revaccination with meningococcal vaccine is recommended for previously vaccinated persons who remain at high risk for meningococcal disease. (See CDC. Updated recommendations from the ACIP for vaccination of persons at prolonged increased risk for meningococcal disease. MMWR 2009;58:[1042-3])

18 Menactra can be given as young as 9 months for high-risk children. Menveo can be given as young as 2 months for high-risk children. MenHibrix can be given as young as 6 weeks for high-risk children. MenHibrix is given as a four dose series at 2 months, 4 months, 6 months and 12-18 months.

19 A second dose of PPSV 5 years after the first dose is recommended for persons <65 years of age at highest risk for serious pneumococcal infection, and for those who are likely to have a rapid decline in pneumococcal antibody concentration. (See CDC. Prevention of pneumococcal disease: recommendations of the ACIP. MMWR 1997;46[No. RR-8].)

20 A fourth dose is not needed if the third dose was administered on or after the 4th birthday and at least 6 months after the previous dose.

21 The first dose of rotavirus must be administered between 6 weeks 0 days and 14 weeks 6 days. The vaccine series should not be started after age 15 weeks 0 days. Rotavirus vaccine should not be administered to children older than 8 months 0 days, regardless of the number of doses received A before that age. 22 If two doses of Rotarix are administered as age appropriate, a third dose is not necessary.

23 Only one dose of Tdap is recommended. Subsequent doses should be given as Td. For management of a tetanus-prone wound in a person who has received a primary series of a tetanus-toxoid containing vaccine, the minimum interval after a previous dose of any tetanus- containing vaccine is 5 years.

24 For persons beginning the series on or after the 13th birthday, the minimum interval from varicella-1 to varicella-2 is 4 weeks. While it is not recommended, if a child younger than 13 years receives varicella-2 at an interval of 4 weeks or longer from varicella-1, the dose does not need to be repeated.

25 A special grace period of 2 months, based on expert opinion, can be applied to the minimum age of 15 months when evaluating records retrospectively, which will result in an acceptable minimum age of 13 months. An additional 4 days should not be added to this grace period.

Adapted from Table 1, ACIP General Recommendations on Immunization. June 2014

Centers for Disease Control and Prevention Epidemiology and Prevention of Vaccine-Preentable Diseases, 13th Edition April, 2015 It’s Federal Law! You must give Top 10 Facts About VISs your patients current Vaccine fact It’s federal law! You must give current VISs Information Statements (VISs) 1 to all your patients before vaccinating them. Federal law requires that VISs must be used for patients of all ages when administering these vaccines: What are Vaccine Information Statements (VISs)? • DTaP (includes DT) • MMR and MMRV • Td and Tdap • meningococcal Vaccine Information Statements (VISs) are documents produced • Hib • pneumococcal conjugate by the Centers for Disease Control and Prevention (CDC), in con- • hepatitis A • polio sultation with panels of experts and parents, to properly inform vac- • hepatitis B • rotavirus cinees (or their parents/legal representatives) about the risks and • HPV • varicella (chickenpox) benefits of each vaccine. VISs are not meant to replace interactions • influenza (inactivated with health care providers, who should address any questions or and live, intranasal concerns that the vaccinee (or parent/legal representative) may have. vaccines)

Using VISs is legally required! For the vaccines not covered under the National Childhood Vaccine Injury Act (i.e., adenovirus, anthrax, Japanese encephalitis, pneu- Federal law (under the National Childhood Vaccine Injury Act) mococcal polysaccharide, rabies, shingles, typhoid, and yellow requires a health care provider to give a copy of the current VIS to fever), providers are not required by federal law to use VISs unless an adult patient or to a child’s parent/legal representative before they have been purchased under CDC contract. However, CDC rec- vaccinating an adult or child with a dose of the following vaccines: ommends that VISs be used whenever these vaccines are given. diphtheria, tetanus, pertussis, measles, mumps, rubella, polio, fact hepatitis A, hepatitis B, Haemophilus influenzae type b (Hib), influ­ 2 VISs can be given to patients in a variety of ways. enza, pneumococcal conjugate, meningococcal, rotavirus, human papillomavirus (HPV), or varicella (chicken pox only). In most medical settings, VISs are provided to patients (or their parents/legal representatives) in paper form. However, VISs also may be provided using electronic media. Regardless of the format Where to get VISs used, the goal is to provide a current VIS just prior to vaccination.

continued on next page ▼ All available VISs can be downloaded from the websites of the Immunization Action Coalition at www.immunize.org/vis or CDC at www.cdc.gov/vaccines/hcp/vis/index.html. Ready­to­copy versions Most current versions of VISs (table) may also be available from your state or local health department. As of November 12, 2015, the most recent versions of the VISs are as follows: Translations: You can find VISs in more than 30 languages on the Immunization Action Coalition website at www.immunize.org/vis. Adenovirus ...... 6/11/14 MMR ...... 4/20/12 Anthrax ...... 3/10/10 MMRV ...... 5/21/10 Chickenpox ...... 3/13/08 Multi-vaccine ...... 11/5/15 To obtain translations of VIS in languages other than DTaP ...... 5/17/07 PCV13 ...... 11/5/15 English, go to www.immunize.org/vis. Hib ...... 4/2/15 PPSV ...... 4/24/15 Hepatitis A ...... 10/25/11 Polio ...... 11/8/11 Hepatitis B ...... 2/2/12 Rabies ...... 10/6/09 HPV-Cervarix ...... 5/3/11 Rotavirus ...... 4/15/15 According to CDC, the appropriate VIS must be given: HPV-Gardasil ...... 5/17/13 Shingles ...... 10/6/09  Prior to the vaccination (and prior to each dose of a HPV-Gardasil 9 ...... 4/15/15 Td ...... 2/24/15 multi-dose series); Influenza ...... 8/7/15 Tdap ...... 2/24/15  Regardless of the age of the vaccinee; Japanese enceph ...... 1/24/14 Typhoid ...... 5/29/12 ...... 10/14/11 ...... 3/30/11 ˛ Regardless of whether the vaccine is given in a public MCV4/MPSV4 Yellow fever or private health care setting. MenB ...... 8/14/15 A handy list of current VIS dates is also available at www.immunize.org/catg.d/p2029.pdf.

Technical content reviewed by the Centers for Disease Control and Prevention Saint Paul, Minnesota • 651-647-9009 • www.immunize.org • www.vaccineinformation.org www.immunize.org/catg.d/p2027.pdf • Item #P2027 (11/15)

50 It’s Federal Law! You Must Give Your Patients Current Vaccine Information Statements (VISs) (continued) page 2 of 2

(For information on special circumstances involving vaccination The Multi-Vaccine VIS may be used in place of the individual VISs for of a child when a parent/legal representative is not available DTaP, Hib, hepatitis B, polio, and pneumococcal when two or more at the time of vaccination, see CDC’s Frequently Asked Questions of these vaccines are administered during the same visit. It may at www.cdc.gov/vaccines/hcp/vis/about/vis­faqs.html.) be used for infants as well as children through 6 years of age. The Multi­Vaccine VIS should not be used for adolescents or adults. Prior to vaccination, VIS may be: • Provided as a paper copy fact VISs should be given in a language/format that • Offered on a permanent, laminated office copy 7 the recipient can understand, whenever possible. • Downloaded by the vaccinee (parent/legal representative) to a smartphone or other electronic device (VISs have been specially For patients who don’t read or speak English, the law requires that formatted for this purpose) providers ensure all patients (parent/legal representatives) receive • Made available to be read before the office visit, e.g., by giving a VIS, regardless of their ability to read English. To obtain VISs in the patient or parent a copy to take home during a prior visit, or more than 30 languages, visit the Immunization Action Coalition telling them how to download or view a copy from the Internet. website at www.immunize.org/vis. Providers can supplement VISs These patients must still be offered a copy in one of the formats with visual presentations or oral explanations as needed. described previously to read during the immunization visit, as a reminder. fact Federal law does not require signed consent in 8 Regardless of the way the patient is given the VIS to read, providers order for a person to be vaccinated. must still offer a copy (which can be an electronic copy) of each Signed consent is not required by federal law for vaccination appropriate VIS to take home following the vaccination. However, (although some states may require it). the vaccinee may decline. fact To verify that a VIS was given, providers must fact VISs are required in both public and private 9 record in the patient’s medical record (or perma- 3 sector health care settings. nent office log or file) the following information:

Federal law requires the use of VISs in both public and private sec- • The edition date of the VIS • The date the VIS is provided tor settings, regardless of the source of payment for the vaccine. (found on the back at the (i.e., the date of the visit when right bottom corner) the vaccine is administered) fact You must provide a current VIS before a vaccine In addition, providers must record: 4 is administered to the patient. • The office address and name • The date the vaccine is A VIS provides information about the disease and the vaccine and and title of the person who administered must be given to the patient before a vaccine is administered. administers the vaccine • The vaccine manufacturer It is also acceptable to hand out the VIS well before administering and lot number vaccines (e.g., at a prenatal visit or at birth for vaccines an infant will receive during infancy), as long as you still provide a current fact VISs should not be altered before giving them to VIS right before administering vaccines. 10 patients, but you can add some information. fact You must provide a current VIS for each dose Providers should not change a VIS or write their own VISs. However, 5 of vaccine you administer. it is permissible to add a practice’s name, address, and contact information to an existing VIS. The most current VIS must be provided before each dose of vaccine is given, including vaccines given as a series of doses. For example, if 5 doses of a single vaccine are required (e.g., DTaP), the patient Additional resources on VISs and their use are available from (parent/legal representative) must have the opportunity to read the following organizations: the information on the VIS before each dose is given. Immunization Action Coalition • VIS general information and translations in more than 30 languages: fact You must provide VISs whenever you administer www.immunize.org/vis 6 combination vaccines. • Current Dates of Vaccine Information Statements: If you administer a combination vaccine that does not have a www.immunize.org/catg.d/p2029.pdf stand­alone VIS (e.g., Kinrix, Quadracel, Pediarix, Pentacel, Twinrix) Centers for Disease Control and Prevention you should provide the patient with individual VISs for the compo- • VIS website: www.cdc.gov/vaccines/hcp/vis nent vaccines, or use the Multi­Vaccine VIS (see below). • VIS Facts: www.cdc.gov/vaccines/hcp/vis/about/facts­vis.html • VIS FAQs: www.cdc.gov/vaccines/hcp/vis/about/vis­faqs.html

Immunization Action Coalition • Saint Paul, Minnesota • 651-647-9009 • www.immunize.org • www.vaccineinformation.org www.immunize.org/catg.d/p2027.pdf • Item #P2027 (11/15)

51 Vaccines for children Program (Vfc) information for healthcare ProViders from cdc

VFC will beneFit your Patients and your PraC tiC e!

are you a VFC provider? What are the benefits of VFC?

Being a VFC provider is a sound investment in your The VFC program provides routine vaccines to all practice and in your patients. It reduces your states, the District of Columbia, and territories up-front costs because you will not have to pay to for participating healthcare providers. All vaccines purchase vaccines for VFC-eligible children. Also, you recommended by the Advisory Committee on can charge an administrative fee to offset your costs Immunization Practices (ACIP) and approved by CDC of doing business. Your patients benefit because and HHS are covered under the VFC Program at no they won’t have to go somewhere else to get the cost to the participating healthcare provider. You vaccines they need, and there is no charge to you, don’t have to be a Medicaid provider to participate in the provider. VFC. Any healthcare provider authorized to prescribe Children and adolescents are eligible if it is before vaccines under your state law can be a VFC provider. their 19th birthdays and they meet one or more of the following criteria: How can you become a VFC provider? ► Medicaid-eligible ► Uninsured Contact your State/Territory VFC coordinator. ► American Indian or Alaska Native ► ► Underinsured (Underinsured children are only You can find him or her athttp://www.cdc . eligible for VFC Vaccines through FQHC/RHC.) gov/vaccines/programs/vfc/contacts- state.html. All you need to do is ask for a what do you mean by “underinsured?” Provider Enrollment Package to be mailed to you. ► Complete the State Provider Enrollment forms Underinsured means your patient has health and return them as soon as possible. insurance, but it won’t cover the vaccine(s) because: ► Prepare your office and staff for a site visit to go ► It doesn’t cover any vaccines. over the administrative requirements of the ► It doesn’t cover certain vaccines. program and to ensure proper storage and ► It covers vaccines, but it has a fixed dollar limit or cap for vaccines. Once that fixed dollar handling of vaccines when you receive them. amount has been reached, your patient ► Once you’re enrolled, tell parents you are now a is eligible. VFC provider.

the VFC Program will:

► Keep your patients in their medical home. ► Reduce your up-front costs. ► Help provide quality care to vulnerable children and adolescents.

For more information about the VFC program, go to www.cdc.gov/vaccines/programs/vfc/. Get an answer to your specific question by [email protected] or calling 800-CdC-inFo (232-4636) anytime.

09/22/09 CS204495-D 52

HOW TO ADMINISTER

VACCINES

53 The Six Vaccine Administration Rights

1. Right Patient 2. Right Vaccine 3. Right Dose 4. Right Route 5. Right Time 6. Right Documentation

General Rules of All Vaccines

 All vaccines can be administered at the same visit o Exception is Prevnar (PCV13) & Pneumovax (PPSV23)  Live vaccines not administered at the same time must be separated by 4 weeks (minimum of 28 days)  Re-administer vaccines given earlier than the minimum interval  If a dose is given later than a minimum interval, it is ok and counts as a valid dose Decreasing Missed Opportunities It is OK to vaccinate if:  Mild illness or is recovering from illness  Currently taking antibiotics  Was exposed to disease  Lives with someone who is pregnant or has suppressed immune system  Breastfeeding  Baby born prematurely  Non-anaphylactic reaction following a vaccine  Family history of vaccine adverse events

54 Preparing Your Work Area  Have your vaccination area clean and clear of anything a child could grab or get injured on  Gather all items needed and place within reach o Gauze, alcohol wipes, band aids, Kleenex o Sharps container-all syringes go in immediately after use. Do not lay them down. o Drawn up vaccines . Set up in order to be given . Labeled –different methods include:  Place vaccine vials next to syringe  Place syringe in labeled tray  Use preprinted or colored labels

55 Administering Vaccines: Dose, Route, Site, and Needle Size Vaccine Dose Route Injection Site and Needle Size Diphtheria, Tetanus, Pertussis 0.5 mL. . IM .. Subcutaneous (Subcut) injection (DTaP, DT, Tdap, Td) Use a 23–25 gauge needle. Choose the injection site that is appropriate to Haemophilus influenzae type b (Hib) 0.5 mL IM the person’s age and body mass. ≤18 yrs: 0.5 mL Needle Hepatitis A (HepA) IM age length injection site ≥19 yrs: 1.0 mL Fatty tissue over anterolateral Infants (1–12 mos) ⅝" Hepatitis B (HepB) ≤19 yrs: 0.5 mL thigh muscle Persons 11–15 yrs may be given Recombivax HB (Merck) IM 1.0 mL adult formulation on a 2-dose schedule. ≥20 yrs: 1.0 mL Fatty tissue over anterolateral Children 12 mos or older, ⅝" thigh muscle or fatty tissue Human papillomavirus (HPV) 0.5 mL IM adolescents, and adults over triceps 0.2 mL (0.1 mL in Intranasal Influenza, live attenuated (LAIV) each nostril) spray Intramuscular (IM) injection Use a 22–25 gauge needle. Choose the injection site and needle length that Influenza, inactivated (IIV); recombinant 6–35 mos: 0.25 mL IM is appropriate to the person’s age and body mass. (RIV), for ages 18 years and older ≥3 yrs: 0.5 mL needle Influenza (IIV) Fluzone Intradermal, age injection site 0.1 mL ID length for ages 18 through 64 years Newborns (1st 28 days) ⅝" Anterolateral thigh muscle Measles, Mumps, Rubella (MMR) 0.5 mL Subcut Infants (1–12 mos) 1" Anterolateral thigh muscle Meningococcal conjugate 0.5 mL IM 1–1¼" Anterolateral thigh muscle or (MCV4 [MenACWY]) Toddlers (1–2 years) ⅝–1" deltoid muscle of arm Meningococcal serogroup B (MenB) 0.5 mL IM Children and teens ⅝–1"* Deltoid mucle of arm or Meningococcal polysaccharide (MPSV) 0.5 mL Subcut (3–18 years) 1–1¼" anterolateral thigh muscle Pneumococcal conjugate (PCV) 0.5 mL IM Adults 19 years or older IM or Pneumococcal polysaccharide (PPSV) 0.5 mL Female or male <130 lbs ⅝–1"* Deltoid muscle of arm Subcut Female or male 130–152 lbs 1" Deltoid muscle of arm IM or Polio, inactivated (IPV) 0.5 mL Female 153–200 lbs Subcut 1–1½" Deltoid muscle of arm Male 130–260 lbs Rotarix: 1.0 mL Rotavirus (RV) Oral Female 200+ lbs 1½" Deltoid muscle of arm Rotateq: 2.0 mL Male 260+ lbs Varicella (Var) 0.5 mL Subcut Zoster (Zos) 0.65 mL Subcut * A 5/8" needle may be used for patients note: Always refer to the package insert included Combination Vaccines weighing less than 130 lbs (<60 kg) for with each biologic for complete vaccine administration IM injection in the deltoid muscle only information. CDC’s Advisory Committee on Immunization DTaP-HepB-IPV (Pediarix) if the skin stretched tight, the subcuta- Practices (ACIP) recommendations for the particular neous tissue is not bunched, and the DTaP-IPV/Hib (Pentacel) vaccine should be reviewed as well. Access the ACIP DTaP-IPV (Kinrix; Quadracel) 0.5 mL IM injection is made at a 90-degree angle. recommendations at www.immunize.org/acip. Hib-HepB (Comvax) Hib-MenCY (MenHibrix) MMRV (ProQuad) ≤12 yrs: 0.5 mL Subcut HepA-HepB (Twinrix) ≥18 yrs: 1.0 mL IM

Intramuscular (IM) injection Subcutaneous (Subcut) injection Intradermal (ID) administration Intranasal (NAS) administration of Fluzone ID vaccine of Flumist (LAIV) vaccine

90° angle 90° angle 45° angle Administer skin skin in area of deltoid subcutaneous tissue subcutaneous tissue

muscle muscle

Technical content reviewed by the Centers for Disease Control and Prevention Immunization Action Coalition Saint Paul, Minnesota • 651-647-9009 • www.immunize.org • www.vaccineinformation.org www.immunize.org/catg.d/p3085.pdf • Item #P3085 (11/15)

56 Preparing Liquid Vaccines

Before You Start

• Wash your hands. • Check vaccine against physician’s • Gather alcohol pads, appropriate written order. needle, and, as needed, syringe. • Check that today’s date is sooner than • Get the vial or syringe of vaccine. vaccine’s expiration date.

Drawing Up Liquid Vaccine

Single-dose vials Multi-dose vials • Remove plastic cap. • Remove plastic cap. • Shake vial. • Shake vial. • Cleanse stopper with alcohol • Cleanse stopper with alcohol pad and let it dry. pad and let it dry. • Assemble needle and syringe. • Assemble needle and syringe. • Uncap needle. • Uncap needle. • Hold vial steady on counter. • Pull back syringe plunger equal to one dose of vaccine, usually 0.5 cc. • Insert needle straight into center of vial stopper. • Hold vial steady on counter. • Invert vial and pull needle back so • Insert needle straight into center of the tip is in the liquid. stopper and inject air into vial. • Pull back on plunger and draw up • Invert vial so needle tip is in liquid. entire contents of vial. • Withdraw one dose. • Withdraw needle. • Return needle and vial to counter top. • Tap syringe and push out air. • Withdraw needle. • Recap the clean needle. • Tap syringe and push out air. • Recap the clean needle.

Pre-fi lled syringes • Shake syringe thoroughly. • Remove syringe tip cover.over. • Attach needle to syringe.ge.

www.eziz.org

California Department of Public Health, Immunization Branch IMM-896 (12/11) 57 Vaccines with Diluents: How to Use Them Be sure to reconstitute the following vaccines correctly before • Only use the diluent provided by the manufacturer for that administering them! Reconstitution means that the lyophi- vaccine as indicated on the chart. lized (freeze-dried) vaccine powder or wafer in one vial must • ALWAYS check the expiration date on the diluent and vaccine. be reconstituted (mixed) with the diluent (liquid) in another. NEVER use expired diluent or vaccine.

Lyophilized Time allowed between Diluent Vaccine Liquid diluent vaccine reconstitution and use, as storage product name Manufacturer (may contain vaccine) (powder) stated in package insert* environment

ActHIB (Hib) Sanofi Pasteur Hib 0.4% sodium chloride 24 hrs Refrigerator Refrigerator Hiberix (Hib) GlaxoSmithKline Hib 0.9% sodium chloride 24 hrs or room temp

† Imovax (RABHDCV) Sanofi Pasteur Rabies virus Sterile water Immediately Refrigerator Refrigerator M-M-R II (MMR) Merck MMR Sterile water 8 hrs or room temp MenHibrix Refrigerator GlaxoSmithKline Hib-MenCY 0.9% sodium chloride Immediately† (Hib-MenCY) or room temp Single-dose vial: Menomune Sanofi Pasteur MPSV4 Distilled water Immediately† Refrigerator (MPSV4) Multidose vial: 35 days Menveo (MCV4) Novartis MenA MenCWY 8 hrs Refrigerator Pentacel Sanofi Pasteur Hib DTaP-IPV Immediately† Refrigerator (DTaP-IPV/Hib) Refrigerator ProQuad (MMRV) Merck MMRV Sterile water 30 min or room temp

† RabAvert (RABPCECV) Novartis Rabies virus Sterile water Immediately Refrigerator Sterile water, Refrigerator Rotarix (RV1)‡ GlaxoSmithKline RV1 calcium carbonate, 24 hrs or room temp and xanthan Refrigerator Varivax (VAR) Merck VAR Sterile water 30 min or room temp YF-VAX (YF) Sanofi Pasteur YF 0.9% sodium chloride 60 min Refrigerator Refrigerator Zostavax (HZV) Merck HZV Sterile water 30 min or room temp

Always refer to package inserts for detailed instructions on reconstituting specific vaccines. In general, follow the steps below. 1 For single-dose vaccine products (exception is 3 Reconstitute (i.e., mix) vaccine just prior to use by vaccine cannot be thoroughly mixed, mark the vial Rotarix‡), select a syringe and needle of proper length • removing the protective caps and wiping each stop- as “DO NOT USE,” return it to proper storage to be used for both reconstitution and administration per with an alcohol swab, conditions, and contact your state or local health of the vaccine. Following reconstitution, Menomune • inserting needle of syringe into diluent vial and department immunization program or the vaccine in a multidose vial will require a new needle and withdrawing entire contents, and manufacturer. syringe for each dose of vaccine to be administered. • injecting diluent into lyophilized vaccine vial and 5 If reconstituted vaccine is not used immediately ‡ For Rotarix, see the package insert. rotating or agitating to thoroughly dissolve the or comes in a multidose vial (i.e., multi-dose Meno- 2 Before reconstituting, check labels on both the lyo- lyophilized powder. mune), be sure to philized vaccine vial and the diluent to verify that 4 Check the appearance of the reconstituted vaccine. • clearly mark the vial with the date and time the • they are the correct two products to mix together, • Reconstituted vaccine may be used if the color and vaccine was reconstituted, • the diluent is the correct volume (especially for appearance match the description on the package • maintain the product at 35°–46°F (2°–8°C); do not Menomune in the multidose vial), and insert. freeze, and • neither the vaccine nor the diluent has expired. • If there is discoloration, extraneous particulate • use only within the time indicated on chart above. matter, obvious lack of resuspension, or the

* If the reconstituted vaccine is not used within this time period, it must be discarded. † For purposes of this guidance, IAC defines “immediately” as within 30 minutes or less. ‡ Rotarix vaccine is administered by mouth using the applicator that contains the diluent. It is not administered as an injection.

Technical content reviewed by the Centers for Disease Control and Prevention Immunization Action Coalition Saint Paul, Minnesota • 651-647-9009 • www.immunize.org • www.vaccineinformation.org www.immunize.org/catg.d/p3040.pdf • Item #P3040 (8/15)

58 Preparing Reconstituted Vaccines

Before You Start • Wash your hands. • Gather alcohol pads, appropriate needle, and syringe. • Get one dose each of vaccine and diluent. • Check vaccine against physician’s written order. • Check that today’s date is sooner than vaccine’s and diluent’s expiration dates.

Mixing the Vaccine • Remove plastic caps. • Cleanse stoppers with alcohol pad and let dry.* • Assemble needle and syringe. • Uncap needle. • Hold diluent vial steady on the counter. • Insert needle straight into the center of the vial stopper. • Invert vial and pull needle back so the tip is in the liquid. • Draw up all diluent into syringe and then withdraw needle. • Hold vaccine vial steady on the counter. • Insert needle into center of stopper. • Inject diluent • Holding vial and syringe together, shake to mix.

*Be sure that MMR, Varicella and MMRV stoppers are thoroughly dry before drawing up doses. Alcohol may damage these live vaccines.

Drawing Up the Vaccine

• Invert vial and pull needle back so the tip is in the liquid. • Pull back on plunger and draw up entire contents of vial. • Withdraw needle. • Tap syringe and push out air. • Recap the clean needle. • Use reconstituted vaccine promptly. www.eziz.org

California Department of Public Health, Immunization Branch IMM-897 (12/11) 59 TdapTdap oror DTaPDTaP Pertussis is widespread–are your patients protected?

Tetanus toxoid, Reduced Diphtheria toxoid, For Those Tdap:Tdap: Acellular Pertussis vaccine Age 7 Years or Older

ADACEL™ (sanofip asteur)pasteur) Boostrix®Boostrix (GlaxoSmithKline)

Diphtheria and Tetanus toxoid, For Those Ages 6 Weeks DTaP:DTaP: Acellular Pertussis vaccine Through 6 Years DTaP only DAPTACEL® (sanofi pasteur) Infanrix® (GlaxoSmithKline)

Combination: DTaP + Others

DTaP + HepB + IPV DTaP + IPV + Hib DTaP + IPV Pediarix® (GlaxoSmithKline) Pentacel® (sanofi pasteur) Kinrix® (GlaxoSmithKline) Ages 6 weeks through 6 years Ages 6 weeks through 4 years Ages 4 years through 6 years

Booster Dose Only Use Tdap or DTaP to stop pertussis. For more info, visit EZIZ.org

California Department of Public Health, Immunization Branch IMM-508 (12/12) This publication was supported by Grant Number H23/CCH922507 from the Centers for Disease Control and Prevention (CDC). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of CDC.

60 DTaP, Tdap, and Td Catch-up Vaccination Recommendations by Prior Vaccine History and Age

Current No. of Prior Minimum Interval Between Doses of D TaP, Tdap, or Td Age of Child Documented Starting from the Most Recent Dose Given or Adult Doses dose 1 to dose 2 dose 2 to dose 3 dose 3 to dose 4 dose 4 to dose 5 4 months Unknown 4 weeks 4 weeks 6 month s ¹ 6 month s ² through 0 4 weeks 4 weeks 6 month s ¹ 6 month s ² 6 years 1 4 weeks 4 weeks 6 month s ¹ 6 month s ² 2 4 weeks 6 month s ¹ 6 month s ² 3 6 month s ¹ 6 month s ² 4 6 month s ² 7 through Unknown 4 weeks 6 month s 18 years3 0 4 weeks 6 month s 4 weeks, if dose 1 given at or 6 months, if dose 1 younger than age 12 mos; 1 4 weeks given at younger 6 months if dose 1 given Adults age than age 12 mos 19 years at age 12 mos or older 4 4 weeks, if dose 1 given at and older 6 months, if dose 1 younger than age 12 mos; 2 given at younger 6 months if dose 1 given than age 12 mos at age 12 mos or older 6 months, if dose 1 3 given at younger than age 12 mos This table summarizes the recommendations of For use in DTaP = Diphtheria and For use in Tdap = Tetanus and infants and tetanus toxoids with age 7 thru adult: diphtheria toxoids CDC’s Advisory Committee on Immunization children acellular pertussis vaccine w/ acellular pertussis Practices for the use of DTaP, Tdap, and Td in through age DT (pediatric) = Diphtheria Td (adult) = Tetanus and tetanus toxoids (no children, adolescents, and adults who are 6 years diphtheria toxoids pertussis) unvaccinated or who have fallen behind.

• Children ages 2 months through 6 years should • Pregnant women should receive Tdap during footnotes receive DTaP; the pediatric product, DT, should only each pregnancy, preferably between 27 and 36 1 Infants should be no younger than be used in children with a valid contraindication to weeks’ gestation. Women who have never received age the pertussis component. Tdap and fail to receive it during their pregnancy 12 months when receiving dose should receive it immediately postpartum. #4. • The routine schedule for administering DTaP to 2 Dose 5 should be given no younger children is a 3-dose series at age 2, 4, and 6 months, • Tdap can be given with no minimum interval since the previous tetanus toxoid-containing product than age 4 years. Dose 5 is not followed by boosters at age 15–18 months and 4–6 (e.g., DTaP, Td). necessary if dose 4 was given after years. The first booster may be given at age 12–15 age 4 years. months as long as there is an interval of at least 6 • Patients needing prophylaxis against tetanus 3 Children age 7 years or older should be given DTaP, Tdap, or Td, as months from the preceding dose. with an incomplete history of DTaP appropriate, rather than single antigen tetanus • Adults who have not completed a 3-dose primary should be given Tdap as the first (i.e., TT), unless there is a contraindication to the series with Td-containing vaccine, including any dose in the catch-up series. For other vaccine components. doses received as children, should begin or these children, an additional complete a series with Tdap as the first dose • Adults and adolescents who have received Tdap, adolescent Tdap should not be given. administered. should be given Td as their subsequent 10-year 4 Adults of all ages who have never • For children and adults who fall behind in completion booster doses. received Tdap as an adolescent or of their vaccine series, there is no need to restart the All adults should receive 1 dose adult, or for whom vaccine status is series. Simply resume where they’ve of Tdap if they have not previously received it. unknown, should receive Tdap as their left off. first dose, followed by Td to either • Products manufactured by different companies are complete their primary series or as their interchangeable. 10-year boosters.

61 Administering Injectable Vaccines

Cleaning the Injection Site

1. Wash your hands. 2. Clean the injection site with an alcohol pad or a cotton ball soaked with alcohol. Using a circular motion, wipe from the center of the injection site out about two inches in a spiral pattern. 3. Allow the alcohol to dry for several seconds. (Alcohol stings if it gets into the injection.) 4. Throw away the cotton ball.

