Volume 18 – Number 3 October 2014 (Content current VACCINATE ADULTS! as of October 21) from the Action Coalition — www.immunize.org

New ACIP Recommendations Include Important Changes What’s In This Issue for the Use of Influenza and Pneumococcal ACIP Recommendations: An Update ...... 1 Ask The Experts: CDC Answers Questions...... 1 Influenza New! Visit “Adult Vaccination” on Immunize.org... 2 The Centers for Disease Control and Prevention tions of ACIP” in MMWR available at www.cdc. Highlights ...... 4 (CDC) published its updated influenza recommen- gov/mmwr/pdf/wk/mm6337.pdf, pages 822–825. dations titled “Prevention and Control of Seasonal It is now recommended that all adults age 65 Checklist for Vaccine Contraindications...... 5 Influenza with Vaccines: Recommendations of years and older receive both pneumococcal con- New! Standing Orders: How to Use Them…...... 6 ACIP—U.S., 2014–15 Influenza Season” in the jugate vaccine (PCV13, Prevnar 13, ) and Medical Management of Vaccine Reactions...... 7 August 15 issue of MMWR available at www.cdc. pneumococcal polysaccharide vaccine (PPSV23, New! Foodborne Hepatitis A Outbreaks ...... 8 gov/mmwr/pdf/wk/mm6332.pdf, pages 691–697. Pneumovax, Merck). Both PCV13 and PPSV23 New! Patient Handouts on .... 9 All people age 6 months and older who do not have should be administered routinely in series to all CDC Fact Sheet: Adult Pneumococcal Vaccines .... 10 contraindications should receive influenza vacci- adults age 65 years and older. For specific details about timing and spacing of these doses, refer to 2014–15 Influenza VISs in Many Languages .... 11 nation annually—this has been a core ACIP recom- mendation since the 2010–11 influenza season. For the published recommendations as well as IAC’s Mandatory Influenza Vaccination Policies .....12-13 IAC’s up-to-date screening checklists for precau- “Ask the Experts” on page 23. Also, see page 10 for Screening Checklists for Contraindications tions and contraindications to influenza vaccina- a two-page CDC fact sheet for patients and provid- to Influenza Vaccines...... 14-15 tion for adults, see pages 14 and 15 of this issue. ers titled “Pneumococcal Vaccines (PCV13) and Standing Orders for Influenza Vaccines...... 16 For complete details about (PPSV23): Addressing Common Questions about Influenza Vaccination and Egg Allergy...... 17 use in 2014–15, including contraindications and Pneumococcal Vaccination for Adults.” Influenza Materials for Healthcare Professionals.... 18 precautions, consult the ACIP recommendations. Influenza Handouts for Patients...... 19 Influenza Vaccine Products for 2014–2015...... 20 Pneumococcal Vaccination Immunization questions? On September 19, CDC published “Use of How to Give IM, ID, and IN Flu Vaccines...... 21 13-Valent Pneumococcal and • Email [email protected] Seek Emergency Medical Care for Your Family.... 22 23-Valent Pneumococcal Polysaccharide Vaccine • Call your state health dept. (phone numbers IAC’s Immunization Resources Order Form...... 24 Among Adults Aged ≥65 Years: Recommenda- at www.immunize.org/coordinators)

severe allergy to eggs with symptoms sugges- older. Can we give both vaccines at the same Ask the tive of , then the provider can use a visit? recombinant influenza vaccine (RIV3, Flublok, According to the ACIP recommendations pub- Protein Sciences) that is egg-free. Unlike current lished in September 2014, both pneumococcal Experts production methods for other available seasonal conjugate vaccine (PCV13, Prevnar 13, Pfizer) and influenza vaccines, production of RIV3 does not pneumococcal polysaccharide vaccine (PPSV23, use the whole influenza or chicken eggs in Pneumovax, Merck) should be administered its manufacturing process. If RIV3 is not available routinely in a series to all adults age 65 years and

or the person is not age-eligible, then inactivated ▲ Ask the Experts . . . continued on page 23 influenza vaccine should be administered by a physician with experience in the recognition and management of severe allergic conditions. FEDERAL and A study has now been published (N Engl J MILITARY Med 2014; 371:635–45) that found that the injectable vaccine Fluzone High-Dose () EMPLOYEES protects people 65 years and older better than Donna L. Weaver, RN, MN Andrew T. Kroger, MD, MPH standard-dose Fluzone. Does ACIP preferen- Make the tially recommend use of Fluzone High-Dose The Immunization Action Coalition thanks medi- for all people age 65 years and older? Immunization Action Coalition cal officer Andrew T. Kroger, MD, MPH, and Despite published evidence of better protection your charity of choice for the nurse educator Donna L. Weaver, RN, MN, both from Fluzone High-Dose when compared to Combined Federal Campaign. from the National Center for Immunization and standard-dose Fluzone, ACIP has not stated a Respiratory Diseases at the Centers for Disease Use agency code Control and Prevention. preference for this vaccine for people age 65 years and older. #10612 Influenza vaccine The Immunization Action Coalition is a 501(c)(3) charitable organization I’ve heard there is a newer influenza vaccine and your contribution is tax-deductible Please describe the new ACIP recommenda- that can be given to people with severe egg to the fullest extent of the law. allergy. Is that true? tions for the use of PCV13 vaccine along with Yes. If someone age 18 through 49 years has a PPSV23 vaccine in people age 65 years and Vaccinate Adults! online at www.immunize.org/va Immunization Action Coalition New! Visit “Adult Vaccination” 2550 University Ave. W., Suite 415 North Saint Paul, MN 55114 Phone: (651) 647-9009 on immunize.org Email: [email protected] To provide one-stop access to practical and clinically Websites: www.immunize.org www.vaccineinformation.org relevant information about vaccinating adults, www.immunizationcoalitions.org the Immunization Action Coalition (IAC) has Vaccinate Adults is a publication of the developed a new section on immunize.org titled Immunization Action Coalition (IAC) writ- “Adult Vaccination.” Visit www.immunize.org/adult- ten for health professionals. Content is re- vaccination often! viewed by the Centers for Disease Control­ and Prevention (CDC) for technical accuracy. The new web page brings together resources from This publication is supported by CDC Grant No. U38IP000589. The content is solely the multiple sources, including CDC, the National Vaccine responsibility of IAC and does not neces- Advisory Committee (NVAC), state health depart- sarily represent the official views of CDC. ments, professional societies, medical journals, and ISSN 1526-1824. IAC. You’ll find helpful vaccination-related resources, Publication Staff Executive Editor: Deborah L. Wexler, MD such as Advisory Committee on Immunization Prac- Editor: Mary Quirk tices (ACIP) recommendations, educational materials Associate Editor: Diane C. Peterson for healthcare providers, videos, selected journal Consulting Editors: Teresa Anderson, DDS, articles, patient handouts, PowerPoint presentations, MPH; Marian Deegan, JD; Linda Moyer, RN and much more. Editorial Assistant: Janelle T. Anderson, MA Layout: Kathy Cohen Adult Vaccination Resources Library Website Design: Sarah Joy IAC’s online library gives healthcare providers and www.immunize.org/adult-vaccination IAC Staff the general public quick access to reliable, science- Chief Strategy Officer: L.J (Litjen) Tan, MS, PhD based information about adult immunization. Recently updated, the IAC library now includes approximately Assoc. Director for Immunization Education: that their adult patients are fully immunized and have William L. Atkinson, MD, MPH 250 adult immunization resources from a variety of maximum protection from serious diseases. CDC has Associate Director for Research: sources. Materials are available in many media formats, created new materials to assist healthcare professionals Sharon G. Humiston, MD, MPH including print, video, online, web-on-demand, and in implementing NVAC's new standards, including a Coordinator for Public Health: interactive. Access the library at www.immunize.org/ Laurel Wood, MPA series of fact sheets encouraging improvement of vac- adult-vaccination/resources.asp. Coordinator for Hepatitis B Projects: cine assessment, recommendation, administration, and Lynn Pollock, RN, MSN referral. Access information on the NVAC standards at Adult Handouts for Patients and Staff Sr. Admin. for Grants and Leadership: www.immunize.org/adult-vaccination. Julie Murphy, MA IAC’s new Adult Vaccination Handouts section, www. Operations Manager: Robin VanOss immunize.org/handouts/adult-vaccination.asp, features Journal Articles Associate Operations Manager: Casey Pauly more than 50 educational pieces for healthcare profes- Be sure to check out IAC’s newest resource listing of IAC publishes a free email news service (IAC sionals and their patients. From screening checklists more than 100 key medical journal articles about adult Express) and two free periodicals (Needle to patient information materials, this collection helps Tips and Vaccinate Adults). To subscribe, go vaccination at www.immunize.org/journalarticles/ you carry out your vaccination activities. Several pa- to www.immunize.org/subscribe. peop_adults.asp. IAC, a 501(c)(3) charitable organization, pub- tient handouts are also available in Spanish and other lishes practical immunization information for languages. Also, don’t miss IAC’s series of standing And finally, stay up to date on adult vaccination by health professionals to help increase immuniza- orders for adult vaccination; all are available at www. signing up to receive Vaccinate Adults, IAC’s quarterly tion rates and prevent disease. immunize.org/standing-orders. periodical on adult vaccination. We also suggest that The Immunization Action Coalition is you subscribe to our weekly email news service, IAC also supported by Merck Sharp & Dohme Corp. NVAC’s Standards for Adult Immunization Express. Once you complete the sign-up form at www. Novartis Vaccines • Pfizer Inc. Earlier this year, NVAC released “Standards for Adult immunize.org/subscribe, you’ll start receiving weekly • AstraZeneca Immunization Practice.” The updated NVAC standards news and information via email about the latest news GlaxoSmithKline • bioCSL Inc. ask healthcare professionals to take steps to ensure in immunization. Ortho Clinical Diagnostics, Inc. Physicians’ Alliance of America American Pharmacists Association many other generous donors To receive “Question of the Week” by email, subscribe to IAC maintains strict editorial independence in its publications. IAC Express, the Immunization Action Coalition’s e-news IAC Board of Directors and information service at www.immunize.org/subscribe Stephanie L. Jakim, MD Olmsted Medical Center Sheila M. Specker, MD DISCLAIMER: Vaccinate Adults! is available to all readers free of charge. Some of the information in this issue is supplied to us by the University of Minnesota Centers for Disease Control and Prevention in Atlanta, Georgia, and some information is supplied by third-party sources. The Immuniza- tion Action Coalition (IAC) has used its best efforts to accurately publish all of this information, but IAC cannot guarantee that the original Debra A. Strodthoff, MD information as supplied by others is correct or complete, or that it has been accurately published. Some of the information in this issue is Amery Regional Medical Center created or compiled by IAC. All of the information in this issue is of a time-critical nature, and we cannot guarantee that some of the in- Deborah L. Wexler, MD formation is not now outdated, inaccurate, or incomplete. IAC cannot guarantee that reliance on the information in this issue will cause no Immunization Action Coalition injury. Before you rely on the information in this issue, you should first independently verify its current accuracy and completeness. IAC is not licensed to practice medicine or pharmacology, and the providing of the information in this issue does not constitute such practice. Any claim against IAC must be submitted to binding arbitration under the auspices of the American Arbitration Association in St. Paul, Minnesota.

2 Vaccinate Adults! • October 2014 • Immunization Action Coalition • (651) 647-9009 • www.immunize.org • www.vaccineinformation.org Advisory Board

Liaisons from Organizations Where in the world is IAC? Bernadette A. Albanese, MD, MPH Council of State & Territorial Epidemiologists Stephen L. Cochi, MD, MPH We have settled into our newly designed Nat’l Ctr. for Immun. & Resp. Diseases, CDC Paul Etkind, DrPH, MPH offices at the dynamic Court International Please mark down our new address Nat’l. Assn. of County & City Health Officials Bruce Gellin, MD, MPH building in a vibrant area of Saint Paul, so you can come visit when you’re National Vaccine Program Office, DHHS Minnesota. in town: Neal A. Halsey, MD Institute for Vaccine Safety, Johns Hopkins Univ. Claire Hannan, MPH Immunization Action Coalition Association of Immunization Managers Carol E. Hayes, CNM, MN, MPH 2550 University Avenue West American College of Nurse-Midwives Gregory James, DO, MPH, FACOFP Suite 415 North American Osteopathic Association Saint Paul, MN 55114 Samuel L. Katz, MD Pediatric Infectious Diseases Society (651) 647-9009 Elyse Olshen Kharbanda, MD, MPH Society for Adolescent Health and Medicine Marie-Michele Leger, MPH, PA-C American Academy of Physician Assistants Harold S. Margolis, MD Nat’l Ctr. for Emerg. & Zoonotic Inf. Diseases, CDC Martin G. Myers, MD Wallet-sized immunization record cards for all ages: National Network for Immunization Information Kathleen M. Neuzil, MD, MPH For adults, children & teens, and for a lifetime! American College of Physicians Paul A. Offit, MD Now you can give any patient a permanent vaccination record Vaccine Education Ctr., Children’s Hosp. of Phila. Walter A. Orenstein, MD card designed specifically for their age group: adult, child & teen, or Emory Vaccine Center, Emory University lifetime. These brightly colored cards are printed on durable rip-, Mitchel C. Rothholz, RPh, MBA American Pharmacists Association smudge-, and water-proof paper. To view the cards or for more Thomas N. Saari, MD details, go to www.immunize.org/shop and click on the images. American Academy of Pediatrics William Schaffner, MD Infectious Diseases Society of America Buy 1 box (250 cards) for $45 (first order of a 250-card box comes Anne Schuchat, MD Nat’l Ctr. for Immun. & Resp. Diseases, CDC with a 30-day, money-back guarantee). Discounts for larger orders: Rhoda Sperling, MD 2 boxes $40 each; 3 boxes $37.50 each; 4 boxes $34.50 each Amer. College of Obstetricians & Gynecologists Thomas E. Stenvig, RN, PhD American Nurses Association To order, visit www.immunize.org/shop, or use the order form on page 24. Kathryn L. Talkington, MPAff Assn. of State & Territorial Health Officials To receive sample cards, contact us: [email protected] Ann S. Taub, MA, CPNP National Assn. of Pediatric Nurse Practitioners John W. Ward, MD Division of Viral Hepatitis, NCHHSTP, CDC Patricia N. Whitley-Williams, MD, MPH National Medical Association Walter W. Williams, MD, MPH "Immunization Techniques — Best Practices Nat’l Ctr. for Immun. & Resp. Diseases, CDC with Infants, Children, and Adults" Individuals The California Department of Public Health, Immunization Branch, Hie-Won L. Hann, MD Jefferson Medical College, Philadelphia, PA updated its award-winning training video, “Immunization Tech- Mark A. Kane, MD, MPH niques: Best Practices with Infants, Children, and Adults.” The Consultant, Seattle, WA Edgar K. Marcuse, MD, MPH 25-minute DVD can be used to train new employees and to University of Washington School of Medicine Brian J. McMahon, MD refresh the skills of experienced staff on administering injectable, Alaska Native Medical Center, Anchorage, AK oral, and nasal-spray vaccines to children, teens, and adults. Stanley A. Plotkin, MD Vaxconsult.com Make sure your healthcare setting has the 2010 edition! Gregory A. Poland, MD Mayo Clinic, Rochester, MN The cost is $17 each for 1–9 copies; $10.25 each for 10–24 Sarah Jane Schwarzenberg, MD University of Minnesota copies; $7 each for 25–49 copies; $5.75 each for 50–99 copies. Coleman I. Smith, MD Minnesota Gastroenterology, Minneapolis, MN To order, visit www.immunize.org/shop, or use the order form on page 24. Richard K. Zimmerman, MD, MPH University of Pittsburgh For 100 or more copies, contact us for discount pricing: [email protected]

For healthcare settings in California, contact your local health department immunization program for a free copy.

Vaccinate Adults! • October 2014 • Immunization Action Coalition • (651) 647-9009 • www.immunize.org • www.vaccineinformation.org Vaccinate Adults! • October 2014 • Immunization Action Coalition • (651) 647-9009 • www.immunize.org • www.vaccineinformation.org 3 Vaccine Highlights Subscribe to IAC Express! Recommendations, schedules, and more www.immunize.org/subscribe Editor's note: The information in Vaccine High- lights is current as of October 21, 2014. Influenza vaccine news Get weekly On Aug. 19, CDC issued two updated influenza updates on Next ACIP meetings Vaccine Information Statements (VISs). The VIS for IIV is intended for use with all injectable for- vaccine A committee of 15 national experts, the Advisory mulations. The VIS for LAIV is intended for use information Committee on Immunization Practices (ACIP), when administering nasal-spray vaccine. Access advises CDC on the appropriate use of vaccines. the IIV VIS in English and 18 translations at www. while ACIP meets three times a year in Atlanta; meet- immunize.org/vis/vis_flu_inactive.asp. The LAIV ings are open to the public and available online via VIS and 17 translations are available at www.im- it’s still live webcast. The next meetings will be held on munize.org/vis/vis_flu_live.asp. Oct. 29–30 and Feb. 25–26. For more information, news! visit www.cdc.gov/vaccines/acip. ACIP periodically issues recommendations on HPV vaccine news All the news we publish in the use of vaccines; they are published and readily On Aug. 29, CDC published Human Papilloma- available in the Morbidity and Mortality Weekly virus Vaccination: Recommendations of the ACIP “Vaccine Highlights” will be sent by Report (MMWR). Clinicians who vaccinate should (MMWR 2014; 63[RR5]), a compendium of all cur- email to you every Tuesday. Free! have a current set for reference. Here are sources: rent recommendations for the use of HPV vaccines. • Download from IAC’s website at: See www.cdc.gov/mmwr/pdf/rr/rr6305.pdf. To sign up for IAC Express—and any of www.immunize.org/acip. • Download from CDC’s website at: our other free publications—visit www.cdc.gov/vaccines/hcp/acip-recs. news In addition, extensive information on ACIP meet- On Aug. 22, CDC published “Update on Recom- www.immunize.org/subscribe ings is available at www.cdc.gov/vaccines/acip/ mendations for Use of Herpes Zoster Vaccine” meetings/meetings-info.html. (MMWR 2014; 63[33]), in which ACIP maintains its current recommendation that zoster vaccine be routinely recommended for adults age 60 years and Pneumococcal vaccine news older. Access the recommendations at www.cdc. On Sept. 19, CDC published “Use of 13-Valent gov/mmwr/pdf/wk/mm6333.pdf, pages 729–31. information for healthcare providers at www.cdc. Pneumococcal Conjugate Vaccine and 23-Valent gov/vhf/ebola/hcp/index.html. Pneumococcal Polysaccharide Vaccine Among Ebola news Adults Aged ≥65 Years: Recommendations of the ACIP” (MMWR 2014; 63[37]). At its special On Aug. 6–7, the WHO director-general convened Current VIS dates meeting on August 13, ACIP voted to recommend an Emergency Committee meeting regarding the a dose of PCV13 (Prevnar 13, Pfizer) in series with 2014 Ebola virus disease outbreak in West Africa. Check the dates on your supply of Vaccine PPSV 23 (Pneumovax, Merck) for all adults age 65 It was the committee’s unanimous view that the Information Statements (VISs). If any are years and older. For detailed information, access conditions for a Public Health Emergency of In- outdated, get current versions and VISs in more the recommendations at www.cdc.gov/mmwr/pdf/ ternational Concern had been met. For updates on than 30 languages at www.immunize.org/vis. wk/mm6337.pdf, pages 822–5. the Ebola outbreak, access CDC’s website on Ebola Adenovirus...... 6/11/14 Meningococcal....10/14/11 Anthrax...... 3/10/10 Multi-vaccine..unavailable Chickenpox...... 3/13/08 Expected mid-2014 DTaP...... 5/17/07 PCV13...... 2/27/13 Hib...... 2/4/14 PPSV...... 10/6/09 Hepatitis A...... 10/25/11 Polio...... 11/8/11 To find more than 1,000 “Ask the Experts” Q&As answered Hepatitis B...... 2/2/12 Rabies...... 10/6/09 by CDC experts, visit HPV-...... 5/3/11 Rotavirus...... 8/26/13 To find more than 1,000 “Ask the Experts” Q&As answered HPV-...... 5/17/13 Shingles...... 10/6/09 www.immunize.org/askexperts Influenza...... 8/19/14 Td...... 2/4/14 by CDC experts, visit Japanese enceph...1/24/14 Tdap...... 5/9/13 www.immunize.org/askexperts MMR...... 4/20/12 Typhoid...... 5/29/12 To receive “Ask the Experts – Question of the Week” by email, MMRV...... 5/21/10 Yellow fever.....3/30/11 To receive “Ask subscribethe Experts to – IAC Question Express of at the Week” by email, www.immunize.org/subscribe  subscribe to IAC Express at For a ready-to-print version of this table for www.immunize.org/subscribe posting in your practice, go to www.immunize. org/catg.d/p2029.pdf.

4 Vaccinate Adults! • October 2014 • Immunization Action Coalition • (651) 647-9009 • www.immunize.org • www.vaccineinformation.org Screening Checklist for Contraindications to Vaccines for Adults

Patient name: Date of birth: (mo.) (day) (yr.) This checklist covers precau- tions and contraindications to Screening Checklist for Contraindications to vaccination. 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 Ask your patients to complete means additional questions must be asked. If a question is not clear, please ask your healthcare provider to explain it. the checklist on page 1. Page 2 Don’t Yes No Know is not for patients, it is reference 1. Are you sick today?    material for you. 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?    Information for Health Professionals about the Screening Checklist for Contraindications To Vaccines for Adults 4. Do you have a long-term health problem with heart disease, lung disease, asthma, Are you interested in knowing  why  we included a certain question on the screening checklist? If so, read the information kidney disease, metabolic disease (e.g., diabetes), anemia, or other blood disorder? below. If you want to find out even more, consult the references listed at the bottom of this page.

