Healthcare Personnel Vaccination Recommendations 1

Transcription

1 Vaccine Hepatitis B Influenza MMR Varicella (chickenpox) Healthcare Personnel Vaccination Recommendations Tetanus, diphtheria, pertussis Meningococcal Recommendations in brief Give 3-dose series (dose # now, # in month, #3 approximately 5 months after #). Give IM. Obtain anti- HBs serologic testing months after dose #3. Give dose of influenza vaccine annually. Give inactivated injectable vaccine intramuscularly or live attenuated influenza vaccine (LAIV) intranasally. For healthcare personnel (HCP) born in 957 or later without serologic evidence of immunity or prior vaccination, give doses of MMR, 4 weeks apart. For HCP born prior to 957, see below. Give SC. For HCP who have no serologic proof of immunity, prior vaccination, or history of varicella disease, give doses of varicella vaccine, 4 weeks apart. Give SC. Give a dose of Tdap as soon as feasible to all HCP who have not received Tdap previously and to pregnant HCP with each pregnancy (see below). Give Td boosters every 0 years thereafter. Give IM. Give dose to microbiologists who are routinely exposed to isolates of N. meningitidis and boost every 5 years if risk continues. Give MCV4 IM; if necessary to use MPSV4, give SC. Hepatitis A, typhoid, and polio vaccines are not routinely recommended for HCP who may have on-the-job exposure to fecal material. Hepatitis B Healthcare personnel (HCP) who perform tasks that may involve exposure to blood or body fluids should receive a 3-dose series of hepatitis B vaccine at 0-, -, and 6-month intervals. Test for hepatitis B surface antibody (anti-hbs) to document immunity months after dose #3. If anti-hbs is at least 0 miu/ml (positive), the patient is immune. No further serologic testing or vaccination is recommended. If anti-hbs is less than 0 miu/ml (negative), the patient is unprotected from hepatitis B virus (HBV) infection; revaccinate with a 3-dose series. Retest anti-hbs months after dose #3. If anti-hbs is positive, the patient is immune. No further testing or vaccination is recommended. If anti-hbs is negative after 6 doses of vaccine, patient is a non-responder. For non-responders: HCP who are non-responders should be considered susceptible to HBV and should be counseled regarding precautions to prevent HBV infection and the need to obtain HBIG prophylaxis for any known or probable parenteral exposure to hepatitis B surface antigen (HBsAg)-positive blood. It is also possible that non-responders are people who are HBsAg positive. Testing should be considered. HCP found to be HBsAg positive should be counseled and medically evaluated. Note: Anti-HBs testing is not recommended routinely for previously vaccinated HCP who were not tested months after their original vaccine series. These HCP should be tested for anti-hbs when they have an exposure to blood or body fluids. If found to be anti-hbs negative, the HCP should be treated as if susceptible. Influenza All HCP, including physicians, nurses, paramedics, emergency medical technicians, employees of nursing homes and chronic care facilities, students in these professions, and volunteers, should receive annual vaccination against influenza. Live attenuated influenza vaccine (LAIV) may be given only to non-pregnant healthy HCP age 49 years and younger. Inactivated injectable influenza vaccine (IIV) is preferred over LAIV for HCP who are in close contact with severely immunosuppressed people (e.g., stem cell transplant patients) when patients require protective isolation. Measles, Mumps, Rubella (MMR) HCP who work in medical facilities should be immune to measles, mumps, and rubella. HCP born in 957 or later can be considered immune to measles, mumps, or rubella only if they have documentation of (a) laboratory confirmation of disease or immunity or (b) appropriate vaccination against measles, mumps, and rubella (i.e., doses of live measles and mumps vaccines given on or after the first birthday and separated by 8 days or more, and at least dose of live rubella vaccine). HCP with documented doses of MMR are not recommended to be serologically tested for immunity; but if they are tested and results are negative or equivocal for measles, mumps, and/or rubella, these HCP should be considered to have presumptive evidence of immunity to measles, mumps, and/or rubella and are not in need of additional MMR doses. Although birth before 957 generally is considered acceptable evidence of measles, mumps, and rubella immunity, healthcare facilities should consider recommending doses of MMR vaccine routinely to unvaccinated HCP born before 957 who do not have laboratory evidence of disease or immunity to measles and/or mumps, and should consider dose of MMR for HCP with no laboratory evidence of disease or immunity to rubella. For these same HCP who do not have evidence of