Giving an Intramuscular (IM) Injection

1. Clean the injection site. (See above.) 2. With your left hand*, bunch up the muscle. 3. With your right hand*, insert the needle at a 90-degree angle to the muscle. 4. Push down on the plunger and inject the entire contents of the syringe. Do not aspirate. 5. Remove the needle and simultaneously apply light pressure to the injection site with a dry cotton ball or gauze. Hold it in place for several seconds. 6. If there is any bleeding, cover the injection site with a bandage. 7. Put the used syringe in a sharps container. * Use opposite hand if you are left-handed.

Giving a Subcutaneous (SC) Injection

1. Clean the injection site. (See above.) 2. With the thumb and index  nger of your left hand*, pinch up the fatty tissue of the injection site. 3. With your right hand*, insert the needle at a 45-degree angle to the skin. Insert the entire needle. 4. Push down on the plunger and inject the entire contents of the syringe. Do not aspirate. 5. Remove the needle and simultaneously apply light pressure with a dry cotton ball or gauze on the injection site. Hold it in place for several seconds. 6. If there is any bleeding, cover the injection site with a bandage. 7. Put the used syringe in a sharps container.

Important! Dispose of used needles immediately after use. Never re-cap a used needle or try to separate it from the syringe.

www.eziz.org EZ-IZ Vaccine Administration Job Aid

California Department of Public Health, Immunization Branch IMM-898 (8/09) 62 COMFORTING RESTRAINT FOR IMMUNIZATIONS

• The method: This method involves the parent in embracing the child and controlling all four limbs. It avoids “holding down” or overpowering the child, but it helps you steady and control the limb of the injection site.

• For infants and toddlers:

Have parent hold the child on parent’s lap.

1. One of the child's arms embraces the parent's back and 1 2 is held under the parent's arm.

2. The other arm is controlled by the parent's arm and hand. For infants, the parent can control 3 both arms with one hand.

3. Both legs are anchored with the child's feet held firmly between the parent's thighs, and con- trolled by the parent's other arm.

• For kindergarten and older children:

Hold the child on parent’s lap or have the child stand in front of the seated parent.

1. Parent's arms embrace the child 1 during the process.

2. Both legs are firmly between parent's legs.

2 O Safe•Effective•Caring

Arnold Schwarzenegger, Governor—State of Californiaˈ Kimberly Belshé, Secretary—Health and Human Services Agency Sandra Shewry, Director—Department of Health Servicesˈ Immunization Branch • 2151 Berkeley Way • Berkeley, CA 94704 IMM-720 (12/01) 63 Immunization Site Map

Suggested sites for infant immunizations:

RD: LD:

RT:

LT: RT:

LT:

LD= Left deltoid (IM) or subcutaneous tissue on upper arm (SC). LT= Left vastus lateralis (IM) or subcu- RD= Right deltoid (IM) or subcutaneous taneous tissue on thigh (SC). tissue on upper arm (SC). RT= Right vastus lateralis (IM) or subcuta- neous tissue on thigh (SC).

O Safe•Effective•Caring

California Department of Public Health • Immunization Branch • 850 Marina Bay Parkway • Richmond, CA 94804 IMM-718 (5/01) 64 Immunization Site Map

Suggested sites for toddler immunizations:

LD: RD:

RT: LT: RT: LT:

LD= Left deltoid (IM) or subcutaneous tissue on upper arm (SC). RD= Right deltoid (IM) or subcutaneous LT= Left vastus lateralis (IM) or subcu- tissue on upper arm (SC). taneous tissue on thigh (SC). RT= Right vastus lateralis (IM) or subcuta- neous tissue on thigh (SC).

O Safe•Effective•Caring

California Department of Public Health • Immunization Branch • 850 Marina Bay Parkway • Richmond, CA 94804 IMM-718 (5/01) 65 66 67 How to Administer Intradermal, Intranasal, and Oral Vaccinations

While most vaccines are administered by either intra­ route, and the oral route. Here are some simple muscular or subcutaneous injection, there are several instructions to use as a guide. Complete information vaccines that are administered through other means. is available in the package inserts and can also be These include the intradermal route, the intranasal obtained at www.immunize.org/packageinserts.

Intradermal (ID) administration Intranasal (NAS) administration Fluzone by Sanofi Pasteur, Intradermal Inactivated Influenza Vaccine FluMist by MedImmune, Live Attenuated Influenza Vaccine (LAIV) 1 Gently shake the microinjection system before administering 1 FluMist (LAIV) is for intranasal administration only. Do not the vaccine. inject FluMist. 2 Hold the system by placing the thumb and 2 Remove the rubber tip protector. Do not remove the dose­ middle finger on the finger pads; the index divider clip at the other end of the sprayer. finger should remain free. 3 With the patient in an upright position, place the tip just 3 Insert the needle perpendicular to the skin, in the region of inside the nostril to ensure LAIV is deliv­ the deltoid, in a short, quick movement. ered into the nose. The patient should breathe normally. 4 Once the needle has been inserted, maintain light pressure on the surface of the skin 4 With a single motion, depress the plunger and inject using the index finger to push on as rapidly as possible until the dose­divider the plunger. Do not aspirate. clip prevents you from going further. 5 Remove the needle from the skin. With the needle directed 5 Pinch and remove the dose­divider clip away from you and others, push very firmly with the thumb from the plunger. on the plunger to activate the needle shield. 6 Place the tip just inside the other nostril, You will hear a click when the shield extends dose­divider clip and with a single motion, depress plunger to cover the needle. as rapidly as possible to deliver the remaining vaccine. 6 Dispose of the applicator in a sharps container. 7 Dispose of the applicator in a sharps container.

Oral administration: Rotavirus vaccines Rotateq by Merck Rotarix by GlaxoSmithKline Transfer adapter 1 Tear open the pouch and remove the dosing 1 Remove the cap of the vial and push the transfer tube. Clear the fluid from the dispensing adapter onto the vial (lyophilized vaccine). Vial tip by holding the tube vertically and tapping 2 Shake the diluent in the oral applicator Oral applicator the cap. (white, turbid suspension). Connect the 2 Open the dosing tube in two easy motions: oral applicator to the transfer adapter. a) Puncture the dispensing tip by screwing cap clockwise 3 Push the plunger of the oral applicator to until it becomes tight. transfer the diluent into the vial. The b) Remove the cap by turning it counterclockwise. suspension will appear white and cloudy. 3 Administer the dose by gently squeezing 4 Withdraw the vaccine into the oral applicator. liquid into infant’s mouth toward the inner cheek until dosing tube is empty. (A residual 5 Twist and remove the oral applicator from drop may remain in the tip of the tube.) the vial. 4 Discard the empty tube and cap in an approved biological 6 Administer the dose by gently placing the applicator plunger waste container according to local regulations. into the infant’s mouth toward the inner cheek and gently expelling the contents until the applicator is empty. Note: If, for any reason, an incomplete dose is administered (e.g., infant spits or regurgitates the vaccine), a replacement dose is not recommended. 7 Discard the empty vial, cap, and oral applicator in an approved biological waste container according to local regulations.

Note: If, for any reason, an incomplete dose is administered (e.g., the infant spits or regurgitates the vaccine), a replacement dose is not recommended.

Technical content reviewed by the Centers for Disease Control and Prevention Saint Paul, Minnesota • 651-647-9009 • www.immunize.org • www.vaccineinformation.org www.immunize.org/catg.d/p2021.pdf • Item #P2021 (11/15)

68 Registry Participation Instructions

Nevada law states that all shots administered in Nevada must be recorded in Nevada WebIZ. This requirement extends to patients of ALL ages.

Per Nevada Revised Statute (NRS) 439.265 and the regulations adopted to support this law, all shots given in Nevada must be recorded in Nevada WebIZ, our statewide immunization registry. The steps necessary to successfully comply with this law are listed below:

1) DISCLOSURE Print the Disclosure Statement Poster and post it prominently in your lobby, waiting room or registration area. This Poster will serve as notification to vaccination patients that their information will be entered into the registry.

2) ENTERING THE PATIENT DATA Patients DO NOT need to give consent for their (or their child’s) information to be entered into the registry. Please make sure the patient (or parent/guardian) understands what the registry is and offer to answer any questions they may have. You may always refer them to the Nevada WebIZ Help Desk for further information. o THE PATIENT DOES NOT NEED TO SIGN A FORM IF THEY DO NOT OBJECT to having their (or their child’s) data entered into the registry. You may now enter their data. o If the patient objects to having their data entered into the registry, DO NOT enter their data and move on to step 3.

3) PARTICIPATION FORM The Participation Form serves two functions: o Patients may sign this form if they do not want to have their (or their child’s) information entered into the registry. o Patients who previously did not want to participate and now do may sign this form to have their information entered into the registry. ONLY provide the Form to patients who do not want to participate and to those that previously did not want to participate and now do.

4) SUBMITTING SIGNED FORMS TO THE WEBIZ HELP DESK If any of your patients sign a Participation Form for EITHER of the reasons listed above, you must submit a copy of the form to the Nevada WebIZ Help Desk. o At the end of each month, please mail or fax photocopies of any forms received during that month to the Help Desk (address and fax # listed below).

Nevada WebIZ Help Desk Phone: (775) 684-5954 4150 Technology Way Suite 101 Toll-free (877) NV-WebIZ Carson City NV 89706 Fax: (775) 687-7596 NEW!

69

- If IMM-694B (9/01) Plan of Action* www.immunize.org/dvd Supervisor Review Plan of Action (p. 2) that will help Exceeds Meets or Need to Improve www.immunize.org/catg.d/p7010.pdf • Item #P7010 (2/14) page 1 of 2 Exceeds Meets or Self-Assessment Need to Improve vide immunizations to several patients and score in the Supervisor Review columns. portunity to score themselves in advance. Next, observe their performance as they pro The DVD “Immunization Techniques: Best Practices with Infants, Children, and Adults” ensures that staff administer vaccines correctly. Order online at them achieve the level of competence you expect; circle desired actions or write in others. improvement is needed, meet with them to develop a score themselves in advance. Next observe their performance as they provide immunizations observe their performance as they provide Next in advance. themselves score is needed, improvement columns. If Review in the Supervisor patients and score to several of com- the level that will help them achieve (over) Action of a Plan meet with them to develop 30 days, observe actions or write in others. In their perfor- desired expect; circle petence you Checklist in their meet expectations, file the Skills When all competency areas mance again. observe them the end of probationary At period and annually thereafter, personnel folder. Checklist. aga in and complete the Skills - - - " for IM (DTaP, Td, Hib, HepA, HepB, Pneumo 2 / 1 1"-1 for IM and SC. " for SC (MMR, Var); IPV and Pneumo Poly depends on route to be used. 8 / 5 Conj., Flu); help make them feel comfortable and informed about the procedure. vaccines and had time to read them and ask questions. inviting questions. emergency protocol, reference material). situations where its use would be indicated. injury log. drawing up. Inverts vial and draws up correct dose of vaccine. Rechecks vial label. logs refrigerator temperature. Skills Checklist for Immunization Skills Checklist for ou indicate further study, practice or change is needed. When practice or change is needed. ou indicate further study, ou indicate you believe you are performing at the expected level are you believe ou indicate you y Clinical Skills,Techniques,and Procedures y 2. Maintains aseptic technique throughout. 1. Welcomes patient/family, establishes rapport, and answers any questions. 2. Explains what vaccines will be given and which type(s) of injection will be done. 3. Accommodates language or literacy barriers and special needs of patient/parents to 4. Verifies patient/parents received the Vaccine Information Statements for indicated 5. Screens for contraindications. (MA: score NA–not applicable–if this is MD function.) 6. Reviews comfort measures and after care instructions with patient/parents, 1. Identifies the location of the medical protocols (i.e. immunization protocol, 2. Identifies the location of the epinephrine, its administration technique, and clinical 3. Maintains up-to-date CPR certification. 4. Understands the need to report any needlestick injury and to maintain a sharps 1. Checks vial expiration date. Double-checks vial label and contents prior to 3. Selects the correct needle size. 4. Shakes vaccine vial and/or reconstitutes and mixes using the diluent supplied. 5. Labels each filled syringe or uses labeled tray to keep them identified. 6. Demonstrates knowledge of proper vaccine handling, e.g. protects MMR from light, Need to Improve, you indicate further study, practice, or change is se the Skills Checklist to clarify responsibilities and expectations for staff who Checklist to clarify responsibilities se the Skills U eets or Exceeds eed to Improve M N ✓ Protocols Vaccine Handling Education B. Medical C. Competency A. Patient/Parent upervisors: ou check ou check The Skills Checklist is a self-assessment tool for health care staff who administer immu DepartmentAdapted from California Branch Health • Immunization of Public nizations. To complete it, review the competency areas below and clinical skills, tech niques, and procedures outlined for each of them. Score yourself in the Self-Assessment column. If you check needed. When you check Meets or Exceeds, indicate believe are perform - ing at the expected level of competence, or higher. Supervisors: Use the Skills Checklist to clarify responsibilities and expectations for staff who administer vaccines. When you use it for performance reviews, give staff the op Immunization Action Coalition • Saint Paul, Minnesota (651) 647-9009 • www.vaccineinformation.org • www.immunize.org The DVD “Immunization Techniques: Best Practices with Infants, Children, and Adults” ensures that staff administer vaccines correctly. Order online at www.immunize.org/shop/dvd-immunization-techniques.asp correctly. ensures that staff administer vaccines Children, and Adults” with Infants, Best Practices Techniques: “Immunization The DVD The Skills Checklist is a self-assessment tool for health care staff who administer immuniza- Checklist is a self-assessment tool for health care The Skills and the clinical skills, techniques below the competency areas complete it, review To tions. column. If in the Self-Assessment yourself outlined for each of them. Score and procedures y y S of competence, or higher. of competence, or higher. administer vaccines. When you use it for performance reviews, give staff the opportunity use it for performance give When you to reviews, administer vaccines.

70 Observe IMM-694B (9/01) f. Plan of Action* Role play with other staff interac- j. Supervisor Review Exceeds Meets or Attend health care customer satisfaction or Watch video on immunization techniques. l. Plan of Action Deadline Plan of Review Date of Next Performance Need to Improve Review vaccine handling guidelines or video. www.immunize.org/catg.d/p7010.pdf • Item #P7010 (2/14) page 2 of e. Exceeds Meets or Self-Assessment Be mentored by someone who has these skills. Date Date Need to Improve Review package inserts. i. d. Attend a skills training or other courses or training. k. (IM for DTaP, Td, ______Other: Read Vaccine Information Statements. h. Renew CPR certification. Review manuals, textbooks, wall charts or other guides. m. c. Practice injections. g. landmarks specific for IM or SC 2" to 3" circle. Allows alcohol to dry. live vaccine vial. manufacturer, site, VIS date, name/initials. skin and inserts it quickly at the appropriate angle (45º for SC or 90º for IM). it to each visit. Hib, HepA, HepB, Pneumo Conj, Flu; SC for MMR, Var; Either SC or IM for IPV and Pneumo Poly). record, assess what is due today, and update computer immunization history. Review office protocols. Clinical Skills,Techniques,and Procedures 1. Rechecks the physician’s order or instructions against prepared syringes. 2. Washes hands and if office policy puts on disposable gloves. 3. Demonstrates knowledge of the appropriate route for each vaccine. 4. Positions patient and/or restrains the child with parent’s help; locates anatomic 5. Preps the site with an alcohol wipe using a circular motion from the center to a 6. Controls the limb with the non-dominant hand; holds the needle an inch from the 7. Injects vaccine using steady pressure; withdraws needle at angle of insertion. 8. Applies gentle pressure to injection site for several seconds with a dry cotton ball. 9. Properly disposes of needle and syringe in sharps container. Properly disposes of 10.Encourages comfort measures before, during and after the procedure. 1. Fully documents each immunization in patient’s chart: date, lot number, 3. Asks for and updates patient’s record of immunizations and reminds them to bring Employee Signature Employee Supervisor Signature 2. If applicable, demonstrates ability to use IZ registry or computer to call up patient other staff with patients. cultural competency training. Circle desired next steps and write in the agreed deadline and date for the follow-up performance review. performance the follow-up deadline and date for steps and write in the agreed next desired Circle a. tions with parents and patients, including age-appropriate comfort measures. b. Procedures Administering Immunizations Competency Plan of Action: E. Records California California Department of Health • ServicesBerkeley, Way • CAImmunization Branch • 94704 2151 Berkeley D. Immunization Action Coalition • Saint Paul, Minnesota (651) 647-9009 • www.vaccineinformation.org • www.immunize.org

71 72 VACCINE SAFETY & MEDICAL MANAGEMENT OF EVENTS

73 Appendix D

The Vaccine Adverse Event Reporting System (VAERS)

VAERS is a national vaccine safety surveillance program co-sponsored by the Centers for Disease Control and Prevention (CDC) and the Food and Drug Administration (FDA). VAERS collects and analyzes information from reports of adverse events following receipt of US-licensed vaccines. In recent years, VAERS has received approximately 30,000 US reports annually, most of which describe mild adverse events like fever and injection site reactions. Very rarely, people experience serious adverse events following immunization. By monitoring such events, VAERS can help to identify important new safety concerns.

VAERS is a spontaneous reporting system, meaning that reports about adverse events can be submitted voluntarily by anyone. VAERS has limitations as a surveillance system: data may, and often do, include incorrect and incomplete information. Underreporting, or failure to report events, is another limitation. Serious medical events are more likely to be reported than minor ones. Importantly, VAERS cannot determine cause and effect. The report of an adverse event to VAERS does not indicate that a vaccine caused the event. It only indicates that the event occurred sometime after vaccine receipt. VAERS accepts all reports without judging whether or not the event was caused by the vaccine. More information on the limitations of VAERS data can be found at: http://vaers.hhs.gov/data/index

WHO CAN REPORT? Anyone can submit a VAERS report. Most reports are sent in by vaccine manufacturers and health care providers, but vaccine recipients, parents/guardians, and others may also submit reports.

WHAT SHOULD BE REPORTED? VAERS encourages reporting of any clinically significant adverse event that occurs after the administration of any vaccine licensed in the United States.

The National Childhood Vaccine Injury Act of 1986 requires health care providers to report: - Any health event listed by the vaccine manufacturer as a contraindication to subsequent doses of the vaccine, - Any event listed in the Reportable Events Table that occurs within the specified time period after the vaccination.

A copy of the Reportable Events Table can be found on the following page, or at http://vaers.hhs.gov/resources/VAERS_Table_of_Reportable_Events_Following_Vaccination.pdf.

HOW TO REPORT There are three ways to report to VAERS:

- Online. Complete a VAERS online form at https://vaers.hhs.gov/esub/step1. Before you begin, review the Instructions for Completing the VAERS On-Line Form at http://vaers.hhs.gov/esub/help. The VAERS On-Line form must be completed in a single sitting (i.e., you cannot save your work and return later to finish). Information supplied on this form is transmitted securely to VAERS.

- Fax. Download a VAERS form at http://vaers.hhs.gov/resources/vaers_form.pdf, or request a form by sending an e-mail to [email protected], by calling 800-822-7967, or by faxing a request to 877-721-0366. Review the Instructions for Completing the VAERS Paper Form at http://vaers.hhs.gov/helpinstructions. Fax the completed form to 877-721-0366.

- Mail. Download a VAERS form at http://vaers.hhs.gov/resources/vaers_form.pdf, or request a form by sending an e-mail to [email protected], by calling 800-822-7967, or by faxing a request to 877-721-0366. Review the Instructions for Completing the VAERS Paper Form at http://vaers.hhs.gov/helpinstructions. Mail the completed form to VAERS, P.O. Box 1100, Rockville, MD 20849-1100. A pre-paid postage stamp is included on the back of the form. D

For more information, visit the VAERS website at http://vaers.hhs.gov .

Updated March 18, 2013

Centers for Disease Control and Prevention Epidemiology and Prevention of Vaccine-Preventable Diseases, 13th Edition April, 2015 Appendix D-1

74 Appendix D

VAERS Table of Reportable Events Following Vaccination* Vaccine/Toxoid Event and Interval from Vaccination A. Anaphylaxis or anaphylactic shock (7 days) Tetanus in any B. Brachial neuritis (28 days) combination: DTaP, DTP, C. Any acute complications or sequelae (including death) of above events DTP-Hib, DT, Td, TT, Tdap, (interval - not applicable) DTaP-IPV, DTaP-IPV/Hib, D. Events described in manufacturer’s package insert as contraindications to DTaPHepB-IPV additional doses of vaccine (interval - see package insert) A. Anaphylaxis or anaphylactic shock (7 days) Pertussis in any B. Encephalopathy or encephalitis (7 days) combination: DTaP, DTP, C. Any acute complications or sequelae (including death) of above events DTP-Hib, Tdap, P, (interval - not applicable) DTaP-IPV, DTaP-IPV/Hib, Events described in manufacturer’s package insert as contraindications to DTaP-HepB-IPV D. additional doses of vaccine (interval - see package insert) A. Anaphylaxis or anaphylactic shock (7 days) B. Encephalopathy or encephalitis (15 days) Measles, mumps and C. Any acute complications or sequelae (including death) of above events rubella in any combination: (interval - not applicable) MMR, MR, M, MMRV, R D. Events described in manufacturer’s package insert as contraindications to additional doses of vaccine (interval - see package insert) A. Chronic arthritis (42 days) B. Any acute complications or sequelae (including death) of above event Rubella in any combination: (interval - not applicable) MMR, MMRV, MR, R C. Events described in manufacturer’s package insert as contraindications to additional doses of vaccine (interval - see package insert) A. Thrombocytopenic purpura (7-30 days) B. Vaccine-strain measles viral infection in an immunodeficient recipient (6 Measles in any months) combination: MMR, MMRV, C. Any acute complications or sequelae (including death) of above events MR, M (interval - not applicable) D. Events described in manufacturer’s package insert as contraindications to additional doses of vaccine (interval - see package insert) A. Paralytic polio o in a non-immunodeficient recipient (30 days) o in an immunodeficient recipient (6 months) o in a vaccine-associated community case (interval - not applicable) B. Vaccine-strain polio viral infection in a non-immunodeficient recipient (30 days) Oral Polio (OPV) o o in an immunodeficient recipient (6 months) o in a vaccine-associated community case (interval - not applicable) C. Any acute complication or sequelae (including death) of above events (interval - not applicable) D. Events described in manufacturer’s package insert as contraindications to additional doses of vaccine (interval - see package insert) A. Anaphylaxis or anaphylactic shock (7 days) Inactivated Polio: IPV, B. Any acute complication or sequelae (including death) of the above event DTaP-IPV, DTaP-IPV/HIB, (interval - not applicable) DTaP-HepB-IPV C. Events described in manufacturer’s package insert as contraindications to additional doses of vaccine (interval - see package insert) A. Anaphylaxis or anaphylactic shock (7 days) Hepatitis B in any B. Any acute complications or sequelae (including death) of the above event combination: HepB, (interval - not applicable) HepA-HepB, C. Events described in manufacturer’s package insert as contraindications to DTaP-HepB-IPV, Hib-HepB additional doses of vaccine (interval - see package insert) Hemophilus influenzae type b in any combination Events described in manufacturer’s package insert as contraindications to D (conjugate): Hib, Hib-HepB, additional doses of vaccine (interval – see package insert) DTP-Hib, DTaP-IPV/Hib Varicella in any Events described in manufacturer’s package insert as contraindications to combination: VAR, MMRV additional doses of vaccine (interval – see package insert) Rotavirus (monovalent or Events described in manufacturer’s package insert as contraindications to pentavalent) RV1, RV5 additional doses of vaccine (interval – see package insert) Pneumococcal conjugate Events described in manufacturer’s package insert as contraindications to (7-valent or 13-valent) additional doses of vaccine (interval – see package insert) PCV7, PCV13

Appendix D-2 Centers for Disease Control and Prevention Epidemiology and Prevention of Vaccine-Preventable Diseases, 13th Edition April, 2015 75 All vaccines have the potential to cause an adverse reaction. Medical Management In order to minimize adverse reactions, patients should be carefully screened for precautions and contraindications before of Vaccine Reactions vaccine is administered. Even with careful screening, reactions may occur. These reactions can vary from trivial and inconven- in Children and Teens ient (e.g., soreness, itching) to severe and life threatening (e.g., anaphylaxis). If reactions occur, staff should be prepared with procedures for their management. The table below describes procedures to follow if various reactions occur.

reaction symptoms management

Localized Soreness, redness, itching, or swelling Apply a cold compress to the injection site. at the injection site Consider giving an analgesic (pain reliever) or antipruritic (anti-itch) medication.

Slight bleeding Apply an adhesive compress over the injection site.

Continuous bleeding Place thick layer of gauze pads over site and maintain direct and firm pressure; raise the bleed- ing injection site (e.g., arm) above the level of the patient’s heart.

Psychological Fright before injection is given Have patient sit or lie down for the vaccination. fright and syncope Extreme paleness, sweating, coldness Have patient lie flat or sit with head between knees (fainting) of the hands and feet, nausea, light- for several minutes. Loosen any tight clothing headedness, dizziness, weakness, or and maintain an open airway. Apply cool, damp visual disturbances cloths to patient’s face and neck.

Fall, without loss of consciousness Examine the patient to determine if injury is present before attempting to move the patient. Place patient flat on back with feet elevated.

Loss of consciousness Check the patient to determine if injury is pres- ent before attempting to move the patient. Place patient flat on back with feet elevated. Call 911 if patient does not recover immediately.

Anaphylaxis Sudden or gradual onset of generalized See “Emergency Medical Protocol for Manage - itching, erythema (redness), or urticaria ment of Anaphylactic Reactions in Children and (hives); angioedema (swelling of the Teens” on the next page for detailed steps to lips, face, or throat); severe broncho­ follow in treating anaphylaxis. spasm (wheezing); shortness of breath; shock; abdominal cramping; or cardio- vascular collapse

continued on next page �

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76 Medical Management of Vaccine Reactions in Children and Teens (continued) page 2 of 3

Emergency medical protocol for management of anaphylactic Needed medications for a reactions in children and teens community immunization clinic first-line medication 1 If itching and swelling are confined to the injection site where the vaccination Epinephrine, aqueous 1:1000 dilution, was given, observe patient closely for the development of generalized in ampules, vials of solution, or prefilled symptoms. syringes, including epinephrine auto- injectors (e.g., EpiPen and Auvi-Q). If 2 If symptoms are generalized, activate the emergency medical system autoinjectors are stocked, at least three (EMS; e.g., call 911) and notify patient’s physician. This should be done by should be available (both pediatric and a second person, while the primary healthcare professional assesses the adult formulations). airway, breathing, circulation, and level of consciousness of the patient. Optional medication: H₁ antihistamines 3 drug dosing information: The first-line and most important therapy in Diphenhydramine (e.g., Benadryl) oral (12.5 mg/5 mL liquid, 25 or 50 mg anaphylaxis is epinephrine. There are NO contraindications to epinephrine capsules/tablets) or injectable in the setting of anaphylaxis. (50 mg/mL solution). a First-line treatment: Administer aqueous epinephrine 1:1000 dilution Hydroxyzine (e.g., Atarax, Vistaril) oral (10 mg/5 mL or 25 mg/5 mL liquid, 10 (i.e., 1 mg/mL) intramuscularly; the standard dose is 0.01 mg/kg body mg or 25 mg tablets, or 25 mg capsules). weight, up to 0.5 mg maximum single dose in children and adolescents. See dosing chart on page 3. Needed supplies for a community immunization clinic b Optional treatment: H₁ antihistamines for hives or itching, you may also Syringes (1 and 3 cc) and needles (22 administer diphenhydramine (either orally or by intramuscular injection; and 25 g, 1", 1½", and 2") for epinephrine, the standard dose is 1–2 mg/kg body weight, up to 50 mg maximum diphenhydramine, or hydroxyzine. For dose in children and adolescents*) or hydroxyzine (orally; the standard ampules, use filtered needles. dose is 0.5–1 mg/kg/dose up to 50–100 mg maximum per day in children Alcohol wipes and adolescents). See dosing charts on page 3. Tourniquet * According to AAP’s Red Book, for children age ≥12 years, the diphenhydramine maximum single dose is 100 mg. Pediatric and adult airways (small, medium, and large) 4 Monitor the patient closely until EMS arrives. Perform cardiopulmonary Pediatric and adult size pocket masks resuscitation (CPR), if necessary, and maintain airway. Keep patient in supine with one-way valve position (flat on back) unless he or she is having breathing difficulty. If Oxygen (if available) breathing is difficult, patient’s head may be elevated, provided blood pres- Stethoscope sure is adequate to prevent loss of consciousness. If blood pressure is low, Sphygmomanometer (blood pressure elevate legs. Monitor blood pressure and pulse every 5 minutes. measuring device) with child, adult, and extra­large cuffs 5 If EMS has not arrived and symptoms are still present, repeat dose of Tongue depressors epinephrine every 5–15 minutes for up to 3 doses, depending on patient’s Flashlight with extra batteries (for exam­ response. ination of the mouth and throat) 6 Record all vital signs, medications administered to the patient, including the Wristwatch with a second hand or other timing device time, dosage, response, and the name of the medical personnel who admin- Cell phone or access to onsite phone istered the medication, and other relevant clinical information. continued on next page 7 Notify the patient’s primary care physician. �

These standing orders for the medical management of vaccine reactions in child and teenage patients shall remain in effect for patients of the until rescinded or until name of clinic date

medical director’s signature date of signing

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77 Medical Management of Vaccine Reactions in Children and Teens (continued) page 3 of 3

For your convenience, approximate dosages based on weight and age are provided in the following charts. Please confirm that you are administering the correct dose for your patient.

First-Line Treatment: Epinephrine Epinephrine Dose 1 mg/mL injectable (1:1000 Epinephrine auto-injector, Age group Range of Range of dilution); intramuscular 0.15 mg or 0.3 mg weight (lb) weight (kg)* Minimum dose: 0.05 mL Recommended dose 1–6 months 9–19 lb 4–8.5 kg 0.05 mL (or mg) off label is 0.01 mg/kg body 7–36 months 20–32 lb 9–14.5 kg 0.1 mL (or mg) off label weight up to 0.5 mg Infants and 37–59 months 33–39 lb 15–17.5 kg 0.15 mL (or mg) 0.15 mg/dose maximum dose. children 5–7 years 40–56 lb 18–25.5 kg 0.2–0.25 mL (or mg) 0.15 mg/dose May be repeated every 5–15 minutes 8–10 years 57–76 lb 26–34.5 kg 0.25–0.3 mL (or mg) 0.15 mg or 0.3 mg/dose for a total of 3 doses. 11–12 years 77–99 lb 35–45 kg 0.35–0.4 mL (or mg) 0.3 mg/dose Teens 13 years & older 100+ lb 46+ kg 0.5 mL (or mg) – max. dose 0.3 mg/dose

note: If body weight is known, then dosing by weight is preferred. * Rounded weight at the 50th percentile If weight is not known or not readily available, dosing by age is appropriate. for each age range

Optional Treatment: Diphenhydramine Diphenhydramine Dose Liquid: 12.5 mg/5 mL

▲ Age group Range of Range of Tablets: 25 mg or 50 mg commonly weight (lb) weight (kg)* Injectable: 50 mg/mL (IV or IM) known as 7–36 months 20–32 lb 9–14.5 kg 10–15 mg/dose Benadryl Infants 37–59 months 33–39 lb 15–17.5 kg 15–20 mg/dose and 5–7 years 40–56 lb 18–25.5 kg 20–25 mg/dose Recommended children dose is 1–2 mg/kg 8–12 years 57–99 lb 26–45 kg 25–50 mg/dose† body weight every Teens 13 years & older 100+ lb 46+ kg 50 mg/dose (up to 50 mg or 100 mg† single dose) 4–6 hrs note: If body weight is known, then dosing by weight is preferred. * Rounded weight at the 50th percentile If weight is not known or not readily available, dosing by age is appropriate. for each age range †According to AAP’s Red Book, for children age ≥12 years, the diphenhydramine maximum single dose is 100 mg.