5. Do you have cancer, leukemia, HIV/AIDS, or any other problem?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] 6. In the past 3 months, have you taken medications that weaken your immunevaccine system, 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 such as cortisone, prednisone, other steroids, or anticancer drugs, or have youMild illnesseshad (such as upper respiratory  or diarrhea) are NOT neurologic problem is a precaution to the use of Tdap. For people with stable radiation treatments? 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 7. Have you had a seizure or a brain or other nervous system problem? 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) 8. During the past year, have you received a transfusion of blood or blood products,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 - . A  local reaction  to a prior  vaccine dose or vaccine compo- fluenza vaccine, vaccinate with IIV if at high risk for severe influenza complications. or been given immune (gamma) globulin or an antiviral drug? 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 9. For women: Are you pregnant or is there a chance you could become pregnant antiviral drug? [LAIV, MMR, VAR] appendices/B/latex-table.pdf. For  an extensive  list of vaccine components, see during the next month? 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 through 49 years with egg allergy of any severity who have no other recommendations for current information on intervals between antiviral drugs, 10. Have you received any in the past 4 weeks? contraindications. People who do not meet the age criteria for RIV3 who have immune globulin or blood product administration and live virus vaccines. (1) experienced a serious systemic or anaphylactic reaction (e.g., hives, swelling 9. For women: Are you pregnant or is there a chance you could of the lips or tongue, acute respiratory distress, or collapse) after eating eggs become pregnant during the next month? [MMR, LAIV, VAR, ZOS] Form completed by: ______can usually Date: be vaccinated______with inactivated influenza vaccine (IIV); consult ACIP Live virus vaccines (e.g., MMR, VAR, ZOS, LAIV) are contraindicated one recommendations (see reference 3). month before and during pregnancy because of the theoretical risk of virus Form reviewed by: ______3. Have Date: 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 Did you bring your immunization record card with you? or vaccine yes component no is a contraindication for subsequent doses (1). Under grounds, inactivated poliovirus vaccine should not be given during pregnancy; It is important for you to have a personal record of your vaccinations. If younormal don’t circumstances, have a personal vaccines record,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 ask your healthcare provider to give you one. Keep this record in a safe placea community and bring pertussis it with outbreak). you every contraindicated in pregnancy. At the provider’s discretion, either vaccine may time you seek medical care. Make sure your healthcare provider records all your vaccinations on it. 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? Technical contentdiabetes), reviewed anemia,by the Centers or for otherDisease Control blood and disorder? Prevention [LAIV] [LAIV, MMR, VAR, yellow fever] People who were given either LAIV or an in- Immunization Action Coalition Saint Paul, Minnesota • 651-647-9009 • www.immunize.orgThe safety • www.vaccineinformation.org of intranasal live attenuated influenza vaccine (LAIV) in people with jectable live virus vaccine (e.g., MMR, VAR, ZOS, yellow fever) should wait 28 www.immunize.org/catg.d/p4065.pdfthese conditions has not been •established. Item #P4065 These (9/14) 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--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- For a ready-to-copy 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 (3, 4, 5). mm6332.pdf, pages 691–7. 4. CDC. Measles, mumps, and rubella—vaccine use and strategies for elimination 8⅟2 x 11" version of this 6. In the past 3 months, have you taken medications that weak- of measles, rubella, and congenital rubella syndrome and control of mumps. en your immune system, such as cortisone, prednisone, other MMWR 1998; 47 (RR-8). steroids, or anticancer drugs, or have you had radiation treat- 5. CDC. Prevention of varicella: Recommendations of the Advisory Committee on Im- 2-page piece, visit ments? [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 www.immunize.org/ 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 catg.d/p4065.pdf 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

Vaccinate Adults! • October 2014 • Immunization Action Coalition • (651) 647-9009 • www.immunize.org • www.vaccineinformation.org 5 Technical content reviewed by the Centers for Disease Control and Prevention • www.immunize.org/catg.d/p3066.pdf • Item #P3066 (10/14)

Using Standing Orders for Administering Vaccines: What You Should Know

What are standing orders? 4. provision of any federally required information (e.g., Vaccine Information Statement); Standing orders authorize nurses, pharmacists, and The use of standing 5. how to document vaccination in the patient record; other appropriately trained healthcare personnel, where orders for vaccination 6. a protocol for the management of any medical allowed by state law, to assess a patient’s immuniza- facilitates the delivery emergency related to the administration of the vac- tion status and administer vaccinations according to a cine; and protocol approved by an institution, physician, or other of immunization 7. how to report possible adverse events occurring services to patients in authorized practitioner. The standing orders work by after vaccination. enabling assessment and vaccination of the patient with- clinics, hospitals, and out the need for clinician examination or direct order Who is authorized to administer vaccines under community settings. from the attending provider at the time of the interaction. Standing orders can be established for the administra- standing orders? Standing orders tion of one or more specific vaccines to a broad or narrow Each of the 50 states separately regulates the practice set of patients in healthcare settings such as clinics, have been shown to of medicine, nursing, pharmacy, and other health-related hospitals, pharmacies, and long-term care facilities. practitioners. For further information about who can increase vaccination carry out standing orders in your state, contact your state coverage rates. Who recommends standing orders for immunization program or the appropriate state body vaccination? (e.g., state board of medical/nursing/pharmacy practice). The Community Preventive Services Task Force (Task Who is authorized to sign the standing order? Force): The Task Force1 recommends standing orders for vaccinations based on strong evidence of effective- In general, standing orders are approved by an institu- ness in improving vaccination rates: tion, physician, or authorized practitioner. State law ▼ 1. in adults and children, or regulatory agency might authorize other healthcare Go to 2. when used alone or when combined with addition- professionals to sign standing orders. www.immunize.org/ al interventions, and standing-orders 3. across a range of settings and populations. What should be done with the standing orders for the most current Read the full Task Force Finding and Rationale State- after they have been signed? versions of sample ment at www.thecommunityguide.org/vaccines/ Signed standing orders should be kept with all other standing orders standingorders.html signed medical procedures and protocols that are The Centers for Disease Control and Prevention (CDC): operational in one’s clinic setting. A copy should also CDC’s Advisory Committee on Immunization Practices be available for clinic staff who operate under those (ACIP) specifically recommends standing orders for standing orders. influenza and pneumococcal vaccinations and several other vaccines (e.g., hepatitis B, varicella). See Use of Do standing orders need to be renewed Standing Orders Programs to Increase Adult Vaccination (e.g., yearly)? footnote Rates: Recommendations of the ACIP. MMWR 2000;49 1 The Task Force was established (No. RR-1) at www.cdc.gov/mmwr/preview/mmwrhtml/ Generally, standing orders will include an implementation in 1996 by the U.S. Department of Health and Human Services rr4901a2.htm. date as well as an expiration date. Periodic review of to identify population health in- standing orders is important, because vaccine recom- terventions that are scientifically What are the elements of a standing order? mendations may change over time. proven to save lives, increase life­spans, and improve quality of A comprehensive standing order should include the life. The Task Force produces Where can I find sample standing orders? recommendations (and identifies following elements: evidence gaps) to help inform 1. who is targeted to receive the vaccine; The Immunization Action Coalition has developed tem- the decision making of federal, 2. how to determine if a patient needs or should plates of standing orders for vaccines that are routinely state, and local health depart- ments, other government agencies, receive a particular vaccination (e.g., indications, recommended to children and adults. They are updated communities, healthcare providers, contraindications, and precautions); as needed and reviewed for technical accuracy by immu- employers, schools, and research 3. procedures for administering the vaccine (e.g., vac- nization experts at CDC. The most current versions organizations. For more infor-mation, see www.thecommunityguide. cine name, schedule for vaccination, appropriate can be accessed by going to www.immunize.org/ org/index.html. needle size, vaccine dosage, route of administration); standing-orders.

6 Vaccinate Adults! • October 2014 • Immunization Action Coalition • (651) 647-9009 • www.immunize.org • www.vaccineinformation.org Medical Management of Vaccine Reactions in Adult Patients

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 Visit www.immunize.org/ of Vaccine Reactions vaccine is administered. Even with careful screening, reactions may occur. These reactions can vary from trivial and inconven- in Adult Patients ient (e.g., soreness, itching) to severe and life threatening catg.d/p3082.pdf (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.  Table describes procedures at the injection site Consider giving an analgesic (pain reliever) or antipruritic (anti-itch) medication. you can follow if various Slight bleeding Apply an adhesive compress over the injection site.

Continuous bleeding Place thick layer of gauze pads over site and reactions occur. 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. Medical Management of Vaccine Reactions in Adults (continued) page 2 of 2 Loss of consciousness Check the patient to determine if injury is present

before attempting to move the patient. Place Emergency medical protocol for management of anaphylactic patient flat on back with feet elevated. Call 911 if Needed medications for a reactions in adults patient does not recover immediately.community immunization clinic If itching and swelling are confined to the injection site where the vaccina- first-line medication 1 Anaphylaxis Sudden or gradual onset of generalized See “Emergency Medical Protocol for Manage - Epinephrine, aqueous 1:1000 (i.e., tion was given, observe patient closely for the development of generalized itching, erythema (redness), or urticaria ment of Anaphylactic Reactions in Adults”1 mg/mL) on dilution,the in ampules, vials of symptoms. (hives); angioedema (swelling of the next page for detailed steps to follow insolution, treating or prefilled syringes, including 2 If symptoms are generalized, activate the emergency medical system lips, face, or throat); severe broncho­ anaphylaxis. epinephrine autoinjectors (e.g., EpiPen and Auvi-Q). If autoinjectors are stocked, (EMS; e.g., call 911) and notify the patient’s physician. This should be done spasm (wheezing); shortness of breath; at least three should be available. shock; abdominal cramping; or cardio- by a second person, while the primary healthcare professional assesses the vascular collapse. Optional medication: H₁ antihistamines airway, breathing, circulation, and level of consciousness of the patient. Diphenhydramine (e.g., Benadryl) 3 drug dosing information: The first-line and most important therapy in continuedoral on (12.5 next mg/5 page mL liquid, 25 or 50 mg capsules/tablets)� or injectable anaphylaxis is epinephrine. There are NO contraindications to epinephrine immunization action coalition (50 mg/mL solution). in the setting of anaphylaxis. Technical content reviewed by the Centers for DiseaseHydroxyzine Control and Prevention (e.g., Atarax, Vistaril) oral Saint Paul, Minnesota • 651-647-9009 • www.immunize.org • www.vaccineinformation.org (10 mg/5 mL or 25 mg/5 mL liquid, a First-line treatment: Administer aqueous epinephrine 1:1000 dilution www.immunize.org/catg.d/p3082.pdf • 25Item mg #P3082 capsules). (9/14) intramuscularly, 0.01 mL/kg/dose (adult dose ranges from 0.3 mL to 0.5 IimmAuniCze.org Needed supplies for a community mL, with maximum single dose of 0.5 mL). 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 ; and 25 g, 1", 1½", and 2") for epinephrine, diphenhydramine, or hydroxyzine. For the standard dose is 1–2 mg/kg every 4–6 hrs, up to 50 mg maximum ampules, use filtered needles. single dose) or hydroxyzine (standard oral dose is 0.5–1 mg/kg every Alcohol wipes 4–6 hrs up to 100 mg maximum single dose). Tourniquet 4 Monitor the patient closely until EMS arrives. Perform cardiopulmonary Adult airways (small, medium, and large) resuscitation (CPR), if necessary, and maintain airway. Keep patient in supine Adult size pocket mask with one-way valve position (flat on back) unless he or she is having breathing difficulty. If breath- Oxygen (if available) ing is difficult, patient’s head may be elevated, provided blood pressure is Stethoscope adequate to prevent loss of consciousness. If blood pressure is low, elevate Emergency medical legs. Monitor blood pressure and pulse every 5 minutes. Sphygmomanometer (blood pressure measuring device) with adult-size and extra­large cuffs 5 If EMS has not arrived and symptoms are still present, repeat dose of epineph- protocol and supplies list  Tongue depressors rine every 5–15 minutes for up to 3 doses, depending on patient’s response. Flashlight with extra batteries (for exam­ 6 Record all vital signs, medications administered to the patient, including the ination of the mouth and throat) time, dosage, response, and the name of the medical personnel who admin- are ready for your use. Wristwatch with a second hand or other timing device istered the medication, and other relevant clinical information. Cell phone or access to onsite phone 7 Notify the patient’s primary care physician.

references These standing orders for the medical management of vaccine Simons FE, Camargo CA. Anaphylaxis: Rapid recognition and treatment. In: UpToDate, Bochner reactions in adult patients shall remain in effect for patients of the BS (Ed). UpToDate: Waltham, MA, 2013. until rescinded or until Boyce JA, Assa’ad A, Burks AW, et al. Guidelines name of clinic date for the Diagnosis and Management of Food Allergy in the United States: Report of the NIAID­ Sponsored Expert Panel. Allergy Clin Immunol medical director’s signature date of signing 2010; 126(6): S1–S57.

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/p3082.pdf • Item #P3082 (9/14) IimmAuniCze.org

Vaccinate Adults! • October 2014 • Immunization Action Coalition • (651) 647-9009 • www.immunize.org • www.vaccineinformation.org 7 Foodborne Hepatitis A Outbreaks in the U.S. Are Well-documented; Vaccine Provides Lifetime Protection

Hepatitis A can be spread by exposure to fecal material, Three outbreaks illustrate the potential magnitude through household or sexual contact with an infected person of foodborne hepatitis A outbreaks or by consuming hepatitis A virus-contaminated food or • In 2013, at least 162 people in 10 states became ill with water. People who get infected with the hepatitis A virus hepatitis A after consuming products containing pomegran- can become extremely ill, and sometimes die of fulminant ate seeds from Turkey. At least 71 people were hospital- (overwhelming) . ized. It has not yet been determined how the pomegranate The Centers for Disease Control and Prevention operates seeds became contaminated with hepatitis A virus.** a reporting system for foodborne outbreaks due to , • Beginning in late August 2005, at least 10 clusters of , fungi, parasites, and chemical and toxin contami- hepatitis A illnesses, totaling 39 people, occurred in nation. Summary information about these outbreaks is 4 states among restaurant patrons who ate raw oysters. available from the Foodborne Outbreak Online Database.* Hepatitis A virus was detected in multiple recalled sam- This database includes startling information about food- ples, indicating that as many as 1 in every 15 oysters borne hepatitis A outbreaks in the United States from 1997 from this source was contaminated.†† through 2011. • In 1997, a multi-state outbreak of hepatitis A was associ- Summary of hepatitis A outbreaks ated with consumption of frozen strawberries. The out- break involved 242 persons from five states and included • Total number of foodborne hepatitis A outbreaks, 1998– children from 36 schools.‡‡ 2011: 81 (average of 6 outbreaks per year, range 1 to 12 outbreaks per year) Foodborne outbreaks of hepatitis A are unpredictable. They can be caused by many different types of food (particularly • Total number of outbreak-associated illnesses: 2,202† foods eaten raw or minimally cooked) and in any food service (average of 28 illnesses per outbreak) setting. These outbreaks can result in serious illness, hos- • Number of states reporting foodborne hepatitis A out- pitalization, and death. Unlike most other types of foodborne breaks: 27 (2 outbreaks involved more than 1 state) illnesses, those caused by hepatitis A virus can be prevented • Largest outbreaks: Pennsylvania, 2003 (565 cases‡), and by vaccination. Two doses of hepatitis A vaccine separated Georgia, 2003 (297 cases§) by 6 months can provide lifelong protection against this dangerous virus infection. • Outbreak-associated hospitalizations: 290 sources • Outbreak-associated deaths: 8 * Available at wwwn.cdc.gov/foodborneoutbreaks. Accessed June 4, 2014. † The 2002 reported outbreak-associated illnesses underestimates the true num- • Most common food products implicated in hepatitis A ber of infections since many people (particularly children) infected with hepa- transmission: vegetables (often salads) and fruit. Fresh titis A will not have symptoms and may not be reported as part of an outbreak. produce can become contaminated during cultivating, ‡ The 2003 Pennsylvania outbreak was traced to green onions served in a single chain restaurant’s salsa. The green onions were grown in Mexico and had harvesting, processing, or distribution. Many other types most likely been contaminated during growing, harvesting, packing, or distri- of food were also implicated in outbreaks, including sea- bution; green onions require extensive handling and their surface is complex food, ice, milk products, and sandwiches. and vulnerable to contamination. § Green onions were also implicated in the Georgia outbreak. Molecular epidemi- • Most common setting of outbreaks: restaurants (including ology indicated the source of the contaminated produce to the same area in fast food and sit-down types), private homes, workplaces, northern Mexico as the Pennsylvania outbreak. ** Available at www.cdc.gov/hepatitis/Outbreaks/2013/A1b-03-31. Accessed picnics, and schools. Most reported hepatitis A foodborne June 4, 2014. outbreaks have been related to hepatitis A-infected food †† Shieh YC, Khudyakov YE, Xia G, et al. Molecular confirmation of oysters as handlers. the vector for hepatitis A in a 2005 multistate outbreak. J Food Prot 2007; 70(1):145–50. ‡‡ Hutin YJ, Pool V, Cramer EH, et al. A multi-state, foodborne outbreak of hepa- titis A. N Engl J Medicine 1999 Feb 25; 340(8):595-602.

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/p2104.pdf • Item #P2104 (7/14)

8 NEW! Handouts about Hepatitis A Vaccinations for Your Patients

These handouts describe Hepatitis A Vaccine: Reasons to Consider Vaccination how easy it is to get infected Hepatitis A is a serious liver disease caused by with the hepatitis A virus infection with hepatitis A virus • Hepatitis A virus is found in the feces (poop) of people who are infected with the virus. It is usually spread by get- through contaminated food ting invisible particles of hepatitis A virus-contaminated feces in your mouth. or drink. These pieces clearly • The most common way for you to get infected is through close personal contact, such as living with a person infected with hepatitis A virus or having sex with an infected per- make the case that such son. You can also get infected if you travel abroad where sanitation practices may not be adequate. This might hap- outbreaks are unpredictable, pen when you eat hepatitis A virus-contaminated food or drink hepatitis A virus-contaminated water only – and it can even happen in four-star restaurants in the United States. potentially serious, and You can feel quite sick when you’re infected with hepatitis A and some people die preventable by vaccination. • If you have symptoms, they usually come on suddenly and can include fever, tiredness, loss of appetite, nausea, belly pain, cola-colored urine, and yellowing of the skin and eyes. died from liver failure. The outbreak was caused by green onions from Mexico that had been contaminated with • The illness usually lasts several weeks, but you might feel hepatitis A virus during growing, harvesting, packing, or sick for as long as six months. distribution. • There is no medicine to treat you for hepatitis A – only Hepatitis A Is a Serious Liver Disease • Investigators linked 64 cases of hepatitis A to food pur- supportive care is available. chased at a retail buyer’s club where a hepatitisvaccination A virus- can protect you! • Safe, effective hepatitis A vaccines have been available infected baker contaminated baked goods while applying since 1995. sugar glaze. What is hepatitis A? Who should get hepatitis A vaccine? • 91 people were infected with hepatitis A virus after attend- Consider your answers to the following questions ing various events in Kentucky catered by a companyHepatitis A is a serious liver disease caused by infection with The following groups of people should get vaccinated Is all the food you eat as clean and safe as you think it is? employing a food handler who was infected withthe hepatitishepatitis A virus. against hepatitis A virus: A virus. • Any person who wishes to be protected from hepatitis A • Hepatitis A virus can spread when an infected food How is hepatitis A virus spread? handler contaminates your food. This can happen if • 262 persons in five states, including children from virus infection the food handler uses the toilet and does not wash his 36 schools, ate contaminated strawberries andHepatitis became A virus is usually spread from getting particles • All children who are 12 to 23 months of age or her hands well before touching your food. Food can infected with hepatitis A virus. of fecal material (poop) into your mouth that are too small • Men who have sex with men also become contaminated with hepatitis A virus during to be seen. This can happen through household or sexual • Users of street drugs (injecting and non-injecting) Is all the water and ice you drink as clean and safe as you growing, harvesting, or processing. contact with an infected person or by eating hepatitis A • People who travel or work in any area of the world except think it is? virus-contaminated food or drinking hepatitis A virus- the U.S., Canada, Western Europe, Japan, New Zealand, • Your food can be contaminated in four-star restaurants, • Food and beverage handlers in bars, restaurants,contaminated or at water. Casual contact, such as in a school or and Australia bars, catered events, schools, or even at home. catered events who are infected with hepatitiswork A virus setting, has not been known to spread hepatitis A virus. • People who will have close personal contact with an • More than 550 persons got hepatitis A after eating at a and don’t wash their hands can contaminate your bever- international adoptee from a country where hepatitis A single chain restaurant in Pennsylvania. Three persons ages, especially those containing ice. What are the symptoms of hepatitis A virus infection? virus infection is common (all countries except the U.S., continued on the next page Canada, Western Europe, Japan, New Zealand, and Infected people� can have no symptoms at all or be extremely Australia) during the first 60 days following the adoptee’s ill. Only 30% of children less than six years of age develop arrival in the U.S. Technical content reviewed by the Centers for Disease Controlsymptoms, and Prevention while 70% of older children and adults develop • People with chronic liver disease, including hepatitis C Saint Paul, Minnesota • 651-647-9009 • www.immunize.org • www.vaccineinformation.org symptoms. • People working with hepatitis A virus in a laboratory www.immunize.org/catg.d/p2103.pdf • Item #P2103 (7/14) If a person does develop symptoms, they might include • People with clotting factor disorders (such as hemophilia) fever, tiredness, loss of appetite, nausea, abdominal pain, • People who have been exposed to hepatitis A virus in the dark urine, or jaundice (yellowing of the eyes and skin). past 2 weeks These symptoms can last up to six months. Even without symptoms, people infected with hepatitis A virus can spread For families considering international adoption, who the infection to others. should receive hepatitis A vaccine? How serious is hepatitis A virus infection? People who anticipate having close personal contact (such as household contact or regular babysitting) with an inter- About 30% of people with hepatitis A virus require hospital- national adoptee from a country where hepatitis A virus ization. Adults who become ill often miss several weeks infection is common (all countries except the U.S., Canada, 2 of work. Although deaths due to hepatitis A virus are uncom- Western Europe, Japan, New Zealand, and Australia) during For ready-to-copy 8⅟ x 11" versions mon, death still can occur from overwhelming hepatitis A the first 60 days following the adoptee’s arrival in the U.S. virus infection that causes liver failure. should get the vaccine. In addition to the adoptee’s new of these 2-page pieces, visit parents and siblings, this group could include grandparents How can hepatitis A virus infection be prevented? and other members of the extended family, caregivers, and Safe and effective vaccines to prevent hepatitis A virus healthcare providers. Ideally, the first dose of hepatitis A www.immunize.org/catg.d/p2103.pdf infection have been available in the U.S. since 1995. Good vaccine should be given to close contacts as soon as adop- hand washing will also help reduce the spread of hepatitis tion is planned but no later than 2 weeks prior to the arrival A virus. Always wash your hands with soap and water after of the adoptee. A second dose should be given no sooner using the toilet, changing a diaper, and before preparing than 6 months after the first dose. www.immunize.org/catg.d/p4080.pdf continued on the next page or eating food. �

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/p4080.pdf • Item #P4080 (7/14)

Vaccinate Adults! • October 2014 • Immunization Action Coalition • (651) 647-9009 • www.immunize.org • www.vaccineinformation.org 9 CDC Creates Fact Sheet about Pneumococcal Vaccines for Older Adults

Pneumococcal Vaccines (PCV13 and PPSV23) Make copies Addressing Common Questions about Pneumococcal Vaccination for Adults and give them to

What diseases do these vaccines protect against? your patients! There are two vaccines that protect against pneumococcal disease, which is caused by infection with a common bacterium called What could happen if I get . this disease? Pneumococcal disease ranges from mild to • PCV13 (pneumococcal conjugate vaccine) protects against very dangerous. Pneumococcal disease can 13 of the approximately 90 types of pneumococcal bacteria spread from the nose and throat to ears or that can cause pneumococcal disease, including , sinuses, causing generally mild infections, or , and bacteremia. spread to other parts of the body, leading to • PPSV23 (pneumococcal polysaccharide vaccine) protects severe health problems such as lung infections against 23 types of pneumococcal bacteria. This vaccine helps (pneumonia), blood infections (bacteremia), prevent invasive infections like meningitis and bacteremia, and infection of the lining of the brain and but only offers low levels of protection against pneumonia. spinal cord (meningitis). How common is pneumococcal disease? These illnesses can lead to disabilitiesAddressing like Common Questions about Pneumococcal Vaccination for Adults Each year in the United States, pneumococcal disease kills deafness, brain damage, or loss of arms thousands of adults, including 18,000 adults 65 years or older. or legs. These illnesses can also be Thousands more end up in the hospital because of life threatening: pneumococcal disease. Who should get these vaccines? • Pneumococcal pneumoniaWhen and kills abouthow often are they needed? 1 out of 20 people who get it. Who should not get How does pneumococcal disease spread? PCV13: Adults should get one dose of this vaccine before starting or these vaccines? • Pneumococcal bacteremiacontinuing kills doses about of PPSV23. It is recommended for: Pneumococcal bacteria can spread from person to person by direct 1 out of 5 people who get it. PCV13: Anyone who has ever had a life- contact with respiratory secretions, like saliva or mucus. People • All adults 65 years or older threatening allergic reaction to a dose of the • Pneumococcal meningitis kills about can carry the bacteria in their nose and throat, and can spread the • Adults 19 years or older with certain medical conditions vaccine, to an earlier pneumococcal vaccine 3 out of 10 people who get it. bacteria without feeling sick. • Adults 19 years or older who are taking medications that lower called PCV7 (or Prevnar), or to any vaccine Adults with chronic conditionsthe are body’s at increased resistance to infection containing diphtheria (for example, Who is at risk for pneumococcal disease? risk of developing complications from DTaP), should not get PCV13. Anyone with a PPSV23: Adults should get one, two, or three doses of this vaccine, • People 65 years and older pneumococcal disease. severe allergy to any component of PCV13 depending on their age, health condition, and timing of the first dose. should not get the vaccine. • People with certain health conditions, such as chronic lung It is recommended for: PPSV23: Anyone who has ever had a life- disease or diabetes • All adults 65 years or older threatening allergic reaction to a dose of • People who are taking medications that lower the body’s • Adults 19 years or older with certain health conditions the vaccine or with a severe allergy to any resistance to infection (immunocompromised) • Adults 19 years or older who have a disease or condition, or are component of the vaccine should not get • People who smoke cigarettes taking medications that lower the body’s resistance to infection the vaccine. • Adults 19 years or older who smoke cigarettes

How well do the vaccines work? PCV13: Studies done on PCV13 use in adults showed the vaccine to be 75% effective in preventing invasive pneumococcal disease, like bloodstream infections and meningitis, and 45% effective at preventing non-invasive pneumonia caused by the DON’T13 WAIT. strains it covers. PPSV23: In adults with healthy immune systems, this vaccine has been shown to be 50-85% effective in preventing invasive disease caused by the 23 strains it covers. For more information on this and VACCINATE! other vaccines for adults, How safe are these vaccines? Pneumococcal vaccines are very safe. They went through years of testing before being licensed by the FDA and continue to visit www.cdc.gov/vaccines/adults. be monitored for safety by the FDA and CDC. Is it safe to get if I have certain health conditions or am taking prescription meds? Unless you have had an allergic reaction in the past to the vaccine or have allergies to certain components of the vaccine, it is safe to get. It is safe for people taking prescription medications to get vaccines. What are the potential side effects of these vaccines?