immunity, healthcare facilities should recommend doses of MMR vaccine during an outbreak of measles or mumps and dose during an outbreak of rubella. Varicella It is recommended that all HCP be immune to varicella. Evidence of immunity in HCP includes documentation of doses of varicella vaccine given at least 8 days apart, history of varicella or herpes zoster based on physician diagnosis, laboratory evidence of immunity, or laboratory confirmation of disease. Tetanus/Diphtheria/Pertussis (Td/Tdap) All HCPs who have not or are unsure if they have previously received a dose of Tdap should receive a dose of Tdap as soon as feasible, without regard to the interval since the previous dose of Td. Pregnant HCP need to get repeat doses during each pregnancy. All HCPs should then receive Td boosters every 0 years thereafter. Meningococcal Vaccination with MCV4 is recommended for microbiologists who are routinely exposed to isolates of N. meningitidis. Use MPSV4 only if there is a permanent contraindication or precaution to MCV4. References. CDC. Immunization of Health-Care Personnel: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR, 0; 60(RR-7).. See Table 3 in Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HBV, HCV, and HIV and Recommendations for Postexposure Prophylaxis, MMWR, 00; 50(RR-). For additional specific ACIP recommendations, refer to the official ACIP statements published in MMWR. To obtain copies, visit CDC s website at pubs/acip-list.htm; or visit the Immunization Action Coalition (IAC) website at www. immunize.org/acip. Technical content reviewed by the Centers for Disease Control and Prevention Immunization Action Coalition 573 Selby Avenue St. Paul, MN Item #P07 (6/3)

2 Hepatitis B and the healthcare worker CDC answers frequently asked questions about how to protect healthcare workers The Immunization Action Coalition thanks Eric E. Mast, MD, MPH, chief, Prevention Branch, Division of Viral Hepatitis, National Center for HIV/AIDS, Hepatitis, STD, and TB Prevention; William L. Atkinson, MD, MPH, medical epidemiologist, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention; and Linda A. Moyer, RN, consultant to the Immunization Action Coalition, for reviewing and updating the following questions and answers. Healthcare workers need more vaccinations than just hepatitis B! For information about additional vaccines you may need, see the references at the bottom of page 3. Which workers in the healthcare setting need hepatitis B vaccine? The Occupational Safety and Health Administration (OSHA) requires that hepatitis B vaccine be offered to healthcare workers (HCWs) who have a reasonable expectation of being exposed to blood on the job. This requirement does not include HCWs who would not be expected to have occupational risk, such as receptionists, billing staff, and general office workers. At what anatomic site should hepatitis B vaccine be administered to adults? What needle size should be used? The deltoid muscle is recommended for routine intramuscular (IM) vaccination among adults. The gluteus muscle should not be used as a site for administering hepatitis B vaccine. The suggested needle size is depending on the recipient s gender and weight ( for females weighing less than 70 kg; ½ for females weighing kg; ½ for males weighing less than 0 kg; and for males weighing 0 kg or more and females more than 00 kg). A - to 5-gauge needle should be used. For optimal protection, it is crucial that the vaccine be administered IM, not subcutaneously. If a HCW had one dose only of hepatitis B vaccine 4 months ago, should the series be restarted? No. The hepatitis B vaccine series should not be restarted when doses are delayed; rather, the series should be continued from where it stopped. The HCW should receive the second dose of vaccine now and the third dose at least 8 weeks later. There needs to be at least 6 weeks between the first and the third doses and at least 8 weeks between the second and third doses of vaccine. Is it safe for HCWs to be vaccinated during pregnancy? Yes. Limited data indicate no apparent risk for adverse events to developing fetuses. Current hepatitis B vaccines contain noninfectious hepatitis B surface antigen (HBsAg) and should pose no risk to the fetus. If the mother is being vaccinated because she is at risk for hepatitis B virus (HBV) infection (e.g., a HCW, a person with a sexually transmitted disease, an injection drug user, multiple sex partners), vaccination should be initiated as soon as her risk factor is identified during the pregnancy. If not vaccinated, a pregnant woman may contract an HBV infection, which might result in severe disease for the mother and chronic infection for the newborn. In addition, giving hepatitis B vaccine to the mother is not a contraindication to breastfeeding. Which HCWs need serologic testing after receiving 3 doses of