Optional Treatment: Hydroxyzine Hydroxyzine Dose Liquid: 10 mg/5 mL or 25 mg/5 mL

▲ Age group Range of Range of Tablets: 10 mg or 25 mg commonly weight (lb) weight (kg)* Capsules: 25 mg known as 7–36 months 20–32 lb 9–14.5 kg 5–7.5 mg/dose Atarax, Vistaril Infants 37–59 months 33–39 lb 15–17.5 kg 7.5–10 mg/dose and 5–7 years 40–56 lb 18–25.5 kg 10–12.5 mg/dose Recommended oral children dose is 0.5–1 mg/kg 8–10 years 57–76 lb 26–34.5 kg 12.5–15 mg/dose body weight every 11–12 years 77–99 lb 35–45 kg 15–25 mg/dose 4–6 hrs Teens 13 years & older 100+ lb 46+ kg 25 mg/dose (50–100 mg, maximum per day)

note: If body weight is known, then dosing by weight is preferred. * Rounded weight at the 50th percentile If weight is not known or not readily available, dosing by age is appropriate. for each age range

references ● Simons FE, Camargo CA. Anaphylaxis: Rapid recognition ● Boyce JA, Assa’ad A, Burks AW, et al. Guidelines for the and treatment. In: UpToDate, Bochner BS (Ed). UpToDate: Diagnosis and Management of Food Allergy in the United Waltham, MA, 2013. States: Report of the NIAID­Sponsored Expert Panel. ● Charts adapted from American Academy of Pediatrics. Red Allergy Clin Immunol 2010; 126(6): S1–S57. Book: 2012 Report of the Committee on Infectious Diseases. Pickering LK, ed. 29th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2012: pp. 67–69.

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78 INITIAL OFFICE MANAGEMENT OF ANAPHYLAXIS

Anaphylaxis is an acute life threatening and rare event. Routine childhood immunizations rarely cause anaphylaxis.

1 CALL FOR MD 2 EVALUATE PATIENT FOR ANAPHYLAXIS

INFANTS CHILDREN & ADULTS Onset of symptoms Over several minutes, usually within 15 min after injection

First symptoms Unable to complain Dizzy, itching, breathing difficulty

Level of consciousness Irritable, high pitched cry, anxious, Some confusion or less responsive, restless usually no loss of consciousness Appearance Flushed (pink-red) with hives Flushed (pink-red), hives, facial swelling

Vital signs Pulse often above 200 Rapid, weak pulse and low blood pressure

Breathing Rapid with retractions; Wheezing or stridor with possible wheezing, stridor, or cough progressive distress

3 CALL 911 Ask clerk or assistant to call, do not leave patient 4 GENERAL TREATMENT  LIE ON BACK, WITH LEGS ELEVATED AS TOLERATED– INFANTS MAY BE HELD BY PARENT  IF AVAILABLE, GIVE OXYGEN

5 SPECIFIC TREATMENT OF ANAPHYLAXIS AQUEOUS EPINEPHRINE 1:1000 (I ML = I MG) (INTRAMUSCULAR OR SUBCUTANEOUS) 0.01 ML/KG PER DOSE (MAY BE REPEATED EVERY 5 MINUTES AS NECESSARY, UP TO 3 DOSES)

USUAL DOSAGE Infants: 0.05–0.1 ML Under 20 lbs 0.1 ML Children: 0.1–0.3 ML 20–35 lbs 0.15 ML 35–50 lbs 0.2 ML Adolescents/Adults: 0.3–0.5 ML 50–100 lbs 0.3 ML *Epinephrine available in glass ampule & EpiPen® & EpiPen Jr.® Replace if expiration date exceeded.

6 EMS TRANSPORT TO ACUTE CARE FACILITY

California Department of Public Health • Immunization Branch • 850 Marina Bay Parkway • Richmond, CA 94804 IMM-910 (11/13) 79 80 TOOLS FOR TALKING WITH PARENTS

81 82 Top Ten Reasons to Protect Your Child by Vaccinating

Here are the top ten reasons to protect your child by vaccinating him or her against serious diseases. 1 Parents want to do everything possible to make sure their children are healthy and protected from preventable diseases. Vaccination is the best way to do that. 2 Vaccination protects children from serious illness and complications of vaccine- preventable diseases which can include amputation of an arm or leg, paralysis of limbs, hearing loss, convulsions, brain damage, and death. 3 Vaccine-preventable diseases, such as measles, mumps, and whooping cough, are still a threat. They continue to infect U.S. children, resulting in hospitalizations and deaths every year. 4 Though vaccination has led to a dramatic decline in the number of U.S. cases of several infectious diseases, some of these diseases are quite common in other countries and are brought to the U.S. by international travelers. If children are not vaccinated, they could easily get one of these diseases from a traveler or while traveling themselves. 5 Outbreaks of preventable diseases occur when many parents decide not to vaccinate their children. 6 Vaccination is safe and effective. All vaccines undergo long and careful review by scientists, doctors, and the federal government to make sure they are safe. 7 Organizations such as the American Academy of Pediatrics, the American Academy of Family Physicians, and the Centers for Disease Control and Prevention all strongly support protecting children with recommended vaccinations. 8 Vaccination protects others you care about, including family members, friends, and grandparents. 9 If children aren’t vaccinated, they can spread disease to other children who are too young to be vaccinated or to people with weakened immune systems, such as trans- plant recipients and people with cancer. This could result in long-term complications and even death for these vulnerable people. 10 We all have a public health commitment to our communities to protect each other and each other’s children by vaccinating our own family members. immunization action coalition Technical content reviewed by the Centers for Disease Control and Prevention Saint Paul, Minnesota • 651-647-9009 • www.immunize.org • www.vaccineinformation.org www.immunize.org/catg.d/p4016.pdf • Item #P4016 (11/14) IimmAunize.orgC

83 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 whooping cough? develop certain infectious diseases than older children. • All children should be vaccinated on schedule with Cocooning is a way to protect babies from catching dis- DTaP (the childhood whooping cough vaccine). eases from the people around them – people like their • All teenagers and adults need a one-time dose of Tdap parents, siblings, grandparents, friends, child-care provid- vaccine (the teen and adult whooping cough vaccine). ers, babysitters, and healthcare providers. Once these • Pregnant women should receive a Tdap vaccination in people are vaccinated, they are less likely to spread these each pregnancy, preferably during the 3rd trimester. contagious diseases to the baby. They surround the baby This will protect the pregnant woman as well as her with a cocoon of protection against disease until he or she baby! is old enough to get all the doses of vaccine needed to be fully protected. How can we protect babies against flu? Why is cocooning important? Everyone age 6 months and older needs to receive flu Babies less than 6 months old are too young to have vaccine every year. received all the doses of vaccine that are needed to protect them from whooping cough (pertussis), flu (influenza), and other dangerous diseases. To be fully protected, information from trusted sources babies 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, http://cocooning.preventpertussis.org 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/hcp/patient-ed/conversations/ Currently, towns and cities across the nation have had whoop- prevent-diseases/index.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 (3/13)

84 IMM-686 E/S (1/01) ots . ots . reduce redness, reduce ere nce. om e cloth can At h A cool wet A cool wet appointment. state- vaccine information Review possible reactions. ments for Mark your calendar for your next your calendar for Mark your for the next 24 hours. for fe ver. child plenty of fluids. your Give It is normal if he/she eats less than usual bath with lukewarm water to reduce bath with lukewarm Also try child a sponge giving your a non-aspirin pain reliever. may recommend you give your child your give you recommend may To reduce pain or fever, reduce doctor your To doctor or seek medical attention. doctor reaction that concerns you,reaction call your notice a fever. child has any If your days. might see a small rash or You Observe your child for the next few child for Observe your soreness, the where swelling and/or shot was given. • • • • • • • the di ff all the nt’s love pare nt’s A es during sh during sh ma k shot s il d il d After –Also try: –Comfort by: Reassuring your child that your Reassuring is okay. everything Giving praises and hugs or a surprise. when you get home.when you using a non-aspirin pain reliever Holding, cuddling, caressing, and/or breastfeeding and soothingly. lovingly Talking advice on for doctor Asking your • Toddlers • • • • Infants shot s 948 04 –Also try: During –Distract and comfort by: ic hm ond, CA R around the room. around Pointing out posters or objects out posters Pointing Using a hand puppet. and slowly blow out the pain. blow and slowly Helping your child take deep breaths child take Helping your your lap. your child. to or singing with your Talking Holding your child securely on child securely Holding your him/her. Making eye contact as you smile at contact as you Making eye Touching soothingly and talking softly. soothingly Touching force him/her to be brave. force him/her tell you one. him/her tell you child to cry, your Allowing don’t Telling your child a story your or have Telling • • • • • Toddlers • • Infants or your ch • • or your ch f f Ma rina Parkway • Bay ri ng 50 8 •C a O ti ve er e er e un izatio n Branch • shot s Effec • He alt h • Im m lic –All above, plus: Befo re Safe t of Pub men t of toddler. and comfort, your not to scare Encourage older siblings to reassure Encourage nurse give you a shot.” you give nurse “If you are not good, are “If you the I will have Never threaten your child with shots, your threaten Never seconds.” Reassure your child honestly,“It your Reassure last a few might sting but it will only feelings. Stay calm–your baby picks up your baby calm–your Stay Bring along a favorite toy or blanket. toy Bring along a favorite Ask any questions. Ask any Bring your child’s Bring your immunization record. statements. Read vaccine information Be th Be th De pa rt • • Toddlers • • • • Infants: • •

85 Tips for a Less Stressful Shot Visit

Making the choice to vaccinate your child is vital for their health and well-being. Even so, getting shots can still be stressful for you and your little one. Fortunately, there are simple ways you can support your child before, during, and after shots.

Before Getting Shots Come prepared! Take these steps before your child gets a shot to help make the immunization visit less stressful on you both. • Read any vaccine materials you received from your child’s health care professional and write down any questions you may have. • Find your child’s personal immunization record and bring it to your appointment. An up-to-date record tells your doctor exactly what shots your child has already received. • Pack a favorite toy or book, and a blanket that your child uses regularly to comfort your child. For older children • Be honest with your child. Explain that shots can pinch or Help children see vaccines as a sting, but that it won’t hurt for long. good thing. Never threaten your • Engage other family members, especially older siblings, to child with shots, by saying “If you support your child. misbehave I will have the nurse give you a shot.” Instead, remind • Avoid telling scary stories or making threats about shots. children that vaccines can keep At the Doctor’s Office them healthy. If you have questions about immunizations, ask your child’s doctor or nurse. Before you leave the appointment, ask your child’s doctor for advice on using non-aspirin pain reliever and other steps you Ways to soothe your baby: can take at home to comfort your child. • Swaddling Try these ideas for making the shots easier on your child. • Skin-to-skin contact • Distract and comfort your child by cuddling, singing, or • Offering a sweet beverage, talking softly. like juice (when the child is older than 6 months) • Smile and make eye contact with your child. Let your child know that everything is ok. • Breastfeeding • Comfort your child with a favorite toy or book. A blanket that smells familiar will help your child feel more comfortable. Your health care professional may • Hold your child firmly on your lap, whenever possible. cool or numb the injection site to reduce the pain associated with your child’s shots.

The Centers for Disease Control and Prevention (CDC), the American Academy of Family Physicians (AAFP), and the American Academy of Pediatrics (AAP) adapted this information from Be There for Your Child during Shots, California Department of Public Health Immunization Branch.

CS218609 86 For older children • Take deep breaths with your child to help “blow out” the pain. • Point out interesting things in the room to help Remember to schedule your next visit! create distractions. Staying current with your child’s immunizations • Tell or read stories. provides the best protection against disease. • Support your child if he or she cries. Never scold a child for not “being brave.” Once your child has received all of the shots, be especially supportive. Hold, cuddle, and, for infants, breastfeed or offer a bottle. A soothing voice, combined with praise and hugs will help reassure your child that everything is ok. After the Shots Sometimes children experience mild reactions from vaccines, such as pain at the injection site, a rash or a fever. These reactions are normal and will soon go away. The following tips will help you identify and minimize mild side effects. • Review any information your doctor gives you about the shots, especially the Vaccine Information Take a moment to read the Vaccine Information Statements or other sheets that outline which side Sheet your health care professional gives you effects might be expected. during your visit. This sheet has helpful information and describes possible side effects • Use a cool, wet cloth to reduce redness, soreness, and swelling in the place where the shot was given. your child may experience. • Reduce any fever with a cool sponge bath. If your doctor approves, give non-aspirin pain reliever. • Give your child lots of liquid. It’s normal for some children to eat less during the 24 hours after getting vaccines. • Pay extra attention to your child for a few days. If you see something that concerns you, call your doctor.

800-CDC-INFO (800-232-4636) • www.cdc.gov/vaccines ­

87 After the What to do if your child has discomfort Shots... I think my child has a fever. What should I do? Check your child’s temperature to find out if there is a fever. An easy way Your child may need extra love and care to do this is by taking a temperature in the armpit using an electronic ther- after getting vaccinated. Some vaccinations mometer (or by using the method of temperature-taking your healthcare that protect children from serious diseases provider recommends). If your child has a temperature that your healthcare also can cause discomfort for a while. provider has told you to be concerned about or if you have questions, call Here are answers to questions many parents your healthcare provider. have after their children have been vac­ cinated. If this sheet doesn’t answer your Here are some things you can do to help reduce fever: questions, call your healthcare provider. n Give your child plenty to drink.

n Vaccinations may hurt a little... Dress your child lightly. Do not cover or wrap your child tightly. n but disease can hurt a lot! Give your child a fever- or pain-reducing medicine such as acetamino- phen (e.g., Tylenol) or ibuprofen (e.g., Advil, Motrin). The dose you give your child should be based on your child’s weight and your heathcare provider’s instructions. See the dose chart on page 2. Do not give aspirin. Recheck your child’s temperature after 1 hour. Call your healthcare Call your healthcare provider right provider if you have questions. away if you answer “yes” to any of the following questions: My child has been fussy since getting vaccinated. What should I do? Does your child have a temper- ature that your healthcare After vaccination, children may be fussy because of pain or fever. To reduce provider has told you to be discomfort, you may want to give your child a medicine such as acetami n- concerned about? ophen or ibuprofen. See the dose chart on page 2. Do not give aspirin. If your child is fussy for more than 24 hours, call your healthcare provider. Is your child pale or limp? Has your child been crying My child’s leg or arm is swollen, hot, and red. What should I do? for more than 3 hours and just n won’t quit? Apply a clean, cool, wet washcloth over the sore area for comfort. n For pain, give a medicine such as acetaminophen or ibuprofen. See the Is your child’s body shaking, dose chart on page 2. Do not give aspirin. twitching, or jerking? n If the redness or tenderness increases after 24 hours, call your healthcare Is your child very noticeably provider. less active or responsive? My child seems really sick. Should I call my healthcare provider? If you are worried at all about how your child looks or feels, call your health- care provider! s Please see page 2 for information on the healthcare provider: please fill in the information below. proper amount of medicine to give your child to reduce pain or fever. If your child’s temperature is °F or °C or higher, or if you have questions, call your healthcare provider. Healthcare provider phone number: immunization [ ] action coalition Technical content reviewed by the Centers for Disease Control and Prevention Saint Paul, Minnesota • 651-647-9009 • www.immunize.org • www.vaccineinformation.org www.immunize.org/catg.d/p4015.pdf • Item #P4015 (7/14) IimmAunize.orgC

88 after the shots: what to do if your child has discomfort – page 2 Medicines and Dosages to Reduce Pain and Fever Choose the proper medicine, and measure the dose accurately. 1. Ask your healthcare provider or pharmacist which medicine is best for your child. 2. Give the dose based on your child’s weight. If you don’t know your child’s weight, give the dose based on your child’s age. Do not give more medicine than is recommended. 3. If you have questions about dosage amounts or any other concerns, call your healthcare provider. 4. Always use a proper measuring device. For example: ■ When giving acetaminophen liquid (e.g., Tylenol), use the device enclosed in the package. If you misplace the device, consult your healthcare provider or pharmacist for advice. Kitchen spoons are not accurate measures. ■ When giving ibuprofen liquid (e.g., Advil, Motrin), use the device enclosed in the package. Never use a kitchen spoon! Take these two steps to avoid causing a serious medication overdose in your child. 1. Don’t give your child a larger amount of acetaminophen (e.g., Tylenol) or ibuprofen (e.g., Motrin, Advil) than is shown in the table below. Too much of any of these medicines can be extremely dangerous. 2. When you give your child acetaminophen or ibuprofen, don’t also give them over-the-counter cough or cold medicines. This can cause a medication overdose because cough and cold medicines often contain acetamino- phen or ibuprofen. In fact, to be safe, don’t ever give over-the-counter cough and cold medicines to your child unless you talk to your child’s healthcare provider first.

Acetaminophen (Tylenol or another brand): How much to give? Give every 4 to 6 hours, as needed, no more than 5 times in 24 hours (unless directed to do otherwise by your healthcare provider).

old formulations Infants’ New formulation children’s junior child’s weight child’s infants’ drops or children’s liquid chewables strength age 80 mg in each 0.8 mL 160 mg in each 5 mL (1 tsp) or in each 1.0 mL Kitchen spoons are not accurate measures. 80 mg in each tab 160 mg in each tab 6–11 lbs (2.7–5 kg) 0–3 mos Advised dose* 1 12–17 lbs (5.5–7.7 kg) 4–11 mos No longer ⁄2 teaspoon or 2.5 mL available 3 18–23 lbs (8.2–10.5 kg) 12–23 mos for purchase ⁄4 teaspoon or 3.75 mL 24–35 lbs (10.9–15.9 kg) 2–3 yrs in the U.S. 1 teaspoon or 5 mL 2 tablets Please discard 1 36–47 lbs (16.4–21.4 kg) 4–5 yrs old product. 1 ⁄2 teaspoon or 7.5 mL 3 tablets 48–59 lbs (21.8–26.8 kg) 6–8 yrs 2 teaspoons or 10 mL 4 tablets 2 tablets 1 1 60–71 lbs (27.3–32.3 kg) 9–10 yrs 2 ⁄2 teaspoons or 12.5 mL 5 tablets 2 ⁄2 tablets 72–95 lbs (32.7–43.2 kg) 11 yrs 3 teaspoons or 15 mL 6 tablets 3 tablets

Ibuprofen (Advil, Motrin, or another brand): How much to give? Give every 6 to 8 hours, as needed, no more than 4 times in 24 hours (unless directed to do otherwise by your healthcare provider).

children’s liquid old formulation children’s child’s infants’ drops children’s chewables or child’s weight 100 mg in each 5 mL (1 tsp) age 50 mg in each 1.25 mL chewables junior tablets Kitchen spoons are not accurate measures. 50 mg in each tab 100 mg in each tab less than 11 lbs (5 kg) 0–5 mos 12–17 lbs (5.5–7.7 kg) 6–11 mos 1.25 mL Advised dose* No longer available 18–23 lbs (8.2–10.5 kg) 12–23 mos 1.875 mL Advised dose* for purchase 24–35 lbs (10.9–15.9 kg) 2–3 yrs 1 teaspoon or 5 mL in the U.S. 1 tablet Please discard 1 1 36–47 lbs (16.4–21.4 kg) 4–5 yrs 1 ⁄2 teaspoon or 7.5 mL old product. 1 ⁄2 tablets 48–59 lbs (21.8–26.8 kg) 6–8 yrs 2 teaspoons or 10 mL 2 tablets 1 1 60–71 lbs (27.3–32.3 kg) 9–10 yrs 2 ⁄2 teaspoons or 12.5 mL 2 ⁄2 tablets 72–95 lbs (32.7–43.2 kg) 11 yrs 3 teaspoons or 15 mL 3 tablets

* healthcare provider: please fill in the advised dose. Immunization Action Coalition n www.immunize.org/catg.d/p4015.pdf

89 Vaccine Safety:

10 Facts for Medical Assistants California Immunization Coalition

One of the most important ways that you keep Scientists study VAERS reports carefully to help children healthy is by giving them vaccines. make sure that vaccines are safe. Some parents have questions about vaccines. 2. Why do children today get so many They may worry about what is safe for their child. immunizations? Doctors should always answer patients’ medical questions—including worries about vaccines. But To save lives! Today’s vaccines protect us against it’s a good idea for you to know about the questions more than 15 dangerous diseases. Who benefits that parents may have. Doctors have reviewed this most? Babies! Their tiny bodies may be too weak fact sheet. You can use it to better understand the to fight off a serious disease. Vaccine-preventable scientific facts about vaccines. diseases (like measles, chickenpox, mumps, whooping cough, and meningitis) can cause 1. Are vaccines safe? seizures, brain damage, blindness, and even death. Yes. Vaccines are safe. Millions of children and adults are vaccinated every year. However, any 3. Are diseases of the “old days” really still medicine can cause reactions in some people. something to worry about? The most common side effects are swelling or Yes! Diseases are still here, but are not as common, tenderness at the injection site and fever. Serious so most young parents haven’t seen them. This reactions are very rare, happening in 1-2 people out is the success of immunization. But kids without of a million shots given. their shots can still get very sick from diseases like influenza, whooping cough, and chickenpox. Many steps are taken to make sure that a vaccine Not too many kids get chickenpox these days. is safe. After years of research, thousands of But before there was a vaccine, 11,000 Americans people volunteer to test it. Then, the Food and Drug went to the hospital for chickenpox every year. Administration (FDA) decides if it’s safe. If it is, they Dangerous diseases like meningitis, measles, and will license it. After that, the Vaccine Adverse Events mumps can spread quickly to other people. Some Reporting System (VAERS) tracks any side effects diseases are just a plane ride away. International that happen hours, days, weeks, or even months travelers without all their shots can bring a disease later. Anyone can report a possible side effect. back home and infect other people.

1 California Immunization Coalition (CIC) — IMM-1016 (06/10) 90 Vaccine Safety:

10 Facts for Medical Assistants California Immunization Coalition 4. What about holistic medicine or safe. In fact, today’s vaccines use the latest science “natural immunity”? and need fewer antigens. So, even though kids get Holistic medicines do not prevent the diseases that more vaccines, they get fewer antigens all together. vaccines are made for. Before vaccines, millions of It is not possible to overwhelm a healthy immune children became ill with whooping cough, measles, system with vaccines. mumps and other diseases. Most vaccines prevent 6. What about getting shots later, or more these illnesses over 99% of the time. spread out? Some people believe getting a disease is a “natural” Most doctors follow the recommended immunization way to start the body’s defenses. If you get chicken- schedule. This is because skipping or delaying shots pox once, you will not get it again, so you are means a child could get sick before getting his “immune.” Vaccines work the same way. They shots. Getting only one shot per visit is not any safer, give you immune protection—but not the disease. it just means more appointments and stress for the Natural immunity from the real disease can be child. Young children and babies can get very sick dangerous. That’s because it means getting sick from certain diseases. That’s why it’s important for and maybe getting serious complications. babies to get shots and why most doctors use the standard schedule. If parents in your clinic ask about 5. Is it safe for a child’s immune system to waiting longer or skipping shots, suggest that they have multiple shots? talk to the doctor to make a safe decision. Yes. Children touch or breathe hundreds of viruses or bacteria (called antigens). This happens every 7. Do vaccines cause autism? day when eating and playing. Antigens make the No. Autism diagnoses are increasing around the world. immune system do its work. Vaccines use antigens Studies show that it happens to the same number of very safely even in “live” vaccines, like MMR. That’s vaccinated and unvaccinated children. No one knows yet because vaccine antigens are weakened or killed, all of the causes of autism. But we do know that children so they cannot hurt the immune system—even for get autism at about the same age they get their regular babies. If a child has a weakened immune system shots. This can make it seem like shots are related. (like from cancer or AIDS), ask the doctor before Twenty-three studies have tested hundreds of thousands giving live vaccines. Vaccines are less dangerous of children and found no link between autism and than the germs children face every day. vaccines. The American Medical Association, American What about “combination” vaccines (when a single Academy of Pediatrics, Institute on Medicine, and World shot protects against more than one disease)? Or Health Organization all agree that there is no connection getting several shots in one visit? Multiple shots are between vaccines and autism.

8. Is a baby safe from vaccine-preventable diseases at home? Not necessarily. Even the family home cannot guarantee that a new baby is safe from contagious disease. For example, babies can get very sick— even die—from whooping cough spread from the mom, a sibling, or even a babysitter. Parents and older children in the household should get a Tdap booster shot to protect the new baby. Babies can start getting DTaP vaccine at 6 weeks old.

2 California Immunization Coalition (CIC) — IMM-1016 (06/10) 91 Vaccine Safety:

10 Facts for Medical Assistants California Immunization Coalition

9. What about thimerosal (or mercury)  Formaldehyde prevents contamination of the in vaccines? vaccine bottle. It’s used in tiny amounts in some vaccines. It’s also in the environment and is a Thimerosal was removed from all child natural part of the body’s metabolism. vaccines (except some flu shots) in 2001 as a precaution. Thimerosal is a preservative made  False claims: Vaccines do not contain anti- with ethylmercury, which is very different from the freeze, chick embryos, or monkey kidneys. This is mercury found in some fish. Thimerosal prevents false information. contamination of the vaccine bottle, and scientific studies show no link between thimerosal in vaccines Make your research work for you and autism in children. Recent research shows that Be choosy about what you read. autism cases continue to go up even after thimerosal is We recommend these trusted sites: gone from vaccines. American Academy of Pediatrics By California law, children under age 3 and pregnant www.aap.org/immunization women cannot have vaccines with thimerosal. Some National Network for Immunization flu vaccines for adults or older children still use www.immunizationinfo.org thimerosal. If parents are worried, you can ask the doctor if your clinic has “thimerosal-free” flu vaccine. Thimerosal FAQs www.fda.gov/CBER/vaccine/thimerosal.htm 10. What about other vaccine ingredients? Do Vaccines Cause That? (Book) Vaccine ingredients are safe for babies and young www.i4ph.org children. That’s because the ingredients are used in Evaluating Health Information on the Web tiny amounts for very specific purposes. www.immunizationinfo.org/parents/evaluatingWeb.cfm  Aluminum: Aluminum in vaccines helps the Parents of Kids with Infectious Diseases body’s immune response to a disease. There is www.pkids.org no reason to worry about aluminum in vaccines. Aluminum is in many foods and drinks like fruit The California Immunization Coalition (CIC) is a and vegetables — even breast milk and infant non-profit, public-private partnership dedicated formula. It’s also in antacids, antiperspirants, to achieving and maintaining full immunization cooking pots, and soda cans. Babies get more protection to promote health and prevent serious aluminum from breast milk than they get from illness across the life span. vaccines. Formula-fed babies get even more daily aluminum — especially from soy formulas.

California Immunization Coalition 909 12th Street, Suite 200 Sacramento, CA 95814 (916) 447-7063 ext. 333 www.immunizeCA.org

3 California Immunization Coalition (CIC) — IMM-1016 (06/10) 92 Clear Answers & Smart Advice About Your Baby’s Shots By Ari Brown, MD, FAAP Dr. Brown received her medical degree from Baylor College of Medicine in Houston, Texas; she did her pediatric residency at Harvard Medical School/Boston Children’s Hospital. In private practice since 1995, Dr. Brown is perhaps best known as the coauthor of the 411 parenting book series — Expecting 411: Clear Answers and Smart Advice for Your Pregnancy, Baby 411, and Toddler 411 (Windsor Peak Press). In response to the recent media attention given to vaccines, autism, and other controversies concerning vaccines, the Immunization Action Coalition (IAC) has reprinted a special excerpt from Baby 411 that answers these questions and more. IAC thanks Dr. Brown for this clearly written information, but mostly, we are grateful for her continued advocacy for safe and effective vaccines.

Vaccines. Autism. Controversy. As a new parent dren may have little interest in playing with toys. Or they may play (or parent-to-be), it’s hard not to hear the great debate in parenting in an odd way— such as using a phone as a comfort object. circles these days—do vaccines cause autism? If not, what causes Bottom line: Children with autism have autism long before their autism and why is it on the rise? first birthdays, even though their “official” diagnosis usually occurs Let’s start at the beginning—just what is autism? in their second year of life.