PCV13: Adults receiving the vaccine have reported redness, pain, and swelling where the shot was given. Mild fever, fatigue, s

headache, chills, or muscle pain have also been reported. Life-threatening allergic reactions from this vaccine are very rare.

PPSV23: About half of people who get PPSV23 have mild side effects, such as redness or pain where the shot is given. Less s than 1% develop a fever, muscle aches, or more severe local reactions. The risk of a vaccine causing serious reaction, or death, is extremely small. Where can I get these vaccines? How much do the vaccines cost? Pneumococcal vaccines may be available at private doctor Most private health insurance covers pneumococcal Visit www.cdc.gov/vaccines/ offices, public or community health clinics, pharmacies, or other vaccines. At this time, Medicare Part B typically covers community locations (such as schools/universities, workplaces, only the first dose of pneumococcal vaccine for religious centers or places of worship). Check with your doctor or older adults and pays 100% of the cost of covered hcp/patient-ed/adults/ pharmacist or use the Adult Vaccine Finder (vaccine.healthmap.org) pneumococcal vaccines. Check with your insurance to help find places that provide pneumococcal vaccines provider for details on whether there is any cost to near you. you and for a list of in-network vaccine providers. downloads/fs-pneumo-hcp.pdf If you have insurance that supplements Medicare Part B, check with them to see if they cover both recommended pneumococcal vaccines.

September 2014 CS249797A

10 Vaccinate Adults! • October 2014 • Immunization Action Coalition • (651) 647-9009 • www.immunize.org • www.vaccineinformation.org 2014–201­5 InfluenzaV accine Information Statements Are Available in Many Languages!

HOJA DE INFORMACIÓN SOBRE VACUNAS (Vacuna contra la Many Vaccine Information Statements are available in Spanish and other languages. Vacuna contra la influenza See www.immunize.org/vis influenza, inactivada Spanish, Arabic, Chinese Muchas de las declaraciones informativas o recombinante) sobre vacunas están disponibles en español Lo que necesita saber y otros idiomas. 2014-2015 Consulte www.immunize.org/vis. Se recomienda vacunarse contra la influenza una vez al año. ¿Por qué es necesario (simplified and traditional), Algunos niños de entre 6 meses y 8 años de edad podrían 1 vacunarse? necesitar dos dosis al año. La influenza es una enfermedad contagiosa que se propaga a lo Los virus de la influenza cambian constantemente. La vacuna largo de los Estados Unidos cada invierno, generalmente, entre contra la influenza anual se fabrica para proteger contra 3 o octubre y mayo. 4 virus que probablemente causen la enfermedad ese año. Si French (European), Russian, La influenza es causada por los virus de la influenza y se bien la vacuna contra la influenza no puede prevenir todos los transmite principalmente al toser, estornudar y mediante un casos de influenza, es la mejor defensa contra la enfermedad. contacto cercano. Luego de la vacunación, la protección demora unas 2 semanas Todas las personas pueden contraer influenza, pero el riesgo en desarrollarse y dura entre varios meses a un año. Somali, Vietnamese, and de contraerla es mayor en los niños. Los síntomas se presentan de forma repentina y pueden durar varios días. Estos pueden Algunas enfermedades que no son causadas por el virus de la incluir los siguientes: influenza suelen confundirse con influenza. La vacuna contra • fiebre/escalofríos la influenza no previene estas enfermedades. Solo puede • dolor de garganta prevenir la influenza. • dolores musculares more! • fatiga Algunas vacunas contra la influenza inactivadas contienen • tos una cantidad muy pequeña de un conservante hecho a base de • dolor de cabeza mercurio, que se llama timerosal. Estudios han demostrado • rinorrea o congestión nasal que el timerosal presente en las vacunas no es perjudicial, La influenza puede afectar a algunas personas mucho más que pero existen vacunas contra la influenza que no contienen a otras. Entre estas se incluyen los niños pequeños, las personas conservantes. mayores de 65 años, las mujeres embarazadas y las personas con ciertas afecciones de salud, como enfermedades cardíacas, Algunas personas no deben pulmonares o renales, trastornos del sistema nervioso o un 3 sistema inmunitario debilitado. La vacunación contra la recibir esta vacuna influenza es especialmente importante para estas personas y Informe lo siguiente a la persona que le aplique la vacuna: para todas las que están en contacto cercano con ellas. • Si tiene alguna alergia severa que representa un riesgo 疫苗資訊聲明 La influenza también puede provocar neumonía y empeorar para la vida. Si alguna vez tuvo una reacción alérgica que las afecciones médicas existentes. En los niños, puede causar representa un riesgo para la vida después de haber recibido （流感疫苗、活性、 diarrea y convulsiones. Many Vaccine Information Statements are una dosis de la vacuna contra la influenza o si tiene una 流行性感冒疫苗 鼻內） available in Traditional Chinese and other Cada año, miles de personas mueren por influenza en los languages. See www.immunize.org/vis alergia severa a cualquier parte de esta vacuna, que incluye, 許多疫苗資訊聲明有繁體中文及其他語言 Estados Unidos, y muchas más son hospitalizadas. por ejemplo, alergia a la gelatina, los antibióticos o los 您需要知道什麼 2014-2015 年 版本。請瀏覽 www.immunize.org/vis La vacuna contra la influenza es la mejor protección contra huevos, es posible que le recomienden no recibir la vacuna. la influenza y sus complicaciones. La vacuna contra la La mayoría de los tipos de vacuna contra la influenza, pero no 可注射的流感疫苗會在一份不同的疫苗資訊聲明中 influenza también ayuda a prevenir el contagio de la influenza todos, contienen una pequeña cantidad de proteínas de huevo. 為何要接種疫苗？ de persona a persona. • Si alguna vez tuvo el síndrome de Guillain-Barré 1 描述。 (Guillain-Barré Syndrome, GBS) (una enfermedad severa 流行性感冒（「流感」）是一種傳染性疾病，在美 流感疫苗建議每年接種一次。某些 6 個月到 8 歲的 que causa parálisis). Algunas personas con antecedentes de Vacunas contra la influenza 國，每年冬季（通常在 10 月和 5 月之間）是流感高 兒童一年可能會需要接種兩次。 2 GBS no deben recibir esta vacuna. Esto debe ser analizado inactivadas y recombinantes 發期。 con su médico. 流感病毒會不斷變化。每年的流感疫苗均為預防該 Usted recibirá una vacuna contra la influenza inyectable, la • Si no se siente bien. Por lo general, puede recibir la vacuna 流感由流行性感冒病毒引起，並且主要是透過咳 年最可能引發疾病的病毒而配製。LAIV 可預防 4 種 cual puede ser una vacuna “inactivada” o “recombinante”. contra la influenza cuando tiene una enfermedad leve, pero 嗽、打噴嚏和近距離接觸傳播。 不同的流行性感冒病毒。雖然流感疫苗無法預防所 Estas vacunas no contienen ningún virus de influenza vivo. Se es posible que se le recomiende que espere hasta sentirse aplican mediante inyección con una aguja y suelen llamarse 任何人都可能患上流感，但是兒童患上流感的風險 有流感病例，但它是預防疾病的最佳方法。 mejor. Debe regresar cuando se sienta mejor. “vacuna contra la influenza”. 最高。流感症狀會突然出現，並可能持續數天。症 接種後，疫苗需大約 2 週才能發揮作用，其預防效 Una vacuna contra la influenza diferente,con virus vivos, 狀包括： 用可持續數月至一年。 atenuada (debilitada) se administra a través de las fosas 發燒／發冷 • 某些並非由流行性感冒病毒引起的疾病經常被誤認 nasales en forma de aerosol. Esta vacuna se describe en una • 喉嚨痛 Hoja de información sobre vacunas por separado. 為流感。流感疫苗無法預防這些疾病。它只能預防 • 肌肉酸痛 流行性感冒。 • 疲勞 的人均可接種 。它可與其他疫苗 • 咳嗽 2 歲到 49 歲 LAIV Influenza (inactivated) VIS - Spanish - 08/19/2014 同時安全接種。 • 頭痛 • 流鼻涕或鼻塞 LAIV 不含局部抗菌劑或其他防腐劑。 某些人的流感症狀可能會較其他人嚴重。這些人包 括幼兒、65 歲及以上的老人、孕婦及有特定健康狀 3 某些人不應接種該疫苗 況的人 － 例如患有心臟、肺或腎病、神經系統異 如果您有以下情況，請告訴為您接種疫苗的人： 常，或減弱的免疫系統的人。對於這些人以及與之 密切接觸的任何人來說，接種流感疫苗尤其重要。 • 如果您出現任何嚴重、危及生命的過敏情況，包括 （例如）對明膠或抗生素過敏。如果您曾在接種一 流感會引起肺炎，並造成現有醫療狀況惡化。它會 劑流感疫苗後出現危及生命的過敏反應，或對該疫 引起兒童腹瀉和癲癇。 苗的任何成份嚴重過敏，則不應接種此疫苗。 每年有數千人死於流感，並有更多人因流感而住 • 如果您曾患有格林巴利綜合症（一種嚴重的癱瘓疾 院。 病，亦稱作 GBS）。某些曾患有 GBS 的人不應接 流感疫苗是預防流感及其併發症的最佳方法。流感 種此疫苗。您應與您的醫生討論此情況。 疫苗亦有助於防止流感在人與人之間傳播。 • 如果您有長期的健康問題，例如某些心臟、呼吸、 腎臟、肝臟、或神經系統方面的問題，醫生可以幫 活性、減毒流感疫苗 — LAIV、 您決定是否應該接種 LAIV。 2 鼻霧噴劑 您正要接種活性減毒流行性感冒疫苗（稱作 LAIV）， 它是一種鼻霧噴劑。「減毒」意味著毒性減弱。 疫苗中的病毒被減弱，因此不會使您得到流感。 還有其它不包括活性病毒的「滅活」型和「重組」 型流感疫苗。這些「流感針」是用針頭以注射方式 接種的。

VIS Influenza (live, intranasal) - Traditional Chinese - 08/19/2014 s For all Vaccine Information Statements published in the United States and their translations, in up to 35 languages, visit www.immunize.org/vis

Vaccinate Adults! • October 2014 • Immunization Action Coalition • (651) 647-9009 • www.immunize.org • www.vaccineinformation.org 11 First Do No Harm: Mandatory Influenza Vaccination Policies for Healthcare Personnel Help Protect Patients

View the complete list: Refer to the position statements of the leading medical organizations listed below to help www.immunize.org/honor-roll/ you develop and implement a mandatory influenza at your healthcare influenza-mandates institution or medical setting. Policy titles, publication dates, links, and excerpts follow.

American Academy of Family Physicians (AAFP) American Public Health Association (APHA) AAFP Mandatory Influenza Vaccination of Health Care Personnel (6/11) Annual Influenza Vaccination Requirements for Health Workers (11/9/10)

� www.aafp.org/news-now/health-of-the-public/20110613 � www.apha.org/advocacy/policy/policysearch/default.htm?id=1410 mandatoryfluvacc.html “Encourages institutional, employer, and public health policy to require influ- “The AAFP supports annual mandatory influenza immunization for health care enza vaccination of all health workers as a precondition of employment and personnel (HCP) except for religious or medical reasons (not personal prefer- thereafter on an annual basis, unless a medical contraindication recognized in ences). If HCP are not vaccinated, policies to adjust practice activities during national guidelines is documented in the worker’s health record.” flu season are appropriate (e.g. wear masks, refrain from direct patient care).” Association for Professionals in Infection Control and American Academy of Pediatrics (AAP) (APIC) Policy Statement – Recommendation for Mandatory Influenza Influenza Vaccination Should Be a Condition of Employment for Health- Immunization of All Health Care Personnel (10/1/10) care Personnel, Unless Medically Contraindicated (2/1/11) http://pediatrics.aappublications.org/cgi/content/abstract/peds. � � www.apic.org/resource_/tinymcefilemanager/advocacy-pdfs/apic_ 2010-2376v1 influenza_immunization_of_hcp_12711.pdf “The implementation of mandatory annual influenza immunization programs “As a profession that relies on evidence to guide our decisions and actions, we for HCP nationwide is long overdue. For the prevention and control of influenza, can no longer afford to ignore the compelling evidence that supports requiring now is the time to put the health and safety of the patient first.” influenza vaccine for HCP. This is not only a patient safety imperative, but is a moral and ethical obligation to those who place their trust in our care.” American College of Physicians (ACP) ACP Policy on Influenza Vaccination of Health Care Workers (9/1/10) Infectious Diseases Society of America (IDSA)

� www.acponline.org/clinical_information/resources/adult_ Mandatory Immunization of Health Care Personnel Against Influenza immunization/flu_hcw.pdf and Other Infectious Diseases (rev. 12/10/13)

“Vaccinating HCWs [healthcare workers] against influenza represents a duty � www.idsociety.org/HCW_Policy of care, and a standard of quality care, so it should be reasonable that this duty “Preventing healthcare-associated transmission of influenza and other infectious should supersede HCW personal preference.” diseases can protect patients, HCP, and local communities. For this reason, IDSA supports mandatory immunization of HCP according to recommenda- American Hospital Association (AHA) tions of the Advisory Committee for Immunization Practices (ACIP) of the AHA Endorses Patient Safety Policies Requiring Influenza Vaccination of Centers for Disease Control and Prevention (CDC).” Health Care Workers (7/22/11)

� www.aha.org/advocacy-issues/tools-resources/advisory/2011/110722- National Business Group on Health (NBGH) quality-adv.pdf Hospitals Should Require Flu Vaccination for all Personnel to Protect “To protect the lives and welfare of patients and employees, AHA supports man- Patients’ Health and Their Own Health (10/18/11)

datory patient safety policies that require either influenza vaccination or wear- � www.businessgrouphealth.org/pub/f314b0a7-2354-d714-511f- ing a mask in the presence of patients across healthcare settings during 57f12807ba2c flu season. The aim is to achieve the highest possible level of protection.” “Hospitals should require flu vaccination for all personnel to protect patients’ health and their own health.” American Medical Directors Association (AMDA) Mandatory Immunization for Long Term Care Workers (3/11) National Patient Safety Foundation (NPSF)

� www.amda.com/governance/resolutions/J11.cfm NPSF Supports Mandatory Flu Vaccinations for Healthcare Workers “Therefore be it resolved, AMDA – Dedicated to Long-Term Care Medicine – (11/18/09)

supports a mandatory annual influenza vaccination for every long-term health � www.npsf.org/updates-news-press/press/media-alert-npsf-support s- care worker who has direct patient contact unless a medical contraindication mandatory-flu-vaccinations-for-healthcare-workers or religious objection exists.” “NPSF recognizes vaccine-preventable diseases as a matter of patient safety and supports mandatory influenza vaccination of health care workers to protect the American Pharmacists Association (APhA) health of patients, health care workers, and the community.” Requiring Influenza Vaccination for All Pharmacy Personnel (4/11) Society for Healthcare Epidemiology of America (SHEA) � www.pharmacist.com/sites/default/files/files/2011 ActionsoftheAPhAHoD-Public.pdf Influenza Vaccination of Healthcare Personnel (rev. 8/31/10)

“APhA supports an annual influenza vaccination as a condition of employment, � www.journals.uchicago.edu/doi/full/10.1086/656558 training, or volunteering, within an organization that provides pharmacy ser- “SHEA views influenza vaccination of HCP as a core patient and HCP safety vices or operates a pharmacy or pharmacy department (unless a valid medical practice with which noncompliance should not be tolerated.” or religious reason precludes vaccination).”

continued on next page �

Immunization Action Coalition Saint Paul, Minnesota • 651-647-9009 • www.immunize.org • www.vaccineinformation.org

www.immunize.org/catg.d/p2014.pdf • Item #P2014 (9/14) 12 Vaccinate Adults! • October 2014 • Immunization Action Coalition • (651) 647-9009 • www.immunize.org • www.vaccineinformation.org first do no harm continued Practical Resources for Vaccinating Healthcare Personnel Against Influenza

U.S. Department of Health and Human Services (HHS) Immunization Action Coalition (IAC) Influenza Vaccination of Healthcare Personnel, part of HHS’ National Action Plan to Prevent Visit the IAC’s Influenza Vaccination Honor Roll Healthcare-Associated Infections: Roadmap to to view stellar examples of influenza vaccination Elimination mandates in healthcare settings: www.hhs.gov/ash/initiatives/hai/hcpflu.html � www.immunize.org/honor-roll/influenza-mandates

Centers for Disease Control Visit IAC’s Influenza web section: www.immunize.org/influenza and Prevention (CDC) Get these IAC print materials online: Read the joint HICPAC/ACIP Recommendations Influenza Vaccination of Health-Care Personnel • Healthcare Personnel Vaccination Recommendations: www.immunize.org/catg.d/ (MMWR, 2/24/06) p2017.pdf www.cdc.gov/mmwr/PDF/rr/rr5502.pdf • Access Influenza Vaccine Information Statements (VISs) in more than 35 languages: � www.immunize.org/vis For more recent guidance from CDC, see

Immunization of Health-Care Personnel: Recom- copy this for your patients Standing Orders for Administering Influenza Vaccine to Adults

