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Immunization Information for Office Staff

Updated 10/2015

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Providing immunizations is a team effort. It is important that all staff be well-informed and properly trained. The following information is especially well-suited for non-physician providers.

  • ​​​
    Whether you work at the front desk, room patients, provide immunizations, or have other responsibilities, you have the opportunity to support the providers’ recommendation to vaccinate. Disc​​uss with the provider in the office what they are recommending and what the best way for you to support it is. It might be as simple as saying telling parents that you see they have made a choice to protect their child from dangerous diseases or just presenting them with the recommendation, “Today your child is due to get vaccines X, Y, and Z, you can ask (provider’s name), any questions you may have.”
  • There are safe and effective vaccines recommended by the Centers for Disease Control and Prevention (CDC) and the American Academy of Pediatrics (AAP) to protect against certain strains of Human Papillomavirus (HPV) that cause cancers in males and females, as well as genital warts. ​​Right now across the nation, almost half of our youth is protected through vaccination, but we can do better. Most parents who hear about the opportunity to prevent HPV infection and cancers want their children protected.  Chances are that parents in your practice want this level of care, too. 

    As a staff member in a primary care office you have the opportunity to help prevent cancer. Here are some steps to help you:

    Understand Why HPV Vaccine is Important

    • Every year in the United States, 27,000 people still get cancer caused by HPV. That's one person every 20 minutes of every day, all year long.
      • HPV causes cancers of the mouth or throat and anus in men and women, as well as cancer of the penis in men AND cancers of the cervix, vagina, and vulva in women.
      • There are many more pre-cancers of the cervix requiring treatment that can have lasting effects on a woman's fertility.
    • HPV is so common that almost everyone will be infected at some point.
      • We have no way of knowing who will go on to get cancers caused by HPV once they are infected.
      • Most people infected with HPV will never know they are infected.
      • Even if someone waits until marriage to have sex, or only has one partner in their entire lif​​e, they could still be exposed if their partner has been exposed.
    • The HPV vaccine is effective!  It prevents infection with the most common and aggressive HPV types that cause cancers.

    Make a Strong Recommendation

    • Bundle the adolescent vaccines and give a strong recommendation for boys and girls age 11-12. This is as simple as saying (while handing them the VIS);
      • Today your child needs 3 vaccines; HPV, Tdap, HPV and Meningococcal.  Do you have any questions for the doctor?
        Or
      • Today your child is due for 3 vaccines. They're designed to protect your child from the cancers caused by HPV and from meningitis, tetanus, diphtheria, & pertussis. Do you have any questions for the doctor?
    • Adolescents may not want to get three vaccines in one visit, but we know patients this age don't come to the office that often, so giving the 3 vaccines in one visit is the best way to make sure they are protected.
    • Giving three vaccines at one visit is safe and the protection we are offering adolescents is important and can save lives.

    Finish the 3-Dose Series

    • Starting the series is an important step, but three shots are required for full protection. So before the patient leaves the office after HPV vaccination #1, make sure to set appointments for doses 2 & 3. 
    • Make sure that systems are in place to remind patients of their vaccine appointments.
    • If a patient misses an appointment, a system to flag and recall patients is important.

    More information about HPV vaccination:

    Ask your OB-GYN or Ear Nose and Throat (ENT) doctor about the importance of preventing HPV disease.

  • Guidance is developed by experts at the CDC. State Vaccine for Children programs requires participating practices implement this guidance as a minimum. They may choose to require stricter criteria for their programs. This guidance is intended to keep vaccines stored safely, so that they are not exposed to temperatures at which they could lose potency and become ineffective.
    • The vaccine manufacturers offer product-specific information, including:
        • At what temperature the vaccine should be stored.
        • How to store and use a diluent to reconstitute a vaccine (if needed).
        • When to discard a vaccine.
    • The CDC Vaccine Storage and Handling Toolkit offers recommendations that are good for all offices, but serve as minimum requirements for VFC providers:
        • Using a temperature buffered probe rather than measuring ambient air temperatures.
        • Using a digital data logger with a detachable probe that continuously records and stores temperature information at frequent programmable intervals.
        • Using a stand-alone refrigerator and stand-alone freezer units suitable for vaccine storage rather than combination (refrigerator + freezer) or other units not designed for storing vaccines.
        • Discontinuing use of dorm-style or bar-style refrigerator/freezers for ANY vaccine storage, even temporary.
        • Weekly review of vaccine expiration dates and rotation of vaccine stock.
    • The AAP Immunization Training Guide also contains tips for storing and monitoring your vaccines, including:
        • Refrigerator should measure between 2°C and 8°C.
        • Freezer should measure —15°C or lower.
        • Vaccines meant to be stored in the refrigerator should never be frozen.
        • Temperatures of the refrigerator and freezer should be checked at least twice each day and documented on a temperature log. The maximum and minimum temperatures reached each day should also be recorded on this log.
    • Vaccine Storage and Handling Tip Sheet Series (See resources below)