Q: What is autism? Q: I have a friend whose child has autism. She said Autism Spectrum Disorder (ASD) is really a collection of several he was “perfectly normal” until he was about disorders that have three abnormal areas in common: social skills, 18 months old. Does this happen? communication skills, and repetitive or obsessive traits. Specialists use the terms ASD and Pervasive Developmental Disorders (PDD) A small minority of ASD children have completely normal mile- interchangeably. To add even more confusion, Pervasive Devel- stones and then regress, which is known as “late onset autism.” opmental Disorder, not otherwise specified (PDD-NOS), and As- These children most likely have a distinct genetic abnormality that perger’s Syndrome also are other categories that fall under the ASD turns on or off without any trigger. umbrella. However, for most kids with ASD, parents and doctors just miss (or There is a very broad range of severity within ASD. A child may dismiss) the early signs in the first year of life and the child’s atypi- have normal intelligence and language, but be socially awkward cal development only becomes apparent at 18 months. and have panic attacks if his sandwich is cut in triangles instead of Doctors rely heavily on parents to point out concerns. And parents squares. Or a child may appear out of touch with reality and spend (especially first-timers) don’t know what is normal and what isn’t. his entire day rocking and flapping his hands. Both children have ASD. As you might suspect, children with severe problems as in The mother of one of my ASD patients told me that she only real- classic autism are diagnosed much earlier than kids who can com- ized how unusual her son’s development was after she watched her municate but have trouble with social skills, as in Asperger’s Syn- second child, without ASD, breeze through her milestones. Even the drome. most vocal ASD mom of all, Jenny McCarthy, agrees. Her son was 5 months old when he first smiled at her (that’s abnormal), when Children are usually diagnosed by 18-24 months of age when lan- all of her friends’ babies smiled at 2 months of age (that’s normal). guage delays are obvious. Many children with Asperger’s Syndrome may not be diagnosed until preschool (or sometimes even later). Some parents report that their ASD child spoke a few words and then “lost” the ability to say them. If you delve a bit deeper, the child However, clues to the diagnosis appear long before that time. Some may have randomly said a few things, but was not consistently using early clues include: not smiling back at people, poor eye contact, not words like “juice” or “no” to communicate his needs. imitating, not gesturing (waving bye-bye), not responding to being called by name, and not trying to communicate/connect/engage with There is growing research in language development that looks at other people by 1 year of age. brain anatomy. Primitive brain parts control early language develop- ment from birth to 18 months. At 18 to 24 months, the mature brain There also are some unusual behaviors. Cuddling may not be sooth- parts turn on and language takes off. With autistic children, mature ing. In fact, an autistic child may get very upset by being touched. language does not take off. But from a parent’s perspective, it may Bright lights and noises often bother them. Because they are bugged look like a loss of skills. by the outside world, they may turn inward and find comfort in re- petitive behaviors (rocking, head banging, spinning). Autistic chil-

www.immunize.org/catg.d/p2068.pdf • Item #P2068 (9/13)

Immunization Action Coalition • 1573 Selby Ave. • St. Paul, MN 55104 • (651) 647-9009 • www.immunize.org • www.vaccineinformation.org 93 Clear Answers & Smart Advice About Your Baby’s Shots page 2 of 6

And again, children with subtle atypical behaviors may be harder • Environmental triggers: Is there some environmental exposure to diagnose early on. Reviewing home movies of a child once the that sets off abnormal brain development in a genetically diagnosis is made often shows that early signs are overlooked.1 predisposed baby? Maybe. And that exposure may happen at or shortly after conception, before a mother even knows she is pregnant. The embryo has a critical period of brain development Q: OK, so what causes autism? at 20–24 days after conception. That is when the developing brain The million-dollar question. is most sensitive to injury. Studies done by the Environmental Working Group have detected over 280 environmental toxins in In the 1980s, one in 10,000 kids was diagnosed with autism. Today, umbilical cord blood, so clearly pregnant moms are exposed to a one in 150 American 8-year-olds has some form of autism. Boys variety of toxins. Could one of these be the autism trigger? We outnumber girls four to one. The United States is not the only coun- don’t know. try seeing this trend. It is increasingly diagnosed worldwide. Viral infections during pregnancy also may be a key environmental For starters, is it really an epidemic? Or, are more people being diag- trigger that causes abnormal genes in the fetus. Those infections nosed? Many children who were diagnosed with mental retardation include rubella, CMV (cytomegalovirus), and influenza (yes, 30 years ago are children who are diagnosed with classic autism “the flu”).5 today. And mildly disabled ASD kids today are children who never would have had a diagnosis 30 years ago. Those verbal, but socially What about vaccines as an environmental trigger? Researchers awkward, children account for the majority of new ASD cases. and scientists have taken a long, hard look at vaccines—and there is conclusive evidence that vaccine exposure is NOT the turn-on Here are the hottest areas of autism research today: switch for autism.6 • Genetics: There is no question genetics plays a role. Autism runs Bottom line: There’s evidence that newborns who are later in families. I have a family in my practice and all four children diagnosed with ASD already have abnormal levels of certain have a diagnosis on the autism spectrum. proteins in their brains. So, whatever the trigger is (if there is Studying twins is an obvious way to detect genetic disorders. If one), it has been fired before the baby even enters the world. one identical twin has autism, up to 90 percent of the time, so will • Prematurity: A developing brain is quite vulnerable. Premature, the other twin. To date, studies suggest there is more than just one very low birth-weight babies (under three pounds) have a 25 “autism gene”; there appear to be several. percent chance of developing an autism spectrum disorder.7 ASD children have several different abnormalities with their • Older parents: Another possible reason for the increase of DNA. However the X chromosome is one of interest because of autism: the trend of parents having babies at a later age. Moms the high prevalence of boys with ASDs.2 who conceive after the age of 40 have a 30 percent increased risk Fragile X Syndrome, which is a known genetic cause of autism, of having a child with autism. Dads who conceive after the age of also points to a defective X chromosome in ASD. 40 have a 50 percent increased risk of having an autistic child.8 Scientists speculate that an older dad’s sperm may have defective And Rett Syndrome, which is a disorder causing developmental genetic material, possibly altered by environmental toxins. regression and autistic behaviors in girls, is caused by a defective MECP2 gene located on the X chromosome.3 • Closely spaced pregnancies: A 2011 study compared children who were conceived at least three years after their sibling We also know that kids with autism and defects on Chromosome was born to closer-spaced pregnancies and found that babies 11 have dysfunctional “neurexin 1 protein.” Researchers are conceived less than 12 months after the birth of the first-born looking into how this defective protein affects fetal and infant child were THREE times more likely to be diagnosed with autism brain growth. spectrum disorder. Babies conceived from 12 to 23 months after Finding these specific genetic defects may help in genetic the birth of the first-born child had almost two times the risk of counseling, as well as therapies, in the future. Animal studies ASD. And, even babies conceived 23 to 35 months after the first- already are underway for targeted genetic therapy in both Fragile born child had a slightly greater risk of ASD. X and Rett Syndrome. Unfortunately, the researchers have no idea why the odds are • Abnormal brain growth: ASD children have problems with greater when the spacing between pregnancies is shorter. Perhaps brain growth. Babies are born with immature brains that grow it’s because a woman’s nutritional stores have not had enough rapidly and make nerve connections called synapses ... like an time to be replenished. Or maybe women who have put off information superhighway. In the normally growing brain, some parenthood until later in life have more closely spaced babies— branches of this superhighway get “pruned.” In the autistic brain, and parental age itself is a risk factor for having a child with an this pruning process seems to be defective. This may explain ASD. why babies who are autistic have abnormally rapid head growth This study alone should not necessarily influence your decision under 1 year of age. No one has yet figured out what causes on how long to wait between pregnancies. However, the current that defective nerve growth. Of note, boys with ASD have recommendation from the Centers for Disease Control and higher levels of hormones (insulin-like growth factor) that may Prevention is to wait at least 18 to 23 months between pregnancies 4 contribute to their larger head size, weight, and body mass index. for a mother’s and baby’s optimal health.9

94 Clear Answers & Smart Advice About Your Baby’s Shots page 3 of 6

Bottom line: Researchers don’t know what causes autism, One small case report of only eight patients in 1998 led a research although the above factors provide clues. The goal is to find a group to feel that the combination measles, mumps, and rubella way to prevent autism … but we aren’t there yet. (MMR) vaccine might cause autism.11 But, don’t try to find the article online because the journal that published it later retracted it Vaccines when a former member of the research lab revealed that the data reported in the study was fabricated!12 Twelve years later, the lead Q: Why do you care whether I vaccinate my child author lost his license to practice medicine in England and was or not? accused of fraud. The whole thing was a hoax. For starters, we want your baby to be protected. Before this came to light, several reputable scientists tried to duplicate the findings of this now discredited researcher. No one But we also want you to realize that the decision to vaccinate ever could—and now we know why! your child impacts the health of other children in the community. Choosing NOT to vaccinate your child is choosing to put your child Unfortunately, frightened parents chose to skip the MMR vaccine AND your community’s children at risk. As a parent, you want and measles epidemics occurred in the United Kingdom and the to make the right choices to protect your child. I want you to ask United States as a result of these unfounded claims. questions. I want you to be informed. And I want you to get your child vaccinated. YOUR decision impacts ALL children. Why? Bottom line: Don’t base health decisions for your child on one research study or what the media says! Talk to your child’s doctor There are two critical points for vaccination to work: about any vaccine safety concerns. 1. You need to be vaccinated. Q: If the MMR vaccine doesn’t cause autism, why 2. Your neighbor needs to be vaccinated. is the diagnosis made around the same time as the This concept is called herd immunity. And yes, you are a member of vaccination? a herd. When 90 to 95 percent of “the herd” is protected, it is nearly One of the criteria used to make a diagnosis of autism is a language impossible for a germ to cause an epidemic. Think of germs as rain. delay. Because children do not have significant expressive language Vaccination is a raincoat. Even with a raincoat on, you can still get under a year of age, doctors have to wait until 15 to 18 months to wet. You need an umbrella, too. The umbrella is “herd immunity.” confirm a language delay and make the diagnosis. That’s about the Those who don’t vaccinate expect someone to share their umbrella same time as the MMR vaccination, which leads some parents to when it rains. But society can only buy umbrellas TOGETHER. And wonder about autism and vaccination. raincoats aren’t made for newborns—they need umbrellas! Some parenting decisions have little or no impact on the community Q: I’ve heard mercury preservative is in vaccines. Is at large. Deciding whether or not your child eats organic baby food, this true? goes to preschool, or sleeps in a family bed is entirely up to you— Only a few remain. Preservatives and stabilizers are used in your decision only affects your child. vaccines so the vaccinations remain potent and uncontaminated. A However, your decision whether or not to vaccinate your child popular preservative used to be a chemical called thimerosal, which affects all our kids. If you are a parent who is considering delaying contained trace amounts of ethylmercury. Thimerosal use began in or skipping vaccinations altogether, please realize the impact of the 1940s. your decision. Thimerosal was removed from all vaccines given to infants younger If more than 10 percent of American parents choose to “opt out” than age 6 months by 2001. This deserves repeating: YOUR young of vaccines, there’s no question that our entire country will see baby will not be getting vaccines that contain mercury (thimerosal) these horrible diseases of bygone days return. Fortunately, very as a preservative. The one exception is the influenza vaccine that few parents decide to do this. What is most concerning today is that is found in multi-dose vials that need a preservative to prevent there are pockets of under-vaccinated children. Birds of a feather contamination. Influenza vaccine that is packaged in single dose flock together. Like-minded parents who don’t vaccinate their kids vials does not need a preservative and many clinics choose to use tend to live in the same community and send their kids to the same these individual vials with the youngest patients. Remember, it’s schools. With lower immunization rates, there is no herd immunity. very important that children get vaccinated against influenza each We have these “Ground Zero” areas to thank for recent measles and fall or winter beginning when they are 6 months old. 10 whooping cough outbreaks of 2008 and 2011. Despite the fact that most vaccines are mercury preservative-free now, speculation persists about vaccines previously containing Q: I’ve heard that the MMR vaccine might cause mercury and links to autism. This speculation continues even after autism. Is this true? the Institute of Medicine (IOM) published a conclusive report in 2004 negating any association between vaccines and autism. (The No. Parents also hear that vaccinations cause multiple sclerosis, IOM spent four years studying both the mercury question and the diabetes, asthma, and Sudden Infant Death Syndrome (SIDS). None MMR combo vaccine question and published a series of eight of these are caused by vaccination. The government operates a safety reports on the subject.) monitoring system (Vaccine Adverse Event Reporting System, Food and Drug Administration, CDC) watching for any possible adverse A quick chemistry lesson: Certain compounds have completely effects from vaccines. No one wants to increase autism rates. different properties even though they may be related. For instance,

95 Clear Answers & Smart Advice About Your Baby’s Shots page 4 of 6 take the alcohol family. Methanol is anti-freeze; ethanol is a the anticipated flu strains. Since millions of doses of flu vaccine are Bud Light. Keep this in mind when we discuss mercury. We are needed every year, the most efficient way to produce the shot is in all exposed to small amounts of mercury. The type of mercury multi-dose vials, which require a preservative. that has raised health concerns is called methylmercury. High concentrations of methylmercury can be found in tuna, swordfish Hence, some flu shots (not the flu nasal spray) contain the and shark from contaminated waters. The information known preservative thimerosal. However, there are single-dose preparations about mercury poisoning comes from unfortunate communities of flu vaccine that are mercury preservative-free. These can be that have experienced it. Example: There is a large amount of data given to young children and pregnant women. Ask your doctor for a from the Faroe Islands, near Iceland. The people there would eat thimerosal-free flu vaccine if you are concerned. whale blubber contaminated with toxic levels of methylmercury Even though thimerosal is safe, it would be ideal for all flu vaccines and polychlorinated biphenyls (PCBs). Children, especially those to be thimerosal preservative-free—this would put any concerns to exposed as fetuses during their mother’s pregnancy, seemed to have rest. However, the technology just isn’t there yet. lower scores on memory, attention, and language tests than their unexposed peers. (They were not diagnosed with autism or Attention The Institute for Vaccine Safety at Johns Hopkins University has a Deficit Disorder, however.)13 chart online that tracks any thimerosal content in vaccines: www. vaccinesafety.edu/thi-table.htm. Chronic exposure to liquid methylmercury causes Mad Hatter’s Disease, named for hat makers who used liquid mercury in the FYI: Many vaccines such as the combination measles, mumps, and hat-making process. The disease consists of psychiatric problems, rubella vaccine never used thimerosal in the production process or insomnia, poor memory, sweating, tremors, and red palms. Chronic as a preservative. mercury poisoning also impairs kidney function. Reality Check: Worried about the mercury preservative Methylmercury is a small molecule that can get into the brain—it (thimerosal) in your child’s flu vaccine? Consider this: A tuna takes almost two months to break down in the body. Ethylmercury fish sandwich has five times more mercury than a thimerosal- (the type of mercury that was previously used as a vaccine preserved flu vaccine.15 And the type of mercury (methylmercury) preservative) is a large molecule that cannot enter the brain and is found in tuna is the one that has health concerns. Also, a baby who rapidly eliminated from the body within a week. is exclusively breastfed for six months of life consumes about 0.36 mg of methylmercury from breast milk. That’s 15 times the Because of the increased number of vaccinations that children get, quantity of ethylmercury in one flu vaccine! the potential cumulative exposure to mercury became a concern in 1999. Bottom line: As a doc, I am much more concerned about your There are three federal groups that set standards for acceptable daily baby’s mercury exposure from the environment than what’s in a flu mercury exposure (the Environmental Protection Agency [EPA], shot. Here’s a look at the numbers: the Food and Drug Administration [FDA], and the Agency for Toxic Substances and Disease Registry). When the exposure was Product Amount of Mercury Type of Mercury calculated, the cumulative dose was higher than acceptable levels Tuna, 5.6 oz can 0.115 mg Methyl set by the EPA only (the other groups’ standards were higher). As a Breast milk, 1 liter 0.015 mg Methyl result of these findings, the Public Health Service (which includes Flu vaccine with thimerosal 0.025 mg Ethyl the FDA) and the American Academy of Pediatrics issued a joint statement as a precautionary measure, urging vaccine manufacturers to reduce or eliminate thimerosal in vaccines as soon as possible.14 Q: Does thimerosal cause autism? This was issued in 1999 before scientists had an opportunity to No. The Institute of Medicine reached this conclusion in 2004. What study the potential health effects of thimerosal-containing vaccines. proof do we have? Numerous studies have since shown that there is no relationship between vaccines, either with or without thimerosal, and the Thimerosal has been removed from most vaccines since 2001, but development of autism or other neurologic problems in children. the rates of autism are still skyrocketing. A 2008 survey of autism rates in California confirms that mercury is essentially out and autism rates are still going up. If thimerosal was the cause and it Q: I heard that I should still ask my doctor if the was removed from vaccines seven years ago, autism rates would vaccines for my baby are thimerosal-free. What do be going down by now. Why? Because autism spectrum disorders you suggest? are usually diagnosed by 3 years of age. By now, any reduction in autism should have been obvious if thimerosal caused the disorder.16 We think you should ask as many questions as you need to feel comfortable. Remember that since 2001, most childhood vaccines • Mercury preservatives were removed from vaccines in Denmark given to infants and children went thimerosal (mercury) preservative- in 1992. Canada and the European Union followed suit shortly free. If your doctor has a 2001 vintage vaccine vial sitting on the thereafter. However, their autism rates are going up too. shelf (which would be expired by now), he needs to re-stock. To give you some perspective, my practice buys its vaccine supply on • Mad Hatter’s Disease (mercury poisoning) and autism are very a monthly basis. different disorders (see chart in next column). Why does flu vaccine need thimerosal or any other preservative? • A study of 100,000 kids in England compared those receiving First, understand the flu vaccine is reformulated every year to reflect thimerosal-containing vaccines to those who did not. The ones who had the t-free shots had HIGHER rates of autism.17

96 Clear Answers & Smart Advice About Your Baby’s Shots page 5 of 6

• A 2007 study showed that children between 7 and 10 years of age Why is aluminum used in vaccines? Aluminum enhances the who got those mercury-containing vaccines (before 2001) have immune system’s response to the vaccine. It’s been used safely no significant differences in tests of attention and processing for several decades. By using aluminum salts, some inactivated information. Although the study did not look specifically at vaccines require fewer booster shots for the body to mount an autism, it showed that mercury preservatives did not make much adequate immune response. of an impact on brain functions in general. A follow-up study that specifically addresses autism is underway.18 Are there any health concerns with aluminum in vaccines? No. There is significantly less aluminum in vaccines than what babies are Did thimerosal cause autism? Notice the differences between autism exposed to in the environment. Both the National Vaccine Program and mercury poisoning: Office and the World Health Organization have determined that the aluminum content in the childhood vaccination series is safe. Autism Mercury Poisoning19 Does aluminum poisoning cause autism? No. People with aluminum Motor Repetitive movements Wobbly, shaky gait poisoning have bone problems (osteomalacia) and anemia, as well as Vision Normal Impaired neurologic issues. These include memory loss, fatigue, depression, Speech Delay, repetitive sounds Articulation problem behavioral changes, and learning impairment. Aluminum also has been proposed as the cause of Alzheimer’s Disease. To date, Sensory Hyper-responsive Loss of sensation however, there is little evidence that aluminum causes that disorder.21 Psychiatric Aloof, likes sameness Psychosis, depression Head size Large Small How much aluminum is in vaccines? Very little. If your baby follows the standard immunization schedule, he is exposed to about four to six milligrams (mg) of aluminum at six months of life. By comparison, he’s also exposed to 10 mg of aluminum if he is Q: Are there other additives in the vaccines? breastfed, 40 mg if he is fed cow’s milk-based formula, or 120 mg Yes. And you should know about them. if he is fed soy formula. None of these are very large amounts, by the way. To put things in perspective, there are about 200 mg of Vaccines contain the active ingredients that provide immunity. But aluminum in a standard antacid tablet. In fact, the average adult there are inactive ingredients that improve potency and prevent ingests seven to nine milligrams of aluminum every day. Here’s a contamination. Below is a list of additives and why they are there. look at how much aluminum is in breast milk/formula, compared These products are present in trace amounts and none have been with vaccines: proven harmful in animals or humans.20 • Preservatives: Prevent vaccine contamination with germs Amount of aluminum exposure (milligrams per liter)22 (bacteria, fungus). Examples: 2-phenoxyethanol, phenol, and Product Amount of aluminum thimerosal (prior to 2001). Breast milk 0.01–0.05 mg/L • Adjuvants: Improve potency/immune response. Example: Cow’s milk-based infant formula 0.06–0.15 mg/L aluminum salts. Soy-based infant formula 0.46–0.93 mg/L Prevnar vaccine 0.125 mg/dose • Additives: Prevent vaccine deterioration and sticking to the side of the vial. Examples: gelatin, albumin, sucrose, lactose, MSG, DTaP vaccine 0.17–0.625 mg/dose glycine. HIB vaccine 0.225 mg/dose Hep A vaccine 0.225–0.25 mg/dose • Residuals: Remains of vaccine production process. Examples: formaldehyde, antibiotics (Neomycin), egg protein, yeast protein. Hep B vaccine 0.25–0.5 mg/dose DTaP/IPV/HIB vaccine 1.5 mg/dose See our website (www.Baby411.com, click on “Bonus Material”) for a list of ingredients for the routine childhood vaccination series. Is it a good idea to space out vaccinations that contain aluminum salts? No. Since aluminum-containing vaccines do not cause any Q: Why is aluminum in vaccines? health risk, separating or spacing out these vaccines has no benefit. Now that the mercury (thimerosal) saga is coming to an end, anti- In fact, there is a risk to spacing out the vaccines—your baby will go vaccine crusaders have come up with a new bad guy: aluminum. unprotected against real vaccine-preventable disease. Yes, trace amounts of aluminum salts are used in some childhood vaccines. Here’s all you need to know (and more) about aluminum. Reality Check: If vaccines contain ingredients like aluminum Bottom line: We are not worried about it. or formaldehyde, wouldn’t it be better if vaccine makers got rid of these additives? Shouldn’t vaccines be “greener”? Aluminum is everywhere. It’s the most common metal in our earth’s This is a red herring argument against vaccines—current vac- crust. So it is naturally present in our water, soil, and even in the cines are safe, even with tiny/trace amounts of preservatives or air. Fruits, vegetables, nuts, flour, cereal, dairy products, and yes, additives like aluminum. And your baby is exposed to many of even baby formula and breast milk … all contain some aluminum. these ingredients every day … simply by eating or breathing. Do you wear antiperspirant? It’s in there, too. To avoid aluminum exposure, you’d have to quit wearing antiperspirant … and basically leave the planet.

97 Clear Answers & Smart Advice About Your Baby’s Shots page 6 of 6

Q: Why is formaldehyde in vaccines? Q: If I want to do a staggered vaccination schedule, Small amounts of formaldehyde are used to sterilize the vaccine fluid how should I do it? so your child doesn’t get something like flesh-eating Strep bacteria I suggest setting up a consultation with your own pediatrician to when he gets his shots. We know when you think of formaldehyde, discuss what both of you feel comfortable with doing. Remember, you think of that ever-present smell wafting from the anatomy lab in the ultimate goal is to have your child vaccinated in a timely manner. high school. But what you probably don’t know is that formaldehyde is also a naturally occurring substance in your body. And if you use Q: Didn’t the government concede that vaccines baby shampoo, paper towels or mascara, or have carpeting in your home, you’ve been exposed to formaldehyde. The small amount caused a child’s autism? used in vaccines is not a health concern.23 During the equivalent of a class action lawsuit against the government (called the “Omnibus Autism Proceedings”), one child, Hannah Poling, received a monetary settlement. The court did not Q: Is it true that anti-freeze is used in vaccines? hear her case. Hannah’s case was being reviewed to serve as one No. Antifreeze has never been a component of vaccines. Antifreeze of the test cases for a suit to represent 5,000 families who believe products commonly contain either ethylene glycol or propylene vaccines caused their child’s autism. glycol. A product with a similar name, polyethylene glycol (PEG), is used in the production process to purify vaccines. PEG is not During the review process, it was determined that Poling did not antifreeze! PEG is also found in medications, toothpastes, laxatives, represent a test case because she had a rare, underlying genetic lubricant eye drops, and various skin care creams. mitochondrial disorder that caused her deterioration and autism. For rare kids like her, any stress could have caused her to deteriorate. This is the equivalent of being born with an aneurysm, a ticking Q: Is it safer to delay vaccines or use an alternative time bomb that could go off at any moment. Although she was not vaccination schedule? diagnosed prior to being vaccinated, experts recommend that even Easy answer: No. The CDC publishes a recommended vaccine children with known mitochondrial disorders still be vaccinated. schedule for American children. Many, many doctors, scientists, and researchers work together with the CDC to decide what is the best Bottom line: The government did NOT concede that vaccines timing to give shots. The goal: Protect babies as soon as it is safe cause autism in the Poling case. and effective to do so. This schedule was not created out of thin air. Between anti-vaccine activists shouting “too many shots, too soon” Citations and Dr. Bob Sears hawking his book, new parents wonder if it would 1. Maestro S. Psychopathology. 1999;32(6):292–300. somehow be safer to wait on shots altogether or stagger them out on 2. Jamain S, et al. Nature Genetics. 2003;34:27–9. 3. Chahrour M, et al. Science. 2008;320(5880):1224–9. “Dr. Bob’s schedule.” 4. Mills JL, et al. Clinical Endocrinology. 2007;67(2):230-7. Here’s a nasty little truth about alternative vaccination schedules: 5. Fatemi SH, et al. Schizophrenia Research. 2008;99(1-3):56-70. They are all fantasy. There is absolutely no research that says 6. American Academy of Pediatrics. Immunizations. Available at www.aap.org/ delaying certain shots is safer. Dr. Bob is making up “Dr. Bob’s immunization/families/safety.html. Accessed January 4, 2012. Schedule” all by himself. He even admits that. In an interview with 7. Limperopoulos C, et al. Pediatrics. 2008; 121(4):758–65. 8. Croen LA, et al. Archives of Pediatric and Adolescent Medicine. 2007;161(4):334– iVillage, he commented, “My schedule doesn’t have any research 40. behind it. No one has ever studied a big group of kids using my 9. Cheslack-Postava K. et al. Pediatrics. 2011;127(2):246–53. schedule to determine if it’s safe or if it has any benefits.” 10. Omer SB, et al. American Journal of Epidemiology 2008; 168(12):1389–96. A 2010 study actually did evaluate children whose vaccinations were 11. Wakefield AJ, et al. Lancet. 1998;351:637–41. delayed and found absolutely no difference in their development 12. Begley S. Newsweek 2009;153(9):42–7. compared with children who had received their shots on time. I’d 13. American Academy of Pediatrics. Pediatrics 2001;108(1):197–205. much rather follow a schedule that has been extensively researched 14. Centers for Disease Control and Prevention. MMWR 1999;48:563–5. for both safety and effectiveness by experts in the field of infectious 15. Food and Drug Administration. Mercury Levels in Commercial Fish and Shellfish (1990–2010). Available at www.fda.gov/Food/FoodSafety/Product- diseases. SpecificInformation/Seafood/FoodbornePathogensContaminants/Methylmercury/ ucm115644.htm. Accessed January 4, 2012. What we do know about alternative vaccination schedules is that 16. Schechter R, et al. Archives of General Psychiatry 2008;65(1):19–24. delaying shots is playing Russian roulette with your child. The 17. Andrews N, et al. Pediatrics 2004;114(3):584–91. simple truth is that you are leaving your child unprotected, at a time 18. Thompson WW, et al. New England Journal of Medicine. 2007;357:1281–92. when she is the most vulnerable. 19. Nelson K. Pediatrics 2003;111(3):674–9. We realize that parents who choose to delay or opt out on vaccines 20. Offit P. Pediatrics 2003;112(6):1394–1401. are not bad parents. They are scared parents. What we are trying to 21. Verreault R, et al. Canadian Medical Association Journal 2001;165(11):1495–8. 22. The Children’s Hospital of Philadelphia,Vaccine Education Center, available at help you realize is that the fear you should have is for the diseases www.vaccine.chop.edu/service/vaccine-education-center/hot-topics/aluminum. that vaccines prevent. If you are on the fence about vaccinations, html. Accessed on January 4, 2012. please take the time to research the disease—and talk to your child’s 23. Food and Drug Administration, HHS, Common Ingredients in U.S. Licensed doctor. Vaccines. Available at www.fda.gov/BiologicsBloodVaccines/SafetyAvailability/ VaccineSafety/ucm187810.htm. Accessed on January 4, 2012.

98 Need help responding to vaccine-hesitant parents? Science-based materials are available from these respected organizations

American Academy of Pediatrics (AAP) from the popular book “Baby 411” by Dr. Ari Brown. Healthcare providers can find numerous resources on the AAP’s web- www.immunize.org/catg.d/p2068.pdf site to help with parents and caregivers who have questions about vac- • “Decision to Not Vaccinate My Child” cinating their child at www2.aap.org/immunization/families/deciding. www.immunize.org/catg.d/p4059.pdf html. When parents cannot be convinced, consider using AAP’s Re- fusal to Vaccinate form at www2.aap.org/immunization/pediatricians/ • “Reliable Sources of Immunization Information: Where to go to pdf/RefusaltoVaccinate.pdf. find answers!” www.immunize.org/catg.d/p4012.pdf • “Vaccines Work!” www.immunize.org/catg.d/p4037.pdf California Immunization Coalition The California Immunization Coalition (CIC) has developed several Institute for Vaccine Safety, Johns Hopkins University excellent provider pieces that discuss common questions many parents The Institute for Vaccine Safety collects vaccine-specific safety in- may have regarding vaccines for their children. These include formation. Of particular interest is its “Components of Vaccines” section, which contains tables specifying the contents of various • “Responding to Parents’ Top 10 Concerns” vaccines: www.vaccinesafety.edu/components.htm. www.cdph.ca.gov/programs/immunize/Documents/IMM-917.pdf • “Talking with Parents About Vaccine Safety” Vaccine Education Center (VEC) www.cdph.ca.gov/programs/immunize/Documents/IMM-915.pdf Children’s Hospital of Philadelphia • “Alternate Vaccine Schedules: Helping Parents Separate Fact From VEC offers handouts in English and Spanish as well as four colorful Fear” http://eziz.org/assets/docs/IMM-988.pdf booklets covering immunization of infants, teens, and adults, as well as one about vaccine safety. These educational materials can Centers for Disease Control and Prevention (CDC) be downloaded at www.chop.edu/service/vaccine-education-center/ Among CDC’s many online immunization resources is the “Parent’s Guide order-educational-materials/order-educational-materials.html. VEC to Childhood Immunization,” a 64-page booklet that can be ordered or print- has developed a number of patient handouts covering vaccine topics ed at www.cdc.gov/vaccines/pubs/parents-guide. In addition, visit CDC’s of interest. These include the following “Provider Resources for Vaccine Conversations with Parents” web section at www.cdc.gov/vaccines/hcp/patient-ed/conversations/index.html • “Too Many Vaccines? What you should know” at: www.chop.edu/ export/download/pdfs/articles/vaccine-education-center/too-many- Other CDC materials, designed to help healthcare providers work with vaccines.pdf hesitant parents, include the following: • “Vaccine Ingredients: What you should know” at: www.chop.edu/ • “If You Choose Not to Vaccinate Your Child, Understand the export/download/pdfs/articles/vaccine-education-center/vaccine- Risks and Responsibilities” www.cdc.gov/vaccines/hcp/patient-ed/conversations/downloads/not- ingredients.pdf vacc-risks-color-office.pdf For parents with concerns about vaccines • “Infant Immunizations FAQs” www.cdc.gov/vaccines/parents/parent-questions.html and autism AAP has issued a statement that can be printed at www2.aap. • “Talking with Parents about Vaccines for Infants” org/advocacy/releases/autismparentfacts.htm. Parents may www.cdc.gov/vaccines/hcp/patient-ed/conversations/downloads/ wish to investigate further at www.healthychildren.org/English/ talk-infants-color-office.pdf health-issues/conditions/developmental-disabilities/Pages/Autism- Spectrum-Disorders.aspx. IAC also recommends these books: Every Child by Two (ECBT) • Autism’s False Prophets: Bad Science, Risky Medicine, and the Created by Every Child by Two, www.vaccinateyourbaby.org focuses Search for a Cure, by Paul A. Offit, MD on answering parents’ commonly asked questions about vaccines. It • Unstrange Minds: Remapping the World of Autism, by Roy features video clips and links to current vaccine news stories. Richard Grinker, PhD Immunization Action Coalition (IAC) And, here are three well-researched handouts from IAC and one from VEC: IAC’s Talking about Vaccines web section provides healthcare professionals with top vaccination resources from trusted sources such • “MMR Vaccine Does Not Cause Autism: Examine the Evi- dence!” as CDC, AAP, IAC, VEC, and many more. Visit www.immunize. www.immunize.org/catg.d/p4026.pdf org/concerns. Refer parents to IAC’s website for the public at www. vaccineinformation.org • “Evidence shows vaccines unrelated to autism” www.immunize.org/catg.d/p4028.pdf IAC has developed several patient handouts for vaccine-hesitant parents. •“Vaccines and Autism: What you should know” These include: www.chop.edu/export/download/pdfs/articles/vaccine- • “Clear Answers & Smart Advice About Your Baby’s Shots,” an excerpt education-center/autism.pdf

Technical content reviewed by the Centers for Disease Control and Prevention www.immunize.org/catg.d/p2070.pdf • Item #P2070 (1/14)

Immunization Action Coalition • 1573 Selby Ave. • St. Paul, MN 55104 • (651) 647-9009 • www.vaccineinformation.org • www.immunize.org 99

VACCINES THROUGH THE LIFESPAN

Pregnancy & Postpartum Catchup

Hep B Birth Dose

Children/Tweens/Teens

Adults/Seniors/Medical Conditions

Vaccinations for Pregnant Women The table below shows which vaccinations you should have to protect your health when you are pregnant. Make sure you and your healthcare provider keep your vaccinations up to date.