Seek emergency medical care if you or Purpose: To reduce morbidity and mortality from influenza by vaccinating all adults who meet the criteria established by the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices. a family member shows the signs Policy: Under these standing orders, eligible nurses and other healthcare professionals (e.g., pharmacists), where mendations of the Advisory Committee on Immu- allowed by state law, may vaccinate patients who meet any of the criteria below. below – a life couldcopy this for be your at patients risk! Procedure: It’s a fact – every year, people of all ages in the 1. Identify adults with no history of influenza vaccination for the current influenza season. Don’t take chances with your Patient name: 2. Screen all patients for contraindications and precautions Date of to birth: influenza vaccine: (mo.) (day) (yr.) U.S. die from influenza and its complications. a. Contraindications: a serious systemic or anaphylactic reaction after ingesting eggs, after receiving a previous family’s health – make sure you all dose of influenza vaccine, or to an influenza vaccine component. For a list of vaccine components, go to nization Practices (MMWR, 11/25/11) www.cdc.gov/vaccines/pubs/pinkbook/downloads/appendices/B/excipient-table-2.pdf. Do not give live get vaccinated against influenza Screening attenuated Checklist influenza vaccine for Contraindications(LAIV; nasal spray) to an adult with a historyto of hypersensitivity to eggs, either Emergency warning signs Any child or teen who shows the following emergency anaphylatic or non-anaphylactic; who is pregnant, is age 50 years or older, or who has chronic pulmonary (includ- Standing Orders for Administering Influenza Vaccines to Children and Adolescents every year!warning signs needs urgent medical attention – take them ing asthma), cardiovascular (excluding hypertension), renal, hepatic, neurologic/neuromuscular, hematologic, or for children or teens with INACTIVATED Patient name: Inactivated Injectable Date ofInfluenza birth: Vaccination to an emergency room or call 9-1-1. metabolic (including diabetes) disorders; immunosuppression, including that caused by medications or HIV. influenza Purpose: To reduce morbidity and mortality from influenza by vaccinating all children and adolescents who meet the b. Precautions: moderate or severe acute(mo.) illness(day) with(yr.) or without fever; history of Guillain Barré syndrome within Here’s how• Fast breathing influenza or trouble can breathing hurt your family. . . criteria established by the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices. INFLUENZA For adult patients as well6 weeks as parents of a previous of children influenza to vaccination; be vaccinated: for TIV The only, following allergic questions reaction to eggs consisting of hives only (ob- www.cdc.gov/mmwr/pdf/rr/rr6007.pdf • Bluish skin color VACCINE Policy: Under these standing orders, eligible nurses and other healthcare professionals (e.g., pharmacists), where allowed by Screening Checklistwill help us determine for if thereserve Contraindications is patientany reason for at we least should 30 minutes not give following you to or your vaccination); child inactivated for LAIV injectable only, close contact with an immunosup- � • Not waking up Wor not H interacting A T Y O U N E E D T O K N O W state law, may vaccinate children and adolescents who meet any of the criteria below. influenza vaccination today. pressed If you person answer when “yes” the to person any questio requiresn, it protectivedoes not necessarilyisolation, receipt mean of you influenza (or antivirals (e.g., amantadine, riman- tadine, zanamivir, or oseltamivir) within the previous 48 hours or possibility of use within 14 days after vaccination Influenza can• Being make so you, irritable that theInfluenza child does usually not wantcomes to on be suddenly. held Symptoms can include high fever,2011-12 Procedure: Live Attenuatedyour child) Intranasal should not be vaccinated. Influenza It just means Vaccinationadditional questions must be asked. If a question is Many Vaccine Information Statements are available in Spanish and other languages. See www.immunize.org/vis chills, headaches, exhaustion, sore throat, cough, and all-over body aches. 1. Identify children and adolescents ages 6 months and older who have not completed their influenza vaccination(s) for the not clear, pleaseAdapted ask 3.fromyour Provide Summary*healthcare all patients providerRecommenda- with to a explain copy of it. the most current federal Vaccine InformationDon’t Statement (VIS). You must docu- your children,or• Not drinkingyour parents enough Hojasfluids de Informacián Sobre Vacunas están disponibles en español y en muchos otros idiomas. Visite www.immunize.org/vis InfluenzaV accinationFor use with peopleof P ageseople 2 through 49 years: The following questions will help us determine if there is Some people LIVE,say, “It felt like a truckINTRANASAL hit me!” Symptoms can also be mild. current influenza season. tions: Prevention and Control of Influ ment in the patient’s medical- record or office log, the publicationYes dateNo of the KnowVIS and the date it was given to the really sick. Some inactivated infl uenza vaccine contains a preservative any reason we should not give you or yourenza child with live attenuatedVaccines: Recommendationsintranasal influenza vaccine (FluMist) today. If you • Not urinating or noWhy tears Regardless,getwhen vaccinated? crying when influenza strikes your family, the result is lost time from 2. Screen all patients for contraindications and precautions to influenza vaccine: patient. Provide non-English speaking patients with a copy of the VIS in their native language, if available and 1 called thimerosal. Thimerosal-free infl uenza vaccine is with a History ofanswer Egg “yes” Allergyto any question, it does not necessarilyof the ACIP mean–U.S., you 2 01(or3 –your14 at child) www.cdc. should not be vaccinated. It just • Severe or persistent vomitingwork and school. a. Contraindications: a serious systemic or anaphylactic reaction after ingesting eggs, after receiving a previous dose 1. Is the person to be vaccinated preferred; sick these today? can be found at www.immunize.org/vis.    Infl uenza (“fl u”) is a contagiousINFLUENZA disease. available. Ask your doctor for more information. means additional questions must be asked.gov/flu/professionals/acip/2013-sum If a question is not clear, please ask your- of influenza vaccine, or to an influenza vaccine component. For a list of vaccine components, go to www.cdc.gov/ Don’t • Influenza-like symptoms improve but then return with fever and VACCINE 4. Administer influenza vaccine as follows: a) For adults of all ages, give 0.5 mL of injectable trivalent inactivated in- 1. Persons with a history of egg allergy who healthcarehave experienced provider only to explain it. mary-recommendations.htm. Yes No Know Visit CDC’s Influenza web section It is caused by the infl uenza virus, which can be spread by vaccines/pubs/pinkbook/downloads/appendices/B/excipient-table-2.pdf. Do not give live attenuated influenza vac- fluenza vaccine (TIV-IM) intramuscularly (22–25g, 1–1½" needle) in the deltoid muscle. (Note: A e" needle may worse cough hives after exposure to egg should receive influenza vaccine. 2. Does the person to be vaccinated have an allergy to eggs or coughing, sneezing, or nasal secretions.W H A T Y O U N E EWho D shouldT O K get N inactivatedO W cine (LAIV; nasal spray) to people with a history of hypersensitivity to eggs, either anaphylactic or non-anaphylac-    Influenza spreads easily from An infected person can spread influenza when they 3cough, sneeze, or just Because relatively little data are available for use of LAIV in this to a component of the be vaccine? used for adults weighing less than 130 lbs (<60 kg) for injection in the deltoid muscle only if the skin is stretched infl uenza vaccine and when?2011-12 tic; pregnant adolescents; children younger than age 2 yrs; children age 2 through 4 yrs who have experienced wheez- 1. Is the person to be vaccinated sick today?    person to person. Anyone can gettalk infl nearuenza, others. but rates They of can infection also Vaccinespread are highestInformation it by touching Statements or sneezing are available on inan Spanish object and many other languages. See www.immunize.org/vis setting, IIV or RIV should be used. RIV is egg-free and may be Recommendations regarding tight, influenza subcutaneous vaccination tissue of is not bunched, and the injection is made at a 90 degree angle; or b) For healthy adults Influenza V accineing or asthma within Pr oductsthe past 12 mos, forbased onthe a healthcare 2013 provider’s–201 statement;4 Influenza or children or adolescents Season with among children.that For someone most people, else touchessymptomsHojas later lastde. And,Informacián only an a infected Sobre VacunasWHO person están doesn’t disponibles have toen feelespañol y en muchos otros idiomas. Visite www.immunize.org/vis used for persons aged 18–49 years who have no other contrain- persons who report allergy youngerto eggs: ACIP,than ageUnited 50 years,States, give 0.2 mL of intranasal LAIV; 0.1 mL is sprayed into each nostril while the patient chronic pulmonary (including asthma), cardiovascular (excluding hypertension), renal, hepatic, neurologic/neuromus- 2. Does the person to be vaccinated3. Has have the anperson allergy to tobe eggs vaccinated or to a evercomponent had a serious of reaction to Emergency warning signs Any adult whofew days.shows They thesick include: following to be contagious: emergency they can warning spread influenza signs toAll others people when 6 months they feel of age and older should get fl u Manufacturer Trade Name How Supplied Mercury Age Group Product Code dications. However, IIV (egg- or cell-culture based) may also be 2013–14 influenza season. is in an upright position; or c) For adults ages 18 through 64 years, give  0.1 ml TIV-ID intradermally by inserting 1 Why get vaccinated? 3 Who can receive LAIV? cular, hematologic, or metabolic (e.g., diabetes) disorders; immunosuppression, including that caused by medications used, with the following additional safety measures (see figure the influenza vaccine? influenza vaccine in the past? needs urgent• fever/chills medical attentionwell • sore – before throat – take their •themsymptoms muscle to aches an have emergency •even fatigue begun. vaccine. (vaccine abbreviation)1 Content the needle of the microinjection system at a 90 degree angle in the deltoid muscle; or d) For adults ages 65 years and for adults with influenza or HIV; long-term aspirin therapy (applies to a child or adolescent age 6 mos(μg through Hg/0.5mL) 18 yrs). in column to right) • cough • headache Infl uenza • runny (“fl or u”)stuffy is a nose contagious disease. LAIV is recommended for healthy people 2 through 49 years older, give 0.5 mL of high-dose TIV-IM intramuscularly (22–25g, 1–1½" needle) in the deltoid muscle. room or call 9-1-1. Vaccination is especially important for people at higher 0.5 mL (single-dose syringe) 0 90656 3. Has the person to be vaccinatedCan the ever person had eat a lightly serious reactionyes to intranasal of age, who are not pregnant and do not have certain health b. Precautions: moderate or severe acute illness with or without fever; history of Guillain-Barré syndrome within a) Vaccine should be administered by a healthcare provider who is 4. Has the person to be vaccinatedAdminister ever hadvaccine Guillain-Barré per syndrome?      • It is caused by the infl uenza virus, which can be spread by 2 influenza vaccine (FluMist) cookedin the eggpast? (e.g., scrambled www.cdc.gov/flu Difficulty breathingOther illnesses or shortness can have of the breath same symptoms and are often risk of severe infl uenza and their close contacts, CSL Limited 6 weeksAfluria of (IIV3) a previous influenza vaccination; for TIV only, allergic reaction to eggs consisting9 years &of older hives only (observe90658 familiar with the potential manifestations of egg allergy; and 5. Documentusual protocol.each patient’s vaccine administration information and follow up in the following places: � Influenza and its complications Each year, morecoughing, than 200,000 sneezing, people or nasal are hospitalized secretions. in the U.S. from conditions (see #4, below). 5.0 mL (multi-dose vial) 24.5 egg) without reaction?*† • Pain or pressuremistaken in thefor inflchest uenza. or abdomen including healthcare personnel and close contacts of patient for 30 minutes following vaccination); for LAIV only, close contact with an immunosuppressed person whenQ2035 (Medicare) a. Medical chart: Record the date the vaccine was administered, the manufacturer and lot number, the vaccina- influenza and its complications. Between 3,000 and 50,000 die, which shows b) Vaccine recipients should be observed4. for Does at least the 30 personminutes forto be vaccinated have a long-term health problem with heart can be so serious that Youngthey can children, people 65 andAnyone older, pregnantcan get infl women, uenza, andbut rates ofchildren infection younger are highest than 6 months. Some people should not receive theFluarix person (IIV3) requires protective 0.5isolation, mL (single-dose receipt of syringe) influenza antivirals (e.g.,0 amantadine, 3 rimantadine,years & older zanamivir,90656 or 1 no tion site and route, and the name and title of the person administering the vaccine. If vaccine was not given, • Confusion how unpredictable influenza can be. The people most likely to be hospitalized GlaxoSmithKline signs of a reaction after administration of disease, each vaccine lung disease,dose. asthma, kidney disease, neurologic or neuromuscular disease,    put you, your children,people or with certain health conditionsamong children.– such as For heart, most lung people, symptoms last only a few 4 oseltamivir)Fluarix (IIV4) within the previous0.5 48mL hours (single-dose or possibility syringe) of use within 14 days0 after vaccination 3 years & older 90686 Form completed by: ______recordAdminister the reasons(s) RIV3 (if patient for non-receipt of the vaccine Date: (e.g., ______medical contraindication, patient refusal). • and die are infants, young children, older adults, andWHEN people of all ages who LAIV 2. Persons who report having had reactions to liver egg disease, involving metabolic such disease (e.g., diabetes), or anemia or another blood disorder? Severe or persistentor kidney disease,vomiting or a weakeneddays. immune They include:system – can get 3. Provide all patients (or, in the case of a minor, their parent or legal representative) with a copy of the most current federal After eating eggs or b. Personalaged 18 throughimmunization 49 years); record card: Record the date of vaccination and the name/location of the administer- your parents in the hospital – LAIV is not recommended for everyone. The following ID Biomedical Corp. of 90658 symptoms as angioedema, respiratory distress, lightheadedness, yes • have conditions such as heart or lung disease. ButGet remember the vaccine, it’s not as soononly theas it is available. This should FluLaval (IIV3) 5.0 mL (multi-dose vial) <25 3 years & older egg-containing Form reviewed foods, does by: ______ing orclinic. administer IIV to any Date: ______Sudden dizzinessmuch sicker. Flu can cause high• fever/chillsfever and pneumonia, • sore throat and • muscle aches • fatigue Quebec, a subsidiary ofVaccine Information Statement (VIS). You must document in the patient’s medical record or office log, the publication Q2036date (Medicare) or recurrent emesis; or who required epinephrine or another patient for whom IIV is or lead to death. youngest, oldest, or sickest who die: Every year influenzaprovide kills protection people whoif the were fl u seasonpeople comes should early. get the You inactivated can vaccine (fl u shot) instead: 5. If the person to be vaccinatedthe personis a child experience age 2 through 4 years, in the past 12 months, • Influenza-likemake symptoms existing medical improve conditions but •then cough worse. return It can with cause • headachefever diarrhea and • runny or stuffy nose GlaxoSmithKline of theFluLaval VIS and (IIV4) the date it was given5.0 mLto the (multi-dose patient (parent/legal vial) representative). <25Provide non-English3 years & speakingolder patients90688 with emergency medical intervention may receive RIV3, if aged 18 only hives? 6. Be preparedindicated for and management observe for of a medical  emergency  related to the administration of vaccine by having a written get the vaccine as long as illness• Adults is occurring 50 years in of your age and older or children from 6 has a healthcare provider ever told you that he or she had wheezing or asthma? and seizures in children.otherwise Each healthy. year thousands of people die a copy of the VIS in their native language, if available and preferred; these can be found at www.immunize.org/vis. through 49 years and there are no other contraindications. If emergencyreaction medical for at least protocol 30 min- available, as well as equipment and medications. worse cough community. MedImmune FluMist (LAIV4) 0.2 mL (single-use nasal spray) 0 2 through 49 years 90672 no utes after vaccination. from infl uenza and even moreOther require illnesses hospitalization. can have the same symptoms and are often through 23 months of age. (Children younger than 6 4. Administer injectable trivalent (TIV) intramuscularly in the vastus lateralis for infants (and toddlers RIV3 is not available or the recipient is not within the indicated mistaken for infl uenza. months should not get either infl uenza vaccine.) 0.5 mL (single-dose syringe) <1 90656 age range, such persons should be referred6. Does to a physicianthe person with to be vaccinated have cancer, leukemia,7. Report HIV/AIDS, all adverse or any reactions other to influenza vaccine to the federal Reporting System By getting fl u vaccine you can protect yourself from Infl uenza can occur at any time, but most infl uenza occurs lacking adequate deltoid mass) or in the deltoid muscle (for toddlers, children, and teens). Use a 22–25 g needle. Choose    Fluvirin (IIV3) 4 years & older 90658 expertise in the management of allergic conditions immune forsystem further problem; or,Does in thethe person past 3experience months, have (VAERS) they taken at www.vaers.hhs.gov medications that or (800) 822-7967. VAERS report forms are available at www.vaers.hhs.gov. Influenza can be a very serious There’s no substituteYoung children, for yearly people vaccination 65 and in older, protectingfrom pregnant October the women, people through andyou May.love In• recentChildren seasons, younger most than 5 years with asthma or one or more Novartis needle length appropriate to the child’s5.0 mL (multi-doseage and body vial) mass: infants 6 through 1125 mos: 1"; 1 through 2 yrs: 1–13"; 3yrs Keep this handy! Post it on your refrigerator or anotherinfl uenza placeand may where also avoid it will spreading be easy in tofl uenzafind! to others. Q2037 (Medicare) risk assessment before receipt of vaccine (see figure in column weaken the immuneto system,other such symptoms as cortisone, such as prednisone, other steroids, or disease for you, your family, from influenza.people Either with type certain of influenza health vaccine conditions (theinfections – “shot” such as or haveheart, nasal occurred lung spray) in Januaryepisodes and of February. wheezing Getting within the past year. and older: 1–1½". Give 0.25 mL to children 6–35 mos and 0.5 mL for all others age 3 yrs and older. (Note: A e" anticancer drugs; or have they had radiation treatments?This policy and procedure shall remain in effect for all patients of the until Flucelvax (ccIIV3) 0.5 mL (single-dose syringe) 0 18 years & older 90661 right). • Cardiovascular changes (name of practice or clinic) American Nurses Association (ANA) and friends – but you can2 all beInactivatedwill help keep infl or youuenza kidney and your disease, vaccine loved or ones a weakened safe from immune vaccinateda potentially system in deadly –December, can get disease. or even• Pregnant later, will women. still be needle may be used for patients weighing less that 130 lbs (<60kg) for injection in the deltoid muscle only if the skin (e.g., hypotension)? rescindedAdminister or until RIV3 (if patient (date). 3. All vaccines should be administered in settings in which personnel aged 18 through 49 years) Get vaccinatedmuch every sicker. year, and Flu makecan cause sure high your fever childrenbenefi and cialpneumonia,and inyour most parents andyears. are is stretched tight, subcutaneous tissue is not bunched, and the injection is made at a 90-degree angle.) Alternatively,90673 7. Is the person to be vaccinated• Respiratory receiving distress antiviral medications?yes    Protein Sciences Corp. Flublok (RIV3) 0.5 mL (single-dose vial) 0 18 through 49 years and equipment for rapid recognition and treatment of anaphy- or refer to a physician with protected by getting vaccinated.There are two typesvaccinated, of infl uenzatoo.make vaccine: existing medical conditions worse. It can cause diarrhea • People who have long-term health problems with: healthy children age 2 yrs and older may be given 0.2 mL of intranasal LAIV; 0.1 mL is sprayed into each nostril whileQ2033 (Medicare) (e.g., wheezing)? Medical Director’s signature: Effective date: Adapted from the Centers for Disease Control and Prevention Adults and older children need one- heart dose disease of infl uenza - kidney or liver disease laxis are available. • Gastrointestinal expertise in management Technical content reviewed by the Centersand for seizuresDisease Control in andchildren. Prevention, Each August year2010. thousands of people die the patient is in an upright position.0.25 Children mL (single-dose age 6 mos syringe) through 8 yrs should 0receive a second6 through dose 354 wks months or more 90655after 1. Inactivated (killed) vaccine, the “fl u shot,” is given by vaccine each year. But some children- lung younger disease than - 9 metabolic years disease, such as diabetes 8. Is the child or teen to be vaccinated(e.g., nausea/vomiting)? receiving aspirin therapy orof allergicaspirin-containing conditions for therapy?    • • • from infl uenza and• even more require hospitalization. 4. Some persons who report allergy to egg might not be egg-allergic. • further evaluation. Immunization Action Coalition 1573 Selby Avenue St. Paul, MN 55104 651 647-9009 www.vaccineinformation.org www.immunize.org - asthma - anemia, and other blood disorders the first dose if they are receiving0.5 influenza mL (single-dose vaccine syringe) for the first time or if they0 did not receive 3 years at &least older 1 dose of vaccine90656 Reaction requiring Technical content reviewed by the Centers for Disease Control and Prevention, August 2011. www.immunize.org/catg.d/p3074.pdf • Item #P3074 (8/11) injection with a needle. of age need two doses to be protected. Ask your doctor. Those who are able to eat lightly cooked egg (e.g., scrambled epinephrine? www.immunize.org/catg.d/p4073.pdf • Item #P4073 (8/10) in the 2010–2011 vaccination season.0.5 mL (single-dose vial) 0 3 years & older 90656 By getting fl u vaccine you can protect yourself from • Anyone with certain muscle or nerve disorders (such Fluzone (IIV3) egg) without reaction are unlikely to be9. allergic. Is the Egg-allergic person to per-be vaccinated• Reaction pregnant requiring or could emer- sheImmunization become pregnant Action Coalition within • 1573 Selby Ave. • St. Paul, MN 55104 • (651) 647-9009 • www.immunize.org • www.vaccineinformation.org Get vaccinated every2. Live, attenuated year! Get (weakened) your infl childrenuenza vaccine isvaccinated! Infl uenza vaccine may be given at the same time as other 5. Document each patient’s vaccine administration information and follow up in the following places:    infl uenza and may also avoid spreading infl uenza to others. as seizure disorders or cerebral palsy) that can lead to 5.0 mL (multi-dose vial) 25 6 through 35 months 90657 sons might tolerate egg in baked productsthe (e.g., next bread month? or cake). gency medical attention? sprayed into the nostrils. This vaccine is described in a vaccines, including pneumococcal vaccine. a. Medical chart: Record the date the vaccine was administered, the manufacturer and lot number, the vaccination site separate Vaccine Information Statement. breathing or swallowing problems. 90658 Tolerance to egg-containing foods does not exclude the possibil- Unite to Fight the Flu! Be sure your parents get vaccinated,too! and route, and the name and title5.0 mLof the (multi-dose person administering vial) the vaccine. If25 vaccine was3 yearsnot given, & older record the ity of egg allergy.2 Egg allergy can be confirmed by a consistent * Individuals with egg allergy might tolerate egg in baked products (e.g., tool kit provides a listing 10. Has the person to be vaccinated ever had Guillain-Barré syndrome?    Live, attenuated infl uenza Q2038 (Medicare) Some people should not get sanofi pasteur bread or cake). Tolerance to egg-containing foods does not exclude the pos- A “high-dose” inactivated infl uenza2 vaccine is available • Anyone with a weakened immune system. reason(s) for non-receipt of the vaccine (e.g., medical contraindication, patient refusal). medical history of adverse reactions to eggs and egg-containing Technical content reviewed by the Centers for Disease Control and Prevention www.immunize.org/catg.d/p4066.pdf • Item#P4066 (10/12) vaccine - LAIV (nasal spray)inactivated infl uenza vaccine or 0.25 mL (single-dose syringe) 0 6 through 35 months 90685 sibility of egg allergy. for people 65 years of age and older. Ask your doctor for 4 • Anyone in close contact with someone whose immune b. Personal immunization record card: Record the date of vaccination and the name/location of the administering clinic. foods, plus skin and/or blood testing11. for immunoglobulinDoes the person E anti- to be vaccinated live with or expect to have close contact with Technical content reviewed by the Centers for Disease Control andshould Prevention, November wait 2010. Fluzone (IIV4) 0.5 mL (single-dose syringe) 0 3 years & older 90686 bodies to egg proteins. † For individuals who have no known history of exposure to egg, but who are more information. There are two types of infl uenza vaccine: system is so weak they require care in a protected 6. Be prepared for management of a medical emergency related to the administration of vaccine by having a written emer- a person whose immune systemsuspected is of severely being egg-allergic compromised on the basis andof previously who mu performedst be inallergy    Immunization Action Coalition 1573 Selby Avenue • St. Paul, MN 55104 • 651 647-9009 • www.vaccineinformation.org • www.immunize.org • Tell your doctor if you have anyenvironment severe (life-threatening) (such as a bone marrow transplant unit). Close gency medical protocol available,0.5 as mL well (single-dose as equipment vial) and medications. 0 3 years & older 90686 5. For individuals who have no known historyprotective of exposure isolation to egg, (e.g., an testing, isolation consultation room with of aa physician bone marrow with expertise transplant in the management unit)? of Infl uenza viruses are always 1.changing,Live, attenuated so annual infl uenza vaccine (LAIV) contains• live allergic conditions should be obtained prior to vaccination. Alternatively, www.immunize.org/catg.d/p4069.pdf allergies, including Item #P4069 a severe(11/10) allergycontacts to of eggs. other A people severe with a weakened immune system Fluzone High-Dose (IIV3) 0.5 mL (single-dose syringe) 0 65 years & older 90662 but who are suspected of being egg-allergic on the basis of pre- Immunization Action Coalition • 1573 Selby Ave. • St. Paul, MN 55104 • (651) 647-9009 • www.immunize.org • www.vaccineinformation.org vaccination is recommended. Eachbut attenuated year scientists (weakened) try to infl uenza virus. It is sprayed into 7. Report all adverse reactions to influenza vaccine to the federal Vaccine Adverse Event Reporting System (VAERS) at RIV3 may be administered if the recipient is aged 18 through 49 years. allergy to any vaccine component(such mayas those be a with reason HIV) not may to receive LAIV. Healthcare www.vaers.hhs.govFluzone Intradermal or (800) (IIV3) 822-7967. 0.1 mL (single-dose VAERS report microinjection forms are availablesystem) at 0www.vaers.hhs.gov.18 through 64 years 90654 viously performed allergy testing, consultation12. Has withthe persona physician to be vaccinated received any other vaccinations in the past 4 weeks?    of links for staff and patient educational materi- match the viruses in the vaccinethe to nostrils. those most likely to with expertise in the management of allergic conditions should get the vaccine. Allergic reactionspersonnel to infl in uenza neonatal vaccine intensive care units or oncology cause fl u that year. Flu vaccine will not prevent disease clinics may receive LAIV. Footnotes This policy and procedure shall remain in effect for all patients of the until be obtained prior to vaccination (see figure in column to right). 2. Inactivated (killed) infl uenza vaccine, are rare.the “fl u shot,” is 1. IIV3 = egg-based and cell culture-based trivalent inactivated influenza vaccine (injectable); where 2. On August 6, 2010, (nameACIP recommended of practice or clinic) that Afluria not be used in children younger than age 9 years. from other viruses, including fl u viruses not contained in rescinded or until (date). Alternatively, RIV3 may be administered Form if the completed recipient isby: aged ______Date:______given by injection with a needle. This vaccine is described • Children or adolescents on long-term aspirin treatment. necessary to refer to cell culture-based vaccine, the prefix “cc” is used (e.g., ccIIV3). IIV4 = egg- If no other age-appropriate IIV is available, Afluria may be considered for a child age 5 through 8 years the vaccine. • Tell your doctor if you ever had a severe reaction after a based quadrivalent inactivated influenza vaccine (injectable); LAIV4 = egg-based quadrivalent live at high risk for influenza complications, after risks and benefits have been discussed with the parent or 18 through 49 years. in a separate Vaccine Information Statement. Medical Director’s signature: Effective date: Form reviewed by: ______Date: ______dose of infl uenza vaccine. attenuated influenza vaccine (nasal spray); RIV3 = trivalent recombinant hemagglutinin influenza guardian. Afluria should not be used in children younger than age 5 years. This recommendation con- 6. A previous severe allergic reaction to influenza vaccine, regardless It takes up to 2 weeks for protection to develop after the Tell your doctor if you have any severe (life-threatening) vaccine (injectable). tinues for the 2013–2014 influenza season. Technical content reviewed by the Centers for Disease Control and Prevention www.immunize.org/catg.d/p4067.pdf • Item #P4067 (10/12) Infl uenza viruses are always changing, so annual vaccination Technical content reviewed by the Centers for Disease Control and Prevention, August 2011. www.immunize.org/catg.d/p3074a.pdf • Item #P3074a (8/11) of the component suspected to be responsible for the reaction, is shot. Protection lasts about a year. • Tell your doctor if you everallergies, had Guillain-Barré including a severe allergy to eggs. A severe allergy Technical content reviewed by the Centers for Disease Control and Prevention is recommended. Each year scientists try to match the viruses a contraindication to future receipt of the vaccine. als, posters, recommendations, and PSAs to any vaccine component may be a reason not to get the Immunization ActionImmunization Coalition Action 1573 Coalition Selby Avenue • 1573 • St. Selby Paul, Ave. MN 55104 • St. •Paul, 651- 6MN47- 900955104 • www.immunize.org • (651) 647-9009 • www.vaccineinformation.org • www.immunize.org • www.vaccineinformation.orgwww.immunize.org/catg.d/p4072.pdf • Item #P4072 (9/13) Immunization Action Coalition • 1573 Selby Ave. • St. Paul, MN 55104 • (651) 647-9009 • www.immunize.org • www.vaccineinformation.org in the vaccine to those most likely to cause fl u that year. Flu vaccine. Allergic reactions to infl uenza vaccine are rare. abbreviations references vaccine will not prevent disease from other viruses, including LAIV = Live attenutated influenza vaccine 1. Kelso JM, Greenhawt MJ, Li JT, Niclas RA, Bernstein DI, Blessing-Moore J, et al. fl u viruses not contained in the vaccine. Tell your doctor if you ever had a severe reaction after a dose IIV = Inactivated Influenza Vaccine Adverse reactions to vaccines practice parameter 2012 update. J Clin All Immunol. RIV3 = Recombinant Influenza Vaccine, Trivalent 2012 Jul;130(1):25–43. of infl uenza vaccine. 2. Erlewyn-Lajeunesse M, Brathwaite N, Lucas JS, Warner JO. Recommendations for the It takes up to 2 weeks for protection to develop after the administration of influenza vaccine in children allergic to egg. BMJ. 2009;339:b3680. Tell your doctor if you ever had Guillain-Barré Syndrome (a vaccination. Protection lasts about a year. Technical content reviewed by the Centers for Disease Control and Prevention severe paralytic illness, also called GBS). Your doctor will • • - - • • LAIV does not contain thimerosal or other preservatives. help you decide whether the vaccine is recommended for you. Immunization Action Coalition 1573 Selby Avenue St. Paul, MN 55104 651 647 9009 www.immunize.org www.vaccineinformation.org � www.anaimmunize.org/flutoolkit www.immunize.org/catg.d/p3094.pdf • Item #P3094 (9/13) Nurse-to-Nurse Influenza Vaccination video uses principles of risk communication to address the • How to Administer Intramuscular, Intradermal, and Intranasal Influenza Vaccines: concerns of a nurse hesitant to receive influ- www.immunize.org/catg.d/p2024.pdf enza vaccine • Influenza Vaccine Products for the 2014–15 Influenza Season:www.immunize.org/ www.anaimmunize.org/flu-video � catg.d/p4072.pdf Colorado Hospital Association • Standing Orders for Administering Influenza Vaccine to Adults: www.immunize.org/ Guidance for Developing a Mandatory Influenza catg.d/p3074.pdf Vaccination Program. This document is intended • Screening Checklist for Contraindications to Inactivated Injectable Influenza Vaccination: to provide guidance and information for develop- www.immunize.org/catg.d/p4066.pdf ing a mandatory influenza vaccination program within individual hospitals: • Screening Checklist for Contraindications to Live Attenuated Intra nasal Influenza acV - cination: www.immunize.org/catg.d/p4067.pdf � www.immunize.org/honor-roll/cha_guidance _mandatory_influenza_policy_hcp.pdf • Influenza Vaccination of People with a History of Egg Allergy: www.immunize.org/ catg.d/p3094.pdf Immunization Action Coalition • of Washington Tool Kit Declination of Influenza Vaccination(for healthcare worker refusal: www.immunize. org/catg.d/p4068.pdf Make the Case toolkit promotes influenza and Tdap immunization among healthcare providers