hepatitis B vaccine? All HCWs who have a reasonable risk of exposure to blood or body fluids containing blood (e.g., HCWs with direct patient contact, HCWs who have the risk of needlestick or sharps injury, laboratory workers who draw or test blood) should have postvaccination testing for antibody to hepatitis B surface antigen (anti-hbs). Postvaccination testing should be done months after the last dose of vaccine. What should be done if a HCW s postvaccination anti-hbs test is negative months after the last dose of vaccine? Repeat the 3-dose series and test for anti-hbs months after the last dose of vaccine. If the HCW is still negative after a second vaccine series, the HCW is considered a non-responder to hepatitis B vaccination. HCWs who do not respond to vaccination should be tested for HBsAg to determine if they have chronic HBV infection. If the HBsAg test is positive, the person should receive appropriate counseling and medical management. Persons who test negative for HBsAg should be considered susceptible to HBV infection and should be counseled about precautions to prevent HBV infection and the need to obtain hepatitis B immune globulin (HBIG) prophylaxis for any known or likely exposure to HBsAg-positive blood. Immunization Action Coalition 573 Selby Ave. St. Paul, MN 5504 (65)

3 How often should I test HCWs after they ve received the hepatitis B vaccine series to make sure they re protected? For immune competent HCWs, periodic testing or periodic boosting is not needed. Postvaccination testing (anti-hbs) should be done months after the last dose of hepatitis B vaccine. If adequate anti-hbs (at least 0 miu/ml) is present, nothing more needs to be done. If postvaccination testing is less than 0 miu/ml, the vaccine series should be repeated and anti-hbs testing done, months after the last dose of the second series. This information should be recorded in the HCW s employee health record. Should a HCW who performs invasive procedures and who once had a positive anti- HBs result be revaccinated if the anti-hbs titer is rechecked and is less than 0 miu/ml? No. Immune competent persons known to have responded to hepatitis B vaccination do not require additional passive or active immunization. Postvaccination testing should be done months after the original vaccine series is completed. In this scenario, the initial postvaccination testing showed that the HCW was protected. Substantial evidence suggests that adults who respond to hepatitis B vaccination (anti-hbs of at least 0 miu/ml) are protected from chronic HBV infection for as long as 3 years, even if there is no detectable anti-hbs currently. Only immunocompromised persons (e.g., hemodialysis patients, some HIV-positive persons) need to have anti-hbs testing and booster doses of vaccine to maintain their protective anti-hbs concentrations of at least 0 miu/ml. Before reading the recommendations of CDC s Advisory Committee on Immunization Practices (ACIP) that say not to do this, we tested our employees for anti-hbs several years after they were vaccinated and some people had inadequate results, even though Table : Recommendations for postexposure prophylaxis after percutaneous or mucosal exposure to HBV in an occupational setting Vaccination and antibody response status of exposed persons Source is HBsAg positive Source is HBsAg negative Treatment Source is unknown or not tested High risk Low risk Unvaccinated HBIG ( dose) and begin a hepatitis B vaccine series Begin a hepatitis B vaccine series Begin a hepatitis B vaccine series Begin a hepatitis B vaccine series Known responder 3 No treatment No treatment No treatment No treatment Nonresponder 3 Not revaccinated 4 HBIG ( dose) and begin a revaccination series Begin a revaccination series HBIG ( dose) and begin a revaccination series Begin a revaccination series After revaccination 4 HBIG ( doses) 5 No treatment HBIG ( doses) 5 No treatment Antibody response unknown Test for anti-hbs 6 If adequate 3, no treatment If inadequate HBIG x and vaccine booster No treatment Test for anti-hbs 6 If adequate 3, no treatment If inadequate, give vaccine booster and check anti-hbs in months. Persons known to have had HBV infection in the past or who are chronically infected do not require HBIG or vaccine.. Hepatitis B immune globulin (0.06 ml/kg) administered IM. 3. Adequate response is anti-hbs of at least 0 miu/ml after vaccination. 4. Revaccination = additional 3-dose series of hepatitis B vaccine administered after the primary series. 5. First dose as soon as possible after exposure and the second dose month later. 6. Testing should be done as soon as possible after exposure Source: This table was adapted from Updated U.S. PHS Guidelines for the Management of Occupational Exposures to HBV, HCV, and HIV and Recommendations for Postexposure Prophylaxis, MMWR, 6/9/0, Vol. 50 (RR-) Page of 4