Vaccine Do you need it during your pregnancy?

Hepatitis A Maybe. You need this vaccine if you have a specific risk factor for hepatitis A virus infection* or simply want (HepA) to be protected from this disease. The vaccine is usually given in 2 doses, 6 months apart. It’s safe to get this vaccine during pregnancy.

Hepatitis B Maybe. You need this vaccine if you have a specific risk factor for hepatitis B virus infection* or simply want (HepB) to be protected from this disease. The vaccine is usually given in 3 doses, over a 6-month period. It’s safe to get this vaccine during pregnancy. It’s important, too, that your newborn baby gets started on his or her hepatitis B vaccination series before leaving the hospital.

Hib (Haemophilus Maybe. Some adults with certain high-risk conditions need vaccination with Hib vaccine.* influenzaetype b)

Human No. This vaccine is not recommended to be given during pregnancy, but if you inadvertently receive it, this papil­loma­virus is not a cause for concern. HPV vaccine is recommended for all women age 26 years or younger, so make (HPV) sure you are vaccinated before or after your pregnancy. The vaccine is given in 3 doses over a 6-month period.

Influenza Yes! You need a flu shot every fall (or winter) for your protection and for the protection of your baby and others around you. It’s safe to get the vaccine at any time during your pregnancy.

Measles, mumps, No. The MMR vaccine is not recommended to be given during pregnancy, but if you inadvertently receive rubella (MMR) it, this is not a cause for concern. At least 1 dose of MMR vaccine is recommended for you if you were born in 1957 or later. (And you may need a second dose.*) It’s best for you (and any future baby) to receive the protection vaccination provides before trying to conceive.

Meningococcal Maybe. You need this vaccine if you have one of several health conditions, or if you are 19–21 and a first- (MCV4, MPSV4) year college student living in a residence hall and you either have never been vaccinated or were vaccinated before age 16.* It’s safe to get the vaccine during pregnancy.

Pneumococcal Maybe. You need 1 or both of these vaccines if you have a certain risk factor for pneumococcal disease, (PCV13 [conju- such as diabetes. If you’re unsure of your risk, talk to your healthcare provider to find out if you need this vac- gate vaccine]; cine.* It’s safe to get the vaccine during pregnancy. PPSV23 [polysac- charide vaccine]) Tetanus, diphthe- Yes! Women who are pregnant need a dose of Tdap vaccine (adult whooping cough vaccine) during each ria, & whooping pregnancy, preferably during the third trimester. After that, you’ll need a Td booster dose every 10 years. cough (pertussis) Talk to your healthcare provider if you haven’t had at least 3 tetanus- and diphtheria-containing shots some- (Tdap, Td) time in your life or if you have a deep or dirty wound.

Varicella No.* Varicella vaccine is not recommended to be given during pregnancy, but if you inadvertently receive it, (chickenpox) this is not a cause for concern. If you haven’t been vaccinated or had chickenpox, it’s best for you (and any (VAR) future baby) to be protected with the vaccine before trying to conceive, or after you’ve completed your preg- nancy. The vaccine is given in 2 doses 4–8 weeks apart.

* Consult your healthcare provider to Are you planning to travel outside the United States? If so, you may need additional vaccines. The Centers determine your level of risk for infection for Disease Control and Prevention (CDC) provides information to assist travelers and their healthcare and your need for this vaccine. providers in deciding which vaccines, medications, and other measures are necessary to prevent illness  and injury during international travel. Visit CDC’s website at wwwnc.cdc.gov/travel/destinations/list, or call 800-CDC-INFO (800-232-4636). You may also consult a travel clinic or your healthcare provider.

Technical content reviewed by the Centers for Disease Control and Prevention Saint Paul, Minnesota • 651-647-9009 www.immunize.org • www.vaccineinformation.org

www.immunize.org/catg.d/p4040.pdf • Item #P4040 (4/15) Provide the best prenatal care to prevent pertussis

Strategies for healthcare professionals

5 Facts about Tdap and Pregnancy 1. Tdap during pregnancy provides the best protection for mother and infant. • Recommend and administer or refer your patients to receive Tdap during every pregnancy. • Optimal timing is between 27 and 36 weeks gestation to maximize the maternal antibody response and passive antibody transfer to the infant. • Fewer babies will be hospitalized for and die from pertussis when Tdap is given during pregnancy rather than during the postpartum period.

2. Postpartum Tdap administration is NOT optimal. • Postpartum Tdap administration does not provide immunity to the infant, who is most vulnerable to the disease’s serious complications. Pertussis is on the rise and outbreaks • Infants remain at risk of contracting pertussis from others, including are happening across the United States. siblings, grandparents, and other caregivers. In recent years, up to 1,450 infants have • It takes about 2 weeks after Tdap receipt for the mother to have been hospitalized and about 10 to 20 have protection against pertussis, which means the mother is still at risk died each year in the United States due to for catching and spreading the disease to her newborn during this pertussis. Most of these deaths are among time. infants who are too young to be protected by the childhood pertussis vaccine series 3. Cocooning alone may not be effective and is hard to implement. that starts when infants are 2 months old. • The term “cocooning” means vaccinating anyone who comes in close contact with an infant. These first few months of life are when • It is difficult and can be costly to make sure that everyone who is infants are at greatest risk of contracting around an infant is vaccinated. pertussis and having severe, potentially life-threatening complications from the 4. Tdap should NOT be offered as part of routine infection. To help protect babies during preconception care. this time when they are most vulnerable, • Protection from pertussis vaccines does not last as long as vaccine women should get the tetanus toxoid, experts would like, so Tdap is recommended during pregnancy in reduced diphtheria toxoid, and acellular order to provide optimal protection to the infant. pertussis (Tdap) vaccine during each • If Tdap is administered at a preconception visit, it should be pregnancy. A strong recommendation from administered again during pregnancy between 27 and 36 weeks you may ultimately be what most influences gestation. whether or not your patients’ newborns are 5. Tdap can be safely administered earlier in pregnancy protected against pertussis. if needed. • Pregnant women should receive Tdap anytime during pregnancy if it is indicated for wound care or during a community pertussis Strongly recommend Tdap to your outbreak. patients during the 3rd trimester • If Tdap is administered earlier in pregnancy, it should not be of each pregnancy. repeated between 27 and 36 weeks gestation; only one dose is recommended during each pregnancy.

February, 2015 Get Free Materials Resources about for Your Patients Tdap and Pregnancy The following resources help for Healthcare Professionals explain the importance of and health benefits behind Get Reimbursed for Tdap Vaccination the Tdap recommendation. They are free to download Coding and billing are known barriers to administering and ready for color or black vaccines during pregnancy. Correct coding enables an and white printing and office to report these activities to third-party payers and reproduction. English and receive appropriate reimbursement for these services. Spanish language versions are available. • ACOG’s Tdap Toolkit provides coding and billing information for Tdap: www.acog.org/TdapToolKit Posters/Print Ads

Mamá Get Vaccine Referral Tips tú siempre protegerás a Getting your tu pequeño whooping milagro. cough vaccine in your 3rd Empieza Not all clinicians are able to stock and administer Tdap trimester... ahora con tu vacuna helps protect contra la or influenza vaccines in their office. your baby tosferina. from the start.

La tosferina (whooping cough) puede enfermar a los bebés y provocarles ataques de tos y Making a strong dificultad para respirar. Cuando te vacunas contra la tosferina durante el tercer trimestre de vaccine referral Outbreaks of whooping cough are happening across the United States. This disease can cause your baby embarazo, le transmitirás a tu bebé los anticuerpos que lo protegerán de esta enfermedad desde to pregnant women to have coughing fits, gasp for air, and turn blue from lack of oxygen. It can even be deadly. When you get the su nacimiento. Estos anticuerpos durarán hasta que reciba su propia vacuna contra la tosferina, • Making a Strong Vaccine Referral to whooping cough vaccine (also called Tdap) during your third trimester, you’ll pass antibodies to your baby. la cual solo se le puede aplicar cuando cumpla 2 meses de edad. This will help keep him protected during his first few months of life, when he is most vulnerable to serious Strategies for healthcare professionals disease and complications. Habla con tu médico o partera sobre la vacuna contra la tosferina (también conocida como la vacuna DPT o Tdap, en inglés). Making the Referral Talk to your doctor or midwife about the whooping cough vaccine.

Begin each referral with a vaccine recommendation that includes information on why the vaccine is beneficial and safe for mother and baby. Pregnant Women fact sheet offers tips Tailoring your message with scientific data or Born with protection against whooping cough. Haz que tu bebé nazca protegido contra la tosferina. personal anecdotes may help convey the vaccine’s importance to individual patients. www.cdc.gov/whoopingcough www.cdc.gov/espanol/tosferina Provide information on where patients can get the vaccine(s) you recommend. For help locating vaccines in your area, the HealthMap Vaccine Finder is available at: http://vaccine.healthmap.org. to increase patient follow through for Always write a patient-specific prescription. This will help your patients obtain the vaccine at another location where a prescription may be required.

Anticipate questions on why patients cannot get vaccinated in your office. For example, if you stock flu vaccine, but not Tdap, be prepared to explain why you offer one vaccine but not the other. referrals: Re-emphasize vaccine importance. Remember to emphasize the fact that just because you do not Stocking and administering vaccines in your office may stock a specific vaccine in your office does not English Spanish not be feasible for all prenatal healthcare professionals, mean it is not important, is less important than other often due to issues with reimbursement. By making a vaccines you do stock, or that you have concerns strong vaccine referral, you can help ensure that your about its safety. pregnant patients receive the recommended influenza (flu) and tetanus toxoid, reduced diphtheria toxoid, and Have a plan in place to answer questions from acellular pertussis (Tdap) vaccines even if you are unable other immunization providers who are concerned with vaccinating your pregnant patients. Questions www.cdc.gov/pertussis/pregnant/hcp to administer them in your office. The strategies outlined are based on research with healthcare professionals should be answered promptly, as it is likely your and pregnant women. The goal is to strengthen vaccine patient is with them at the time they contact you. referrals to increase the likelihood of patient follow through.

Vaccines Routinely Recommended for Pregnant Women It is safe for the flu vaccine and Tdap vaccine to be given to pregnant patients at the same time.

Flu Vaccine Tdap Vaccine • Is recommended for pregnant women and safe to • Is recommended during every pregnancy, ideally administer during any trimester. between 27 and 36 weeks gestation. • Is the best way to protect pregnant women and their • When given during pregnancy, boosts antibodies in babies from the flu, and prevent possible the mother, which are transplacentally transferred flu-associated pregnancy complications. to her unborn baby. Third trimester administration optimizes neonatal antibody levels. • Is safe and can help protect the baby from flu for up to 6 months after birth. This is important because • Helps protect infants, who are at greatest risk for babies younger than 6 months of age are too young developing pertussis and its life-threatening to get a flu vaccine. complications, until they are old enough to start the childhood pertussis vaccine series. Q&A Fact Sheet

You can start protecting your baby from whooping cough before birth Information for pregnant women You can start When you get the whooping cough vaccine during your 3rd trimester, your baby will be born with protection against whooping cough. protecting your baby Read the Current Recommendations Why do I need to get a whooping cough vaccine while I am pregnant? The whooping cough vaccine is recommended during your third trimester so that your body can create antibodies and pass them to your baby before birth. These antibodies will help protect your newborn right after birth and until your baby gets his own first whooping cough vaccine at 2 months of age. from whooping During the first few months of life, your baby is most vulnerable to serious complications from this disease.

Is this vaccine safe for me and my baby? Yes. The whooping cough vaccine is very safe for you and your baby. The most common side effects are mild, like redness, swelling or pain where the shot is given in the arm. This cough before birth should go away within a few days. You cannot get whooping cough from the vaccine. The vaccine does not contain any live Advisory Committee on Immunization Practices: bacteria. Doctors and midwives who specialize in caring for pregnant women agree that the whooping cough vaccine is safe and important to get during the third trimester of each pregnancy. Getting the vaccine during pregnancy does not put you at increased risk for pregnancy complications like low birth Whooping cough (sometimes called pertussis) weight or preterm delivery. www.cdc.gov/mmwr/preview/mmwrhtml/mm6207a4.htm is a serious disease that can cause babies to stop If I recently got this vaccine, why do I need to get breathing. Unfortunately, babies must be 2 months it again? old before they can start getting their whooping The amount of antibodies in your body is highest about 2 weeks after getting the vaccine, but then starts to decrease cough vaccine. The good news is you can avoid over time. That is why the vaccine is recommended during this gap in protection by getting the whooping every pregnancy — so that each of your babies gets the greatest number of protective antibodies from you and the cough vaccine (also called the Tdap shot because it best protection possible against this disease. protects against tetanus, diphtheria, and pertussis) Are babies even getting whooping cough anymore in your third trimester, preferably between your in the United States? th th 27 and 36 week of pregnancy. By getting Yes. In fact, babies are at greatest risk for getting whooping cough. vaccinated, you will pass antibodies to your baby We used to think of this as a disease of the past, but it’s making a comeback. Recently, we saw the most cases we had seen in 60 so she is born with protection against whooping years. Since 2010, we see between 10,000 and 50,000 cases of cough. whooping cough each year in the United States. Cases, which American College of Obstetricians and Gynecologists: include people of all ages, are reported in every state. www.acog.org/TdapCommitteeOpinion www.cdc.gov/whoopingcough American College of Nurse-Midwives: http://www.midwife.org/Immunization-in-Pregnancy- Informational Article for and-Postpartum Patient Newsletters Stay up to date on the studies that support the safe and and Websites effective use of the Tdap vaccine in pregnant women at Record High Cases www.cdc.gov/pertussis/pregnant/research.html of Whooping Cough: Vaccinate to Protect

www.cdc.gov/whoopingcough You can start protecting your baby from whooping cough before birth Information for pregnant women

When you get the whooping cough vaccine during your 3rd trimester, your baby will be born with protection against whooping cough.

Why do I need to get a whooping cough vaccine while I am pregnant? The whooping cough vaccine is recommended during your third trimester so that your body can create antibodies and pass them to your baby before birth. These antibodies will help protect your newborn right after birth and until your baby gets his own first whooping cough vaccine at 2 months of age. During the first few months of life, your baby is most vulnerable to serious complications from this disease.

Is this vaccine safe for me and my baby? Yes. The whooping cough vaccine is very safe for you and your baby. The most common side effects are mild, like redness, swelling or pain where the shot is given in the arm. This should go away within a few days. You cannot get whooping cough from the vaccine. The vaccine does not contain any live bacteria.

Doctors and midwives who specialize in caring for pregnant women agree that the whooping cough vaccine is safe and important to get during the third trimester of each pregnancy. Getting the vaccine during pregnancy does not put you at increased risk for pregnancy complications like low birth Whooping cough (sometimes called pertussis) weight or preterm delivery. is a serious disease that can cause babies to stop If I recently got this vaccine, why do I need to get breathing. Unfortunately, babies must be 2 months it again? old before they can start getting their whooping The amount of antibodies in your body is highest about 2 weeks after getting the vaccine, but then starts to decrease cough vaccine. The good news is you can avoid over time. That is why the vaccine is recommended during this gap in protection by getting the whooping every pregnancy — so that each of your babies gets the greatest number of protective antibodies from you and the cough vaccine (also called the Tdap shot because it best protection possible against this disease. protects against tetanus, diphtheria, and pertussis) Are babies even getting whooping cough anymore in your third trimester, preferably between your in the United States? th th 27 and 36 week of pregnancy. By getting Yes. In fact, babies are at greatest risk for getting whooping cough. vaccinated, you will pass antibodies to your baby We used to think of this as a disease of the past, but it’s making a comeback. Recently, we saw the most cases we had seen in 60 so she is born with protection against whooping years. Since 2010, we see between 10,000 and 50,000 cases of cough. whooping cough each year in the United States. Cases, which include people of all ages, are reported in every state.

www.cdc.gov/whoopingcough

February 2015 Mom, only you can provide your newborn baby with the best protection possible against whooping cough.

You may have heard that your baby’s father, grandparents, and others who will be in contact with your baby will need to get their whooping cough vaccine as well. This strategy of surrounding babies with protection against whooping cough is called “cocooning.” However, cocooning might not be enough to prevent whooping cough illness and death. This is because cocooning does not provide any direct protection (antibodies) to your baby, and it can be difficult to make sureeveryone who is around your baby has gotten their whooping cough vaccine. Since cocooning does not completely protect babies from whooping cough, it is even more important that you get the vaccine while you are pregnant.

How dangerous is whooping cough for babies?

Whooping cough is very serious for babies. Many babies with whooping cough don’t cough at all. Instead it can cause them Where can I go for more information? to stop breathing. About half of babies younger than 1 year old who get whooping cough are hospitalized. Since 2010, about Pregnancy and Whooping Cough website: 10 to 20 babies die from whooping cough each year in the www.cdc.gov/pertussis/pregnant United States. Most whooping cough deaths are among babies who are too young to be protected by their own vaccination. Immunization for Women website: How could my baby be exposed to whooping cough? www.immunizationforwomen.org/ Whooping cough spreads from person to person when immunization_facts/vaccine-preventable_ coughing or sneezing or when spending a lot of time near one another where you share breathing space, like when you hold diseases/pertussis your newborn on your chest. Some people with whooping cough may just have a mild cough or what seems like a Vaccines during Pregnancy website: common cold. Since symptoms can vary, children and adults www.midwife.org/omot-vaccines-during- may not know they have whooping cough and can end up pregnancy spreading it to babies they are in close contact with.

Why is the vaccine recommended during pregnancy American Academy of Family Physicians instead of in the hospital after my baby is born? website: When you get the whooping cough vaccine during pregnancy, www.aafp.org/patient-care/immunizations/ you will pass protective antibodies to your baby before birth, so both you and your baby have protection. disease-population.html The whooping cough vaccine used to be recommended for Tdap Vaccine Information Statement (VIS): women to get in the hospital after giving birth. This helped www.cdc.gov/vaccines/hcp/vis/vis- prevent moms from getting whooping cough and passing it on to their babies. Unfortunately, the babies did not benefit from statements/tdap.html the protective antibodies and could still get whooping cough from others. Is it safe to breastfeed after getting the whooping cough vaccine? Yes, in fact you can pass some whooping cough protection Ask your doctor or midwife to your baby by breastfeeding. When you get a whooping cough vaccine during your pregnancy, you will have protective about getting the antibodies in your breast milk that you can share with your baby as soon as your milk comes in. However, your baby will not get whooping cough vaccine protective antibodies immediately if you wait to get a whooping during your 3rd trimester. cough vaccine until after you give birth. This is because it takes about 2 weeks after getting vaccinated before your body develops antibodies. Pregnant Women Need a Flu Shot

Flu vaccine comes in two Influenza (the flu) is a serious illness, especially when you are pregnant. forms: an injectable form (the flu shot) and a nasal spray. FACT: The flu can cause serious illness in pregnant women. The nasal spray (or LAIV) flu Getting the flu can cause serious problems when you are pregnant. Even if you are generally vaccine is not recommended healthy, changes in immune, heart, and lung functions during pregnancy make you more for pregnant women. likely to get seriously ill from the flu. Pregnant women who get the flu are at higher risk of hospitalization, and even death, than non-pregnant women. Severe illness in the pregnant mother can also be dangerous to her fetus because it increases the chance for serious Pregnant women should problems such as premature labor and delivery. receive the flu shot. The nasal spray is for use in healthy The flu shot is the best protection for you – and your baby. people 2-49 years of age who are not pregnant. FACT: Getting a flu shot is the first and most important step in protecting yourself against the flu. Women who are not pregnant When you get your flu shot, your body starts to make antibodies that help protect you against but are breastfeeding may the flu. Antibodies can be passed on to your unborn baby, and help protect the baby for up to 6 receive the nasal spray months after he or she is born. This is important because babies younger than 6 months of age flu vaccine. are too young to get a flu vaccine. If you breastfeed your infant, antibodies may also be passed in breast milk.

It takes about two weeks to make antibodies after getting flu vaccine. Talk to your doctor, nurse, or clinic about getting vaccinated as soon as you can.

The flu shot is safe for you and for your unborn child.

FACT: The flu shot is safe for pregnant and breastfeeding women and their infants. You can receive the flu shot at any time, during any trimester, while you are pregnant. Millions of flu shots have been given to pregnant women over many years. Flu shots have not been shown to cause harm to pregnant women or their infants.

If you have your baby before getting your flu shot, you still need to get vaccinated. The flu is spread from person to person. You, or others who care for your baby, may get the flu, and pass it to the baby. Because babies younger than 6 months are too young to receive the vaccine, it is important that everyone who cares for your baby get a flu vaccine, including other household members, relatives, and babysitters.

FACT: The side effects of the flu vaccine are mild when compared to the disease itself. After getting your flu shot, you may experience some mild side effects. The most common side effects include soreness, tenderness, redness and/or swelling where the shot was given. Sometimes you might have headache, muscle aches, fever, and nausea or feel tired.

National Center for Immunization and Respiratory Diseases Office of Director

CS243986 Even healthy pregnant women can get the flu and have serious complications – know the signs and symptoms of flu.

FACT: If you have symptoms of the flu, call your doctor immediately. If you have flu-like symptoms--even if you have already had a flu shot--call your doctor, nurse, or clinic right away. Doctors can prescribe medicine to treat the flu and lessen the chance of serious illness. These medicines must be started as soon as possible. If you have any or all of the following symptoms, contact your doctor or nurse immediately: ƒƒ Fever ƒƒ Cough ƒƒ Sore Throat ƒƒ Headache ƒƒ Body aches ƒƒ Runny or stuffy nose ƒƒ Vomiting ƒƒ Diarrhea

Having a fever from flu, or any other infection early in pregnancy, increases the chance of having a baby with birth defects or other problems. Fever can be brought down with Tylenol® (acetaminophen), but you should still call your doctor or nurse.

If you have any of the following signs, call 911 and seek emergency medical care right away: ƒƒ Problems breathing or shortness of breath ƒƒ Pain or pressure in the chest or abdomen ƒƒ Sudden dizziness or confusion ƒƒ Severe or constant vomiting ƒƒ Decreased or no movement of your baby ƒƒ High fever that is not responding to Tylenol® or other acetaminophen

Because you are pregnant, you are recommended to get the flu shot to protect yourself and your baby from the flu. Talk to your health care provider about getting a flu shot. For more information about the flu or the vaccine, call 1-800-CDC-INFO or visit http://www.cdc.gov/flu/.

Page 2 of 2 Give birth to the end of Hep B from the immunization action coalition

Nearly one in three U.S. newborns leaves the To comply with the national standard of care from CDC hospital unprotected from life-threatening and to meet the quality measure of the National Quality hepatitis B infection. As a result, approxi mately Forum, birthing institutions should: 800 U.S. newborns are chronically infected 1. Implement the recommended “universal HepB vaccine each year through perinatal exposure. birth dose policy,” by way of a standard newborn admission order. This ensures that every infant receives HepB vaccine at birth, no later than discharge from A birth dose of HepB vaccine can prevent perinatal the birth unit. transmission – yet today, only 70% of U.S. infants receive the vaccine within three days of birth. That’s why the 2. Follow national recommendations for prophylaxis Immunization Action Coalition (I AC) is urging hospitals of infants born to women who are HBsAg positive or and birthing centers to meet the national standard of care whose HBsAg status is unknown. by providing a universal birth dose of HepB vaccine. 3. Measure and report the percentage of newborns who receive HepB vaccination before discharge. Why should we give HepB vaccine to all newborns? The HepB birth dose is recommended by the: • American Academy of Family Physicians (AAFP) • It prevents mother-to-infant transmission • American Academy of Pediatrics (AAP) Prevents 70%–95% of transmission to infants born to • American College of Obstetricians and Gynecologists HBsAg-positive women (ACOG) • It prevents household transmission • Centers for Disease Control and Prevention (CDC) Protects infants from infected family members and CDC’s complete hepatitis B birth dose recommendations other caregivers are found at www.cdc.gov/mmwr/PDF/rr/rr5416.pdf • It provides protection if medical errors occur Provides a safety net to prevent perinatal transmission when medical errors occur IAC’s complete guide H Why is a safety net needed? epatitis B: Wh Hepatitis B: What Hospitals at Hospita Because medical errors happen! t ls Need to o Protect Do Need to Do to Protect Newborns Newborns Reported medical errors include: *is a complete resource to help • Ordering the wrong hepatitis B screening test birthing institutions establish, implement, and optimize their • Misinterpreting or mistranscribing hepatitis B test birth dose policies.

   results Im muniz ation Actio n Coalition    Am Endorsed by AAFP, AAP, erican Aca d emy of Fam American ily Physicia Academy ns of Ped all Ame iatrics images: i • rican stockpho Coll to.c ege of Obs om Failing to communicate results to or within the hospital Centers tetricians a for Diseas nd Gyneco e Control a logists ACOG, and CDC, IAC’s e-book nd Preven tion • Not giving hepatitis B vaccine to infants born to mothers breaks new ground as a policy of unknown HBsAg status within 12 hours of birth and best practice guide for newborn hepatitis B immunization. • Not giving prophylaxis to an infant even when the mother’s HBsAg-positive status is documented *Download the guide at www.immunize.org/protect-newborns Two More Infants Chronically Infected with Hepatitis B Virus . . . the Medical Errors Continue

Approximately 25,000 women with chronic hepatitis B virus Case #2 (HBV) infection give birth in the United States each year. Al- This case occurred in August 2001, in a different hospital and city. though 85%–95% of perinatal HBV infections can be prevented The mother was also of Asian descent (Indonesian) and had tested by post-exposure prophylaxis (hepatitis B vaccine and hepatitis positive for HBsAg midway through her pregnancy. The HBsAg B immune globulin) given within 12 hours of birth, many high- lab result was recorded on the prenatal record, which was sent to the risk newborns (infants of HBsAg-positive mothers) don’t receive hospital. The hospital staff also recorded the HBsAg-positive test this recommended postexposure prophylaxis, or even hepatitis result on the hospital’s obstetrical evaluation sheet. It was not acted B vaccine alone which will prevent 70%–95% of perinatal HBV upon by either the delivering physician or the labor and delivery infections. staff, nor was the mother’s HBsAg-positive test result communi- Unfortunately, children who become infected when they are cated to or noted by the newborn nursery. The hospital did not have younger than one year of age have a 90% chance of developing a policy in place to address management of babies born to HBsAg- chronic hepatitis B virus infection with all its serious potential positive mothers or to mothers of unknown status. The infant sequelae, including an up to 25% risk of death from cirrhosis or received neither HBIG nor hepatitis B vaccine at birth. In fact, liver cancer later in life. the high-risk infant did not receive the first dose of hepatitis B vaccine until two months of age. Unfortunately, this child has also The following two cases from Colorado illustrate how easily tested HBsAg positive. unprotected babies can become chronically infected children. In reviewing the case, a staff member at the state health depart- Case #1 ment acknowledges that the baby should have been followed more The first case occurred in December 1999. The mother was of closely. Part of the problem was that the health department field Hmong ethnicity, born in Thailand. She had been diagnosed with investigator didn’t contact the hospital before the birth to ensure chronic HBV infection in 1994 during her first pregnancy; this appropriate care would take place. Additionally, after the birth, the pregnancy was her third. In her prenatal record she was docu- hospital sent the state an inaccurate report, stating that the child mented to be HBsAg and HBeAg positive, and this information had received prophylaxis in the hospital. The investigator did not appeared in several places on the record that was sent to the hospi- review the hospital record or call the physician to verify that the tal. Despite this, her baby did not receive HBIG or the first dose of information was accurate. hepatitis B vaccine in the hospital. As a matter of fact, the hepatitis Such errors are not unique to Colorado. The Immunization Action B vaccine order was crossed out in the newborn’s chart. Follow- Coalition (IAC) surveyed state and local hepatitis B coordina- up with the pediatrician at six days of age indicated that the baby tors about perinatal hepatitis B practices in 2001 and again in still had not received any prophylaxis. The first dose of vaccine 2002. The coordinators’ responses contain hundreds of examples was given when the infant was three weeks of age, the second of children who were unprotected or inadequately protected be- three months after the first, and the third six months after the first. cause health professionals, clinic staff, or hospital staff failed to Upon contacting the hospital where the baby was delivered to de- order or misordered the hepatitis B blood test or misinterpreted, termine why HBIG and hepatitis B vaccine were not given within mistranscribed, or miscommunicated the test results of the infants’ 12 hours of birth, the state health department representative was mothers. To read the survey results, visit www.immunize.org/ told that it was unclear how this baby was missed and perhaps it birthdose/birthdosesurvey.asp. was because the hospital had no hepatitis B vaccine at the time In summary, don’t let infants go unprotected against hepa- of delivery. They indicated that the infant was to receive the first dose of vaccine at the pediatrician’s office. However, this did not titis B virus infection because of avoidable human errors. happen until the baby was three weeks of age, and only after the Give every infant a dose of hepatitis B vaccine no later office was contacted by the state health department to request that than hospital discharge. It’s the safety net that will protect it be done. The child’s current status is unfortunate. Diagnosed all newborns. HBsAg-positive at 19 months of age, the child is being followed by a liver specialist for chronic HBV infection.

www.immunize.org/catg.d/p2127.pdf • Item #P2127 (9/12)

Immunization Action Coalition • 1573 Selby Ave. • St. Paul, MN 55104 • (651) 647-9009 • www.vaccineinformation.org • www.immunize.org Testing for Hepatitis B Virus Infection During Pregnancy Flowchart for Prenatal Providers

• Routinely test all women in every pregnancy for hepatitis B surface antigen (HBsAg) • Test in the first trimester, if possible • Test regardless of past testing status

HBsAg HBsAg Maternal • HBsAg results

• Report HBsAg positive test results to public health HBV department perinatal hepatitis B coordinator Yes risk factor No • Provide a copy of lab report indicating woman’s present? HBsAg status to the hospital where delivery is planned • Start HepB vaccine series Risk Factors: • Attach alert notice to woman’s medical record to remind • ≥ 2 sex partners delivery hospital that newborn needs HepB and HBIG in previous 6 months • Retest for HBsAg prior to delivery • STD vaccine within 12 hours of birth at least 30 days after most recent • Injection drug use • Instruct delivery hospital to place a copy of lab report in vaccine dose • HBsAg+ partner infant’s chart Per ACIP recommendations • Clinical hepatitis • Notify pediatric provider (if known) Recommended Follow-up HBsAg HBsAg Maternal • Provide woman with a card noting her HBsAg status HBsAg • Refer woman to a medical specialist for evaluation of results chronic hepatitis B • Educate woman about need to test all contacts (household, sexual, and/or needle sharing) • Provide a copy of lab report indicating woman’s HBsAg • Educate woman about importance of completing infant’s status to hospital where delivery is planned vaccine series • Educate pregnant woman about importance of vaccine birth dose

Resources available at www.CDC.gov/hepatitis/perinatalHepB Prenatal Care Provider Policies and Procedures to Prevent Perinatal Hepatitis B Virus Transmission

Prenatal care providers should test every woman for hepatitis B surface antigen (HBsAg) during an early prenatal visit (e.g., in the first trimester), even if a woman has been previously vaccinated or tested.