� www.withinreachwa.org/what-we-do/ healthy-communities/immunizations/ The Joint Commission Commentary by Arthur L. Caplan, PhD for-providers/health-care-workers-toolkit/ Titled Influenza Information, this web section Managing the Human Toll Caused by Seasonal provides resources for healthcare institutions, Influenza – New York State’s Mandate to Vacci- National Adult and Influenza including a free monograph, Providing a Safer nate or Mask (JAMA, 10/1/2013) Environment for Health Care Personnel and Immunization Summit (NAIIS) � http://jama.jamanetwork.com/article. Co-sponsored by the National Vaccine Program Patients through Influenza Vaccination: Strategies aspx?articleid=1746248 Office, CDC, and the Immunization Action from Research and Practice Why Hospital Workers Should Be Forced to Get Coalition. Visit the Summit website: � www.jointcommission.org/topics/ Flu Shots hai_influenza.aspx � www.izsummitpartners.org/vaccinating- � www.medscape.com/viewarticle/770383 healthcare-personnel (log-in required)

Immunization Action Coalition Saint Paul, Minnesota • 651-647-9009 • www.immunize.org • www.vaccineinformation.org

Vaccinate Adults! • October 2014 • Immunization Action Coalition • (651) 647-9009 • www.immunize.orgwww.immunize.org/catg.d/p • www.vaccineinformation.org2014.pdf • Item #P2014 (9/ 1 4) 13 Screening Checklist for Contraindications to Injectable Influenza Vaccination

Patient name: Date of birth: (mo.) (day) (yr.) This checklist covers precautions and contraindications to vaccina- Screening Checklist for Contraindications to tion with IIV. Inactivated Injectable Influenza Vaccination Patients complete the check- For patients (both children and adults) to be vaccinated: The following questions will help us determine if there is any reason we should not give you or your child inactivated injectable influen- list on page 1. Page 2 provides za vaccination today. If you answer “yes” to any question, it does not necessarily mean you (or your child) should not be vaccinated. It just means additional questions must be asked. If a question is screening information for not clear, please ask your healthcare provider to explain it. Don’t Yes No Know healthcare providers.

1. Is the person to be vaccinated sick today?   

2. Does the person to be vaccinated have an allergy to eggs or    to a component of the vaccine? Information for Health Professionals about the Screening Checklist for Contraindications to Inactivated Injectable Influenza Vaccination 3. Has the person to be vaccinated ever had a serious reaction to Are you interested in knowing  why we included a certain question on the screening checklist? If so, read the information influenza vaccine in the past? below. If you want to find out even more, consult the sources listed at the bottom of this page.

4. Has the person to be vaccinated ever had Guillain-Barré syndrome? 1. Is the person to be vaccinated  sick today? people. Check the package inserts at www.immunize.org/ There is no evidence that acute illness reduces vaccine efficacy packageinserts for information on which vaccines are affected, or increases vaccine adverse events. People with an acute or go to www.cdc.gov/vaccines/pubs/pinkbook/downloads/ febrile illness usually should not be vaccinated until their symp- appendices/B/latex-table.pdf. toms have improved. Minor illnesses with or without fever do Form completed by: ______not Date: contraindicate ______use of influenza vaccine. Do not withhold 3. Has the person to be vaccinated ever had a seri- vaccination if a person is taking antibiotics. ous reaction to influenza vaccine in the past? Form reviewed by: ______Date: ______Patients reporting a serious reaction to a previous dose of 2. Does the person to be vaccinated have an inactivated influenza vaccine should be asked to describe allergy to eggs or to a component of the vaccine? their symptoms. Immediate—presumably allergic—reactions Allergic reactions to any vaccine component can occur. The are usually a contraindication to further vaccination against majority of reactions probably are caused by residual egg protein. influenza. Although most current influenza vaccines contain only a limited Fever, malaise, myalgia, and other systemic symptoms most quantity of egg protein, this protein can induce immediate allergic often affect people who are first-time vaccinees. These mild- reactions among people who have severe egg allergy. to-moderate local reactions are not a contraindication to An egg-free recombinant hemagglutinin vaccine (RIV) may be future vaccination. Also, red eyes or mild upper facial swelling used in people age 18 through 49 years with egg allergy of any following vaccination with inactivated injectable influenza severity who have no other contraindications. If RIV is not avail- vaccine is most likely a coincidental event and not related able, or if the person does not meet the age criteria for RIV to the vaccine; these people can receive injectable vaccine and has experienced a serious systemic or anaphylactic reaction without further evaluation. (e.g., hives, swelling of the lips or tongue, acute respiratory dis- 4. Has the person to be vaccinated ever had tress, or collapse) after eating eggs, that person should have IIV Guillain-Barré syndrome? administered by a physician with experience in the recognition It is prudent to avoid vaccinating people who are not at high and management of severe allergic conditions. risk for severe influenza complications (see source 3) but who Some people who report allergy to egg might not be egg- are known to have developed Guillain-Barré syndrome (GBS) allergic. If a person can eat lightly cooked eggs (e.g., scrambled within 6 weeks after receiving a previous influenza vaccination. Technical contenteggs), reviewed they by the are Centers unlikely for Disease to Controlhave andan Preventionegg allergy. However, peo- As an alternative, physicians might consider using influenza Immunization Action Coalition Saint Paul, Minnesota • 651-647-9009 • www.immunize.orgple • www.vaccineinformation.org who can tolerate egg in baked products (e.g., cake) might antiviral chemoprophylaxis for these people. Although data are www.immunize.org/catg.d/p4066.pdfstill have an egg allergy. •If Item the #P4066person (9/ develops14) hives only after limited, the established benefits of influenza vaccination for the ingesting eggs, CDC recommends they receive either inactivat- majority of people who have a history of GBS, and who are at ed influenza vaccine (IIV) or, if age-eligible, RIV (not LAIV). If IIV high risk for severe complications from influenza, justify yearly is to be administered, CDC further recommends the vaccine vaccination. recipient be observed for at least 30 minutes after receipt of the vaccine for signs of a reaction. Fluzone (sanofi pasteur) contains gelatin as a stabilizer; therefore For a ready-to-copy a history of anaphylactic reaction to gelatin is a contraindica- tion. Some inactivated influenza vaccines contain thimerosal as 8⅟2 x 11" version of this a preservative. Most people who had sensitivity to thimerosal when it was used in contact lens solution do not have reactions Sources: to thimerosal when it is used in vaccines. Check the package 1. CDC. Epidemiology & Prevention of Vaccine-Preventable Diseases, WL Atkinson 2-page piece, visit insert at www.immunize.org/packageinserts for a list of the vac- et al., editors, at www.cdc.gov/vaccines/pubs/pinkbook/index.html. cine components (i.e., excipients and culture media) used in 2. CDC. General Recommendations on Immunization: Recommendations of the Advisory Committee on Immunization Practices (ACIP) at www.cdc.gov/vaccines/ the production of the vaccine, or go to www.cdc.gov/vaccines/ hcp/acip-recs. www.immunize.org/ pubs/pinkbook/downloads/appendices/B/excipient-table-2.pdf. 3. CDC. “Prevention and Control of Seasonal Influenza with Vaccines: Recommenda- tions of the Advisory Committee on Immunization Practices (ACIP) — United Some vaccines also contain latex in the prefilled syringe States, 2014–15 Influenza Season” at www.cdc.gov/mmwr/pdf/wk/mm6332.pdf, catg.d/p4066.pdf cap which may cause allergic reactions in latex sensitive pages 691–7.

Immunization Action Coalition • Item#P4066 • p. 2

14 Vaccinate Adults! • October 2014 • Immunization Action Coalition • (651) 647-9009 • www.immunize.org • www.vaccineinformation.org Screening Checklist for Contraindications to Live Attenuated Intranasal Influenza Vaccination

Patient name: Date of birth: (mo.) (day) (yr.) This checklist covers precau- Screening Checklist for Contraindications to tions and contraindications to Live Attenuated Intranasal Influenza Vaccination vaccination with LAIV. For use with people age 2 through 49 years: The following questions will help us determine if there is any reason we should not give you or your child live attenuated intranasal influenza vaccine (FluMist) today. If you answer “yes” to any question, it does not necessarily mean you (or your child) should not be vaccinated. It just Patients complete the check- means additional questions must be asked. If a question is not clear, please ask your Don’t healthcare provider to explain it. Yes No Know list on page 1. Page 2 provides 1. Is the person to be vaccinated sick today?    screening information for 2. Does the person to be vaccinated have an allergy to eggs or to a component of the    influenza vaccine? healthcare providers. 3. Has the person to be vaccinated ever had a serious reaction to intranasal influenza vaccine    (FluMist) in the past?

4. Is the person to be vaccinated younger than age 2 years or older than age 49 years?    Information for Health Professionals about the Screening Checklist for Contraindications to 5. Does the person to be vaccinated have a long-term health problem with heart disease,Live Attenuated Intranasal Influenza Vaccination lung disease, kidney disease, neurologic or neuromuscular disease, liver disease, Are you interested  in knowing  why we included a certain question on the screening checklist? If so, read the information metabolic disease (e.g., diabetes), or anemia or another blood disorder? below. If you want to find out even more, consult the sources listed at the bottom of this page.

6. If the person to be vaccinated is a child age 2 through 4 years, in the past 12 months, 1. Is the person to be vaccinated sick today? 8. Is the person to be vaccinated receiving antiviral medications?    has a healthcare provider told you the child had wheezing or asthma? There is no evidence that acute illness reduces vaccine efficacy or increases Receipt of certain influenza antivirals (e.g., amantadine, rimantadine, zana- vaccine adverse events. People with an acute febrile illness usually should not mivir, oseltamivir) could reduce LAIV vaccine efficacy; therefore, providers be vaccinated until their symptoms have improved. Minor illnesses with or should defer vaccination with LAIV in people who took these antivirals within 7. Does the person to be vaccinated have cancer, leukemia, HIV/AIDS, or any other immunewithout fever do not contraindicate use of influenza vaccine. Do not withhold the previous 48 hours and to advise avoiding use of these antivirals for 14 system problem; or, in the past 3 months, have they taken medications that weaken the vaccination if a person is taking  antibiotics. days after vaccination, if feasible. immune system, such as cortisone, prednisone, other steroids, or anticancer drugs; or have 9. Is the child or teen to be vaccinated receiving aspirin thera- they had radiation treatments? 2. Does the person to be vaccinated have an allergy to eggs or to a component of the influenza vaccine? py or aspirin-containing therapy? A history of anaphylactic or non-anaphylactic reaction—such as hives, wheez- Because of the theoretical risk of Reye’s syndrome, children age 2 through 8. Is the person to be vaccinated receiving antiviral medications? ing, or difficulty breathing, or circulatory collapse or shock (not fainting)—after 17 years on aspirin therapy should not be given LAIV. Instead they should be eating eggs or receiving any component of the intranasal live attenuated vaccinated with the inactivated injectable influenza vaccine. influenza vaccine (LAIV; tradename FluMist) usually means no further doses. 9. Is the child or teen to be vaccinated receiving aspirin therapy or aspirin-containing therapy?    10. Is the person to be vaccinated pregnant or could she be- An egg-free recombinant hemagglutinin vaccine (RIV) may be used in people come pregnant within the next month? age 18 through 49 years with egg allergy of any severity who have no other Pregnant women or women planning to become pregnant within a month 10. Is the person to be vaccinated pregnant or could she become pregnant within the nextcontraindications. month?  People with egg allergies who do not meet the age crite- should not be given LAIV. All pregnant women should, however, be vacci- ria for RIV can usually be vaccinated with inactivated influenza vaccine (IIV); nated with the inactivated injectable influenza vaccine. 11. Has the person to be vaccinated ever had Guillain-Barré syndrome? consult ACIP recommendations  (see source 3). For a complete list of vaccine components (i.e., excipients and culture media) used in the production of the 11. Has the person to be vaccinated ever had Guillain-Barré vaccine, check the package insert (at www. immunize.org/packageinserts) syndrome? 12. Does the person to be vaccinated live with or expect to have close contact with a personor go whose to www.cdc.gov/vaccines/pubs/pinkbook/downloads/appendices/b/ It is prudent to avoid vaccinating people who are not at high risk for severe immune system is severely compromised and who must be in protective isolation (e.g.,excipient-table-2.pdf. an    influenza complications but who are known to have developed Guillain-Barré isolation room of a bone marrow transplant unit)? 3. Has the person to be vaccinated ever had a serious reaction syndrome (GBS) within 6 weeks after receiving a previous influenza vaccina- to intranasal influenza vaccine (FluMist) in the past? tion. As an alternative, physicians might consider using influenza antiviral che- moprophylaxis for these people. Although data are limited, the established 13. Has the person to be vaccinated received any other vaccinations in the past 4 weeks? Patients reporting a serious  reaction to a previous dose of LAIV should be benefits of influenza vaccination for the majority of people who have a history asked to describe their symptoms. Immediate—presumably allergic—reac- of GBS, and who are at high risk for severe complications from influenza, tions are usually a contraindication to further vaccination with LAIV. Form completed by: ______Date: ______justify yearly vaccination. Form reviewed by: ______Date:4. Is ______the person to be vaccinated younger than age 2 years or 12. Does the person to be vaccinated live with or expect to older than age 49 years? have close contact with a person whose immune system is LAIV is not licensed for use in people younger than age 2 years or older than age Technical content reviewed by the Centers for Disease Control and Prevention severely compromised and who must be in protective isolation • - - • 49 years.• Immunization Action Coalition Saint Paul, Minnesota 651 647 9009 www.immunize.org www.vaccineinformation.org (e.g., an isolation room of a bone marrow transplant unit)? www.immunize.org/catg.d/p4067.pdf • Item #P4067 (9/14) 5. Does the person to be vaccinated have a long-term health Inactivated injectable influenza vaccine is preferred for people who anticipate problem with heart disease, lung disease, kidney disease, close contact with a severely immunosuppressed person during periods in neurologic or neuromuscular disease, liver disease, metabolic which the immunosuppressed person requires care in protective isolation (e.g., disease (e.g., diabetes), or anemia or another blood disorder? in a specialized patient-care area with a positive airflow relative to the corridor, The safety of LAIV in people with any of these health conditions has not been high-efficiency particulate air filtration, and frequent air changes). Either the in- established. These conditions, including asthma in people age 5 years and activated injectable influenza vaccine or LAIV may be used in people who have older, should be considered precautions for the use of LAIV. close contact with people having lesser degrees of immunosuppression.

6. If the person to be vaccinated is a child age 2 through 4 13. Has the person to be vaccinated received any other For a ready-to-copy years, in the past 12 months, has a healthcare provider told vaccinations in the past 4 weeks? you that the child had wheezing or asthma? People who were given an injectable live virus vaccine (e.g., MMR, MMRV, LAIV is not recommended for a child this age if their parent or guardian varicella, zoster, yellow fever) should wait 28 days before receiving LAIV. 8⅟2 x 11" version of this answers yes to this question or if the child has a history of asthma or recur- There is no reason to defer giving LAIV if people were vaccinated with an rent wheezing. Instead, the child should be given the inactivated injectable inactivated vaccine or if they have recently received blood or other antibody- influenza vaccine. containing blood products (e.g., IG). 2-page piece, visit Sources: 7. Does the person to be vaccinated have cancer, leukemia, 1. CDC. Epidemiology & Prevention of Vaccine-Preventable Diseases, WL Atkinson HIV/AIDS, or any other immune system problem; or, in the et al., editors, at www.cdc.gov/vaccines/pubs/pinkbook/index.html. www.immunize.org/ past 3 months, have they taken medications that weaken the 2. CDC. General Recommendations on Immunization: Recommendations of the immune system, such as cortisone, prednisone, other steroids, Advisory Committee on Immunization Practices (ACIP) at www.cdc.gov/vaccines/ or anticancer drugs; or have they had radiation treatments? hcp/acip-recs. catg.d/p4067.pdf People with weakened immune systems should not be given LAIV. Instead, 3. CDC. “Prevention and Control of Seasonal Influenza with Vaccines: Recommenda- tions of the Advisory Committee on Immunization Practices (ACIP) — United States, they should be given the inactivated injectable influenza vaccine. 2014–15 Influenza Season” at www.cdc.gov/mmwr/pdf/wk/mm6332.pdf, pages 691–7.

Immunization Action Coalition • Item #P4067 • p. 2

Vaccinate Adults! • October 2014 • Immunization Action Coalition • (651) 647-9009 • www.immunize.org • www.vaccineinformation.org 15 Standing Orders for Administering Influenza Vaccine to Adults

Purpose: To reduce morbidity and mortality from influenza by vaccinating all adults who meet the criteria established by the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices. Policy: Under these standing orders, eligible nurses and other healthcare professionals (e.g., pharmacists), where allowed by state law, may vaccinate patients who meet any of the criteria below. Procedure: 1. Identify adults with no history of influenza vaccination for the current influenza season. 2. Screen all patients for contraindications and precautions to influenza vaccine: a. Contraindications: a serious systemic or anaphylactic reaction to a prior dose of the vaccine or to any of its compo- nents. For a list of vaccine components, refer to the manufacturer’s package insert (www.immunize.org/package- inserts) or go to www.cdc.gov/vaccines/pubs/pinkbook/downloads/appendices/B/excipient-table-2.pdf. Do not give live attenuated influenza vaccine (LAIV; nasal spray) to a person who has a history of either an anaphylactic or non- anaphylactic allergy to eggs, who is pregnant, who has immunsuppression (including that caused by medications or HIV), who is age 50 years or older, who has received influenza antivirals (e.g., amantadine, rimantadine, zanamivir, or oseltamivir) within the previous 48 hours or has possibility of use within 14 days after vaccination, or who cares for a severely immunosuppressed person who requires a protective environment. b. Precautions: moderate or severe acute illness with or without fever; history of Guillain Barré syndrome within 6 weeks of a previous influenza vaccination; for LAIV only, an adult with a medical condition which might predis- pose the adult to higher risk of complications attributable to influenza (e.g., chronic pulmonary [including asthma], cardiovascular [excluding isolated hypertension], renal, hepatic, neurologic/neuromuscular, hematologic, or meta- bolic [including diabetes] disorders. c. Other considerations: an egg-free recombinant hemagglutin influenza vaccine (RIV) may be used for people ages 18 through 49 years with egg allergy of any severity. People who experience onset of hives only after ingesting eggs: health care providers should administer inactivated influenza vaccine (IIV) and observe the patient for at least 30 minutes after receipt of the vaccine for signs of a reaction. 3. Provide all patients with a copy of the most current federal Vaccine Information Statement (VIS). You must document in the patient’s medical record or office log, the publication date of the VIS and the date it was given to the patient. Pro- vide non-English speaking patients with a copy of the VIS in their native language, if available and preferred; these can be found at www.immunize.org/vis. 4. Administer influenza vaccine as follows: a) Give 0.5 mL of IIV to adults of all ages, or RIV to adults age 18 through 49 years, intramuscularly (22–25g, 1–1½" needle) in the deltoid muscle. (Note: A e" needle may be used for adults weigh - ing less than 130 lbs [<60 kg] for injection in the deltoid muscle only if the subcutaneous tissue is not bunched and the injection is made at a 90 degree angle.) b) For healthy adults younger than age 50 years, give 0.2 mL of intranasal LAIV; 0.1 mL is sprayed into each nostril while the patient is in an upright position. c) For adults age 18 through 64 years, give 0.1 mL IIV-ID intradermally by inserting the needle of the microinjection system at a 90 degree angle in the deltoid muscle. d) For adults age 65 years and older, give 0.5 mL of high-dose IIV-IM intramuscularly (22–25g, 1–1½" needle) in the deltoid muscle. 5. Document each patient’s vaccine administration information and follow up in the following places: a. Medical chart: Record the date the vaccine was administered, the manufacturer and lot number, the vaccination site and route, and the name and title of the person administering the vaccine. If vaccine was not given, record the reasons(s) for non-receipt of the vaccine (e.g., medical contraindication, patient refusal). b. Personal immunization record card: Record the date of vaccination and the name/location of the administering clinic. 6. Be prepared for management of a medical emergency related to the administration of vaccine by having a written emergency medical protocol available, as well as equipment and medications. 7. Report all adverse reactions to influenza vaccine to the federal Vaccine Adverse Event Reporting System (VAERS) at www.vaers.hhs.gov or (800) 822-7967. VAERS report forms are available at www.vaers.hhs.gov. This policy and procedure shall remain in effect for all patients of the ______until rescinded or until ______(date). (name of practice or clinic) Medical Director’s signature: ______Effective date: ______