    Education

    The AAP offers an online course on vaccine storage and handling for continuing education credits, with the goal of increasing the likelihood that:

    • Vaccines are stored according to the manufacturer's recommendations.
    • Children are vaccinated with potent vaccine products that will protect them from disease.
    • Immunizers can use all opportunities to vaccinate if vaccines are potent and available, thanks to good storage conditions.
    • Practices will not be liable for costly vaccines that are destroyed due to poor management.

    This course is available on the AAP PediaLi​nk site.

    Resources:

    Vaccine S​​​torage chart

    Vaccine Where to store Acceptable temperature range Diluent Storage Diluent temperature ranges

    All DTaP vaccines

    (DTaP-Hep B-IPV – Pediarix, DTaP-IPV – KINRIX, DTaP-Hib-IPV – Pentacel

    Refrigerator

    Do not freeze or expose to freezing temperatures

     

    2°C–8°C

    For those with Diluent, Refrigerator2°C–8°C

    Hib vaccines (PedvaxHIB and

    Comvax, ActHIB, Hiberix)

     

    Refrigerator

    Do not freeze or expose to freezing temperatures

    2°C–8°CFor those with Diluent, Refrigerator2°C–8°C

    Hep A: Havrix, VAQTA

    Hep B: Engerix-B,

    Recombivax HB HepA-Hep B: Twinrix

    Refrigerator

    Do not freeze or expose to freezing temperatures

    2°C–8°CNo diluent 

    HPV2: Cervarix HPV4:

    Gardasil

    Refrigerator

    Do not freeze or expose to freezing temperatures

    2°C–8°CNo diluent 

    LAIV:

    FluMist

    Refrigerator

    Do not freeze or expose to freezing temperatures

    2°C–8°CNo diluent 

    IIV

     

    Refrigerator

    Do not freeze or expose to freezing temperatures

    2°C–8°C  
    MMR

    Refrigerator

    or

    Freezer

    -50°C to +8°C

    Refrigerator or room temperature

    Do not freeze or expose to freezing temperatures

    2°C–8°C or 20°C–25°C
    Meningococcal Conjugate Vaccines, Menveo and Menactra

    Refrigerator

    Do not freeze or expose to freezing temperatures

    2°C–8°CFor those with Diluent, refrigerator2°C–8°C
    MPSV4: Menomune

    Refrigerator

    Do not freeze or expose to freezing temperatures

    2°C–8°C

    Refrigerator

     

    2°C–8°C

    PCV13: Prevnar 13

    PPSV23: Pneumovax 23

    Refrigerator

    Do not freeze or expose to freezing temperatures

    2°C–8°C  
    IPV: IPOL

    Refrigerator

    Do not freeze or expose to freezing temperatures

    2°C–8°C  
    RV1: ROTARIX or RV5: RotaTeq

    Refrigerator

    Do not freeze or expose to freezing temperatures

    2°C–8°C

    For Rotarix, store diluent separately at room temperature

     

    20°C–25°C.

     

    Td: DECAVAC DT: Diphtheria and Tetanus Toxoid and Tdap: Tdap: Adacel, Boostrix

    Refrigerator

    Do not freeze or expose to freezing temperatures

    2°C–8°C  
    VAR: Varivax (chickenpox) zoster/shingles)

    Freezer

    Vaccine should be stored only in freezers or refrigerator/freezer units with separate compartments and exterior doors

     

    -50°C to -15°C

    Refrigerator or room temperature

    Store separately from vaccine.