In addition, prenatal care settings should incorporate each of the following actions into their policies and protocols:

For a pregnant woman with a positive HBsAg test result • Report the positive test result to the health department. • Provide a copy of the original laboratory report indicating the pregnant woman’s HBsAg status to the hospital where the delivery is planned and to the health-care provider who will care for the newborn. • Attach an alert notice or sticker to the woman's medical record to remind the delivery hospital/nursery that the infant will need hepatitis B vaccine and HBIG at birth. • Educate the mother about the need for immunoprophylaxis of her infant at birth, and obtain consent for immunoprophylaxis before delivery. Consider printing additional reminder notices for mothers about the importance of immunoprophylaxis for infants and attaching the notices to the inside front or back cover of the medical record. • Advise the mother that all household, sexual, and needle-sharing contacts should be tested for HBV infection and vaccinated if susceptible. • Provide information to the mother about hepatitis B, including modes of transmission, prenatal concerns (e.g., infants born to HBsAg-positive mothers may be breastfed), medical evaluation and possible treatment of chronic hepatitis B, and substance abuse treatment (if appropriate). • Refer the mother to a medical specialist for evaluation of chronic hepatitis B.

For a pregnant woman with a negative HBsAg test result • Provide a copy of the original laboratory report indicating the pregnant woman’s HBsAg status to the hospital where the delivery is planned and to the health-care provider who will care for the newborn. • Include information in prenatal care education about the rationale for and importance of newborn hepatitis B vaccination for all infants. • Administer the hepatitis B vaccine series if the patient has a risk factor for HBV infection during pregnancy (e.g., injection-drug use, more than one sex partner in the previous 6 months or an HBsAg-positive sex partner, evaluation or treatment for a sexually-transmitted disease [STD]). • Repeat HBsAg testing upon admission to labor and delivery for HBsAg-negative women who are at risk for HBV infection during pregnancy or who have had clinical hepatitis since previous testing. Interpretation of Hepatitis B Serologic Test Results

Hepatitis B serologic testing involves measurement of several hepatitis B ■ Hepatitis B surface virus (HBV)-specifi c antigens and antibodies. Different serologic “markers” antigen (HBsAg): or combinations of markers are used to identify different phases of HBV A protein on the surface infection and to determine whether a patient has acute or chronic HBV of hepatitis B virus; it can infection, is immune to HBV as a result of prior infection or vaccination, or be detected in high levels is susceptible to infection. in serum during acute or chronic hepatitis B virus infection. The presence of Tests Results Interpretation HBsAg indicates that the HBsAg negative Susceptible person is infectious. The anti-HBc negative body normally produces anti-HBs negative antibodies to HBsAg as part of the normal immune HBsAg negative Immune due to natural infection response to infection. anti-HBc positive HBsAg is the antigen used anti-HBs positive to make hepatitis B vaccine.

HBsAg negative Immune due to hepatitis B vaccination ■ Hepatitis B surface anti-HBc negative antibody (anti-HBs): anti-HBs positive The presence of anti-HBs is generally interpreted as HBsAg positive Acutely infected indicating recovery and anti-HBc positive immunity from hepatitis B IgM anti-HBc positive virus infection. Anti-HBs anti-HBs negative also develops in a person who has been successfully HBsAg positive Chronically infected vaccinated against anti-HBc positive hepatitis B. IgM anti-HBc negative anti-HBs negative ■ Total hepatitis B core antibody (anti-HBc): HBsAg negative Interpretation unclear; four possibilities: Appears at the onset anti-HBc positive 1. Resolved infection (most common) of symptoms in acute anti-HBs negative 2. False-positive anti-HBc, thus susceptible hepatitis B and persists 3. “Low level” chronic infection for life. The presence of 4. Resolving acute infection anti-HBc indicates previous or ongoing infection with Adapted from: A Comprehensive Immunization Strategy to Eliminate Transmission of Hepatitis B hepatitis B virus in an Virus Infection in the United States: Recommendations of the Advisory Committee on Immunization undefi ned time frame. Practices. Part I: Immunization of Infants, Children, and Adolescents. MMWR 2005;54(No. RR-16). ■ IgM antibody to hepatitis B core antigen (IgM anti-HBc): Positivity indicates recent infection with hepatitis B DEPARTMENT OF HEALTH & HUMAN SERVICES virus (<6 mos). Its presence Centers for Disease Control and Prevention indicates acute infection. Division of Viral Hepatitis

www.cdc.gov/hepatitis Guidance for Developing Admission Orders in Labor & Delivery and Newborn Units to Prevent Hepatitis B Virus Transmission

The guidelines in this document were developed to help hospitals Admission Orders and Procedures for establish policies and standing orders in their labor and delivery Women Admitted to a Birthing Facility (L &D) and newborn units. For pregnant women who have a HBsAg During 20 05 , the Centers for Disease Control and Prevention (CDC) lab report included in their prenatal published updated recommendations of the Advisory Committee on records, do the following: Immunization Practices (ACIP) for prevention of hepatitis B virus (HBV) infections in children which includes the recommendation to 1.Examine a copy of the original laboratory report administer hepatitis B vaccine to all newborns before hospital dis - of the pregnant woman’s HBsA g1 test result

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Hepatitis B: '( What Hospitals Need to Do to Protect Newborns www.immunize.org/protect-newborns For pregnant women who do not have a For newborns of mothers with unknown HBsAg lab report on their prenatal record, HBsAg status, do the following: do the following: 1.Administer single-antigen hepatitis B vaccine 1. Perform HBsA g1 testing ASAP on women who (0.5 mL, IM) within 12 hours of birth. 3, 5 Do not do not have a copy of an original HBsAg labora - wait for test results to return before giving this tory report from the current pregnancy included dose of vaccine. in their prenatal record. 2.Document the hepatitis B vaccine dose in the 2.Instruct the lab to call L&D and the nursery newborn’s medical record, including the date, units with the newly obtained HBsAg test result time, and site of administration, as well as the ASAP. vaccine lot number. Notify immunization registry. 3.Give the mother an immunization record card Admission Orders and Procedures that includes the hepatitis B vaccination date. for Newborns Explain the importance of completing the hepa - titis B vaccine series to protect her baby. Remind Hospital procedures to follow her to bring the immunization record card with for ALL newborns her each time her baby sees a provider. s l

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for the mother’s HBsA g test. a c

test was ordered and that it was ordered during i t

this pregnancy. 5.Verify when the mother’s HBsAg result will be c a available and that it will be reported to L&D and r P 2.Determine if the newborn needs immediate the newborn unit ASAP. postexposure prophylaxis within 12 hours of

birth. To do this you must know the mother’s 6.If the nursery does not receive the report of the m e mother’s HBsAg test at the expected time, call l HBsAg status and the newborn’s birth weight. If b o

the newborn weighs less than 2 kg ( 4.4 lb), see the laboratory for the result. r P

the guidance below and footnotes 2, 5, 6. 7.If the laboratory test indicates the mother’s e h

1 t HBsAg test result is positive, do the following:

3.Prior to vaccination, give parent a Hepatitis B g n Vaccine Information Statement. i

a. Administer HBIG ( 0.5 mL, IM) to the new - s s

born ASAP. (Hepatitis B vaccine should have e r

For newborns of HBsAg-negative mothers been given within 12 hours of birth.) d d 1. Administer single-antigen hepatitis B vaccine b. Document the HBIG dose in the newborn’s A (0.5 mL, IM) before hospital discharge to medical record. There is little benefit in all newborns weighing 2 kg ( 4.4 lb) or more administering HBIG to the newborn if more 2, 3, 4 at birth . than 7 days have elapsed since birth. 2.Document the hepatitis B vaccine dose in the c. Alert the mother’s and newborn’s physician(s) newborn’s medical record, including the date, of the test result. time, and site of administration, as well as the vaccine lot number. Notify the regional d. Follow the instructions below “For newborns immunization registry, if one is available. of HBsAg-positive mothers,” steps 3–7. 3.Give the mother an immunization record card 8.If the newborn must be discharged before the that includes the hepatitis B vaccination date. mother’s HBsAg result is known: Explain the importance of completing the hepa - a. Document the parents’ contact information titis B vaccine series to protect her baby. Remind (e.g., addresses, telephone numbers, emer - her to bring the immunization record card with gency contacts) in case further treatment is her each time her baby sees a provider. needed for the infant.

Hepatitis B: ') What Hospitals Need to Do to Protect Newborns www.immunize.org/protect-newborns b. Obtain the name, address, and phone num - the hepatitis B vaccine series at age 9–18 ber of the mother’s and the newborn’s health - months (usually done at a well-child visit) to care providers. determine if the child developed a protective immune response to vaccination or needs c. Notify the mother’s and newborn’s healthcare additional management; providers that the mother’s HBsAg test result is pending. d. About modes of HBV transmission and the need for testing and vaccination of suscepti - For newborns of HBsAg-positive mothers ble household, sexual, and needle-sharing 1. Administer HBIG ( 0.5 mL, IM) and single- contacts; antigen hepatitis B vaccine 3, 6 (0.5 mL, IM) at e. That she needs to have a medical evaluation separate injection sites within 12 hours of birth. for chronic hepatitis B, including an assess - 2.Document the hepatitis B vaccine and HBIG ment of whether she is a candidate for anti - dose in the newborn’s medical record, including viral treatment. the date, time, and site of administration, as well as the vaccine lot number. If an immuniza - footnotes tion registry is available, notify it of both doses. 1. Be sure the correct test for HBsAg (hepatitis B surface s l

antigen) wa s/ is ordered. The HBsAg test should not be o

3.Give the mother an immunization record card confused with other hepatitis B serologic tests, includ - o T

that includes the hepatitis B vaccination and ing antibody to HBsAg (anti-HBs or HBsAb) or antibody l a

to hepatitis B core antigen (anti-HBc or HBcAb). c HBIG dates. Explain the importance of complet - i t

ing the hepatitis B vaccine series to protect her 2. Infants weighing less than 2 kg ( 4.4 lb) at birth and c a whose mothers are documented to be HBsAg negative r

baby. Remind her to bring the immunization P should receive the first dose of vaccine 1 month after record card with her each time her baby sees a birth or at hospital discharge, whichever comes first. The provider. mother’s HBsAg test result must be part of the infant’s m e

medical record. l

4.Notify the local or state health department of b

3. Federal law requires that you give parents a Hepatitis B o the infant’s birth and the date and time of admin - r

Vaccine Information Statement (VIS) before vaccine P

istration of HBIG and hepatitis B vaccine doses. administration. To obtain a VIS, download it from the e h

IAC website at www.immunize.org/vis or see page 29. t

5.Obtain the name, address, and phone number g 4. According to the CDC recommendations, exceptions to n of the newborn’s primary care provider. i

administering the birth dose of hepatitis B vaccine are s s

allowed on a case-by-case basis and only in rare circum - e

6.Notify the provider of the newborn’s birth, the r

stances. If the hepatitis B vaccine birth dose is not d

date and time of HBIG and hepatitis B vaccine administered, a copy of the mother’s negative HBsAg d doses administered, and the importance of test result from the current pregnancy must be placed in A additional on-time vaccination and postvaccina - the newborn’s medical record and the attending physi - tion testing of the infant for HBsAg and anti - cian must write a specific order directing staff not to administer the birth dose in the hospital. Infants who do body to HBsAg after completion of the hepatitis not receive the first dose of hepatitis B vaccine before B vaccine series. hospital discharge should receive the first dose no later than age 2 months. 7.Provide advice to mother. Tell her the following: 5. An infant weighing less than 2 kg ( 4.4 lb) whose mother’s a. That she may breast-feed her infant upon HBsAg status is unknown should receive HBIG and hepatitis B vaccine within 12 hours of birth. Do not count delivery, even before hepatitis B vaccine and the hepatitis B vaccine dose as the first dose in the vac - HBIG are given; cine series. Reinitiate the full hepatitis B vaccine series at age 1–2 months. b. That it is critical for her infant to complete the 6. An infant weighing less than 2 kg ( 4.4 lb) whose mother full hepatitis B vaccine series on the recom - is HBsAg positive should receive the first dose of hepati - mended schedule; tis B vaccine and HBIG within 12 hours of birth. Do not count the hepatitis B vaccine dose as the first dose in c. That blood will need to be drawn from the the vaccine series. Reinitiate the full hepatitis B vaccine infant after completion of at least 3 doses of series at age 1–2 months.

Hepatitis B: '* What Hospitals Need to Do to Protect Newborns www.immunize.org/protect-newborns Recommended Immunization Schedules for Persons Aged 0 ­­­Through 18 Years UNITED STATES, 2016

This schedule includes recommendations in effect as of January 1, 2016. Any dose not administered at the recommended age should be administered at a subsequent visit, when indicated and feasible. The use of a combination vaccine generally is preferred over separate injections of its equivalent component vaccines. Vaccination providers should consult the relevant Advisory Committee on Immunization Practices (ACIP) statement for detailed recommendations, available online at http://www.cdc.gov/vaccines/hcp/acip-recs/index.html. Clinically significant adverse events that follow vaccination should be reported to the Vaccine Adverse Event Reporting System (VAERS) online (http://www.vaers.hhs.gov) or by telephone (800-822-7967).

The Recommended Immunization Schedules for Persons Aged 0 Through 18 Years are approved by the

Advisory Committee on Immunization Practices (http://www.cdc.gov/vaccines/acip)

American Academy of Pediatrics (http://www.aap.org)

American Academy of Family Physicians (http://www.aafp.org)

American College of Obstetricians and Gynecologists (http://www.acog.org)

U.S. Department of Health and Human Services Centers for Disease Control and Prevention Figure 1. Recommended immunization schedule for persons aged 0 through 18 years – United States, 2016. (FOR THOSE WHO FALL BEHIND OR START LATE, SEE THE CATCH-UP SCHEDULE [FIGURE 2]). These recommendations must be read with the footnotes that follow. For those who fall behind or start late, provide catch-up vaccination at the earliest opportunity as indicated by the green bars in Figure 1. To determine minimum intervals between doses, see the catch-up schedule (Figure 2). School entry and adolescent vaccine age groups are shaded. 19–23 Vaccine Birth 1 mo 2 mos 4 mos 6 mos 9 mos 12 mos 15 mos 18 mos 2-3 yrs 4-6 yrs 7-10 yrs 11-12 yrs 13–15 yrs 16–18 yrs mos

Hepatitis B1 (HepB) 1st dose 2nd dose 3rd dose

Rotavirus2 (RV) RV1 (2-dose See 1st dose 2nd dose series); RV5 (3-dose series) footnote 2 Diphtheria, tetanus, & acellular 1st dose 2nd dose 3rd dose 4th dose 5th dose pertussis3 (DTaP: <7 yrs)

Haemophilus influenzae type b4 rd th 1st dose 2nd dose See 3 or 4 dose, (Hib) footnote 4 See footnote 4 Pneumococcal conjugate5 1st dose 2nd dose 3rd dose 4th dose (PCV13) Inactivated poliovirus6 1st dose 2nd dose 3rd dose 4th dose (IPV: <18 yrs)

7 Annual vaccination (LAIV or Annual vaccination (LAIV or IIV) Influenza (IIV; LAIV) Annual vaccination (IIV only) 1 or 2 doses IIV) 1 or 2 doses 1 dose only

Measles, mumps, rubella8 (MMR) See footnote 8 1st dose 2nd dose

Varicella9 (VAR) 1st dose 2nd dose

Hepatitis A10 (HepA) 2-dose series, See footnote 10

Meningococcal11 (Hib-MenCY > 6 weeks; MenACWY-D >9 mos; See footnote 11 1st dose Booster MenACWY-CRM ≥ 2 mos) Tetanus, diphtheria, & acellular (Tdap) pertussis12 (Tdap: >7 yrs) Human papillomavirus13 (2vHPV: (3-dose females only; 4vHPV, 9vHPV: series) males and females) See footnote 11 Meningococcal B11

Pneumococcal polysaccharide5 See footnote 5 (PPSV23)

Range of recommended Range of recommended ages Range of recommended ages Range of recommended ages for non-high-risk No recommendation ages for all children for catch-up immunization for certain high-risk groups groups that may receive vaccine, subject to individual clinical decision making This schedule includes recommendations in effect as of January 1, 2016. Any dose not administered at the recommended age should be administered at a subsequent visit, when indicated and feasible. The use of a combination vaccine generally is preferred over separate injections of its equivalent component vaccines. Vaccination providers should consult the relevant Advisory Committee on Immunization Practices (ACIP) statement for detailed recommendations, available online at http://www.cdc.gov/vaccines/hcp/acip-recs/index.html. Clinically significant adverse events that follow vaccination should be reported to the Vaccine Adverse Event Reporting System (VAERS) online (http://www.vaers.hhs.gov) or by telephone (800-822-7967). Suspected cases of vaccine-preventable diseases should be reported to the state or local health department. Additional information, including precautions and contraindications for vaccination, is available from CDC online (http://www.cdc.gov/vaccines/recs/vac-admin/contraindications.htm) or by telephone (800-CDC-INFO [800-232-4636]). This schedule is approved by the Advisory Committee on Immunization Practices (http//www.cdc.gov/vaccines/acip), the American Academy of Pediatrics (http://www.aap.org), the American Academy of Family Physicians (http://www.aafp.org), and the American College of Obstetricians and Gynecologists (http://www.acog.org). NOTE: The above recommendations must be read along with the footnotes of this schedule. FIGURE 2. Catch-up immunization schedule for persons aged 4 months through 18 years who start late or who are more than 1 month behind —United States, 2016. The figure below provides catch-up schedules and minimum intervals between doses for children whose vaccinations have been delayed. A vaccine series does not need to be restarted, regardless of the time that has elapsed between doses. Use the section appropriate for the child’s age. Always use this table in conjunction with Figure 1 and the footnotes that follow. Children age 4 months through 6 years

Minimum Minimum Interval Between Doses Vaccine Age for Dose 1 Dose 1 to Dose 2 Dose 2 to Dose 3 Dose 3 to Dose 4 Dose 4 to Dose 5

8 weeks Hepatitis B1 Birth 4 weeks and at least 16 weeks after first dose. Minimum age for the final dose is 24 weeks.

Rotavirus2 6 weeks 4 weeks 4 weeks2

Diphtheria, tetanus, and 3 acellular pertussis3 6 weeks 4 weeks 4 weeks 6 months 6 months

4 weeks4 if current age is younger than 12 months and first dose was administered at younger than age 7 months, and at least 1 previous dose was PRP-T (ActHib, Pentacel) or unknown. 8 weeks 4 weeks 4 if first dose was administered before the st1 and age 12 through 59 months (as final dose for healthy children) birthday. • if current age is younger than 12 months and first dose was administered at age 7 through 11 months (wait until at least 12 months old); 8 weeks (as final dose) Haemophilus influenzae 8 weeks (as final dose) OR This dose only necessary for children age 12 type b4 6 weeks if first dose was administered at age 12 through • if current age is 12 through 59 months through 59 months who received 3 doses before 14 months. and first dose was administered before the st1 birthday, and second dose administered at the 1st birthday. younger than 15 months; No further doses needed if first dose was admin- OR istered at age 15 months or older. • if both doses were PRP-OMP (PedvaxHIB; Comvax) and were administered before the 1st birthday (wait until at least 12 months old). No further doses needed if previous dose was administered at age 15 months or older.

4 weeks 4 weeks if first dose administered before the st1 birthday. if current age is younger than 12 months and previous dose given at <7months old. 8 weeks (as final dose for healthy children) 8 weeks (as final dose for healthy children) 8 weeks (as final dose) st This dose only necessary for children aged 12 5 if first dose was administered at the 1 birthday if previous dose given between 7-11 months (wait until at least 12 months old); Pneumococcal 6 weeks or after. OR through 59 months who received 3 doses before if current age is 12 months or older and at least 1 dose was given before age 12 months. age 12 months or for children at high risk who No further doses needed received 3 doses at any age. for healthy children if first dose administered at No further doses needed for healthy children if previous dose administered at age 24 months or age 24 months or older. older.

Inactivated poliovirus6 6 weeks 4 weeks6 4 weeks6 6 months6 (minimum age 4 years for final dose).

Measles, mumps, rubella8 12 months 4 weeks

Varicella9 12 months 3 months

Hepatitis A10 12 months 6 months

Meningococcal11 (Hib-MenCY ≥ 6 weeks; 11 MenACWY-D ≥9 mos; 6 weeks 8 weeks See footnote 11 See footnote 11 MenACWY-CRM ≥ 2 mos)

Children and adolescents age 7 through 18 years

Meningococcal11 (Hib-MenCY ≥ 6 weeks; Not Applicable 11 MenACWY-D ≥9 mos; (N/A) 8 weeks MenACWY-CRM ≥ 2 mos)

4 weeks Tetanus, diphtheria; if first dose of DTaP/DT was administered before the st1 birthday. 12 6 months if first dose of DTaP/DT was adminis- tetanus, diphtheria, and 7 years 4 weeks tered before the 1st birthday. acellular pertussis12 6 months (as final dose) if first dose of DTaP/DT or Tdap/Td was administered at or after the st1 birthday.

Human papillomavirus13 9 years Routine dosing intervals are recommended.13

Hepatitis A10 N/A 6 months

Hepatitis B1 N/A 4 weeks 8 weeks and at least 16 weeks after first dose.