For standing orders for other vaccines, go to www.immunize.org/standing-orders 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 16 Vaccinate Adults! • October 2014 • Immunization Action Coalition • (651) 647-9009 • www.immunize.orgwww.immunize.org/catg.d/p3074.pdf • www.vaccineinformation.org • Item #P3074 (9/4/14) InfluenzaV accination of People with a History of Egg Allergy • People with a history of egg allergy who have experienced only Recommendations regarding influenza vaccination of hives after exposure to egg should receive influenza vaccine. persons who report allergy to eggs: ACIP, United States, Because relatively few data are available for use of LAIV in this 2014–15 influenza season. setting, inactivated influenza vaccine (IIV) or recombinant yes influenza vaccine (RIV) should be used. RIV is egg-free and Can the person eat lightly Administer vaccine per may be used for people age 18 through 49 years who have cooked egg (e.g., scrambled usual protocol. no other contraindications. However, IIV (egg- or cell-culture egg) without reaction?* based) also may be used, with the following additional safety no measures (see figure in column to right) a) Vaccine should be administered by a healthcare provider who Administer RIV (if patient is is familiar with the potential manifestations of egg allergy; and After eating eggs or yes age 18 through 49 years); egg-containing foods, does or administer IIV to any b) Vaccine recipients should be observed for at least 30 minutes the person experience patient for whom IIV is for signs of a reaction after administration of each vaccine only hives? indicated and observe for dose.1 reaction for at least 30 min- no utes after vaccination. • People who report having had reactions to egg involving such symptoms as angioedema, respiratory distress, lightheaded- After eating eggs or egg- ness, or recurrent emesis; or who required epinephrine or containing foods, does the another emergency medical intervention, may receive RIV, if person experience Administer RIV (if patient is they are age 18 through 49 years and there are no other con- other symptoms such as age 18 through 49 years) traindications. If RIV is not available or the recipient is not • Cardiovascular changes yes or, if RIV is not available, within the indicated age range, IIV should be administered by a (e.g., hypotension)? or patient is younger than physician with experience in the recognition and management • Respiratory distress age 18 years or older than of severe allergic conditions (see figure in column to right). (e.g., wheezing)? age 49 years, IIV should be • Gastrointestinal symp- administered by a physician • All vaccines should be administered in settings in which person- toms with experience in the rec- nel and equipment for rapid recognition and treatment of ana- (e.g., nausea/vomiting)? ognition and management phylaxis are available. ACIP recommends that all vaccination • Reaction requiring of severe allergic conditions. Observe for reaction for at providers should be familiar with the office emergency plan.2 epinephrine? • Reaction requiring emer- least 30 minutes after vac- • People who are able to eat lightly cooked egg (e.g., scrambled gency medical attention? cination. egg) without reaction are unlikely to be allergic. Egg-allergic persons might tolerate egg in baked products (e.g., bread or * People with egg allergy might tolerate egg in baked products (e.g., bread cake). Tolerance to egg-containing foods does not exclude or cake). Tolerance to egg-containing foods does not exclude the pos- the possibility of egg allergy.3 Egg allergy can be confirmed sibility of egg allergy. For people who have no known history of exposure to egg, but who are suspected of being egg-allergic on the basis of by a consistent medical history of adverse reactions to eggs previously performed allergy testing, consultation with a physician with and egg-containing foods, plus skin and/or blood testing for expertise in the management of allergic conditions should be obtained immunoglobulin E antibodies directed against egg proteins. prior to vaccination. Alternatively, RIV may be administered if the recipi- ent is age 18 through 49 years. • For people who have no known history of exposure to egg, but who are suspected of being egg-allergic on the basis of previ- ously performed allergy testing, consultation with a physician references with expertise in the management of allergic conditions 1. Kelso JM, Greenhawt MJ, Li JT, Niclas RA, Bernstein DI, Blessing-Moore J, et al. should be obtained before vaccination (see figure in column Adverse reactions to vaccines practice parameter 2012 update. J Clin All Immunol. 2012 Jul;130(1):25–43. to right). Alternatively, RIV may be administered if the reci- 2. CDC. General recommendations on immunization: recommendations of the ACIP. pient is age 18 through 49 years. MMWR 2011;60(No. RR-2). 3. Erlewyn-Lajeunesse M, Brathwaite N, Lucas JS, Warner JO. Recommendations for the • A previous severe allergic reaction to influenza vaccine, regard- administration of influenza vaccine in children allergic to egg. BMJ. 2009;339:b3680. less of the component suspected to be responsible for the reaction, is a contraindication to future receipt of the vaccine. Adapted from CDC. “Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices (ACIP)– United States, 2014–2015 Influenza Season” at www.cdc.gov/mmwr/pdf/wk/ mm6332.pdf, pages 691–7. abbreviations LAIV = Live Attenuated Influenza Vaccine IIV = Inactivated Influenza Vaccine RIV = Recombinant Influenza Vaccine, Trivalent

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/p3094.pdf • Item #P3094 (9/14) 17 Standing Orders for Administering Influenza Vaccines to Children and Adolescents

Purpose: To reduce morbidity and mortality from influenza by vaccinating all children and adolescents who meet the criteria established by the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices (ACIP). Policy: Under these standing orders, eligible nurses and other healthcare professionals (e.g., pharmacists), where allowed by state law, may1 vaccinate children and adolescents who meet any of the criteria below. Influenza Materials for Procedure: 1. Identify children and adolescents age 6 months and older who have not completed their influenza vaccination(s) for the current influ- enza season. 2. Screen all patients for contraindications and precautions to influenza vaccine: a. Contraindications: a history of a serious reaction (e.g., anaphylaxis) after a previous dose of influenza vaccine or to an influenza vaccine component. For information on vaccine components, refer to the manufacturer’s package insert (www.immunize.org/package-inserts) or go to www.cdc.gov/vaccines/pubs/pinkbook/downloads/appendices/B/excipient-table-2.pdf.Standing Orders for Administering Do not give live attenuated Influenza influenza Vaccine to Adults vaccine (LAIV; nasal spray) to people with either an anaphylactic or non-anaphylactic history of allergy to eggs; pregnant adolescents; children younger than age 2 yrs; children age 2 through 4 yrs who have experienced wheezing or asthma within the past 12 mos, based on Purpose: To reduce morbidity and mortality from influenza by vaccinating all adults who meet the criteria established a healthcare provider’s statement; immunosuppression, including that caused by medications or HIV; long-term aspirin therapy (applies to a Healthcare Professionals child or adolescent age 6 mos throughby 17the yrs); Centers receipt for of influenzaDisease antiviralsControl (e.g.,and Prevention’samantadine, rimantadine, Advisory zanamivir, Committee or oseltamivir) on Immunization Practices. within the previous 48 hours or possibilityPolicy: of use Under within these 14 days standing after vaccination; orders, eligible people whonurses care and for severely other healthcare immunosuppres professionalssed (e.g., pharmacists), where allowed people who require a protective environment. by2 state law, may vaccinate patients who meet any of the criteria below. b. Precautions: moderate or severe acute illness with or without fever; history of Guillain-Barré syndrome within 6 weeks of a previous influenza vaccination; for LAIV only,Procedure: children or adolescents age 5 years or older with asthma; a medical condition which might predis- pose the child to higher risk for complications1. Identify attributable adults with to influenza no history (e.g., of chronic influenza pulmonary, vaccination cardiovascular for the [excluding current influenza isolated hyper- season. tension], renal, hepatic, neurologic, hematologic, or metabolic [e.g., diabetes] disorders). c. Other considerations: onset of hives2. Screenonly after all ingesting patients eggs: for healthcarecontraindications providers shouldand precautions administer inactivated to influenza influenza vaccine: vaccine (IIV) and observe the patient for at least 30 minutesa. Contraindications: after receipt of the vaccine a serious for signs systemic of a reaction. or anaphylactic reaction to a prior dose of the vaccine or to any of its compo- 3. Provide all patients (or, in the case of a minor, nents.their parent For ora listlegal of representative) vaccine components, with a copy ofrefer the mostto the current manufacturer’s federal Vaccine package Informa- insert (www.immunize.org/package- tion Statement (VIS). You must document in theinserts) patient’s or medical go to www.cdc.gov/vaccines/pubs/pinkbook/downloads/appendices/B/excipient-table-2.pdf. record or office log, the publication date of the VIS and the date it was given Do not give First do no harm: Mandatory influenza vaccination policies for to the patient (parent/legal representative). Provide live non-Englishattenuated speakinginfluenza patients vaccine with (LAIV;a copy of nasalthe VIS spray) in their to native a person language, who if hasavailable a history of either an anaphylactic or non- and preferred; these can be found at www.immunize.org/vis. Patient name: Date of birth: healthcare personnel (HCP) help protect patients anaphylactic allergy to eggs, who is pregnant, who has immunsuppression (including that caused by medications or 4. Administer IIV or LAIV as follows (Note: When immediately available, ACIP recommends use of LAIV in healthy children ages 2 through (mo.) (day) (yr.) 8 years who have no contraindications or precautions. HIV), who If LAIV is age is not 50 immediately years or older, available, who IIV has should received be administered.): influenza antivirals (e.g., amantadine, rimantadine, zanamivir, or View the complete list: Refer to the position statements of the leading medical organizations listed below to help oseltamivir) within the previous 48 hours or has possibility of use within 14 days after vaccination, or who cares for a www.immunize.org/honor-roll/ you develop and implement a mandatory influenza vaccination policy at your healthcare a. IIV: Administer IIV intramuscularly in the vastus lateralis for infants (and toddlers lacking adequate deltoid mass) or in the deltoid mus- influenza-mandates cle (for toddlers, children, and teens). Use severely a 22–25 g immunosup needle. Choosepressed needle person length3 appropriatewho requires to the a protectivechild’s age andenvironment. body mass: infants 7 institution or medical setting. Policy titles, publication dates, links, and excerpts follow. 6 through 11 mos: 1"; 1 through 2 yrs:b. 1–1 Precautions:3"; 3yrs and older: moderate 1–12". or Give severe 0.25 mLacute (Fluzone illnessS only) creeningwith to orchildren without 6–35 fever; mos Checklist and history 0.5 mL of to Guillain Barréfor syndromeContraindications within to all others age 3 yrs and older. (Note: A e"6 needleweeks may of abe previous used for patients influenza weighing vaccination; less than 130for lbsLAIV [60 kg] only, for injectionan adult in with the deltoid a medical condition which might predis- muscle only if the subcutaneous tissue is not bunched and the injection is made at a 90-degree angle.) American Academy of Family Physicians (AAFP) American Public Health Association (APHA) pose the adult to higher risk of complications attributable to influenza (e.g., chronic pulmonary [including asthma], AAFP Mandatory Influenza Vaccination of Health Care Personnel (6/11) Annual Influenza Vaccination Requirements for Health Workers (11/9/10) b. LAIV: For children ages 2 yrs and older, administer 0.2 mL of LAIV intranasally by spraying Inactivated0.1 mL into each nostril while Injectable the patient is Influenza Vaccination cardiovascular [excluding isolated hypertension], renal, hepatic, neurologic/neuromuscular, hematologic, or meta- www.aafp.org/news-now/health-of-the-public/20110613 www.apha.org/advocacy/policy/policysearch/default.htm?id=1410 in an upright position. � � bolic [including diabetes] disorders. mandatoryfluvacc.html “Encourages institutional, employer, and public health policy to require influ- c. Children age 6 mos through 8 yrs should receive a second dose of either IIV or LAIV 4 wks or more after the first dose if they 1) are re- c. Other considerations: an egg-free recombinant hemagglutin influenza vaccine (RIV) may be used for people ages 18 “The AAFP supports annual mandatory influenza immunization for health care enza vaccination of all health workers as a precondition of employment and ceiving influenza vaccine for the first time; or 2) did not get at least 1 dose of influenzaFor vaccine patients for the 2013–14 (both season; children or 3) did and not adults)get to be vaccinated: The following questions will help through 49 years with egg allergy of any severity. People who experience onset of hives only after ingesting eggs: health personnel (HCP) except for religious or medical reasons (not personal prefer- thereafter on an annual basis, unless a medical contraindication recognized in at least 2 doses of seasonal influenza vaccine since July 1, 2010; or 4) did not get 2 or moreus determine doses of seasonal if there vaccine is any before reason JulyPatient 1,we 2010, name:should not give you or your child inactivated injectable influen - Date of birth: ences). If HCP are not vaccinated, policies to adjust practice activities during national guidelines is documented in the worker’s health record.” and at least 1 dose of monovalent 2009 H1N1care vaccine; providers or 5)should did not administer get 1 or more inactivated dosesza of vaccination seasonal influenza vaccine vaccinetoday. before If(IIV) youJuly and1,answer 2010, observe and “yes” 1 theor to patient any question, for at least it 30does minutes not necessarily after mean you (or your (mo.) (day) (yr.) flu season are appropriate (e.g. wear masks, refrain from direct patient care).” more doses of seasonal vaccine since July 1, 2010. receipt of the vaccine for signs of a reaction.child) should not be vaccinated. It just means additional questions must be asked. If a question is AssociationDeclination for Professionals of inInfluenza Infection Control Vaccination and 5. Document each patient’s vaccine administration3. Provide information all patients and withfollow a upcopy in the of followingthe most places: current federal Vaccine Information Statement (VIS). You must document American Academy of Pediatrics (AAP) Epidemiology (APIC) a. Medical chart: Record the date the vaccine was administered, the manufacturer and lotnot number, clear, the please vaccination ask siteyour and healthcare route, and the provider to explain it. Don’t Policy Statement – Recommendation for Mandatory Influenza in the patient’s medical record or office log, the publication date of the VIS and the dateScreening it was given to the Checklistpatient. Pro- for Contraindications to Influenza Vaccination Should Be a Condition of Employment for Health- name and title of the person administering the vaccine. If vaccine was not given, record the reason(s) for non-receipt of the vaccine (e.g., Yes No Know Immunization of All Health Care Personnel (10/1/10) care Personnel, Unless Medically Contraindicated (2/1/11) vide non-English speaking patients with a copy of the VIS in their native language, if available and preferred; these can My employer or affiliated health facility, ______, has recommended medical contraindication, patient refusal). 4 � http://pediatrics.aappublications.org/cgi/content/abstract/ped 8 s. www.apic.org/resource_/tinymcefilemanager/advocacy-pdfs/apic_ � be found at www.immunize.org/vis. 2010-2376v1 b. Personal immunization record card: Record the date of vaccination and the name/location1. Is of the the personadministering to be clinic.vaccinated sick today?Live Attenuated Intranasal Influenza  Vaccination that I receive influenzainfluenza_immunization_of_hcp_12711.pdf vaccination to protect the patients I serve. “The implementation of mandatory annual influenza immunization programs 6. Be prepared for management of a medical4. Administer emergency related influenza to the vaccineadministration as follows: of vaccine a) byGive having 0.5 amL written of IIV emergency to adults medica of alll Forproto- ages, use or with RIV peopleto adults age age 2 18 through through 4949 years: The following questions will help us determine if there is any “As a profession that relies on evidence to guide our decisions and actions, we col available, as well as equipment and medications. To prevent syncope in older children, vaccinate patients while they are seated or lying for HCP nationwide is long overdue. For the prevention and control of influenza, can no longer afford to ignore the compelling evidence that supports requiring years, intramuscularly (22–25g, 1–1½" needle) in the deltoid muscle. (Note: Areason e" needle we should may benot used give foryou adults or your weigh child - live attenuated intranasal influenza vaccine (FluMist) today. If you I acknowledge that I am aware of the following facts: down and consider observing them for 15 minutes after receipt of the vaccine. 2. Does the person to be vaccinated have an allergy to eggs or now is the time to put the health and safety of the patient first.” influenza vaccine for HCP. This is not only a patient safety imperative, but ing less than 130 lbs [<60 kg] for injection in the deltoid muscle only if the subcutaneousanswer “yes” tissue to any is question, not bunched it does and not the necessarily mean you (or your child) should not be vaccinated. It just 7. Report all adverse reactions to influenza vaccine to the federal Vaccine Adverse Event Reporting System (VAERS) at www.vaers.hhs.gov or  Influenza is a isserious a moral and respiratory ethical obligation disease to those that who placekills their thousands trust in our ofcare.” people in the United States injection is made at a 90 degree angle.) b) Forto healthya component adults of younger the vaccine? than agemeans 50 years, additional give 0.2 questions mL of mustintranasal be asked. LAIV; If a question is not clear, please ask your American College of Physicians (ACP) (800) 822-7967. VAERS report forms are available at www.vaers.hhs.gov. Don’t each year. 0.1 mL is sprayed into each nostril while the patient is in an upright position. c)healthcare For adults provider age 18 tothrough explain 64 it. years, give Yes No Know ACP Policy on Influenza Vaccination of Health Care Workers (9/1/10) Infectious Diseases Society of America (IDSA) www.acponline.org/clinical_information/resources/adult_ IDSA Policy on Mandatory Immunization of Health Care Workers Against This policy and procedure shall remain 0.1 in effectmL IIV-ID for all intradermally patients of the by inserting 3. the Has needle the person of the microinjection to be vaccinated until system ever had at aa 90serious degree reaction angle toin the deltoid �  Influenza vaccination is recommended for me and all other healthcare workers to protect (name of practice or clinic)    immunization/flu_hcw.pdf Seasonal and Pandemic Influenza (rev. 7/28/10) rescinded or until muscle. (date). d) For adults age 65 years and older, influenza give 0.5 mLvaccine of high-dose in the past? IIV-IM 1. Isintramuscularly the person to be (22–25g, vaccinated 1–1½"sick today? needle)    this facility’s patients from influenza, its complications, and death. How to administer intramuscular, intradermal, and intranasal influenza vaccines “Vaccinating HCWs [healthcare workers] against influenza represents a duty � www.idsociety.org/HCW_Policy Medical Director’s signature: in the deltoid muscle. Effective date: of care, and a standard of quality care, so it should be reasonable that this duty 2. Does the person to be vaccinated have an allergy to eggs or to a component of the  If I contract influenza,“Physicians and I canother healthshed carethe providers virus formust 24 have hours two speci beforeal objectives influenza symptoms appear. should supersede HCW personal preference.” in view when treating patients, namely, ‘to do good or to do no harm’ (Hippocratic 5. Document each patient’s vaccine administration4. TechnicalHas content theinformation personreviewed by the to Centersand be forvaccinatedfollow Disease Control up andeverin Preventionthe had following Guillain-Barré places: syndrome?       My shedding the virus can spread influenza to patients in this facility. influenza vaccine? Corpus in Epidemics: Bk. I, Sect. 5, trans. Adams), and have an ethical and Immunization Action Coalition Sainta. Paul,Medical Minnesota chart: • 651- 6Record47-9009 •the www.immunize.org date the vaccine • www.vaccineinformation.org was administered, the manufacturer and lot number, the vaccinationIntramuscular site injection Intradermal administration Intranasal administration American Hospital Association (AHA) If I become infectedmoral obligation with toinfluenza, prevent transmission even ofif infectious my symptoms diseases to their are patients.” mild or non-existent, I can • 5  and route, and the name and title of thewww.immunize.org/catg.d/p3074a.pdf person administering the vaccine.Item #P3074a If (9/4/ vaccine14) was not given, recordInactivated the Influenza Vaccines (IIV), including re- Inactivated Influenza Vaccine (IIV) Live Attenuated Influenza Vaccine (LAIV) 3. Has the person to be vaccinated ever had a serious reaction to intranasal influenza vaccine AHA Endorses Patient Safety Policies Requiring Influenza Vaccination of reasons(s) for non-receipt of the vaccine (e.g., medical contraindication, patient refusal). combinant hemagglutinin influenza vaccine (RIV)    Health Care Workers (7/22/11) spread it to othersNational and Business they can Group become on Health seriously (NBGH) ill. (FluMist) in the past? www.aha.org/advocacy-issues/tools-resources/advisory/2011/110722- Hospitals Should Require Flu Vaccination for all Personnel to Protect b. Personal immunization record card: Record Form the completed date of vaccination by: ______and the name/location of the administering1. Use clinic.a needle Date: long ______enough to reach deep into the 1. Gently shake the microinjection system before �  I understand that the strains of virus that cause influenza infection change almost every year 1. FluMist (LAIV) is for intranasal administration only. quality-adv.pdf Patients’ Health and Their Own Health (10/18/11) 6. Be prepared for management of a medical emergency related to the administration of vaccine by having a writtenmuscle. Infants age 6 through 11 mos: 1"; administering the vaccine. Do not inject FluMist. and, even if they don’t change, my immunity declines over time. This is why vaccination 4. Is the person to be vaccinated younger than age 2 years or older than age 49 years?    “To protect the lives and welfare of patients and employees, AHA supports man- www.businessgrouphealth.org/pub/f314b0a7-2354-d714-511f- emergency medical protocol available, as wellForm as equipment reviewed by:and ______medications. 1 through 2 Date: yrs: 1–1 ______3"; children and adults against influenza� is recommended each year. 3 yrs and older: 1–1½". 2. Hold the system by placing the 2. Remove rubber tip protector. Do not remove dose- datory patient safety policies that require either influenza vaccination or wear- 57f12807ba2c 7. Report all adverse reactions to influenza vaccine to the federal Vaccine Adverse5. Does Event the Reporting person to be System vaccinated (VAERS) have a long-term at health problem with heart disease, thumb and middle finger on divider clip at the other end of the sprayer. ing a mask in the presence of patients across healthcare settin gs Iduring understand “thatHospitals I cannot should requireget influenza flu vaccination from for allthe personnel influenza to protect vaccine. patients’ flu season. The aim is to achieve the highest possible level of protection.” www.vaers.hhs.gov or (800) 822-7967. VAERS report forms are available at www.vaers.hhs.gov.lung disease, kidney disease, neurologic2. With or your neuromuscular left hand*, bunchdisease, up liver the disease,muscle. the finger  pads; the  index finger health and their own health.” Influenza shouldVaccine remain free. Products for the 20143. With –the2015 patient in an Influenza upright position Season  The consequences of my refusing to be vaccinated could have life-threatening consequences This policy and procedure shall remain in effect for all patients of the ______metabolic disease (e.g., diabetes), 3.or until Withanemia your or right another hand*, blood insert disorder? the needle at a (i.e., head not tilted back), place the American Medical Directors Association (AMDA) National Patient Safety Foundation (NPSF) (name of practice or clinic) to my health and the health of those with whom I have contact, including rescinded or until ______(date). 90° angle to the skin with a quick thrust. 3. Insert the needle perpendicular to the skin, tip just inside the nostril to Mandatory Immunization for Long Term Care Workers (3/11) NPSF Supports Mandatory Flu Vaccinations for Healthcare Workers in the region of the deltoid, in a short, quick Mercury • all patients in this healthcare facility 6. If the person to be vaccinated is a child age 2 through 4 years, in the past 12 months, Trade Name ensure LAIV is delivered � www.amda.com/governance/resolutions/J11.cfm (11/18/09) Medical Director’s signature: ______Effective date: ______4. Push down on the plunger and injectManufacturer the entire 1 How Supplied Content Age Group Product Code movement. (vaccine  abbreviation)  into the nose. The patient “ www.npsf.org/updates-news-press/press/media-alert-npsf-supports- has a healthcare provider told you thecontents child had of wheezingthe syringe. or Thereasthma? is no need to aspi- (μg Hg/0.5mL) Therefore be it resolved, AMDA – Dedicated to Long-Term Care Me • mydicine coworkers – � Technical content reviewed by the Centers for Disease Control and Prevention should breathe normally. supports a mandatory annual influenza vaccination for every long-term health mandatory-flu-vaccinations-for-healthcare-workers Saint Paul, Minnesota • 651-647-9009 • www.immunize.org • www.vaccineinformation.org rate. 4. Once the needle has been • my family Immunization Action Coalition 0.5 mL (single-dose syringe) 0 2, 3 90656 • 6 care worker who has direct patient contact unless a medical contraindication “ NPSF recognizes vaccine-preventable diseases as a matter of patient safety and www.immunize.org/catg.d/p3074.pdf Item #P3074 (9/4/14) bioCSL, Inc. inserted,Afluria maintain (IIV3) light pressure 4. With a single motion, depress 9 years & older 7. Does the person to be vaccinated have cancer, leukemia, HIV/AIDS, or any other immune 5.0 mL (multi-dose vial) 24.5 or90658 religious • Q2035 objection (Medicare) exists.” • my communitysupports mandatory influenza vaccination of health care workers to protect the 5. Remove the needle and simultaneously apply on the surface of the skin and plunger as rapidly as possible system problem; or, in the past 3 months, have they taken medications that weaken the Guide for Determining the Number of Doses of Influenza Vaccinehealth of patients, health care workers, and the community.” pressure to the injection site with a dry cotton ball inject usingFluarix  the (IIV3) index finger to 0.5 mL (single-dose syringe) until the dose-divider clip0 prevents 3 years & older 90656 immune system, such as cortisone, prednisone, other steroids, or anticancerGlaxoSmithKline drugs; or have American Pharmacists Association (APhA) or gauze. Hold in place for several seconds. push onFluarix the plunger.(IIV4) Do not aspirate.0.5 mL (single-dose syringe) you from going further. 0 3 years & older 90686 Despite these facts, I am choosing to decline influenza vaccination right now for the following they had radiation treatments? to Give to Children Age 6 MonthsRequiring Through Influenza Vaccination 8 Yearsfor All Pharmacy During Personnel (4/11) The Society for Healthcare Epidemiology of America (SHEA) 6. If there is any bleeding, cover the injection site with 0.5 mL (single-dose syringe) 0 3 years & older 90656www.pharmacist.com/sites/default/files/files/2011reasons: ______Influenza Vaccination of Healthcare Personnel (rev. 8/31/10) 5. RemoveFluLaval the needle (IIV3) from the skin. With the 5. Pinch and remove the � a bandage. ID Biomedical Corp. of 2014–2015 Influenza Season ActionsoftheAPhAHoD-Public.pdf• www.journals.uchicago.edu/doi/full/10.1086/656558 8. Is the person to be vaccinated receiving antiviral medications? needle directed away from you and others,5.0 mL (multi-dose vial) dose-divider clip from <25 3 years & older 90658 Q2036 (Medicare) ______� Quebec, a subsidiary of push very  firmly with the thumb on the “APhA supports an annual influenza vaccination as a condition of employment, 7. Put the used syringe in a sharps container. 0.5 mL (single-dose syringe) the plunger. 0 3 years & older 90686 “SHEA views influenza vaccination of HCP as a core patient and HCP safety GlaxoSmithKline FluLaval (IIV4) training, or volunteering, within an organization that provides pharmacy ser- plunger to activate the needle shield. 10 dose-divider clip ______practice with which noncompliance should not be tolerated.” 5.0 mL (multi-dose vial) <25 3 years & older 90688 9. Is the child or teen to be vaccinated*Use receiving the opposite aspirin hand therapy if you are or left-handed. aspirin-containing therapy? You will hear  a click when the 6. Place the tip just inside the other vices or operates a pharmacy or pharmacy department (unless a valid medical MedImmune shield FluMistextends (LAIV4) to cover the needle. 0.2 mL (single-use nasal spray)nostril, and with a single 0motion, depress2 through 49 years or90672 religious reason precludes vaccination).” GiveI 1understand dose of that continuedI can change on page my 2mind � at any time and accept influenza vaccination, if vaccine plunger asDid rapidly the as possiblechild receive to deliver theat least 1 dose of Yes is still available. 10. Is the person to be vaccinated pregnant or could she become pregnant within the next month?    0.5 mL (single-dose syringe) <1 90656 2014–15 influenza Technical content reviewed by the Centers for Disease ControlNovartis and Prevention Vaccines and 6. DisposeFluvirin of the (IIV3) applicator in a sharps con- remaininginfluenza vaccine. vaccine for 4the years 2013–14& older season? 5.0 mL (multi-dose vial) 25 90658 • Q2037 (Medicare) St. Paul, Minnesota • 651-647-9009 • www.immunize.org • www.vaccineinformation.org Immunization Action Coalition Saint Paul, Minnesota • 651-647-9009 • www.immunize.org • www.vaccineinformation.org tainer. Immunization Action Coalition vaccine this season. Diagnostics, Inc. 7. Dispose of the applicator in a sharps container. 11. Has the person to be vaccinated ever hadwww.immunize.org/catg.d/p4066.pdf Guillain-Barré syndrome? • Item #P4066 (9/14)  Flucelvax  (ccIIV3) 0.5 mL (single-dose syringe) 0 18 years & older 90661 I have read and fully understand thewww.immunize.org/catg.d/p information on this2014.pdf declination • Item #P2014 (10/ form.13) Protein Sciences Corp. Flublok (RIV3) 0.5 mL (single-dose vial) 0 18 through 49 years 90673 12. Does the person to be vaccinated live with or expect to have close contact with a person whose 90° angle 0.5 mL (single-dose syringe) No/Don’t0 3 years know & older 90656 Signature: ______Date: ______immune system is severely compromised and who must be in protective isolation (e.g., an    isolation room of a bone marrow transplant unit)? skin Fluzone (IIV3) 5.0 mL (multi-dose vial) 25 6 through 35 months 90657 5.0 mL (multi-dose vial) 25 3 years & older 90658 • Q2038 (Medicare) Name (print): ______subcutaneous tissue