4 they had all completed a 3-dose series. What should we do now? ACIP does not recommend periodic testing of vaccinated HCWs because anti-hbs concentrations decline over time, and HCWs remain protected even if their anti-hbs concentration declines to below 0 miu/ml. For HCWs who have been vaccinated in the past and who do not have a documented response to vaccination of at least 0 miu/ml, ACIPrecommends testing for anti-hbs at the time of an exposure and providing appropriate management based on the results of testing. (See postexposure guidelines in Table.) If cost is not a great concern or if an employee or employer wants documented assurance of immunity, a revaccination series can be undertaken followed by testing months after the 3rd dose of hepatitis B vaccine. How often should anti-hbs testing be done on HCWs who perform invasive procedures? For persons whose immune status is normal, periodic serologic testing to assess anti-hbs concentrations is not necessary. Persons who perform invasive procedures should be treated no differently from other HCWs with respect to anti-hbs testing. If a HCW has an exposure (e. g., needlestick), s/he should be evaluated for their need for immunoprophylaxis according to postexposure guidelines in Table. If HCWs received hepatitis B vaccination in the past and were not tested for immunity, should they be tested now? No. In this scenario, a HCW does not need to be tested unless s/he has an exposure. If an exposure occurs, refer to the postexposure guidelines in Table. How should a vaccinated HCW with an unknown anti-hbs response be managed if they have a percutaneous or mucosal exposure to blood or body fluids from an HBsAg-positive source? This person should be tested for anti-hbs as soon as possible after exposure. If the anti-hbs concentration is at least 0 miu/ml, no further treatment is needed. If the anti-hbs concentration is less than 0 miu/ml, HBIG and one dose of hepatitis B vaccine should be administered. Prior to administering the HBIG and vaccine, blood should be drawn for a baseline HBsAg test. Subsequently, in 3 6 months, an additional anti-hbs and an HBsAg test should be performed. If the HBsAg is positive, the person is infected and should be referred for medical evaluation. If the anti-hbs result is at least 0 miu/ml, the person is seroprotected. It is necessary to do postvaccination testing later than the usual recommended time frame because anti-hbs from HBIG might be detected if testing is done any earlier. The postvaccination test result should be recorded in the person s health record. For a pre-employment physical, a HCW states she received all three hepatitis B vaccine doses as an adolescent. Would you test for anti-hbs? If the HCW has written documentation of a full hepatitis B vaccine series, testing for anti-hbs at this point is not necessary. If the HCW has a subsequent exposure to HBV, hepatitis B immunoprophylaxis should be administered following guidelines for a person who has been vaccinated, but the immune response is not known (Table ). This information should be documented in the HCW s employee health record. This approach should be sufficient to meet the needs of the employer and the requirements of OSHA. If there is no written documentation of hepatitis B vaccination, see the next question. Several physicians in our group have no documentation showing they received hepatitis B vaccine. They are relatively sure, however, that they received the doses many years ago. What do we do now? Because there is no documentation of vaccination, the 3- dose vaccination series should be administered and postvaccination testing should be performed months after the third dose of vaccine. There is no harm in receiving extra doses of vaccine. Care should always be taken to document vaccine lot, date, manufacturer, route, and vaccine dosages. Postvaccination testing results should also be documented, including the date testing was performed. All organizations (e.g., hospitals, clinics) should develop policies or guidelines to assure valid hepatitis B immunization. A healthcare worker (HCW) thinks she had 3 doses of hepatitis B vaccine in the past but has no documentation of receiving those doses. Before reading the recommendations to revaccinate her, we obtained an anti-hbs titer and the result was greater than 0 miu/ml. With this lab result, can t we assume she is immune? A positive anti-hbs indicates that the vaccinated person is immune at the time the HCW was tested, but does not necessarily assure that the HCW has long-term immunity. Long-term immunity has been shown only for persons attaining an adequate anti- HBs result of at least 0 miu/ ml after a 3-dose vaccination series. The most direct way to deal with this is to vaccinate the HCW with the 3-dose series of hepatitis B vaccine; test for anti-hbs in months and document the result in the HCW s employee health record. An adequate anti-hbs result from a documented 3-dose vaccine series would assure not only seroprotection, but long-term protection, as well. Of course, it is possible that the HCW has an anti-hbs result of greater than 0 miu/ml because of an HBV infection in the past. If this is of concern, a total anti-hbc Page 3 of 4