    2°C–8°C or 20°C–25°C

    Do not freeze diluent or expose to freezing temperatures.

    MMRV: ProQuad

    Freezer

    Vaccine should be stored only in freezers or refrigerator/freezer units with separate compartments and exterior doors

     

    -50°C to      –15°C

    Refrigerator or room temperature

    Store separately from vaccine.

    2°C–8°C or 20°C–25°C

    Do not freeze diluent or expose to freezing temperatures.

    Zostavax (herpes zoster/shingles)

    Freezer

    Vaccine should be stored only in freezers or refrigerator/freezer units with separate compartments and exterior doors

    -50° to -15°C

    Refrigerator or room temperature

    Store separately from vaccine.

    2°C–8°C or 20°C–25°C

    Do not freeze diluent or expose to freezing temperatures.

  • Immunizations need to be administered according to the 7 rights:


    The right patient:

    All patients should be screened for contraindications and precautions every time a vaccine is administered, even if the patient has previously received a dose of that vaccine. The patient's status can change from one visit to the next or a new contraindication or precaution may have been added. Screening questions are available here.​

    The right vaccine or diluent:

    Some vaccines need to be reconstituted; a specific diluent will be provided by the manufacturer. It is important to follow manufacturer guidelines in reconstituting the vaccine. See Vaccines with Diluents: How to Use Them. Measles, mumps, rubella (MM​R); varicella; zoster; meningococcal polysaccharide (MPSV); and rotavirus vaccines all require reconstitution.

    The right time:

    This includes administering at the correct age, the appropriate interval, and before vaccine or diluent expires. Check the schedule to ensure the patient is getting the vaccine at the right time, and the appropriate interval​.  Each vaccine vial should be checked for the expiration date. A vaccine should never be used if it is expired. Once reconstituted, the vaccine must be administered according to the guidelines or discarded. In most cases, if not used within 30 minutes, the vaccine will lose its potency and the patient will not be properly​​​ immunized.

    The right dosage:

    Vaccine administrators need to make sure they draw the correct amount of immunization when drawing from multidose vials. See Administering Vaccines: Dose, Route, Site, and Needle Size​.

    The right route, needle length, and technique: (see Table 1 below)

    Immunizations are administered through the following routes: intramuscular (IM), subcutaneous (SQ), oral, and nasal. The majority of immunizations are administered IM, but MMR, varicella, zoster, and MPSV are administered SQ. In administering IM injections, it is important to use a needle with the correct length to reach the muscle mass and not seep into SQ tissue.

    When administering IM injections, the needle should be inserted at a 90° angle—and quickly. It is not necessary to aspirate after needle insertion. SQ injections are administered at a 45° angle, and the SQ tissue is pinched up to prevent injection into the muscle. It is not necessary to aspirate after needle insertion. Multiple immunizations should be a minimum of 1 inch apart. Another method of immunization is nasal spray, which has recently become available for live attenuated influenza vaccine. Oral polio vaccine has not been used in the United States since 2000 but is still used in other countries. In the United States, inactivated polio vaccine is given and can be administered SQ or IM./p>

    The right site (see Table 2 below):

    Children of different sizes and ages will need vaccines administered in different locations on the body.

    The right documentation

    Document the following:

    • Vaccine manufacturer,a
    • lot number,a
    • date of administration,a
    • Name and business address of the health care professional administering the vaccine,a
    • Date that VIS is provided (and VIS publication dateb),
    • Site (eg, deltoid area), c
    • route (eg, intramuscular) of administration, c and
    • and expiration date of the vaccinec

      a Required under the National Childhood Vaccine Injury Act.

      b Required by Centers for Disease Control and Prevention (CDC) regulations for vaccines purchased through CDC contract. See the VIS Web site for current versions.

    c Recommended by the American Academy of Pediatrics.