13. Has the person to be vaccinated received any other vaccinations in the past 4 weeks?    0.25 mL (single-dose syringe) Did the child0 receive6 through a total 35 monthsof at least 90685 Give 1 dose of Department: ______muscle 0.5 mL (single-dose syringe) 2 doses of0 seasonal3 influenza years & older vaccine 90686 Yes 2014–15 influenza Form completed by: ______Sanofi Pasteur, Date: Inc. ______Reference: CDC. Prevention and Control of Influenza with Vaccines— Fluzone (IIV4) 0.5 mL (single-dose vial) since0 July 31, years 2010? & older 90686 vaccine this season. Recommendations of ACIP at www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/flu.html Form reviewed by: ______Date: ______5.0 mL (multi-dose vial) 25 6 through 35 months 90687 Technical content reviewed by the Centers for Disease Control and Prevention Technical content reviewed by the Centers for Disease Control and Prevention Immunization Action Coalition SaintTechnical Paul, content Minnesota reviewed by the • Centers651- 6for47 Disease-9009 Control • www.immunize.org and Prevention 5.0 •mL www.vaccineinformation.org (multi-dose vial) 25 3 years & older 90688 Immunization Action Coalition Saint Paul, Minnesota • 651-647-9009 • www.immunize.org • www.vaccineinformation.org • - - • • www.immunize.org/catg.d/p4068.pdf • Item #P4068 (8/14) Immunization Action Coalition Saint Paul, Minnesota 651 647 9009 www.immunize.org www.vaccineinformation.org www.immunize.org/catg.d/p2024.pdfNo/Don’t • Item know #P2024 (9/14) www.immunize.org/catg.d/p4067.pdfFluzone • ItemHigh-Dose #P4067 (IIV3)(9/14) 0.5 mL (single-dose syringe) 0 65 years & older 90662 Fluzone Intradermal (IIV3) 0.1 mL (single-dose microinjection system) 0 18 through 64 years 90654 Footnotes Did the child receive a total of at least 1. IIV3 = egg-based and cell culture-based trivalent inactivated influenza vaccine (injectable); where necessary to refer to 2. In 2010, ACIP recommended that Afluria not be used in children younger than age 9 years. If no other age-appropriate IIV Give 1 dose of cell culture-based vaccine, the prefix “cc” is used (e.g., ccIIV3). IIV4 = egg-based quadrivalent inactivated influenza is available,2 doses Afluria ofmay beseasonal considered for a child influenza age 5 through 8 years vaccine at high risk for influenza complications,Yes after risks vaccine (injectable); LAIV4 = egg-based quadrivalent live attenuated influenza vaccine (nasal spray); RIV3 = trivalent and benefits have been discussed with the parent or guardian. Afluria should not be used in children younger than age 5 – before July 1, 2010, and at least 1 dose of 2014 15 influenza recombinant hemagglutinin influenza vaccine (injectable). years. This recommendation continues for the 2014–2015 influenza season. vaccine this season. 3. Afluria ismonovalent approved by the Food and 2009 Drug Administration H1N1 forvaccine? intramuscular administration with the PharmaJet Stratis Needle-Free Injection System for persons age 18 through 64 years.

No/Don’t knowTechnical content reviewed by the Centers for Disease Control and Prevention VACCINE INFORMATION STATEMENT Immunization Action Coalition Saint Paul, Minnesota • 651-647-9009 • www.immunize.org • www.vaccineinformation.org www.immunize.org/catg.d/p4072.pdf • Item #P4072 (9/14)

(Flu Vaccine, Many Vaccine Information Statements are Inactivated or available in Spanish and other languages. Did the child receive at least 1 dose of Influenza Vaccine See www.immunize.org/vis Give 1 dose of Recombinant) Hojas de información sobre vacunas están seasonal influenza vaccine before disponibles en español y en muchos otros Yes 2014–15 influenza What You Need to Know idiomas. Visite www.immunize.org/vis July 1, 2010, and at least 1 dose of 2014-2015 vaccine this season. 9 seasonal vaccine since July 1, 2010? Flu vaccination is recommended every year. Some 1 Why get vaccinated? children 6 months through 8 years of age might need two doses during one year. Influenza (“flu”) is a contagious disease that spreads No/Don’t know around the United States every winter, usually between Flu viruses are always changing. Each year’s flu vaccine October and May. is made to protect against 3 or 4 viruses that are likely Reference to causeVACCINE disease that INFORMATION year. Flu vaccine cannot STATEMENT prevent all Flu is caused by influenza viruses, and is spread mainly Give 2 doses of 2014–15 influenza Prevention and Control of Seasonal Influenza with Vaccines: cases of flu, but it is the best defense(Flu against Vaccine, the disease. Live, Recommendations of the Advisory Committee on Immunization by coughing, sneezing, and close contact. Many Vaccine Information Statements are vaccine this season, spaced at least Practices — United States, 2014–2015. MMWR, August 15, 2014; It takes about 2 weeks for protection to develop after available in Spanish and other languages. Anyone can get flu, but the risk of Influenzagetting flu is highest Vaccine Intranasal) See www.immunize.org/vis 4 weeks apart. 63(327):691–697. Access recommendations at www.cdc.gov/ the vaccination, and protection lasts several months to a Hojas de información sobre vacunas están among children. Symptoms come on suddenly and may mmwr/pdf/wk/mm6332.pdf year. disponibles en español y en muchos otros last several days. They can include: What You Need to Know 2014-2015 idiomas. Visite www.immunize.org/vis • fever/chills 9 Some illnesses that are not caused by influenza virus are • sore throat often mistaken for flu. Flu vaccine Injectablewill not prevent flu vaccines these are described in a separate Technical content reviewed by the Centers for Disease Control and Prevention • muscle aches 1 Why get vaccinated?illnesses. It can only prevent influenza.Vaccine Information Statement. Immunization Action Coalition Saint Paul, Minnesota • 651-647-9009 • www.immunize.org • www.vaccineinformation.org www.immunize.org/catg.d/p3093.pdf • Item #P3093 (9/14) • fatigue Influenza (“flu”) is a contagiousSome disease inactivated that spreadsflu vaccine containsFlu avaccination very small is recommended every year. Some • cough around the United States everyamount winter, of usually a mercury-based between preservativechildren called 6 months through 8 years of age might need two • headache October and May. thimerosal. Studies have shown thatdoses thimerosal during in one year. • runny or stuffy nose Flu is caused by influenza viruses,vaccines and is is not spread harmful, mainly but flu vaccinesFlu viruses that do are not always changing. Each year’s flu vaccine Flu can make some people much sickerby coughing, than others. sneezing, and closecontain contact. a preservative are available.is made to protect against viruses that are likely to cause These people include young children, people 65 and disease that year. LAIV protects against 4 different Anyone can get flu, but the risk of getting flu is highest older, pregnant women, and people with certain health Some people shouldinfluenza not viruses.get Flu vaccine cannot prevent all cases of among children. Symptoms come on suddenly and may conditions — such as heart, lung or kidney disease, 3 this vaccine flu, but it is the best defense against the disease. nervous system disorders, or a weakenedlast several immune days. They can include: It takes about 2 weeks for protection to develop after system. Flu vaccination is especially• importantfever/chills for these Tell the person who gives you the vaccine: vaccination, and protection lasts several months to a people, and anyone in close contact •with sore them. throat • If you have any severe, life-threatening allergies. If 2 • muscle aches year. IAC’s website: you ever had a life-threatening allergic reaction after a For 8⅟ x 11" copies of the pieces above, visit Flu can also lead to pneumonia, and make existing • fatigue dose of flu vaccine, or have a severeSome allergy illnesses to any that part are not caused by influenza virus are medical conditions worse. It can cause diarrhea and • cough of this vaccine, including (for example)often mistakenan allergy for to flu. Flu vaccine will not prevent these seizures in children. • headache gelatin, antibiotics, or eggs, you mayillnesses. be advised It can not only to prevent influenza. Each year thousands of people in the• runny United or Statesstuffy nosedie get vaccinated. Most, but not all, types of flu vaccine LAIV may be given to people 2 through 49 years of www.immunize.org/handouts/influenza-vaccines.asp from flu, and many more are hospitalized. contain a small amount of egg protein. Flu can make some people much sicker than others. age. It may safely be given at the same time as other • If you ever had Guillain-Barré Syndrome (a severe Flu vaccine is the best protection againstThese flu people and includeits young children, people 65 and vaccines. complications. Flu vaccine also helpsolder, prevent pregnant spreading women, and peopleparalyzing with certain illness, health also called GBS). Some people LAIV does not contain thimerosal or other preservatives. flu from person to person. conditions – such as heart, lung withor kidney a history disease, of GBS should not get this vaccine. This nervous system disorders, or a weakenedshould be immunediscussed with your doctor. 1 Standing orders for administering influenza 7 First do no harm: Protect patients by making Inactivated and recombinantsystem. Flu vaccination is especially• If you important are not feeling for these well . It is usually 3 okay Some to get flupeople should not get 2 people, and anyone in close contactvaccine with when them. you have a mild illness, but youthis might vaccine flu vaccines be advised to wait until you feel better. You should Flu can also lead to pneumonia, and make existing Tell the person who gives you the vaccine: sure all staff receive yearly influenza vaccine! You are getting an injectable flu vaccine, which is either come back when you are better. vaccines to children and adolescents: medical conditions worse. It can cause diarrhea and an “inactivated” or “recombinant” vaccine. These • If you have any severe, life-threatening allergies, seizures in children. vaccines do not contain any live influenza virus. They including (for example) an allergy to gelatin or are given by injection with a needle,Each and oftenyear thousandscalled the of people in the United States die antibiotics. If you ever had a life-threatening allergic www.immunize.org/catg.d/p3074a.pdf www.immunize.org/catg.d/p2014.pdf “flu shot.” from flu, and many more are hospitalized. reaction after a dose of flu vaccine, or have a severe allergy to any part of this vaccine, you should not get A different, live, attenuated (weakened)Flu vaccine influenza is the best protection against flu and its vaccinated. 2 Standing orders for administering influenza 8 Declination of influenza vaccination (for health- vaccine is sprayed into the nostrils. Thiscomplications. vaccine is Flu vaccine also helps prevent spreading • If you ever had Guillain-Barré Syndrome (a severe described in a separate Vaccine Informationflu from Statementperson to . person. paralyzing illness, also called GBS). Some people Live, attenuated flu with a history of GBS should not get this vaccine. This vaccine to adults: care personnel refusal): 2 should be discussed with your doctor. vaccine — LAIV, Nasal Spray • If you have long-term health problems, such as You are getting a live, attenuated influenza vaccine certain heart, breathing, kidney, liver, or nervous www.immunize.org/catg.d/p3074.pdf www.immunize.org/catg.d/p4068.pdf (called LAIV), which is sprayed into the nose. system problems, your doctor can help you decide if “Attenuated” means weakened. The viruses in the you should get LAIV. vaccine have been weakened so they won’t give you the 3 Screening checklist for inactivated injectable 9 Federally required Vaccine Information flu. There are other “inactivated” and “recombinant” flu vaccines that do not contain live virus. These “flu shots” influenza vaccination: Statements in English and other languages: are given by injection with a needle. www.immunize.org/catg.d/p4066.pdf www.immunize.org/vis 4 Screening checklist for live attenuated intra- – Inactivated Influenza Vaccine: What you nasal influenza vaccination: need to know: www.immunize.org/catg.d/p4067.pdf www.immunize.org/vis/flu_inactive.pdf 5 How to administer intramuscular, intra- – Live, Intranasal Influenza Vaccine: dermal, and intranasal influenza vaccines: What you need to know: www.immunize.org/catg.d/p2024.pdf www.immunize.org/vis/flu_live.pdf 6 Influenza vaccine products for the 2014–2015 10 Guide for determining number of doses of influenza season: influenza vaccine for children 6 months www.immunize.org/catg.d/p4072.pdf through 8 years: www.immunize.org/catg.d/p3093.pdf

18 Vaccinate Adults! • October 2014 • Immunization Action Coalition • (651) 647-9009 • www.immunize.org • www.vaccineinformation.org InfluenzaH andouts –

copy this for your patients Don’t take chances with your Make copies and give them family’s health – make sure you all get1 vaccinated against influenza y... every year! to your patients. Here’s how influenza can hurt your famil Influenza usually comes on suddenly. Symptoms can include high fever, chills, headaches, exhaustion, sore throat, cough, and all-over body aches. Influenza can make you, Some people say, “It felt like a truck hit me!” Symptoms can also be mild. or your parents Regardless, when influenza strikes your family, the result is lost time from your children, work and school. really sick. Influenza is a serious disease...

An infected person can spread influenza when they Pcough,rotect sneeze, or just yourself from influenza... talk near others. They can also spread it by touching or sneezing on an object Influenza spreads easily from that someone else touches later. And, an infected person doesn’t have to feel Get vaccinated! 3 Make sure your child is protected! sick to be contagious: they can spread influenza to others when they feel person to person. What is influenza? well – before their symptoms have even begun. 2 eople are hospitalizedWhatd 50, in000 the is die,U.S. influenza? which from shows Influenza (flu) is a serious disease caused by a virus. Influenza (flu) is a serious disease caused eople most likely to be hospitalized Each year, more than 200,000 p nly the Influenza can make you feel miserable! Fever, cough, shaking Influenza can make your child influenza and its complications. en,Between older adults,3,000 an and people of all ages who chills, body aches, and extreme weakness are common how unpredictable influenza can be. The p feel miserable. Fever, cough, by a virus. Influenza and its complications rt or lung disease.ar But influenza remember, kills peopleit’s not whoo symptoms. and die are infants, young childr shaking chills, body aches, and can be so serious that they can have conditions such as hea extreme weakness are common put you, your children, or youngest, oldest, or sickest who die: Every ye How do you catch it? You can catch influenza from people How do you catch symptoms. your parents in the hospital – were otherwise healthy. who cough, sneeze, or even just talk

or lead to death. around you. It is very contagious. influenza? Your child can catch influenza There’s no substitute for yearly vaccination in protecting the people you love from people who cough, sneeze, from influenza. Either type of influenza vaccineIs it (the serious? “shot” or nasal spray) Yes! Tragically, every year infants, or even just talk around him or her. It is very conta will help keep you and your loved ones safe from a potentially deadly disease. Is influenza serious? Influenza can be a very serious children, teens, and adults die Get vaccinated every year, and make sure your children and your parents are disease for you, your family, from influenza. vaccinated, too. Y and friends – but you can all be es. Tragically, every year infants, children, t gious. Get your Influenza is very unpredictable. die from influenza. protected by getting vaccinated. influenza too! No one knows how deadly influenza will be each year. Ask vaccination your child’s Influenza is dangerous for children as well aseens, for peopl and adults healthcare provider every year!ention Even if you have a mild case of influenza, you can still pass if your child is ages. Children younger than 2 y the virus on to your friends, family, and coworkers who could up to date for all high risk for hospitalization due to c Be sure your parents get wedvaccinated, by the Centers for Disease Control and Prev Get vaccinated every year! Get your children vaccinated! vaccines! ears of age are at particularly Technical content revie Item #P4069 (9-14) get very sick or even die. e of all 69.pdf ∙ Influenza is not only serious for your child, but i omplications of influenza. • www.vaccineinformation.orgwww.immunize.org/catg.d/p40 serious for others, such as babies and g on nizati • www.immunize.org immu -647-9009 COPY This FOR YOUR PATIENTS child passes the virus on to them. tion coalition • 651 Am I at risk? Yes. Influenza is most dangerous for people with health ac Is my child at risk? t can be Saint Paul, Minnesota conditions like heart and lung disease, the very young and very randparents, if your old, Keepand pregnant your women. kids But anyone safe can become — get seriously them vaccinated Cize.org Yes. Anyone can becomeInfluenza: seriously sick from Questions influenza − and Answers An Protects BabiesIimmu sick from influenza – even young, healthy people. every fall or winter! How can I protect healthy children. Information about the disease and vaccines Everyone in a baby’s life needs to get vaccinated against my child from 4 How can I protect Vaccination5Is influenza is the bestmore wayserious to prevent influenza.Infants and young children are at risk for getting seriously ill from influenza. influenza? Vaccination6 is the best way to protect your c even whooping cough and flu! That’s why health experts recommend that all children 6 months and older influenza. What causes influenza? er, who are at increased risk for death from influenza myself from Everyonefor kids? age 6 months and older should get vaccinated against influenza? and all adults get vaccinated against influenza each fall or winter. Viruses cause influenza. There are two basic types, complications. The Centers for Disease Control and influenza every year. Everyone 6 months Aof and age B, and which older can shoulcausehild clinical from illness getting in humans. Prevention (CDC) estimates that from the 1976–77 What is cocooning? How can we protect babies against Their genetic material differentiates them. Influ- influenza season to the 2006–07 season, influenza- VaccinationInfluenza not onlyvaccine protects may thesave person whoMost gets people immunized, with influenza are sick for about a week, and then they feel better. against influenza everyenza Ayear. can cause moderate to severe illness in all associated deaths ranged from a low of about 3,000 Babies younger than 6 months old are more likely to whooping cough? age groups and infects humans and other animals. it alsoyour protects child’s the life. people around them –But, for some example, people, babies especially young children, pregnant women, older people, d get vaccinated to a high of about 49,000 each year. It is estimated develop certain infectious diseases than older children. Vaccination not only Influenzaprotects Bpeople causes who milder g disease and affects only that approximately 43–89 million people became ill • All children should be vaccinated on schedule with who are too young to be vaccinated. and people with chronic health problems can get very sick. Some even die. A Cocooning is a way to protect babies from catching dis- DTaP (the childhood whooping cough vaccine). yearly vaccination against influenza is the best way to protect your child from it also protects othershumans, who are primarily around children. them. with 2009 pandemic H1N1 in the U.S. from April Subtypes of the type A influenza virus are identified 2009 to April 2010. eases from the people around them – people like their • All teenagers and adults need a one-time dose of Tdap this serious disease. It is recommended for everyone 6 months and older. et immunized,