5 test could be performed to discern this (a positive result indicates a history of HBV infection at some undefined period in time). I m a nurse who received the hepatitis B vaccine series more than 0 years ago and had a positive follow-up titer (at least 0 miu/ml). At present, my titer is negative (less than 0 miu/ml). What should I do now? Nothing. Data show that vaccine-induced anti-hbs levels might decline over time; however, immune memory (anamnestic anti-hbs response) remains intact indefinitely following immunization. Persons with anti-hbs concentrations that decline to less than 0 miu/ml are still protected against HBV infection. For HCWs with normal immune status who have demonstrated adequate anti-hbs (at least 0 miu/ml) following vaccination, booster doses of vaccine or periodic anti-hbs testing is not recommended. A person who is a known non-responder to hepatitis B vaccine has a percutaneous exposure to HBsAg-positive blood. According to older ACIP recommendations, I have the option to give HBIG x or HBIG x and initiate revaccination. How do I decide which to do? Current recommendations have been revised. The recommended postexposure prophylaxis for persons who are non-responders to hepatitis B vaccine (i.e., have not responded to an initial 3-dose series and revaccination with a 3-dose series) is to give HBIG as soon as possible after exposure and a second dose of HBIG one month later (see Table ). Exposed persons, who are known not to have responded to a primary vaccine series, but have not been revaccinated with a second 3-dose series, should receive a single dose of HBIG and reinitiate the hepatitis B vaccine series with the first dose of hepatitis B vaccine as soon as possible after exposure. If an employee does not respond to hepatitis B vaccination (employee has had two full series of hepatitis B vaccine), does s/he need to be removed from activities that expose her/him to bloodborne pathogens? Does the employer have a responsibility in this area beyond providing the vaccine? There are no regulations that require removal from job situations where exposure to bloodborne pathogens could occur; this is an individual policy decision within the organization. OSHA regulations require that employees in jobs where there is a reasonable risk of exposure to blood be offered hepatitis B vaccine. In addition, the regulation states that adequate personal protective equipment be provided and that standard precautions be followed. Check your state OSHA regulations regarding additional requirements. If there are no state OSHA regulations, federal OSHA regulations should be followed. Adequate documentation should be placed in the employee record regarding non-response to vaccination. HCWs who do not respond to vaccination should be tested for HBsAg to determine if they have chronic HBV infection. If the HBsAg test is positive, the person should receive appropriate counseling and medical management. Persons who test negative for HBsAg should be considered susceptible to HBV infection and should be counseled about precautions to prevent HBV infection and the need to obtain HBIG prophylaxis for any known or likely exposure to HBsAg-positive blood (see Table ). Can a person with chronic HBV infection become a HCW? Yes. All HCWs should practice standard precautions, which are designed to prevent HBV transmission, both from patients to HCW and from HCW to patient. There is, however, one caveat concerning HBV-infected HCWs. Those who are HBsAg positive and HBeAg (hepatitis B e antigen) positive should not perform exposure-prone procedures (e.g., gynecologic, cardiothoracic surgery) unless they have sought counsel from an expert review panel and been advised under what circumstances, if any, they may continue to perform these procedures. Such circumstances might include notifying prospective patients of the HCW s seropositivity before they undergo exposure-prone invasive procedures. For more information on this issue, see the Mortality and Morbidity Weekly Report, Recommendations for Preventing Transmission of Human Immunodeficiency Virus and Hepatitis B Virus to Patients During Exposure-Prone Invasive Procedures, MMWR, 7//9, Vol. 40(RR-8); 9. This document is available at preview/ mmwrhtml/ htm. Keep your own vaccination history! Record the dates you received hepatitis B vaccine, as well as the results of your postvaccination serologic testing (anti-hbs). Remember to save records of any vaccinations you receive so you don t have to repeat them. To order adult immunization record cards, visit www. immunize.org/adultizcards. For more information on vaccination recommendations for healthcare workers, see the following:. Immunization of Health-Care Workers, MMWR, /6/97, Vol. 46 (RR-8), Influenza Vaccination of Health-Care Personnel, MMWR, /4/06, Vol. 55 (RR-), 3. Healthcare Worker Vaccination Recommendations, Immunization Action Coalition,