    Other important vaccine administration tips:

    Dos

    • Do use a separate anatomic site for each injection.
    • Do label vaccines if more than one are drawn up together. This will help with documenting which vaccines were given in which site.
    • Do ensure that the person who drew up the vaccine administers it. This will reduce errors.
    • Do wash hands between patient encounters and before preparing vaccines
    • Do wear gloves to administer a vaccine if there is a risk coming into contact with body fluids or if the administrator has open sores or cuts on the hands.
    • Do consider immunizations for those with only a mild illness. Always screen for other contraindications.
    • Do use safety syringes to reduce the incidence of needle sticks and disease transmission.
    • Do check to see what size needle, route and location should be used.
    • Do give immunizations to patients with a mild illness. If a child has a moderate or severe illness – rescheduled their immunizations.

    Don'ts

    • Do not mix separate vaccines in the same syringe. If more than one vaccine is being administered to the same limb, injection sites should be 1 to 2 inches apart so that any reactions can be determined.
    • Do not pre-draw your own syringes – these are vaccines that are drawn up in syringes and laid out at the beginning of the day or significantly before administration. It is ok to use prefilled syringes that come as single doses from the manufacturer.

    Some immunizations come with a diluent and must be reconstituted, whereas others do not. Always follow the current recommended immunization schedule.

    Table 1

    Adapted From AAP RedBook 

    Common Pediatric Vaccines Administered in the United States and Their Routes of Administration

       
    Diphtheria-tetanus (DT, Td)ToxoidsIM
    DTaPToxoids and inactivated bacterial componentsIM
    DTaP, hepatitis B, and IPVToxoids and inactivated bacterial components, recombinant viral antigen, inactivated virusIM
    DTaP-IPVToxoids and inactivated bacterial components, inactivated virusIM
    DTaP-IPV/Hib (PRP-T reconstituted with DTaP-IPV)Toxoids and inactivated bacterial components, polysaccharide-protein conjugate, inactivated virusIM
    Hepatitis AInactivated virusIM
    Hepatitis BRecombinant viral antigenIM
    Hepatitis A-hepatitis BInactivated virus and recombinant viral antigensIM
    Hib conjugate (tetanus toxoid) b Bacterial polysaccharide-protein conjugateIM
    Hib conjugate (PRP-OMP b ) hepatitis BBacterial polysaccharide-protein conjugate with recombinant viral antigenIM
    Human papillomavirus (HPV2 and HPV4)Recombinant viral antigensIM
    InfluenzaInactivated viral componentsIM
    InfluenzaLive-attenuated virusesIntranasal
    Meningococcal polysaccharide (MPSV4)Bacterial polysaccharideSC
    Meningococcal conjugate (MCV4)Bacterial polysaccharide-protein conjugateIM
    MMRLive-attenuated virusesSC
    MMRVLive-attenuated virusesSC
    Pneumococcal polysaccharide (PPSV)Bacterial polysaccharideIM or SC
    Pneumococcal conjugate (PCV)Bacterial polysaccharide-protein conjugateIM
    Poliovirus (IPV)Inactivated virusesSC or IM
    Rotavirus (RV1 and RV5)Live-attenuated virusOral
    TdapToxoids and inactivated bacterial componentsIM
    TetanusToxoidIM
    VaricellaLive-attenuated virusSC

    Table 2

    From AAP Red Book: Site and Needle Length by Age for Intramuscular Immunization

    Age Group Needle Length, inches (mm) a Suggested Injection Site
    Newborns (preterm and term) and infants <1 mo of age⅝ (16) b Anterolateral thigh muscle
    Term infants, 1–12 mo of age1 (25)Anterolateral thigh muscle
    Toddlers and children⅝ –1 (16–25) b Deltoid muscle of the arm
     1–1¼ (25–32)Anterolateral thigh muscle
    Adults  
     Female and male, weight <60 kg1 (25) c Deltoid muscle of the arm
     Female and male, weight 60–70 kg1 (25)Deltoid muscle of the arm
     Female, weight 70–90 kg1 (25)–1½ (38)Deltoid muscle of the arm
     Male, weight 70–118 kg1 (25)–1½ (38)Deltoid muscle of the arm
    Female, weight >90 kg1½ (38)Deltoid muscle of the arm
     Male, weight >118 kg1½ (38)Deltoid muscle of the arm

     

    a Assumes that needle is inserted fully.

    b If the skin is stretched tightly and subcutaneous tissues are not bunched.

    c Some experts recommend a ⅝-inch needle for men and women who weigh less than 60 kg.

     

    Vaccine Administration Resources

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