Inactivated poliovirus6 N/A 4 weeks 4 weeks6 6 months6

Meningococcal11 N/A 8 weeks11

Measles, mumps, rubella8 N/A 4 weeks

9 3 months if younger than age 13 years. Varicella N/A 4 weeks if age 13 years or older. NOTE: The above recommendations must be read along with the footnotes of this schedule. Footnotes — Recommended immunization schedule for persons aged 0 through 18 years—United States, 2016 For further guidance on the use of the vaccines mentioned below, see: http://www.cdc.gov/vaccines/hcp/acip-recs/index.html. For vaccine recommendations for persons 19 years of age and older, see the Adult Immunization Schedule. Additional information • For contraindications and precautions to use of a vaccine and for additional information regarding that vaccine, vaccination providers should consult the relevant ACIP statement available online at http://www.cdc.gov/vaccines/hcp/acip-recs/index.html. • For purposes of calculating intervals between doses, 4 weeks = 28 days. Intervals of 4 months or greater are determined by calendar months. • Vaccine doses administered 4 days or less before the minimum interval are considered valid. Doses of any vaccine administered ≥5 days earlier than the minimum interval or minimum age should not be counted as valid doses and should be repeated as age-appropriate. The repeat dose should be spaced after the invalid dose by the recommended minimum interval. For further details, see MMWR, General Recommendations on Immunization and Reports / Vol. 60 / No. 2; Table 1. Recommended and minimum ages and intervals between vaccine doses available online at http://www.cdc.gov/mmwr/pdf/rr/rr6002.pdf. • Information on travel vaccine requirements and recommendations is available at http://wwwnc.cdc.gov/travel/destinations/list. • For vaccination of persons with primary and secondary immunodeficiencies, see Table 13,“Vaccination of persons with primary and secondary immunodeficiencies,” in General Recommendations on Immunization (ACIP), available at http://www.cdc.gov/mmwr/pdf/rr/rr6002.pdf.; and American Academy of Pediatrics. “Immunization in Special Clinical Circumstances,” in Kimberlin DW, Brady MT, Jackson MA, Long SS eds. Red Book: 2015 report of the Committee on Infectious Diseases. 30th ed. Elk Grove Village, IL: American Academy of Pediatrics. 1. Hepatitis B (HepB) vaccine. (Minimum age: birth) 3. Diphtheria and tetanus toxoids and acellular pertussis (DTaP) vaccine (cont’d) Routine vaccination: Catch-up vaccination: At birth: • The fifth dose of DTaP vaccine is not necessary if the fourth dose was administered at age 4 years or older. • Administer monovalent HepB vaccine to all newborns before hospital discharge. • For other catch-up guidance, see Figure 2. • For infants born to hepatitis B surface antigen (HBsAg)-positive mothers, administer HepB vaccine and 4. Haemophilus influenzaetype b (Hib) conjugate vaccine. (Minimum age: 6 weeks for PRP-T [AC- 0.5 mL of hepatitis B immune globulin (HBIG) within 12 hours of birth. These infants should be tested THIB, DTaP-IPV/Hib (Pentacel) and Hib-MenCY (MenHibrix)], PRP-OMP [PedvaxHIB or COMVAX], for HBsAg and antibody to HBsAg (anti-HBs) at age 9 through 18 months (preferably at the next well- 12 months for PRP-T [Hiberix]) child visit) or 1 to 2 months after completion of the HepB series if the series was delayed; CDC recently Routine vaccination: recommended testing occur at age 9 through 12 months; see http://www.cdc.gov/mmwr/preview/ • Administer a 2- or 3-dose Hib vaccine primary series and a booster dose (dose 3 or 4 depending on mmwrhtml/mm6439a6.htm. vaccine used in primary series) at age 12 through 15 months to complete a full Hib vaccine series. • If mother’s HBsAg status is unknown, within 12 hours of birth administer HepB vaccine regardless of birth • The primary series with ActHIB, MenHibrix, or Pentacel consists of 3 doses and should be administered at weight. For infants weighing less than 2,000 grams, administer HBIG in addition to HepB vaccine within 2, 4, and 6 months of age. The primary series with PedvaxHib or COMVAX consists of 2 doses and should 12 hours of birth. Determine mother’s HBsAg status as soon as possible and, if mother is HBsAg-positive, be administered at 2 and 4 months of age; a dose at age 6 months is not indicated. also administer HBIG for infants weighing 2,000 grams or more as soon as possible, but no later than age • One booster dose (dose 3 or 4 depending on vaccine used in primary series) of any Hib vaccine should be 7 days. administered at age 12 through 15 months. An exception is Hiberix vaccine. Hiberix should only be used Doses following the birth dose: for the booster (final) dose in children aged 12 months through 4 years who have received at least 1 prior • The second dose should be administered at age 1 or 2 months. Monovalent HepB vaccine should be used dose of Hib-containing vaccine. for doses administered before age 6 weeks. • For recommendations on the use of MenHibrix in patients at increased risk for meningococcal disease, • Infants who did not receive a birth dose should receive 3 doses of a HepB-containing vaccine on a please refer to the meningococcal vaccine footnotes and also to MMWR February 28, 2014 / 63(RR01);1-13, schedule of 0, 1 to 2 months, and 6 months starting as soon as feasible. See Figure 2. available at http://www.cdc.gov/mmwr/PDF/rr/rr6301.pdf. • Administer the second dose 1 to 2 months after the first dose (minimum interval of 4 weeks), administer Catch-up vaccination: the third dose at least 8 weeks after the second dose AND at least 16 weeks after the first dose. The final • If dose 1 was administered at ages 12 through 14 months, administer a second (final) dose at least 8 weeks (third or fourth) dose in the HepB vaccine series should be administered no earlier than age 24 weeks. after dose 1, regardless of Hib vaccine used in the primary series. • Administration of a total of 4 doses of HepB vaccine is permitted when a combination vaccine containing • If both doses were PRP-OMP (PedvaxHIB or COMVAX), and were administered before the first birthday, the HepB is administered after the birth dose. third (and final) dose should be administered at age 12 through 59 months and at least 8 weeks after the Catch-up vaccination: second dose. • Unvaccinated persons should complete a 3-dose series. • If the first dose was administered at age 7 through 11 months, administer the second dose at least 4 weeks • A 2-dose series (doses separated by at least 4 months) of adult formulation Recombivax HB is licensed for later and a third (and final) dose at age 12 through 15 months or 8 weeks after second dose, whichever is use in children aged 11 through 15 years. later. • For other catch-up guidance, see Figure 2. • If first dose is administered before the first birthday and second dose administered at younger than 15 2. Rotavirus (RV) vaccines. (Minimum age: 6 weeks for both RV1 [Rotarix] and RV5 [RotaTeq]) months, a third (and final) dose should be administered 8 weeks later. Routine vaccination: • For unvaccinated children aged 15 months or older, administer only 1 dose. Administer a series of RV vaccine to all infants as follows: • For other catch-up guidance, see Figure 2. For catch-up guidance related to MenHibrix, please see the 1. If Rotarix is used, administer a 2-dose series at 2 and 4 months of age. meningococcal vaccine footnotes and also MMWR February 28, 2014 / 63(RR01);1-13, available at 2. If RotaTeq is used, administer a 3-dose series at ages 2, 4, and 6 months. http://www.cdc.gov/mmwr/PDF/rr/rr6301.pdf. 3. If any dose in the series was RotaTeq or vaccine product is unknown for any dose in the series, a total of Vaccination of persons with high-risk conditions: 3 doses of RV vaccine should be administered. • Children aged 12 through 59 months who are at increased risk for Hib disease, including chemotherapy Catch-up vaccination: recipients and those with anatomic or functional asplenia (including sickle cell disease), human • The maximum age for the first dose in the series is 14 weeks, 6 days; vaccination should not be initiated for immunodeficiency virus (HIV ) infection, immunoglobulin deficiency, or early component complement infants aged 15 weeks, 0 days or older. deficiency, who have received either no doses or only 1 dose of Hib vaccine before 12 months of age, • The maximum age for the final dose in the series is 8 months, 0 days. should receive 2 additional doses of Hib vaccine 8 weeks apart; children who received 2 or more doses of • For other catch-up guidance, see Figure 2. Hib vaccine before 12 months of age should receive 1 additional dose. • For patients younger than 5 years of age undergoing chemotherapy or radiation treatment who received 3. Diphtheria and tetanus toxoids and acellular pertussis (DTaP) vaccine. (Minimum age: 6 weeks. a Hib vaccine dose(s) within 14 days of starting therapy or during therapy, repeat the dose(s) at least 3 Exception: DTaP-IPV [Kinrix, Quadracel]: 4 years) months following therapy completion. Routine vaccination: • Recipients of hematopoietic stem cell transplant (HSCT) should be revaccinated with a 3-dose regimen • Administer a 5-dose series of DTaP vaccine at ages 2, 4, 6, 15 through 18 months, and 4 through 6 years. of Hib vaccine starting 6 to 12 months after successful transplant, regardless of vaccination history; doses The fourth dose may be administered as early as age 12 months, provided at least 6 months have elapsed should be administered at least 4 weeks apart. since the third dose. • A single dose of any Hib-containing vaccine should be administered to unimmunized* children and • Inadvertent administration of 4th DTaP dose early: If the fourth dose of DTaP was administered at least 4 adolescents 15 months of age and older undergoing an elective splenectomy; if possible, vaccine should months, but less than 6 months, after the third dose of DTaP, it need not be repeated. be administered at least 14 days before procedure. For further guidance on the use of the vaccines mentioned below, see: http://www.cdc.gov/vaccines/hcp/acip-recs/index.html. 4. Haemophilus influenzaetype b (Hib) conjugate vaccine (cont’d) 6. Inactivated poliovirus vaccine (IPV). (Minimum age: 6 weeks) (cont’d) • Hib vaccine is not routinely recommended for patients 5 years or older. However, 1 dose of Hib vaccine • If both OPV and IPV were administered as part of a series, a total of 4 doses should be administered, regardless should be administered to unimmunized* persons aged 5 years or older who have anatomic or functional of the child’s current age. If only OPV were administered, and all doses were given prior to 4 years of age, one asplenia (including sickle cell disease) and unvaccinated persons 5 through 18 years of age with HIV dose of IPV should be given at 4 years or older, at least 4 weeks after the last OPV dose. infection. • IPV is not routinely recommended for U.S. residents aged 18 years or older. * Patients who have not received a primary series and booster dose or at least 1 dose of Hib vaccine after 14 • For other catch-up guidance, see Figure 2. months of age are considered unimmunized. 7. Influenza vaccines. (Minimum age: 6 months for inactivated influenza vaccine [IIV], 2 years for 5. Pneumococcal vaccines. (Minimum age: 6 weeks for PCV13, 2 years for PPSV23) live, attenuated influenza vaccine [LAIV]) Routine vaccination with PCV13: Routine vaccination: • Administer a 4-dose series of PCV13 vaccine at ages 2, 4, and 6 months and at age 12 through 15 months. • Administer influenza vaccine annually to all children beginning at age 6 months. For most healthy, • For children aged 14 through 59 months who have received an age-appropriate series of 7-valent PCV nonpregnant persons aged 2 through 49 years, either LAIV or IIV may be used. However, LAIV should NOT (PCV7), administer a single supplemental dose of 13-valent PCV (PCV13). be administered to some persons, including 1) persons who have experienced severe allergic reactions Catch-up vaccination with PCV13: to LAIV, any of its components, or to a previous dose of any other influenza vaccine; 2) children 2 through • Administer 1 dose of PCV13 to all healthy children aged 24 through 59 months who are not completely 17 years receiving aspirin or aspirin-containing products; 3) persons who are allergic to eggs; 4) pregnant vaccinated for their age. women; 5) immunosuppressed persons; 6) children 2 through 4 years of age with asthma or who had • For other catch-up guidance, see Figure 2. wheezing in the past 12 months; or 7) persons who have taken influenza antiviral medications in the Vaccination of persons with high-risk conditions with PCV13 and PPSV23: previous 48 hours. For all other contraindications and precautions to use of LAIV, see MMWR August 7, • All recommended PCV13 doses should be administered prior to PPSV23 vaccination if possible. 2015 / 64(30):818-25 available at http://www.cdc.gov/mmwr/pdf/wk/mm6430.pdf. • For children 2 through 5 years of age with any of the following conditions: chronic heart disease For children aged 6 months through 8 years: (particularly cyanotic congenital heart disease and cardiac failure); chronic lung disease (including asthma • For the 2015-16 season, administer 2 doses (separated by at least 4 weeks) to children who are receiving if treated with high-dose oral corticosteroid therapy); diabetes mellitus; cerebrospinal fluid leak; cochlear influenza vaccine for the first time. Some children in this age group who have been vaccinated previously implant; sickle cell disease and other hemoglobinopathies; anatomic or functional asplenia; HIV infection; will also need 2 doses. For additional guidance, follow dosing guidelines in the 2015-16 ACIP influenza chronic renal failure; nephrotic syndrome; diseases associated with treatment with immunosuppressive vaccine recommendations, MMWR August 7, 2015 / 64(30):818-25, available at http://www.cdc.gov/ drugs or radiation therapy, including malignant neoplasms, leukemias, lymphomas, and Hodgkin disease; mmwr/pdf/wk/mm6430.pdf. solid organ transplantation; or congenital immunodeficiency: • For the 2016-17 season, follow dosing guidelines in the 2016 ACIP influenza vaccine recommendations. 1. Administer 1 dose of PCV13 if any incomplete schedule of 3 doses of PCV (PCV7 and/or PCV13) were For persons aged 9 years and older: received previously. • Administer 1 dose. 2. Administer 2 doses of PCV13 at least 8 weeks apart if unvaccinated or any incomplete schedule of fewer 8. Measles, mumps, and rubella (MMR) vaccine. (Minimum age: 12 months for routine vaccination) than 3 doses of PCV (PCV7 and/or PCV13) were received previously. Routine vaccination: 3. Administer 1 supplemental dose of PCV13 if 4 doses of PCV7 or other age-appropriate complete PCV7 • Administer a 2-dose series of MMR vaccine at ages 12 through 15 months and 4 through 6 years. The series was received previously. second dose may be administered before age 4 years, provided at least 4 weeks have elapsed since the first 4. The minimum interval between doses of PCV (PCV7 or PCV13) is 8 weeks. dose. 5. For children with no history of PPSV23 vaccination, administer PPSV23 at least 8 weeks after the most • Administer 1 dose of MMR vaccine to infants aged 6 through 11 months before departure from the United recent dose of PCV13. States for international travel. These children should be revaccinated with 2 doses of MMR vaccine, the first • For children aged 6 through 18 years who have cerebrospinal fluid leak; cochlear implant; sickle cell at age 12 through 15 months (12 months if the child remains in an area where disease risk is high), and the disease and other hemoglobinopathies; anatomic or functional asplenia; congenital or acquired second dose at least 4 weeks later. immunodeficiencies; HIV infection; chronic renal failure; nephrotic syndrome; diseases associated • Administer 2 doses of MMR vaccine to children aged 12 months and older before departure from the with treatment with immunosuppressive drugs or radiation therapy, including malignant neoplasms, United States for international travel. The first dose should be administered on or after age 12 months and leukemias, lymphomas, and Hodgkin disease; generalized malignancy; solid organ transplantation; or the second dose at least 4 weeks later. multiple myeloma: Catch-up vaccination: 1. If neither PCV13 nor PPSV23 has been received previously, administer 1 dose of PCV13 now and 1 dose • Ensure that all school-aged children and adolescents have had 2 doses of MMR vaccine; the minimum of PPSV23 at least 8 weeks later. interval between the 2 doses is 4 weeks. 2. If PCV13 has been received previously but PPSV23 has not, administer 1 dose of PPSV23 at least 8 weeks 9. Varicella (VAR) vaccine. (Minimum age: 12 months) after the most recent dose of PCV13. Routine vaccination: 3. If PPSV23 has been received but PCV13 has not, administer 1 dose of PCV13 at least 8 weeks after the • Administer a 2-dose series of VAR vaccine at ages 12 through 15 months and 4 through 6 years. The most recent dose of PPSV23. second dose may be administered before age 4 years, provided at least 3 months have elapsed since the • For children aged 6 through 18 years with chronic heart disease (particularly cyanotic congenital heart first dose. If the second dose was administered at least 4 weeks after the first dose, it can be accepted as disease and cardiac failure), chronic lung disease (including asthma if treated with high-dose oral valid. corticosteroid therapy), diabetes mellitus, alcoholism, or chronic liver disease, who have not received Catch-up vaccination: PPSV23, administer 1 dose of PPSV23. If PCV13 has been received previously, then PPSV23 should be • Ensure that all persons aged 7 through 18 years without evidence of immunity (see MMWR 2007 / 56 [No. administered at least 8 weeks after any prior PCV13 dose. RR-4], available at http://www.cdc.gov/mmwr/pdf/rr/rr5604.pdf ) have 2 doses of varicella vaccine. For • A single revaccination with PPSV23 should be administered 5 years after the first dose to children with children aged 7 through 12 years, the recommended minimum interval between doses is 3 months (if the sickle cell disease or other hemoglobinopathies; anatomic or functional asplenia; congenital or acquired second dose was administered at least 4 weeks after the first dose, it can be accepted as valid); for persons immunodeficiencies; HIV infection; chronic renal failure; nephrotic syndrome; diseases associated aged 13 years and older, the minimum interval between doses is 4 weeks. with treatment with immunosuppressive drugs or radiation therapy, including malignant neoplasms, 10. Hepatitis A (HepA) vaccine. (Minimum age: 12 months) leukemias, lymphomas, and Hodgkin disease; generalized malignancy; solid organ transplantation; or Routine vaccination: multiple myeloma. • Initiate the 2-dose HepA vaccine series at 12 through 23 months; separate the 2 doses by 6 to 18 months. 6. Inactivated poliovirus vaccine (IPV). (Minimum age: 6 weeks) • Children who have received 1 dose of HepA vaccine before age 24 months should receive a second dose 6 Routine vaccination: to 18 months after the first dose. • Administer a 4-dose series of IPV at ages 2, 4, 6 through 18 months, and 4 through 6 years. The final dose in the • For any person aged 2 years and older who has not already received the HepA vaccine series, 2 doses of series should be administered on or after the fourth birthday and at least 6 months after the previous dose. HepA vaccine separated by 6 to 18 months may be administered if immunity against hepatitis A virus Catch-up vaccination: infection is desired. • In the first 6 months of life, minimum age and minimum intervals are only recommended if the person is at risk Catch-up vaccination: of imminent exposure to circulating poliovirus (i.e., travel to a polio-endemic region or during an outbreak). • The minimum interval between the 2 doses is 6 months. • If 4 or more doses are administered before age 4 years, an additional dose should be administered at age 4 through 6 years and at least 6 months after the previous dose. • A fourth dose is not necessary if the third dose was administered at age 4 years or older and at least 6 months after the previous dose. For further guidance on the use of the vaccines mentioned below, see: http://www.cdc.gov/vaccines/hcp/acip-recs/index.html. 10. Hepatitis A (HepA) vaccine (cont’d) 11. Meningococcal vaccines (cont’d) Special populations: 3. Menactra • Administer 2 doses of HepA vaccine at least 6 months apart to previously unvaccinated persons who live o Children 9 through 23 months: Administer 2 primary doses at least 12 weeks apart. in areas where vaccination programs target older children, or who are at increased risk for infection. This o Children 24 months and older who have not received a complete series: Administer 2 primary doses at includes persons traveling to or working in countries that have high or intermediate endemicity of least 8 weeks apart. infection; men having sex with men; users of injection and non-injection illicit drugs; persons who work Meningococcal B vaccines: with HAV-infected primates or with HAV in a research laboratory; persons with clotting-factor disorders; 1. Bexsero or Trumenba persons with chronic liver disease; and persons who anticipate close personal contact (e.g., household or o Persons 10 years or older who have not received a complete series. Administer a 2-dose series of Bexsero, regular babysitting) with an international adoptee during the first 60 days after arrival in the United States at least 1 month apart. Or a 3-dose series of Trumenba, with the second dose at least 2 months after from a country with high or intermediate endemicity. The first dose should be administered as soon as the the first and the third dose at least 6 months after the first. The two MenB vaccines are not interchange- adoption is planned, ideally 2 or more weeks before the arrival of the adoptee. 11. Meningococcal vaccines. (Minimum age: 6 weeks for Hib-MenCY [MenHibrix], 9 months for able; the same vaccine product must be used for all doses. MenACWY-D [Menactra], 2 months for MenACWY-CRM [Menveo], 10 years for serogroup B For children who travel to or reside in countries in which meningococcal disease is hyperendemic or epidemic, including countries in the African meningitis belt or the Hajj meningococcal [MenB] vaccines: MenB-4C [Bexsero] and MenB-FHbp [Trumenba]) • administer an age-appropriate formulation and series of Menactra or Menveo for protection against Routine vaccination: serogroups A and W meningococcal disease. Prior receipt of MenHibrix is not sufficient for children • Administer a single dose of Menactra or Menveo vaccine at age 11 through 12 years, with a booster dose at traveling to the meningitis belt or the Hajj because it does not contain serogroups A or W. age 16 years. For children at risk during a community outbreak attributable to a vaccine serogroup • Adolescents aged 11 through 18 years with human immunodeficiency virus (HIV ) infection should receive a • administer or complete an age- and formulation-appropriate series of MenHibrix, Menactra, or Menveo, 2-dose primary series of Menactra or Menveo with at least 8 weeks between doses. Bexsero or Trumenba. • For children aged 2 months through 18 years with high-risk conditions, see below. For booster doses among persons with high-risk conditions, refer to MMWR 2013 / 62(RR02);1-22, available Catch-up vaccination: at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6202a1.htm. • Administer Menactra or Menveo vaccine at age 13 through 18 years if not previously vaccinated. • If the first dose is administered at age 13 through 15 years, a booster dose should be administered at age 16 For other catch-up recommendations for these persons, and complete information on use of through 18 years with a minimum interval of at least 8 weeks between doses. meningococcal vaccines, including guidance related to vaccination of persons at increased risk of infection, • If the first dose is administered at age 16 years or older, a booster dose is not needed. see MMWR March 22, 2013 / 62(RR02);1-22, and MMWR October 23, 2015 / 64(41); 1171-1176 available at • For other catch-up guidance, see Figure 2. http://www.cdc.gov/mmwr/pdf/rr/rr6202.pdf, and http://www.cdc.gov/mmwr/pdf/wk/mm6441.pdf. Clinical discretion: • Young adults aged 16 through 23 years (preferred age range is 16 through 18 years) may be vaccinated 12. Tetanus and diphtheria toxoids and acellular pertussis (Tdap) vaccine. (Minimum age: 10 years with either a 2-dose series of Bexsero or a 3-dose series of Trumenba vaccine to provide short-term for both Boostrix and Adacel) protection against most strains of serogroup B meningococcal disease. The two MenB vaccines are not Routine vaccination: interchangeable; the same vaccine product must be used for all doses. • Administer 1 dose of Tdap vaccine to all adolescents aged 11 through 12 years. Vaccination of persons with high-risk conditions and other persons at increased risk of disease: • Tdap may be administered regardless of the interval since the last tetanus and diphtheria toxoid- Children with anatomic or functional asplenia (including sickle cell disease): containing vaccine. Meningococcal conjugate ACWY vaccines: • Administer 1 dose of Tdap vaccine to pregnant adolescents during each pregnancy (preferred during 27 1. Menveo through 36 weeks gestation) regardless of time since prior Td or Tdap vaccination. o Children who initiate vaccination at 8 weeks: Administer doses at 2, 4, 6, and 12 months of age. Catch-up vaccination: o Unvaccinated children who initiate vaccination at 7 through 23 months: Administer 2 doses, with the second • Persons aged 7 years and older who are not fully immunized with DTaP vaccine should receive Tdap dose at least 12 weeks after the first dose AND after the first birthday. vaccine as 1 (preferably the first) dose in the catch-up series; if additional doses are needed, use Td vaccine. o Children 24 months and older who have not received a complete series: Administer 2 primary doses at least For children 7 through 10 years who receive a dose of Tdap as part of the catch-up series, an adolescent 8 weeks apart. Tdap vaccine dose at age 11 through 12 years should NOT be administered. Td should be administered instead 10 years after the Tdap dose. 2. MenHibrix • Persons aged 11 through 18 years who have not received Tdap vaccine should receive a dose followed by o Children who initiate vaccination at 6 weeks: Administer doses at 2, 4, 6, and 12 through 15 months of age. tetanus and diphtheria toxoids (Td) booster doses every 10 years thereafter. o If the first dose of MenHibrix is given at or after 12 months of age, a total of 2 doses should be given at • Inadvertent doses of DTaP vaccine: least 8 weeks apart to ensure protection against serogroups C and Y meningococcal disease. -- If administered inadvertently to a child aged 7 through 10 years may count as part of the catch-up 3. Menactra series. This dose may count as the adolescent Tdap dose, or the child can later receive a Tdap booster o Children 24 months and older who have not received a complete series: Administer 2 primary doses at least dose at age 11 through 12 years. 8 weeks apart. If Menactra is administered to a child with asplenia (including sickle cell disease), do not -- If administered inadvertently to an adolescent aged 11 through 18 years, the dose should be counted administer Menactra until 2 years of age and at least 4 weeks after the completion of all PCV13 doses. as the adolescent Tdap booster. Meningococcal B vaccines: • For other catch-up guidance, see Figure 2. 1. Bexsero or Trumenba 13. Human papillomavirus (HPV) vaccines. (Minimum age: 9 years for 2vHPV [Cervarix], 4vHPV o Persons 10 years or older who have not received a complete series. Administer a 2-dose series of Bexsero, at [Gardasil] and 9vHPV [Gardasil 9]) least 1 month apart. Or a 3-dose series of Trumenba, with the second dose at least 2 months after the Routine vaccination: first and the third dose at least 6 months after the first. The two MenB vaccines are not interchangeable; • Administer a 3-dose series of HPV vaccine on a schedule of 0, 1-2, and 6 months to all adolescents aged 11 the same vaccine product must be used for all doses. through 12 years. 9vHPV, 4vHPV or 2vHPV may be used for females, and only 9vHPV or 4vHPV may be used Children with persistent complement component deficiency (includes persons with inherited or chronic for males. deficiencies in C3, C5-9, properidin, factor D, factor H, or taking eculizumab (Soliriis®): • The vaccine series may be started at age 9 years. Meningococcal conjugate ACWY vaccines: • Administer the second dose 1 to 2 months after the first dose (minimum interval of 4 weeks); 1. Menveo administer the third dose 16 weeks after the second dose (minimum interval of 12 weeks) and 24 weeks after the first dose. o Children who initiate vaccination at 8 weeks: Administer doses at 2, 4, 6, and 12 months of age. • Administer HPV vaccine beginning at age 9 years to children and youth with any history of sexual abuse or o Unvaccinated children who initiate vaccination at 7 through 23 months: Administer 2 doses, with the assault who have not initiated or completed the 3-dose series. second dose at least 12 weeks after the first dose AND after the first birthday. Catch-up vaccination: o Children 24 months and older who have not received a complete series: Administer 2 primary doses at • Administer the vaccine series to females (2vHPV or 4vHPV or 9vHPV) and males (4vHPV or 9vHPV) at age least 8 weeks apart. 13 through 18 years if not previously vaccinated. 2. MenHibrix • Use recommended routine dosing intervals (see Routine vaccination above) for vaccine series catch-up. o Children who initiate vaccination 6 weeks: Administer doses at 2, 4, 6, and 12 through 15 months of age. o If the first dose of MenHibrix is given at or after 12 months of age, a total of 2 doses should be given at least 8 weeks apart to ensure protection against serogroups C and Y meningococcal disease. CS260933-A

NEVADA CHILD CARE REQUIREMENTS 2016

MMIIINNIIIMMAALL IIINNTTEERRVVAALL NNEEVVAADDAA RREEQQUUIIIRREEDD AACCIIIPP RREECCOOMMMMEENNDDEEDD SSCCHHEEDDUULLEE RREEQQUUIIIRREEMMEENNTTSS VVAACCCCIIINNEESS FFOORR CCHHIIILLDD CCAARREE BIRTH 2 MONTHS 4 MONTHS 6 MONTHS 12 MONTHS 15 MONTHS 18 MONTHS 4-6 YEARS

DTaP, DTP, DT Final dose should be administered on or Other DTAP vaccines: after the 4th birthday & at least 6 months Kinrix (DTAP/IPV) 1 2 3 4* 5 following the previous dose Pentacel (DTAP/IPV/HIB) *Note: NV Health Officer recommends #4 Pediarix (DTAP/IPV/HEP B) DTaP 12 months with 6 months between Daptacel, Infanrix #3 & #4. Final dose should be administered on or POLIO (IPV) after the 4th birthday & at least 6 mos Kinrix (DTAP/IPV) 1 2 3 4 following the previous dose. May have Pentacel (DTAP/IPV/HIB) extra dose if given Pentacel as an Pediarix (DTAP/IPV/HEP B) infant/toddler. MMR nd (Measles, Mumps, 1 2 May accept 2 dose if administered after Rubella) 12 months of age & four weeks after 1st Other MMR vaccines: dose. PROQUAD (MMR/CPOX) HIB # of doses that complete the series may ActHib, Hiberix, PRP- depend on when the first dose is given. 1 2 3 4 No further doses needed. NOS, PRP-OMP, PRP-T See HIB Vaccine dose schedule. eg: If HibTiter, PedvaxHIB one dose given after 15 months, series is Pentacel (DTAP/IPV/HIB) complete; no need for further doses.

HEPATITIS B Must be 8 wks between #2 & #3 No further doses Other HEP B vaccines: 1 2 3 and 4 mos between #1 & #3 PEDIARIX: needed Must be 24 weeks for dose #3. (DTAP/IPV/HEP B) If Pediarix vaccine is used, may have extra Engerix-B, Recombivax dose at 4 months. Varicella (Chickenpox) Other Varicella vaccines: 1 2 #2 must be at least 28 days after the first VARIVAX, dose. PROQUAD(MMR/CPOX) # of doses that complete the series may PREVNAR 1 2 3 4 No further doses needed depend on when the first dose is given. PCV13, PCV See PCV Vaccine dose schedule.

HEPATITIS A Minimum Age at 12 months; Should 2 doses must be Havrix, Vaqta separated by 6 mos complete by Age 2.

2016 Centers for Disease Control and Prevention. www.cdc.gov/vaccines/hcp/acip-recs/index.html.

NEVADA CHILD CARE REQUIREMENTS 2016

Should Complete by 24 months SCHOOL/ DDUUEE BBYY TTyyppee oofff VVaacccciiinnee By 3 By 5 By 7 By 16 By 19 By Preschool (4 year old) NOTES MONTHS MONTHS MONTHS MONTHS MONTHS /School Entry NOTES

Final dose should be administered on or after the 4th birthday & at least 6 mos following the DTaP, DTP, DT 1 2 3 4* 5 previous dose *Note: NV Health Officer recommends #4 DTaP at 12 months if there is 6 months between #3 & #4.

Final dose should be administered on or after POLIO (IPV) 1 2 3 4 the 4th birthday & at least 6 mos following the previous dose. May have extra dose if given Pentacel as an infant/toddler.

Minimum age 12 months for 1st dose MMR 1 2 May accept 2nd dose if administered after 12

mos of age & 4 weeks after 1st dose.

# of doses that complete the series may HIB 1 2 3 4 depend on when the first dose is given. If 1 dose given after 15 months, no need for further doses.

Must be 8 wks between #2 & #3; HEPATITIS B 1 2 3 16 wks between #1 & #3 Must be at least 24 weeks for dose #3.

Minimum age 12 months for 1st dose Varicella (Chickenpox) 1 2 May accept 2nd dose if administered after 12

mos of age & 4 weeks after 1st dose.

PREVNAR or PCV13 1 2 3 4 No further doses needed Only 1 dose needed after age 2

Minimum Age 12 months for first dose HEPATITIS A Should complete See notes 2 doses must be separated by 6 months. by 24 months Two doses required for school entry.

2016 SNHD Immunization Child Care Program Centers for Disease Control and Prevention. www.cdc.gov/vaccines/hcp/acip-recs/index.html. Guide for Determining the Number of Doses of Influenza Vaccine to Give to Children Age 6 Months Through 8 Years During the 2015–2016 Influenza Season

Did the child receive at Give 1 dose of least 2 doses of trivalent or

▲ 2015–16 quadrivalent influenza yes influenza vaccine vaccine* this season. before July 1, 2015?

no / don’t know ▲

Give 2 doses of 2015–16 influenza vaccine this season, spaced at least 4 weeks apart.

* The two doses need not have been received during the reference same season or consecutive seasons. Prevention and Control of Influenza with Vaccines: Recommendations of the Advisory Committee on note: The two doses can both be inactivated influenza Immunization Practices – United States, 2015–2016 vaccine (IIV), or, for children age 2 through 8 years who Influenza Season.MMWR , August 7, 2015; 64(30): have no contraindications to live attenuated influenza 818–825. Access recommendations at www.cdc.gov/ vaccine (LAIV), can both be LAIV, or alternatively, 1 dose mmwr/pdf/wk/mm6430.pdf. of IIV and 1 dose of LAIV.

Technical content reviewed by the Centers for Disease Control and Prevention Immunization Action Coalition Saint Paul, Minnesota • 651-647-9009 • www.immunize.org • www.vaccineinformation.org www.immunize.org/catg.d/p3093.pdf • Item #P3093 (10/15) Recommended Adult Immunization Schedule United States - 2016

The 2016 Adult Immunization Schedule was approved by the Centers for Disease Control and Prevention’s (CDC) Advisory Committee on Immunization Practices (ACIP), the American Academy of Family Physicians (AAFP), the American College of Physicians (ACP), the American College of Obstetricians and Gynecologists (ACOG), and the American College of Nurse-Midwives (ACNM). On February 2, 2016, the adult immunization schedule and a summary of changes from 2015 were published in the Annals of Internal Medicine, and the availability of the schedule was announced in the Morbidity and Mortality Weekly Report (MMWR) on February 4, 2016.

All clinically significant postvaccination reactions should be reported to the Vaccine Adverse Event Reporting System (VAERS). Reporting forms and instructions on filing a VAERS report are available at www.vaers.hhs.gov or by telephone, 800-822-7967.

Additional details regarding ACIP recommendations for each of the vaccines listed in the schedule can be found at www.cdc.gov/vaccines/hcp/acip-recs/index.html.