s by two (proteins involved in the immune ▲ Influenza disease can occur among people of all parents, siblings, grandparents, friends, child-care provid- vaccine (the teen and adult whooping cough vaccine). For more information, visit www.vaccineinformation.org ers, babysitters, and healthcare providers. Once these For more information, visitreaction) www.vaccineinformation.org on the surface of the virus. These antigens ages; however, the risks for complications, hospital- • Pregnant women should receive a Tdap vaccination in What is influenza? Influenza, or “flu,” is an infection of the nose, throat, and lungs. It can easily can change, or mutate, over time. When a “shift” izations, and deaths are higher among people age people are vaccinated, they are less likely to spread these For other vaccine handouts in this series, each pregnancy, preferably during the 3rd trimester. spread from person to person. visit www.immunize.org/vaccine-summaries (major change) occurs, a new influenza virus is born 65 years or older, young children, and people of any contagious diseases to the baby. They surround the baby and an epidemic is likely among the unprotected This will protect the pregnant woman as well as her Technical content reviewed by the Centers for Disease Control and Prevention age who have certain medical conditions. Case re- with a cocoon of protection against disease until he or she For other vaccine handouts in this series, population. This happened when the novel H1N1 ports and epidemiologic studies also indicate that baby! 1573 Selby Avenue • Saint Paul, Minnesota • www.immunize.org is old enough to get all the doses of vaccine needed to be visit www.immunize.org/vaccine-summaries What types of vaccine are • Influenza shots can be given to children 6 months and older. Technical content reviewed byinfluenza the Centers for virus Disease appeared Contr in March of 2009 and led to pregnancy can increase the risk for serious medical www.immunize.org/catg.d/p4408.pdf • Item #P4408 (5/I3) fully protected. available for children? • The nasal-spray influenza vaccine can be given to healthy children 2 years 1573 Selby Avenue a major pandemic, lasting until the summer of 2010. complications from influenza. • How can we protect babies against flu? and older. It can provide better protection in healthy children ages 2 through www.immunize.org/catg.d/p Saint4 Paul, Minnesota ol and Prevention How does influenza spread? In nursing homes, up to 60% of residents may be- 8 years and is preferred for children of this age if it is available in the office or 312.pdf • • Item #P4 www.immunize.org come infected, with up to a 30% fatality rate in Why is cocooning important? Everyone age 6 months and older needs to receive flu Influenza is312 transmitted (6/13) through the air from the clinic; however, if your clinic doesn’t have the vaccine, your child should get the the infected. Risk for influenza-associated death is vaccine every year. respiratory tract of an infected person. It can also Babies less than 6 months old are too young to have influenza shot. be transmitted by direct contact with respiratory highest among the oldest of the elderly: people age received all the doses of vaccine that are needed to protect • Children younger than 5 years who have had wheezing in the past year—or any droplets. 85 years and older are 16 times more likely to die from an influenza-associated illness than people age them from whooping cough (pertussis), flu (influenza), child with chronic health problems—should get the injectable vaccine (a shot), 65–69 years. and other dangerous diseases. To be fully protected, not the nasal-spray vaccine. How long does it take to develop symptoms of influ- information from trusted sources enza after being exposed? babies need to get all the vaccine doses in a series – not • Children younger than 9 years old who are getting influenza vaccine for the Hospitalization from influenza-related complica- Video: Surround Your Baby with Protection The incubation period of influenza is usually two tions is also high among children age 24 months just the first dose. � first time need two doses separated by 4 weeks. (about whooping cough) days but can range from one to four days. and younger—comparable to rates for people age Unvaccinated adults and family members, including parents, http://cocooning.preventpertussis.org 65 and older. There were 153 laboratory-confirmed What are the symptoms of influenza? From the Texas Department of State Health Services influenza-related pediatric deaths reported during are often the ones who unknowingly spread dangerous How else can I protect my • Every year, get an influenza vaccination yourself. Typical influenza disease is characterized by abrupt the 2003–04 influenza season. In the following four diseases to babies. Diseases and the Vaccines That Prevent Them • Urge your child’s close contacts to get vaccinated, too. This is extremely onset of fever, aching muscles, sore throat, and non- � child? influenza seasons, the annual number of pediatric www.cdc.gov/vaccines/hcp/patient-ed/conversations/ important if your child is younger than 5 or if he or she has a chronic health productive cough. Additional symptoms may include deaths reported to CDC ranged from 47 during the Currently, towns and cities across the nation have had whoop- prevent-diseases/index.html runny nose, headache, a burning sensation in the problem such as asthma or diabetes. Because children younger than 6 months 2004–05 season to 88 during the 2007–08 season. ing cough outbreaks. Influenza outbreaks happen every year. From the Centers for Disease Control and Prevention chest, and eye pain and sensitivity to light. Typical can’t be vaccinated, they rely on those around them to get vaccinated. During April 2009–March 2010, over 300 deaths in influenza disease does not occur in every infected � Vaccine Educational Materials for Parents • Wash your hands often and cover your coughs and sneezes. It’s best to use a children due to 2009 H1N1 influenza were reported, person. Someone who has been previously exposed How can we protect babies? www.chop.edu/service/vaccine-education-center/ and over 1,000 deaths were estimated to have oc- tissue and quickly throw it away. If you don’t have a tissue, you should cough to similar virus strains (through natural infection or Everyone has the opportunity to protect babies by getting order-educational-materials curred in children. From the Vaccine Education Center, Children’s Hospital or sneeze into your upper sleeve, not your hands. This will prevent the spread vaccination) is less likely to develop serious clinical vaccinated themselves. Cocooning is an easy and effective of Philadelphia of germs. illness. How is a pandemic different from an epidemic of way that people can work together to prevent the spread Vaccine Information Website • Tell your children to influenza? � How serious is influenza? Occasionally, major influenza epidemics expand to a of whooping cough and flu to babies. www.vaccineinformation.org – Stay away from people who are sick, Although many people think of influenza as the “flu” From the Immunization Action Coalition – Wash their hands often, pandemic. The first recording of such an event was or just a common cold, it is really a specific and seri- in 1580, and at least seven international pandem- – Keep their hands away from their face, and ous respiratory disease that can result in hospitaliza- � Cocooning and Tdap Vaccination Web Section ics have occurred in the nineteenth and twentieth (cocooning information about whooping cough) – Cover coughs and sneezes to protect others. tion and death. In the United States, the number centuries. The “Spanish flu” epidemic of 1918–1919 www.immunize.org/cocooning of influenza-associated deaths has increased since page 1 of 2 caused an estimated 21 million deaths worldwide, From the Immunization Action Coalition 1990. This increase is due in part to the substantial including more than 500,000 Americans. On increase in the number of people age 65 years or old- Page 1 of 6 Technical content reviewed by the Centers for Disease Control and Prevention Technical content reviewed by the Centers for Disease Control and Prevention www.vaccineinformation.org/catg.d/p4208.pdf • Item #P4208 (10/13) 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

• • - - • • Immunization Action Coalition • St. Paul, MN 55104 • (651) 647-9009 • www.vaccineinformation.org • www.immunize.org Immunization Action Coalition 1573 Selby Avenue St. Paul, MN 55104 651 647 9009 www.immunize.org www.vaccineinformation.org www.immunize.org/catg.d/p4070.pdf n Item #P4070 (8/14)

www.immunize.org/catg.d/p4039.pdf • Item #P4039 (3/13)

For 8⅟2 x 11" copies of the pieces above, visit IAC’s website: copy this for your patients Seek emergency medical care if you or 4 Cocooning protects babies a7 family member shows the signs below www.immunize.org/handouts/ www.immunize.org/catg.d/p4039.pdf – a life could be at risk! It’s a fact – every year, people of all ages in the influenza-vaccines.asp spanish: www.immunize.org/catg.d/p4039-01.pdf U.S. die from influenza and its complications.

Emergency warning signs 5 Keep your kids safe – get them vaccinated for children or teens with Any child or teen who shows the following emergency influenza warning signs needs urgent medical attention – take them 1 Don’t take chances with your family’s health – every fall or winter! to an emergency room or call 9 • Fast breathing or trouble breathing-1-1. make sure you all get vaccinated against influenza! • Bluish skin color www.immunize.org/catg.d/p4070.pdf • Not waking up or not interacting www.immunize.org/catg.d/p4069.pdf • Being so irritable that the child does not want to b spanish: www.immunize.org/catg.d/p4070-01.pdf • Not drinking enough fluids e held • Not urinating or no tears when crying arabic: www.immunize.org/catg.d/p4070-20.pdf • Severe or persistent vomiting 2 Protect yourself from influenza...Get vaccinated! • Influenza-like symptoms improve but then return with worse cough chinese: www.immunize.org/catg.d/p4070-08.pdf fever and www.immunize.org/catg.d/p4408.pdf Emergency warning signs for adults with influenza Any adult who shows the following emergency warning sig needs urgent medical attention – take them to an emerg room or call 9 ns spanish: www.immunize.org/catg.d/p4408-01.pdf -1-1. ency 6 Influenza: Questions and answers • Difficulty breathing or shortness of breath • Pain or pressure in the chest or abdomen www.immunize.org/catg.d/p4208.pdf • Confusion 3 Influenza is a serious disease...make sure your • Severe or persistent vomiting • Sudden dizziness • Influenza-like symptoms improve but then return with fever child is protected! 7 Seek emergency medical care if you worse cough and www.immunize.org/catg.d/p4312.pdf or a family member shows the signs below Keep this handy! Post it on your refrigerator or another place where it will be easy to find! immunization spanish: www.immunize.org/catg.d/p4312-01.pdf www.immunize.org/catg.d/p4073.pdf action coalition

Saint Paul, Minnesota • Adapted from the Centers for Disease Control and Preven 651-647-9009 • Technical content reviewed by the Centers for Disease Control a IimmAunize.org www.immunize.org C • www.vaccineinformation.org tion nd Prevention

www.immunize.org/catg.d/p4073.pdf • Item #P4073 (9 /14)

Vaccinate Adults! • October 2014 • Immunization Action Coalition • (651) 647-9009 • www.immunize.org • www.vaccineinformation.org 19 20 Influenza Vaccine Products for the 2014–2015 Influenza Season

Trade Name Mercury Manufacturer 1 How Supplied Content Age Group Product Code (vaccine abbreviation) (μg Hg/0.5mL) 0.5 mL (single-dose syringe) 0 90656 bioCSL, Inc. Afluria (IIV3) 9 years & older2, 3 5.0 mL (multi-dose vial) 24.5 90658 • Q2035 (Medicare) Fluarix (IIV3) 0.5 mL (single-dose syringe) 0 3 years & older 90656 GlaxoSmithKline Fluarix (IIV4) 0.5 mL (single-dose syringe) 0 3 years & older 90686 0.5 mL (single-dose syringe) 0 3 years & older 90656 ID Biomedical Corp. of FluLaval (IIV3) 5.0 mL (multi-dose vial) <25 3 years & older 90658 • Q2036 (Medicare) Quebec, a subsidiary of 0.5 mL (single-dose syringe) 0 3 years & older 90686 GlaxoSmithKline FluLaval (IIV4) 5.0 mL (multi-dose vial) <25 3 years & older 90688 MedImmune FluMist (LAIV4) 0.2 mL (single-use nasal spray) 0 2 through 49 years 90672 0.5 mL (single-dose syringe) <1 90656 Novartis Vaccines and Fluvirin (IIV3) 4 years & older 5.0 mL (multi-dose vial) 25 90658 • Q2037 (Medicare) Diagnostics, Inc. Flucelvax (ccIIV3) 0.5 mL (single-dose syringe) 0 18 years & older 90661 Protein Sciences Corp. Flublok (RIV3) 0.5 mL (single-dose vial) 0 18 through 49 years 90673 0.5 mL (single-dose syringe) 0 3 years & older 90656 Fluzone (IIV3) 5.0 mL (multi-dose vial) 25 6 through 35 months 90657 5.0 mL (multi-dose vial) 25 3 years & older 90658 • Q2038 (Medicare) 0.25 mL (single-dose syringe) 0 6 through 35 months 90685 0.5 mL (single-dose syringe) 0 3 years & older 90686 Sanofi Pasteur, Inc. Fluzone (IIV4) 0.5 mL (single-dose vial) 0 3 years & older 90686 5.0 mL (multi-dose vial) 25 6 through 35 months 90687 5.0 mL (multi-dose vial) 25 3 years & older 90688 Fluzone High-Dose (IIV3) 0.5 mL (single-dose syringe) 0 65 years & older 90662 Fluzone Intradermal (IIV3) 0.1 mL (single-dose microinjection system) 0 18 through 64 years 90654 Footnotes 1. IIV3 = egg-based and cell culture-based trivalent inactivated influenza vaccine (injectable); where necessary to refer to 2. In 2010, ACIP recommended that Afluria not be used in children younger than age 9 years. If no other age-appropriate IIV cell culture-based vaccine, the prefix “cc” is used (e.g., ccIIV3). IIV4 = egg-based quadrivalent inactivated influenza is available, Afluria may be considered for a child age 5 through 8 years at high risk for influenza complications, after risks vaccine (injectable); LAIV4 = egg-based quadrivalent live attenuated influenza vaccine (nasal spray); RIV3 = trivalent and benefits have been discussed with the parent or guardian. Afluria should not be used in children younger than age 5 recombinant hemagglutinin influenza vaccine (injectable). years. This recommendation continues for the 2014–2015 influenza season. 3. Afluria is approved by the Food and Drug Administration for intramuscular administration with the PharmaJet Stratis Needle-Free Injection System for persons age 18 through 64 years.

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/p4072.pdf • Item #P4072 (9/14) How to Administer Intramuscular, Intradermal, and Intranasal Influenza Vaccines

Intramuscular injection Intradermal administration Intranasal administration Inactivated Influenza Vaccines (IIV), including re- Inactivated Influenza Vaccine (IIV) Live Attenuated Influenza Vaccine (LAIV) combinant hemagglutinin influenza vaccine (RIV)

1. Use a needle long enough to reach deep into the 1. Gently shake the microinjection system before 1. FluMist (LAIV) is for intranasal administration only. muscle. Infants age 6 through 11 mos: 1"; administering the vaccine. Do not inject FluMist. 1 through 2 yrs: 1–13"; children and adults 3 yrs and older: 1–1½". 2. Hold the system by placing the 2. Remove rubber tip protector. Do not remove dose- thumb and middle finger on divider clip at the other end of the sprayer. 2. With your left hand*, bunch up the muscle. the finger pads; the index finger should remain free. 3. With the patient in an upright position 3. With your right hand*, insert the needle at a (i.e., head not tilted back), place the 90° angle to the skin with a quick thrust. 3. Insert the needle perpendicular to the skin, tip just inside the nostril to in the region of the deltoid, in a short, quick ensure LAIV is delivered 4. Push down on the plunger and inject the entire movement. into the nose. The patient contents of the syringe. There is no need to aspi- should breathe normally. rate. 4. Once the needle has been inserted, maintain light pressure 4. With a single motion, depress 5. Remove the needle and simultaneously apply on the surface of the skin and plunger as rapidly as possible pressure to the injection site with a dry cotton ball inject using the index finger to until the dose-divider clip prevents or gauze. Hold in place for several seconds. push on the plunger. Do not aspirate. you from going further.

6. If there is any bleeding, cover the injection site with 5. Remove the needle from the skin. With the 5. Pinch and remove the a bandage. needle directed away from you and others, dose-divider clip from push very firmly with the thumb on the 7. Put the used syringe in a sharps container. the plunger. plunger to activate the needle shield. dose-divider clip *Use the opposite hand if you are left-handed. You will hear a click when the 6. Place the tip just inside the other shield extends to cover the needle. nostril, and with a single motion, depress plunger as rapidly as possible to deliver the 6. Dispose of the applicator in a sharps con- remaining vaccine. tainer. 7. Dispose of the applicator in a sharps container.

90° angle

skin

subcutaneous tissue

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/p2024.pdf • Item #P2024 (9/14) 21 copy this for your patients Seek emergency medical care if you or a family member shows the signs below – a life could be at risk! It’s a fact – every year, people of all ages in the U.S. die from influenza and its complications.

Emergency warning signs Any child or teen who shows the following emergency for children or teens with warning signs needs urgent medical attention – take them influenza to an emergency room or call 9-1-1. • Fast breathing or trouble breathing • Bluish skin color • Not waking up or not interacting • Being so irritable that the child does not want to be held • Not drinking enough fluids • Not urinating or no tears when crying • Severe or persistent vomiting • Influenza-like symptoms improve but then return with fever and worse cough

Emergency warning signs Any adult who shows the following emergency warning signs for adults with influenza needs urgent medical attention – take them to an emergency room or call 9-1-1. • Difficulty breathing or shortness of breath • Pain or pressure in the chest or abdomen • Confusion • Severe or persistent vomiting • Sudden dizziness • Influenza-like symptoms improve but then return with fever and worse cough

Keep this handy! Post it on your refrigerator or another place where it will be easy to find!

immunization action coalition Adapted from the Centers for Disease Control and Prevention 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/p4073.pdf • Item #P4073 (9/14) IimmAunize.orgC 22 Ask the Experts . . . continued from page 1

older. The two vaccines should not be given at refrigerator/freezer. Can we use the freezer tion when administering vaccines. the same visit. portion to store staff food? CDC recommends using separate refrigerator and If a patient has had an anaphylactic reaction to Pneumococcal vaccine-naïve persons: Adults a bee sting, is it safe for her to receive injected age 65 years and older who have not previously freezer units for , but still allows use vaccines? received pneumococcal vaccine or whose previous of a combination refrigerator/freezer if you only Yes. Allergy to bee venom is not a contraindication vaccination history is unknown should receive a use the refrigerator portion for storing vaccines for any vaccine. dose of PCV13 first, followed by a dose of PPSV23 (as you are doing). CDC also recommends that 6–12 months later. If PPSV23 cannot be adminis- you store food and beverages in a separate storage tered during this time window, the PPSV23 dose unit from vaccines, which you are technically doing should be given at the next visit. The two pneu- but there may still be an impact on the refrigera- Please describe the new CDC interim recom- mococcal vaccines should not be co-administered. tor temperature by the opening and closing of the mendations for polio vaccination for adults If the doses of PCV13 and PPSV23 are admin- freezer door by staff. (In most two-compartment traveling to and from countries affected by istered at an interval less than 6–12 months apart units, cold air from the freezer is circulated for wild polio. (sooner than recommended), the minimum accept- cooling the refrigerator.) For adults who were routinely vaccinated as able interval between the two doses is 8 weeks The ideal situation would be to get a stand-alone children, CDC states those adults are considered (which means that PPSV23 must be repeated if pharmaceutical/purpose-built refrigerator unit for to have lifelong immunity to poliovirus, but data given earlier than this). your vaccines, and use your refrigerator/freezer are lacking. As a precaution, people age 18 years Previous vaccination with PPSV23: Adults age combination unit for your food and drinks. Please and older who are traveling to areas where there 65 years and older who have previously received refer to pages 30 and 50 of the “Vaccine Storage has been wild poliovirus circulation in the last 12 one or more doses of PPSV23 also should receive and Handling Toolkit” available at www.cdc.gov/ months and who have received a routine series with a dose of PCV13 if they have not yet received it. vaccines/recs/storage/toolkit/storage-handling- either IPV or OPV in childhood should receive A dose of PCV13 should be given at least 1 year toolkit.pdf, for more detailed information. another dose of IPV before departure. For these adults, available data do not indicate the need for after receipt of the most recent PPSV23 dose. For If a patient pulls away during administration of those in whom an additional dose of PPSV23 is a vaccine and the needle comes out, is it okay more than a single lifetime with IPV. indicated, this subsequent PPSV23 dose should be to reintroduce the same needle and finish the For detailed information about how to protect given 6–12 months after PCV13 and at least 5 years injection? adults who are unvaccinated, incompletely vac- after the most recent dose of PPSV23. No. The needle should be considered to be contami- cinated, or whose vaccination status is unknown, nated. The needle and syringe should be discarded. refer to the CDC guidance document titled “Interim A new syringe, needle, and dose of vaccine should CDC Guidance for Polio Vaccination for Travel Zoster vaccine be used. A full repeat dose should be given. to and from Countries Affected by Wild Polio- virus” available at www.cdc.gov/mmwr/pdf/wk/ Is a history of genital herpes a contraindica- I know that immunosuppressed patients can tion or precaution to zoster vaccination? receive inactivated vaccines, but not live mm6327.pdf, pages 591–4. No. There is no evidence that zoster vaccine has vaccines. Will these patients who receive Ten countries (Afghanistan, Cameroon, Equato- any effect on herpes simplex virus. inactivated vaccines develop a sufficient rial Guinea, Ethiopia, Iraq, Israel, Nigeria, Paki- immune response to make vaccinating them stan, Somalia, and Syria) are currently considered worthwhile? polio-infected. For more information for clinicians, Hepatitis A vaccine Inactivated vaccines can be administered to people visit CDC’s Travel website at wwwnc.cdc.gov/ For hepatitis A vaccination, the recommended who take immunosuppressive drugs or who have a travel/news-announcements/polio-guidance-new- interval between the 2-dose series is at least 6 condition that causes them to be immunocompro- requirements. months. Is this the same as 24 weeks? mised. The vaccines might not be as effective as No. The recommended interval between dose #1 they would be when given to a person with an intact To submit an “Ask the Experts” question . . . and #2 of hepatitis A vaccine is 6 calendar months, immune system. If possible, the immunosuppresive Email your questions to the Immunization Action not 24 weeks. See CDC’s The Pink Book (Epide- drug should be discontinued for a month prior to Coalition (IAC) at [email protected]. We miology and Prevention of Vaccine Preventable vaccination, then allow the vaccine 2–3 weeks to will respond to your inquiry. Because we receive Diseases) available at www.cdc.gov/vaccines/ generate an immune response before restarting the hundreds of email messages each month, we can- pubs/pinkbook/downloads/appendices/A/age- immunosuppressive treatment, but obviously, this not promise that we will use your question in “Ask interval-table.pdf, footnote 5. is not always possible. the Experts.” IAC works with CDC to compile new Determination of altered is Q&As for our publications based on commonly General vaccine questions important because incidence or severity of some asked questions. Most of the questions are thus a vaccine-preventable diseases is greater in people composite of several inquiries. Our office is small and we only store vac- with altered immunocompetence. As a result, cer- cine in the refrigerator of a two-compartment tain vaccines (e.g., inactivated influenza vaccine and pneumococcal vaccines) are recommended Stay current with FREE subscriptions specifically for people with altered immunocom- The Immunization Action Coalition’s petence. Vaccinate Adults correction policy 2 periodicals, Vaccinate Adults and More information can be found in ACIP’s Gen- Needle Tips, and our email news If you find an error, please notify us immediately by eral Recommendations on Immunization avail- sending an email message to [email protected]. service, IAC Express, are packed able at www.cdc.gov/mmwr/pdf/rr/rr6002.pdf, We publish notification of significant errors in with up-to-date information. our email announcement service, IAC Express. pages19–23. Subscribe to all 3 free publications in Be sure you’re signed up for this service. To Is protective eyewear needed for those who one place. It’s simple! Go to subscribe, visit www.immunize.org/subscribe. administer vaccines so they can avoid blood spatter? www.immunize.org/subscribe ACIP does not specifically recommend eye protec-

Vaccinate Adults! • October 2014 • Immunization Action Coalition • (651) 647-9009 • www.immunize.org • www.vaccineinformation.org 23 Order Essential Immunization Resources from IAC Immunization record cards for all: for children & teens, for adults, for a lifetime!

Immunization record cards offer healthcare professionals a way to for people in the age group. Sized to fit in a wallet, each is brightly help patients maintain a permanent record of their vaccinations. colored to stand out and is printed on durable rip-, smudge-, and Patient-held cards are handy for patients when they enter daycare or water-proof paper. school, change healthcare providers, or travel abroad. To order record cards or any of our other essential immunization We offer three record cards: adult, child & teen, and lifetime. Each is resources, print out and mail or fax the form below, or place your designed for a specific age group and lists all vaccines recommended order online at www.immunize.org/shop.

It’s convenient to shop at or donate to IAC online at www.immunize.org/shop

Order Essential Immunization Resources How to Place an Order By Credit Card: Order easily online at our secure shopping cart at Qty. DVD – Immunization Techniques: Best Practices Amt. www.immunize.org/shop. with Infants, Children, and Adults By Check, Purchase Order, or Credit Card: Print out this page, fill (call for discounts on bulk orders) out the necessary information, and 1-9 copies–$17 each; 10-24 copies–$10.25 each; 25-49 copies–$7 each ��� D2021 Immunization Techniques: Best Practices with Children/Teens/Adults.....$______Fax this page to: (651) 647-9131 or Mail this page to: Immunization Action Coalition Patient Immunization Record Cards — 2550 University Avenue West, Suite 415 North for children & teens, for adults, and for a lifetime! Saint Paul, MN 55114 (all are wallet-sized; details p. 3; call for discounts on bulk orders) 250 cards/box; 1 box–$45; 2 boxes–$40 each; 3 boxes–$37.50 each; 4 boxes–$34.50 each Our federal ID# is 41-1768237. ��� R2005 Adult immunization record cards ...... $______For Questions or International Orders: Contact us by phone at ��� R2003 Child/teen immunization record cards ...... $______(651) 647-9009 or email [email protected] ��� R2004 Lifetime immunization record cards ...... $______Thank you for your support of the Immunization Action Coalition. We depend on you! Total for Purchases $

Method of payment: ❏ Check enclosed (payable to Immunization Action Coalition) ❏ Purchase order # ______Have you made a charitable contribution to the Immunization Action Coalition this year? ❏ Visa ❏ Mastercard ❏ Am. Express ❏ Discover

I am a ❏ new ❏ renewing contributor. Card # Here is my contribution: ❏ $25 ❏ $50 ❏ $75 ❏ $100 ❏ $125 Expiration Date CV Code #* ❏ $150 ❏ $200 ❏ $250 other: $______mo/yr *The CV Code is the Credit Verification Code, the additional 3- or 4-digit number on your credit card. IAC is a 501(c)(3) charitable organization and your contribution is tax deductible to the fullest extent of the law. Name/Title

Organization Total for Purchases and Contribution $ Shipping address (Check one: This is my ❏ organization address ❏ home address)

City/State/Zip

Telephone

Email address

It’s convenient to shop at or donate to IAC online at www.immunize.org/shop

24 Vaccinate Adults! • October 2014 • Immunization Action Coalition • (651) 647-9009 • www.immunize.org • www.vaccineinformation.org