Standing Order Template s3

Meningococcal Conjugate Vaccine as MenACYW-CRM (Menveo), Protocol for At-risk Persons Age 2 months and Older

1. CONDITION FOR PROTOCOL: To reduce incidence of morbidity and mortality of Neisseria meningitidis disease types A, C, Y, and W-135 in at risk persons ages 2 months and older.

2. POLICY OF PROTOCOL: The nurse will implement this MCV4-CRM protocol.

3. CONDITION-SPECIFIC CRITERIA AND PRESCRIBED ACTIONS: For persons adopting these protocols: The criteria below list indications, contraindications, and precautions that are necessary to implement the vaccine protocol. The prescribed actions include examples shown in [ ] but may not suit your institution’s clinical situation and may not include all possible actions. A licensed prescriber must review the criteria and actions and determine the appropriate action to be prescribed. (Delete this paragraph before version is signed.) Criteria Prescribed Action

Give MenACYW-CRM if meets indication criteria and has Person is currently not acutely ill. no contraindication or precautions.

Give MenACYW-CRM primary series or booster if has no Person age 2 months or older at increased risk for N. contraindications or precautions. ACIP recommends off- meningitidis due to medical indications: label use of MCV4 for persons 56 years and older when multiple doses [i.e., boosters every 5 years] will be  Anatomic or functional asplenia needed.)  Complement component deficiency [Refer persons 56 years and older to primary care provider for administration of off-label MenACYW] [Initiate MenACYW-CRM primary series or give booster dose, regardless of age, if no contraindications or precautions.] (ACIP recommends off-label use of MCV4 Person with routine exposure to isolates of N. for persons 56 years and older when multiple doses [i.e., meningitidis.

s boosters every 5 years] will be needed.) n

o [Refer to primary care provider if 56 year or older for i t

a administration of off-label MenACYW] c i

d Person age 2 months through 55 years at increased n I risk for N. meningitidis due to non-medical-related indications:  traveling to area with hyper-endemic or endemic meningococcal disease Give MenACYW-CRM if has no contraindications or  part of community outbreak caused by a serotype precautions. included in the vaccine  military recruit  first year college student living in residential campus housing Reschedule vaccination when child meets age criteria of Child is less than age 6 weeks. age 6 weeks. Person is age 56 years or older and requires [Follow meningococcal polysaccharide, 4-valent vaccine meningococcal vaccination for travel or due to an (MPSV4) protocol.] outbreak. -

a Person had a life-threatening allergic reaction r

t Do not vaccinate; ______

n (anaphylaxis) to a previous dose of MCV4 vaccine. o C s n o

i Person has a life-threatening allergy to a component of t Do not vaccinate; ______a MCV4 vaccine. c i d n i a

c Person has a mild illness defined as temperature less Proceed to vaccinate. e

r than ____°F/°C with symptoms such as: {to be P Document reviewed and updated:______– Sample protocol: MCV4-CRM (Menveo) At-risk – MDH rev:07-2014 Document reviewedDocument and updated:______P above factors.above risk meningococcalvaccination due to any of the HIV-positiveperson requires who microbiologist) isolatesof deficiency,component routine exposure to or anatomic functionalasplenia, complement the indicate multipleneed (i.e.,for doses 56years olderor      factors: risk years 2 through 55years   factors: years 2 and followingolder the risk with initiating If at ageseries through 7 23months months 2 through 18months RESCRIPTION

  utions meningitidis exposureroutine to isolatesof younger residential in living housing college First year studentage or 21 years recruit military serotype in included vaccine;the outbreakpart of community acaused by endemicmeningococcal disease; travelingto areawith orhyper-endemic Complementcomponent deficiency or Anatomic functionalasplenia as: {to be determinedmedical by prescriber} temperature ____°F/°C higherwith or such symptoms Person moderate hasa to severe illness definedas determinedby medical prescriber} May giveMay atsame the astime routinely other scheduledvaccines. MenACYW-CRM (Menveo)Give ml, 0.5IM. schedule Follow as in described below.table N. :

meningitidis (e.g., microbiologist)(e.g., and hasriskand thatfactors Age (e.g., with followingthe N. – Sampleprotocol: (Menveo)MCV4-CRM At-risk– Give 2 doses Give age-appropriate with interval; providebooster needed if previouslyvaccinated months 2 notif apart 2 doses,Give 1 doseGive previouslyvaccinated months 2 notif apart 2 doses,Give months 3 apart 2 doses,Give 12-15and months at 2m,6m, Give 4m, usingage/riskindications above. Primaryseries prescriber} vaccination Defer {to and be determined medical by   years 3 later, then every years 5 years 3 later, then every years 5 Every 5 Every years   onlyanother if Give indication risk occurs older 5 Every yearspersons for 7 & years years 3 later youngerif than 7age years 5 years persons5 later for 7 & years older years 3 later youngerif than 7 years Booster Booster schedule MDH rev:07-2014 MDH 4. MEDICAL EMERGENCY OR ANAPHYLAXIS: [Depending on clinic staffing, include one of the two options below.]

In the event of a medical emergency related to the administration of a vaccine. RN will apply protocols as described in ______.

In the event of an onset of symptoms of anaphylaxis including:

o rash o itchiness of throat o swollen tongue or throat

o difficulty breathing o bodily collapse

LPN or unlicensed assistive personnel (MA) will immediately contact the RN in order to implement the ______.

5. QUESTIONS OR CONCERNS: In the event of questions or concerns, call Dr. ______at ______.

This protocol shall remain in effect for all patients of ______until rescinded or until

______.

Name of prescriber: ______

Signature:______

Date:______

Document reviewed and updated:______– Sample protocol: MCV4-CRM (Menveo) At-risk – MDH rev:07-2014