American Academy of Family Physicians (AAFP) www.aafp.org/

American College of Physicians (ACP) www.acponline.org/

American College of Obstetricians and Gynecologists (ACOG) www.acog.org/

American College of Nurse-Midwives (ACNM) www.midwife.org/

U.S. Department of Health and Human Services Centers for Disease Control and Prevention Recommended Adult Immunization Schedule—United States - 2016 Note: These recommendations must be read with the footnotes that follow containing number of doses, intervals between doses, and other important information. Figure 1. Recommended immunization schedule for adults aged 19 years or older, by vaccine and age group1

VACCINE  AGE GROUP  19-21 years 22-26 years 27-49 years 50-59 years 60-64 years ≥ 65 years Influenza*,2 1 dose annually

Tetanus, diphtheria, pertussis (Td/Tdap)*,3 Substitute Tdap for Td once, then Td booster every 10 yrs

Varicella*,4 2 doses

Human papillomavirus (HPV) Female*,5 3 doses

Human papillomavirus (HPV) Male*,5 3 doses

Zoster6 1 dose

Measles, mumps, rubella (MMR)*,7 1 or 2 doses depending on indication

Pneumococcal 13-valent conjugate (PCV13)*,8 1 dose

Pneumococcal 23-valent polysaccharide (PPSV23)8 1 or 2 doses depending on indication 1 dose

Hepatitis A*,9 2 or 3 doses depending on vaccine Hepatitis B*,10 3 doses Meningococcal 4-valent conjugate (MenACWY) or polysaccharide (MPSV4)*,11 1 or more doses depending on indication Meningococcal B (MenB)11 2 or 3 doses depending on vaccine Haemophilus influenzae type b (Hib)*,12 1 or 3 doses depending on indication *Covered by the Vaccine Injury Compensation Program Report all clinically significant postvaccination reactions to the Vaccine Adverse Event Reporting System (VAERS). Reporting forms and instructions on filing a VAERS report are available at www.vaers.hhs.gov or by telephone, 800-822-7967. Recommended for all persons who meet the age requirement, lack Information on how to file a Vaccine Injury Compensation Program claim is available atwww.hrsa.gov/vaccinecompensation or by telephone, 800-338-2382. To file a documentation of vaccination, or claim for vaccine injury, contact the U.S. Court of Federal Claims, 717 Madison Place, N.W., Washington, D.C. 20005; telephone, 202-357-6400. lack evidence of past infection; zoster vaccine is recommended regardless of Additional information about the vaccines in this schedule, extent of available data, and contraindications for vaccination is also available at past episode of zoster www.cdc.gov/vaccines or from the CDC-INFO Contact Center at 800-CDC-INFO (800-232-4636) in English and Spanish, 8:00 a.m. - 8:00 p.m. Eastern Time, Monday - Friday, excluding holidays. Recommended for persons with a risk factor (medical, occupational, lifestyle, Use of trade names and commercial sources is for identification only and does not imply endorsement by the U.S. Department of Health and Human Services. or other indication) The recommendations in this schedule were approved by the Centers for Disease Control and Prevention’s (CDC) Advisory Committee on Immunization Practices No recommendation (ACIP), the American Academy of Family Physicians (AAFP), the America College of Physicians (ACP), the American College of Obstetricians and Gynecologists (ACOG) and the American College of Nurse-Midwives (ACNM). Figure 2. Vaccines that might be indicated for adults aged 19 years or older based on medical and other indications1 Immuno- HIV infection Men who Kidney failure, Heart disease, compromising CD4+ count have sex end-stage renal chronic lung Asplenia and persistent Chronic conditions (excluding (cells/μL) 4,6,7,8,13 with men disease, on disease, chronic complement component liver Healthcare VACCINE  INDICATION  Pregnancy HIV infection) 4,6,7,8,13 < 200 ≥ 200 (MSM) hemodialysis alcoholism deficiencies8,11,12 disease Diabetes personnel Influenza*,2 1 dose annually

*,3 1 dose Tdap each Tetanus, diphtheria, pertussis (Td/Tdap) pregnancy Substitute Tdap for Td once, then Td booster every 10 yrs

Varicella*,4 Contraindicated 2 doses

Human papillomavirus (HPV) Female*,5 3 doses through age 26 yrs 3 doses through age 26 yrs

Human papillomavirus (HPV) Male*,5 3 doses through age 26 yrs 3 doses through age 21 yrs

Zoster6 Contraindicated 1 dose

Measles, mumps, rubella (MMR)*,7 Contraindicated 1 or 2 doses depending on indication

Pneumococcal 13-valent conjugate (PCV13)*,8 1 dose

Pneumococcal polysaccharide (PPSV23)8 1, 2, or 3 doses depending on indication

Hepatitis A*,9 2 or 3 doses depending on vaccine

Hepatitis B*,10 3 doses

Meningococcal 4-valent conjugate (MenACWY) 1 or more doses depending on indication or polysaccharide (MPSV4)*,11 Meningococcal B (MenB)11 2 or 3 doses depending on vaccine

*,12 3 doses post-HSCT Haemophilus influenzae type b (Hib) recipients only 1 dose *Covered by the Recommended for all persons who meet the age requirement, lack Recommended for persons with a risk No recommendation Contraindicated Vaccine Injury documentation of vaccination, or lack evidence of past infection; factor (medical, occupational, lifestyle, or Compensation zoster vaccine is recommended regardless of past episode of zoster other indication) Program These schedules indicate the recommended age groups and medical indications for which administration of currently licensed vaccines is commonly recommended for adults aged ≥19 years, as of February 2016. For all vaccines being recommended on the Adult Immunization Schedule: a vaccine series does not need to be restarted, regardless of the time that has elapsed between doses. Licensed combination vaccines may be used whenever any components of the combination are indicated and when the vaccine’s other components are not contraindicated. For detailed recommendations on all vaccines, including those used primarily for travelers or that are issued during the year, consult the manufacturers’ package inserts and the complete statements from the Advisory Committee on Immunization Practices (www.cdc.gov/vaccines/hcp/acip-recs/index.html). Use of trade names and commercial sources is for identification only and does not imply endorsement by the U.S. Department of Health and Human Services. Footnotes—Recommended Immunization Schedule for Adults Aged 19 Years or Older: United States, 2016 1. Additional information • HPV vaccines are not recommended for use in pregnant women. However, • Additional guidance for the use of the vaccines described in this supplement is pregnancy testing is not needed before vaccination. If a woman is found to be available at www.cdc.gov/vaccines/hcp/acip-recs/index.html. pregnant after initiating the vaccination series, no intervention is needed; the • Information on vaccination recommendations when vaccination status is remainder of the 3-dose series should be delayed until completion or termination unknown and other general immunization information can be found in the of pregnancy. General Recommendations on Immunization at 6. Zoster vaccination www.cdc.gov/mmwr/preview/mmwrhtml/rr6002a1.htm. • A single dose of zoster vaccine is recommended for adults aged ≥60 years • Information on travel vaccine requirements and recommendations (e.g., for regardless of whether they report a prior episode of herpes zoster. Although hepatitis A and B, meningococcal, and other vaccines) is available at the vaccine is licensed by the U.S. Food and Drug Administration for use among wwwnc.cdc.gov/travel/destinations/list. and can be administered to persons aged ≥50 years, ACIP recommends that • Additional information and resources regarding vaccination of pregnant women vaccination begin at age 60 years. can be found at www.cdc.gov/vaccines/adults/rec-vac/pregnant.html. • Persons aged ≥60 years with chronic medical conditions may be vaccinated 2. Influenza vaccination unless their condition constitutes a contraindication, such as pregnancy or severe • Annual vaccination against influenza is recommended for all persons aged ≥6 immunodeficiency. months. A list of currently available influenza vaccines can be found athttp:// 7. Measles, mumps, rubella (MMR) vaccination www.cdc.gov/flu/protect/vaccine/vaccines.htm. • Adults born before 1957 are generally considered immune to measles and mumps. • Persons aged ≥6 months, including pregnant women, can receive the inactivated All adults born in 1957 or later should have documentation of 1 or more doses influenza vaccine (IIV). An age-appropriate IIV formulation should be used. of MMR vaccine unless they have a medical contraindication to the vaccine or • Intradermal IIV is an option for persons aged 18 through 64 years. laboratory evidence of immunity to each of the three diseases. Documentation of • High-dose IIV is an option for persons aged ≥65 years. provider-diagnosed disease is not considered acceptable evidence of immunity for • Live attenuated influenza vaccine (LAIV [FluMist]) is an option for healthy, non- measles, mumps, or rubella. pregnant persons aged 2 through 49 years. Measles component: • Recombinant influenza vaccine (RIV [Flublok]) is approved for persons aged ≥18 • A routine second dose of MMR vaccine, administered a minimum of 28 days after years. the first dose, is recommended for adults who: • RIV, which does not contain any egg protein, may be administered to persons —— are students in postsecondary educational institutions, aged ≥18 years with egg allergy of any severity; IIV may be used with additional —— work in a health care facility, or safety measures for persons with hives-only allergy to eggs. —— plan to travel internationally. • Health care personnel who care for severely immunocompromised persons • Persons who received inactivated (killed) measles vaccine or measles vaccine of who require care in a protected environment should receive IIV or RIV; health unknown type during 1963–1967 should be revaccinated with 2 doses of MMR care personnel who receive LAIV should avoid providing care for severely vaccine. immunosuppressed persons for 7 days after vaccination. Mumps component: 3. Tetanus, diphtheria, and acellular pertussis (Td/Tdap) vaccination • A routine second dose of MMR vaccine, administered a minimum of 28 days after • Administer 1 dose of Tdap vaccine to pregnant women during each pregnancy the first dose, is recommended for adults who: (preferably during 27–36 weeks’ gestation) regardless of interval since prior Td or —— are students in a postsecondary educational institution, Tdap vaccination. —— work in a health care facility, or • Persons aged ≥11 years who have not received Tdap vaccine or for whom —— plan to travel internationally. vaccine status is unknown should receive a dose of Tdap followed by tetanus • Persons vaccinated before 1979 with either killed mumps vaccine or mumps and diphtheria toxoids (Td) booster doses every 10 years thereafter. Tdap can be vaccine of unknown type who are at high risk for mumps infection (e.g., persons administered regardless of interval since the most recent tetanus or diphtheria- who are working in a health care facility) should be considered for revaccination toxoid-containing vaccine. with 2 doses of MMR vaccine. • Adults with an unknown or incomplete history of completing a 3-dose primary Rubella component: vaccination series with Td-containing vaccines should begin or complete a primary • For women of childbearing age, regardless of birth year, rubella immunity should vaccination series including a Tdap dose. be determined. If there is no evidence of immunity, women who are not pregnant • For unvaccinated adults, administer the first 2 doses at least 4 weeks apart and the should be vaccinated. Pregnant women who do not have evidence of immunity third dose 6–12 months after the second. should receive MMR vaccine upon completion or termination of pregnancy and • For incompletely vaccinated (i.e., less than 3 doses) adults, administer remaining before discharge from the health care facility. doses. Health care personnel born before 1957: • Refer to the ACIP statement for recommendations for administering Td/Tdap as • For unvaccinated health care personnel born before 1957 who lack laboratory prophylaxis in wound management (see footnote 1). evidence of measles, mumps, and/or rubella immunity or laboratory confirmation 4. Varicella vaccination of disease, health care facilities should consider vaccinating personnel with 2 • All adults without evidence of immunity to varicella (as defined below) should doses of MMR vaccine at the appropriate interval for measles and mumps or 1 receive 2 doses of single-antigen varicella vaccine or a second dose if they have dose of MMR vaccine for rubella. received only 1 dose. 8. Pneumococcal vaccination • Vaccination should be emphasized for those who have close contact with persons • General information at high risk for severe disease (e.g., health care personnel and family contacts of —— Adults are recommended to receive 1 dose of 13-valent pneumococcal persons with immunocompromising conditions) or are at high risk for exposure or conjugate vaccine (PCV13) and 1, 2, or 3 doses (depending on indication) of transmission (e.g., teachers; child care employees; residents and staff members of 23-valent pneumococcal polysaccharide vaccine (PPSV23). institutional settings, including correctional institutions; college students; military — PCV13 should be administered at least 1 year after PPSV23. personnel; adolescents and adults living in households with children; nonpregnant — —— PPSV23 should be administered at least 1 year after PCV13, except among women of childbearing age; and international travelers). adults with immunocompromising conditions, anatomical or functional • Pregnant women should be assessed for evidence of varicella immunity. Women asplenia, cerebrospinal fluid leak, or cochlear implant, for whom the interval who do not have evidence of immunity should receive the first dose of varicella should be at least 8 weeks; the interval between PPSV23 doses should be at vaccine upon completion or termination of pregnancy and before discharge from least 5 years. the health care facility. The second dose should be administered 4–8 weeks after —— No additional dose of PPSV23 is indicated for adults vaccinated with PPSV23 the first dose. at age ≥65 years. • Evidence of immunity to varicella in adults includes any of the following: —— When both PCV13 and PPSV23 are indicated, PCV13 should be administered —— documentation of 2 doses of varicella vaccine at least 4 weeks apart; first; PCV13 and PPSV23 should not be administered during the same visit. — U.S.-born before 1980, except health care personnel and pregnant women; — —— When indicated, PCV13 and PPSV23 should be administered to adults whose —— history of varicella based on diagnosis or verification of varicella disease by a pneumococcal vaccination history is incomplete or unknown. health care provider; • Adults aged ≥65 years (immunocompetent) who: — history of herpes zoster based on diagnosis or verification of herpes zoster — —— have not received PCV13 or PPSV23: administer PCV13 followed by PPSV23 at disease by a health care provider; or least 1 year after PCV13. — laboratory evidence of immunity or laboratory confirmation of disease. — —— have not received PCV13 but have received a dose of PPSV23 at age ≥65 years: 5. Human papillomavirus (HPV) vaccination administer PCV13 at least 1 year after PPSV23. • Three HPV vaccines are licensed for use in females (bivalent HPV vaccine [2vHPV], —— have not received PCV13 but have received 1 or more doses of PPSV23 at quadrivalent HPV vaccine [4vHPV], and 9-valent HPV vaccine [9vHPV]) and two age <65 years: administer PCV13 at least 1 year after the most recent dose of HPV vaccines are licensed for use in males (4vHPV and 9vHPV). PPSV23. Administer a dose of PPSV23 at least 1 year after PCV13 and at least 5 • For females, 2vHPV, 4vHPV, or 9vHPV is recommended in a 3-dose series for years after the most recent dose of PPSV23. routine vaccination at age 11 or 12 years and for those aged 13 through 26 years, if —— have received PCV13 but not PPSV23 at age <65 years: administer PPSV23 at not previously vaccinated. least 1 year after PCV13. • For males, 4vHPV or 9vHPV is recommended in a 3-dose series for routine —— have received PCV13 and 1 or more doses of PPSV23 at age <65 years: vaccination at age 11 or 12 years and for those aged 13 through 21 years, if not administer PPSV23 at least 1 year after PCV13 and at least 5 years after the previously vaccinated. Males aged 22 through 26 years may be vaccinated. most recent dose of PPSV23. • HPV vaccination is recommended for men who have sex with men through age 26 • Adults aged ≥19 years with immunocompromising conditions or anatomical or years who did not get any or all doses when they were younger. functional asplenia (defined below) who: • Vaccination is recommended for immunocompromised persons (including those —— have not received PCV13 or PPSV23: administer PCV13 followed by PPSV23 at with HIV infection) through age 26 years who did not get any or all doses when least 8 weeks after PCV13. Administer a second dose of PPSV23 at least 5 years they were younger. after the first dose of PPSV23. • A complete HPV vaccination series consists of 3 doses. The second dose should —— have not received PCV13 but have received 1 dose of PPSV23: administer be administered 4–8 weeks (minimum interval of 4 weeks) after the first dose; the PCV13 at least 1 year after the PPSV23. Administer a second dose of PPSV23 at third dose should be administered 24 weeks after the first dose and 16 weeks after least 8 weeks after PCV13 and at least 5 years after the first dose of PPSV23. the second dose (minimum interval of 12 weeks). (Continued on next page) Footnotes—Recommended Immunization Schedule for Adults Aged 19 Years or Older: United States, 2016 —— have not received PCV13 but have received 2 doses of PPSV23: administer programs and facilities for chronic hemodialysis patients, and institutions and PCV13 at least 1 year after the most recent dose of PPSV23. nonresidential day care facilities for persons with developmental disabilities. —— have received PCV13 but not PPSV23: administer PPSV23 at least 8 weeks after • Administer missing doses to complete a 3-dose series of hepatitis B vaccine to PCV13. Administer a second dose of PPSV23 at least 5 years after the first dose those persons not vaccinated or not completely vaccinated. The second dose of PPSV23. should be administered at least 1 month after the first dose; the third dose should —— have received PCV13 and 1 dose of PPSV23: administer a second dose of be administered at least 2 months after the second dose (and at least 4 months PPSV23 at least 8 weeks after PCV13 and at least 5 years after the first dose of after the first dose). If the combined hepatitis A and hepatitis B vaccine (Twinrix) PPSV23. is used, give 3 doses at 0, 1, and 6 months; alternatively, a 4-dose Twinrix schedule —— If the most recent dose of PPSV23 was administered at age <65 years, at age may be used, administered on days 0, 7, and 21–30, followed by a booster dose at ≥65 years, administer a dose of PPSV23 at least 8 weeks after PCV13 and at 12 months. least 5 years after the last dose of PPSV23. • Adult patients receiving hemodialysis or with other immunocompromising —— Immunocompromising conditions that are indications for pneumococcal conditions should receive 1 dose of 40 mcg/mL (Recombivax HB) administered vaccination are: congenital or acquired immunodeficiency (including B- or on a 3-dose schedule at 0, 1, and 6 months or 2 doses of 20 mcg/mL (Engerix-B) T-lymphocyte deficiency, complement deficiencies, and phagocytic disorders administered simultaneously on a 4-dose schedule at 0, 1, 2, and 6 months. excluding chronic granulomatous disease), HIV infection, chronic renal failure, 11. Meningococcal vaccination nephrotic syndrome, leukemia, lymphoma, Hodgkin disease, generalized • General information malignancy, multiple myeloma, solid organ transplant, and iatrogenic —— Serogroup A, C, W, and Y meningococcal vaccine is available as a conjugate immunosuppression (including long-term systemic corticosteroids and (MenACWY [Menactra, Menveo]) or a polysaccharide (MPSV4 [Menomune]) radiation therapy). vaccine. —— Anatomical or functional asplenia that are indications for pneumococcal —— Serogroup B meningococcal (MenB) vaccine is available as a 2-dose series of vaccination are: sickle cell disease and other hemoglobinopathies, congenital MenB-4C vaccine (Bexsero) administered at least 1 month apart or a 3-dose or acquired asplenia, splenic dysfunction, and splenectomy. Administer series of MenB-FHbp (Trumenba) vaccine administered at 0, 2, and 6 months; pneumococcal vaccines at least 2 weeks before immunosuppressive therapy the two MenB vaccines are not interchangeable, i.e., the same MenB vaccine or an elective splenectomy, and as soon as possible to adults who are newly product must be used for all doses. diagnosed with asymptomatic or symptomatic HIV infection. —— MenACWY vaccine is preferred for adults with serogroup A, C, W, and Y • Adults aged ≥19 years with cerebrospinal fluid leaks or cochlear implants: meningococcal vaccine indications who are aged ≤55 years, and for adults administer PCV13 followed by PPSV23 at least 8 weeks after PCV13; no additional aged ≥56 years: 1) who were vaccinated previously with MenACWY vaccine dose of PPSV23 is indicated if aged <65 years. If PPSV23 was administered at age and are recommended for revaccination or 2) for whom multiple doses of <65 years, at age ≥65 years, administer another dose of PPSV23 at least 5 years vaccine are anticipated; MPSV4 vaccine is preferred for adults aged ≥56 years after the last dose of PPSV23. who have not received MenACWY vaccine previously and who require a single • Adults aged 19 through 64 years with chronic heart disease (including congestive dose only (e.g., persons at risk because of an outbreak). heart failure and cardiomyopathies, excluding hypertension), chronic lung disease —— Revaccination with MenACWY vaccine every 5 years is recommended for (including chronic obstructive lung disease, emphysema, and asthma), chronic adults previously vaccinated with MenACWY or MPSV4 vaccine who remain at liver disease (including cirrhosis), alcoholism, or diabetes mellitus, or who smoke increased risk for infection (e.g., adults with anatomical or functional asplenia cigarettes: administer PPSV23. At age ≥65 years, administer PCV13 at least 1 year or persistent complement component deficiencies, or microbiologists who after PPSV23, followed by another dose of PPSV23 at least 1 year after PCV13 and are routinely exposed to isolates of Neisseria meningitidis). at least 5 years after the last dose of PPSV23. —— MenB vaccine is approved for use in persons aged 10 through 25 years; • Routine pneumococcal vaccination is not recommended for American Indian/ however, because there is no theoretical difference in safety for persons aged Alaska Native or other adults unless they have an indication as above; however, >25 years compared to those aged 10 through 25 years, MenB vaccine is public health authorities may consider recommending the use of pneumococcal recommended for routine use in persons aged >10 years who are at increased vaccines for American Indians/Alaska Natives or other adults who live in areas with risk for serogroup B meningococcal disease. increased risk for invasive pneumococcal disease. —— There is no recommendation for MenB revaccination at this time. 9. Hepatitis A vaccination —— MenB vaccine may be administered concomitantly with MenACWY vaccine • Vaccinate any person seeking protection from hepatitis A virus (HAV) infection and but at a different anatomic site, if feasible. persons with any of the following indications: —— HIV infection is not an indication for routine vaccination with MenACWY —— men who have sex with men; or MenB vaccine; if an HIV-infected person of any age is to be vaccinated, —— persons who use injection or noninjection illicit drugs; administer 2 doses of MenACWY vaccine at least 2 months apart. —— persons working with HAV-infected primates or with HAV in a research • Adults with anatomical or functional asplenia or persistent complement laboratory setting; component deficiencies: administer 2 doses of MenACWY vaccine at least 2 —— persons with chronic liver disease and persons who receive clotting factor months apart and revaccinate every 5 years. Also administer a series of MenB concentrates; vaccine. —— persons traveling to or working in countries that have high or intermediate • Microbiologists who are routinely exposed to isolates of Neisseria meningitidis: endemicity of hepatitis A (see footnote 1); and administer a single dose of MenACWY vaccine; revaccinate with MenACWY —— unvaccinated persons who anticipate close personal contact (e.g., household vaccine every 5 years if remain at increased risk for infection. Also administer a or regular babysitting) with an international adoptee during the first 60 days series of MenB vaccine. after arrival in the United States from a country with high or intermediate • Persons at risk because of a meningococcal disease outbreak: if the outbreak endemicity of hepatitis A (see footnote 1). The first dose of the 2-dose is attributable to serogroup A, C, W, or Y, administer a single dose of MenACWY hepatitis A vaccine series should be administered as soon as adoption is vaccine; if the outbreak is attributable to serogroup B, administer a series of MenB planned, ideally 2 or more weeks before the arrival of the adoptee. vaccine. • Single-antigen vaccine formulations should be administered in a 2-dose schedule • Persons who travel to or live in countries in which meningococcal disease is at either 0 and 6–12 months (Havrix), or 0 and 6–18 months (Vaqta). If the hyperendemic or epidemic: administer a single dose of MenACWY vaccine combined hepatitis A and hepatitis B vaccine (Twinrix) is used, administer 3 doses and revaccinate with MenACWY vaccine every 5 years if the increased risk for at 0, 1, and 6 months; alternatively, a 4-dose schedule may be used, administered infection remains (see footnote 1); MenB vaccine is not recommended because on days 0, 7, and 21–30 followed by a booster dose at 12 months. meningococcal disease in these countries is generally not caused by serogroup B. 10. Hepatitis B vaccination • Military recruits: administer a single dose of MenACWY vaccine. • Vaccinate any person seeking protection from hepatitis B virus (HBV) infection and • First-year college students aged ≤21 years who live in residence halls: administer a persons with any of the following indications: single dose of MenACWY vaccine if they have not received a dose on or after their —— sexually active persons who are not in a long-term, mutually monogamous 16th birthday. relationship (e.g., persons with more than 1 sex partner during the previous 6 • Young adults aged 16 through 23 years (preferred age range is 16 through 18 months); persons seeking evaluation or treatment for a sexually transmitted years): may be vaccinated with a series of MenB vaccine to provide short-term disease (STD); current or recent injection drug users; and men who have sex protection against most strains of serogroup B meningococcal disease. with men; 12. Haemophilus influenzae type b (Hib) vaccination —— health care personnel and public safety workers who are potentially exposed • One dose of Hib vaccine should be administered to persons who have anatomical to blood or other infectious body fluids; or functional asplenia or sickle cell disease or are undergoing elective splenectomy —— persons who are aged <60 years with diabetes as soon as feasible after if they have not previously received Hib vaccine. Hib vaccination 14 or more days diagnosis; persons with diabetes who are aged ≥60 years at the discretion before splenectomy is suggested. of the treating clinician based on the likelihood of acquiring HBV infection, • Recipients of a hematopoietic stem cell transplant (HSCT) should be vaccinated including the risk posed by an increased need for assisted blood glucose with a 3-dose regimen 6–12 months after a successful transplant, regardless of monitoring in long-term care facilities, the likelihood of experiencing chronic vaccination history; at least 4 weeks should separate doses. sequelae if infected with HBV, and the likelihood of immune response to • Hib vaccine is not recommended for adults with HIV infection since their risk for vaccination; Hib infection is low. —— persons with end-stage renal disease (including patients receiving 13. Immunocompromising conditions hemodialysis), persons with HIV infection, and persons with chronic liver • Inactivated vaccines (e.g., pneumococcal, meningococcal, and inactivated disease; influenza vaccines) generally are acceptable and live vaccines generally should —— household contacts and sex partners of hepatitis B surface antigen– be avoided in persons with immune deficiencies or immunocompromising positive persons, clients and staff members of institutions for persons with conditions. Information on specific conditions is available atwww.cdc.gov/ developmental disabilities, and international travelers to regions with high or vaccines/hcp/acip-recs/index.html. intermediate levels of endemic HBV infection (see footnote 1); and —— all adults in the following settings: STD treatment facilities, HIV testing and treatment facilities, facilities providing drug abuse treatment and prevention services, health care settings targeting services to injection drug users or men who have sex with men, correctional facilities, end-stage renal disease TABLE. Contraindications and precautions to commonly used vaccines in adults 1*† Vaccine Contraindications Precautions Influenza, inactivated (IIV)2 • Severe allergic reaction (e.g., anaphylaxis) after previous dose of any • Moderate or severe acute illness with or without fever influenza vaccine; or to a vaccine component, including egg protein • History of Guillain-Barré Syndrome within 6 weeks of previous influenza vaccination • Adults with egg allergy of any severity may receive RIV; adults with hives- only allergy to eggs may receive IIV with additional safety measures2 Influenza, recombinant (RIV) • Severe allergic reaction (e.g., anaphylaxis) after previous dose of RIV or to a • Moderate or severe acute illness with or without fever vaccine component. RIV does not contain any egg protein2 • History of Guillain-Barré Syndrome within 6 weeks of previous influenza vaccination Influenza, live attenuated (LAIV)2,3 • Severe allergic reaction (e.g., anaphylaxis) to any component of the vaccine, • Moderate or severe acute illness with or without fever. or to a previous dose of any influenza vaccine • History of Guillain-Barré Syndrome within 6 weeks of previous influenza • In addition, ACIP recommends that LAIV not be used in the following vaccination populations: • Asthma in persons aged 5 years and older —— pregnant women • Other chronic medical conditions, e.g., other chronic lung diseases, chronic —— immunosuppressed adults cardiovascular disease (excluding isolated hypertension), diabetes, chronic —— adults with egg allergy of any severity renal or hepatic disease, hematologic disease, neurologic disease, and —— adults who have taken influenza antiviral medications (amantadine, metabolic disorders rimantadine, zanamivir, or oseltamivir) within the previous 48 hours; avoid use of these antiviral drugs for 14 days after vaccination Tetanus, diphtheria, pertussis • Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a • Moderate or severe acute illness with or without fever (Tdap); tetanus, diphtheria (Td) vaccine component • Guillain-Barré Syndrome within 6 weeks after a previous dose of tetanus • For pertussis-containing vaccines: encephalopathy (e.g., coma, decreased toxoid-containing vaccine level of consciousness, or prolonged seizures) not attributable to another • History of Arthus-type hypersensitivity reactions after a previous dose of identifiable cause within 7 days of administration of a previous dose of tetanus or diphtheria toxoid-containing vaccine; defer vaccination until at Tdap, diphtheria and tetanus toxoids and pertussis (DTP), or diphtheria and least 10 years have elapsed since the last tetanus toxoid-containing vaccine tetanus toxoids and acellular pertussis (DTaP) vaccine • For pertussis-containing vaccines: progressive or unstable neurologic disorder, uncontrolled seizures, or progressive encephalopathy until a treatment regimen has been established and the condition has stabilized Varicella3 • Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a • Recent (within 11 months) receipt of antibody-containing blood product vaccine component (specific interval depends on product)5 • Known severe immunodeficiency (e.g., from hematologic and solid tumors, • Moderate or severe acute illness with or without fever receipt of chemotherapy, congenital immunodeficiency, or long-term • Receipt of specific antivirals (i.e., acyclovir, famciclovir, or valacyclovir) 24 immunosuppressive therapy,4 or patients with human immunodeficiency hours before vaccination; avoid use of these antiviral drugs for 14 days after virus [HIV] infection who are severely immunocompromised) vaccination • Pregnancy Human papillomavirus (HPV) • Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a • Moderate or severe acute illness with or without fever vaccine component • Pregnancy Zoster3 • Severe allergic reaction (e.g., anaphylaxis) to a vaccine component • Moderate or severe acute illness with or without fever • Known severe immunodeficiency (e.g., from hematologic and solid tumors, • Receipt of specific antivirals (i.e., acyclovir, famciclovir, or valacyclovir) 24 receipt of chemotherapy, or long-term immunosuppressive therapy,4 or hours before vaccination; avoid use of these antiviral drugs for 14 days after patients with HIV infection who are severely immunocompromised) vaccination • Pregnancy Measles, mumps, rubella (MMR)3 • Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a • Moderate or severe acute illness with or without fever vaccine component • Recent (within 11 months) receipt of antibody-containing blood product • Known severe immunodeficiency (e.g., from hematologic and solid tumors, (specific interval depends on product)5 receipt of chemotherapy, congenital immunodeficiency, or long-term • History of thrombocytopenia or thrombocytopenic purpura 4 immunosuppressive therapy, or patients with HIV infection who are severely 6 immunocompromised) • Need for tuberculin skin testing • Pregnancy Pneumococcal conjugate (PCV13) • Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a • Moderate or severe acute illness with or without fever vaccine component, including to any vaccine containing diphtheria toxoid Pneumococcal polysaccharide • Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a • Moderate or severe acute illness with or without fever (PPSV23) vaccine component Hepatitis A • Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a • Moderate or severe acute illness with or without fever vaccine component Hepatitis B • Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a • Moderate or severe acute illness with or without fever vaccine component Meningococcal, conjugate • Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a • Moderate or severe acute illness with or without fever (MenACWY); meningococcal, vaccine component polysaccharide (MPSV4) Meningococcal serogroup B • Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a • Moderate or severe acute illness with or without fever (MenB) vaccine component Haemophilus influenzae Type b • Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a • Moderate or severe acute illness with or without fever (Hib) vaccine component 1. Vaccine package inserts and the full ACIP recommendations for these vaccines should be consulted for additional information on vaccine-related contraindications and precautions and for more information on vaccine excipients. Events or conditions listed as precautions should be reviewed carefully. Benefits of and risks for administering a specific vaccine to a person under these circumstances should be considered. If the risk from the vaccine is believed to outweigh the benefit, the vaccine should not be administered. If the benefit of vaccination is believed to outweigh the risk, the vaccine should be administered. A contraindication is a condition in a recipient that increases the chance of a serious adverse reaction. Therefore, a vaccine should not be administered when a contraindication is present. 2. For more information on use of influenza vaccines among persons with egg allergies and a complete list of conditions that CDC considers to be reasons to avoid receiving LAIV, see CDC. Prevention and control of seasonal influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices (ACIP) — United States, 2015–16 Influenza Season.MMWR 2015;64(30):818-25. 3. LAIV, MMR, varicella, or zoster vaccines can be administered on the same day. If not administered on the same day, live vaccines should be separated by at least 28 days. 4. Immunosuppressive steroid dose is considered to be >2 weeks of daily receipt of 20 mg of prednisone or the equivalent. Vaccination should be deferred for at least 1 month after discontinuation of such therapy. Providers should consult ACIP recommendations for complete information on the use of specific live vaccines among persons on immune-suppressing medications or with immune suppression because of other reasons. 5. Vaccine should be deferred for the appropriate interval if replacement immune globulin products are being administered. See CDC. General recommendations on immunization: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2011;60(No. RR-2). Available at www.cdc.gov/vaccines/pubs/pinkbook/index.html. 6. Measles vaccination might suppress tuberculin reactivity temporarily. Measles-containing vaccine may be administered on the same day as tuberculin skin testing. If testing cannot be performed until after the day of MMR vaccination, the test should be postponed for at least 4 weeks after the vaccination. If an urgent need exists to skin test, do so with the understanding that reactivity might be reduced by the vaccine. * Adapted from CDC. Table 6. Contraindications and precautions to commonly used vaccines. General recommendations on immunization: recommendations of the Advisory Committee on Immunization Practices. MMWR 2011;60(No. RR-2):40–41 and from Hamborsky J, Kroger, A, Wolfe C, eds. Appendix A. Epidemiology and prevention of vaccine preventable diseases. 13th ed. Washington, DC: Public Health Foundation, 2015. Available at www.cdc.gov/vaccines/pubs/pinkbook/index.html. † Regarding latex allergy, consult the package insert for any vaccine administered.

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