6 Recommended Adult Immunization Schedule United States - 03 Note: These recommendations must be read with the footnotes that follow containing number of doses, intervals between doses, and other important information. VACCINE AGE GROUP 9- years -6 years 7-49 years years years 65 years Influenza,* Tetanus, diphtheria, pertussis (Td/Tdap) 3,* Varicella 4,* Human papillomavirus (HPV) Female 5,* Human papillomavirus (HPV) Male 5,* dose annually Substitute -time dose of Tdap for Td booster; then boost with Td every 0 yrs doses 3 doses 3 doses Zoster 6 Measles, mumps, rubella (MMR) 7,* Pneumococcal polysaccharide (PPSV3) 8,9 Pneumococcal 3-valent conjugate (PCV3) 0,* Meningococcal,* Hepatitis A,* Hepatitis B 3,* *Covered by the Vaccine Injury Compensation Program For all persons in this category who meet the age requirements and who lack documentation of vaccination or have no evidence of previous infection; zoster vaccine recommended regardless of prior episode of zoster Recommended if some other risk factor is present (e.g., on the basis of medical, occupational, lifestyle, or other indication) No recommendation or doses or doses dose or more doses doses 3 doses dose dose Report all clinically significant postvaccination reactions to the Vaccine Adverse Event Reporting System (VAERS). Reporting forms and instructions on filing a VAERS report are available at or by telephone, Information on how to file a Vaccine Injury Compensation Program claim is available at or by telephone, To file a claim for vaccine injury, contact the U.S. Court of Federal Claims, 77 Madison Place, N.W., Washington, D.C. 0005; telephone, Additional information about the vaccines in this schedule, extent of available data, and contraindications for vaccination is also available at gov/vaccines or from the CDC-INFO Contact Center at 800-CDC-INFO ( ) in English and Spanish, 8:00 a.m. - 8:00 p.m. Eastern Time, Monday - Friday, excluding holidays. Use of trade names and commercial sources is for identification only and does not imply endorsement by the U.S. Department of Health and Human Services. The recommendations in this schedule were approved by the Centers for Disease Control and Prevention s (CDC) Advisory Committee on Immunization Practices (ACIP), the American Academy of Family Physicians (AAFP), the American College of Physicians (ACP), American College of Obstetricians and Gynecologists (ACOG) and American College of Nurse-Midwives (ACNM). VACCINE Influenza,* Tetanus, diphtheria, pertussis (Td/Tdap) 3,* Varicella 4,* Human papillomavirus (HPV) Female 5,* Human papillomavirus (HPV) Male 5,* Zoster 6 Measles, mumps, rubella (MMR) 7,* Pneumococcal polysaccharide (PPSV3) 8,9 INDICATION Pregnancy Pneumococcal 3-valent conjugate (PCV3) 0,* Meningococcal,* Hepatitis A,* Hepatitis B 3,* dose Tdap each pregnancy Immunocompromising conditions (excluding human immunodeficiency virus [HIV]) 4,6,7,0,5 Contraindicated Contraindicated Contraindicated HIV infection CD4+ T lymphocyte count 4,6,7,0,4,5 < 00 cells/μl dose IIV annually *Covered by the Vaccine Injury Compensation Program For all persons in this category who meet the age requirements and who lack documentation of vaccination or have no evidence of previous infection; zoster vaccine recommended regardless of prior episode of zoster Recommended if some other risk factor is present (e.g., on the basis of medical, occupational, lifestyle, or other indications) No recommendation 00 cells/μl 3 doses through age 6 yrs 3 doses through age 6 yrs Men who have sex with men (MSM) dose IIV or LAIV annually Heart disease, chronic lung disease, chronic alcoholism or doses or more doses doses 3 doses Asplenia (including elective splenectomy and persistent complement component deficiencies) 0,4 dose doses dose or doses Chronic liver disease dose IIV annually Kidney failure, end-stage renal disease, receipt of hemodialysis Substitute -time dose of Tdap for Td booster; then boost with Td every 0 yrs 3 doses through age 6 yrs 3 doses through age yrs Diabetes Healthcare personnel dose IIV or LAIV annually These schedules indicate the recommended age groups and medical indications for which administration of currently licensed vaccines is commonly indicated for adults ages 9 years and older, as of January, 03. For all vaccines being recommended on the Adult Immunization Schedule: a vaccine series does not need to be restarted, regardless of the time that has elapsed between doses. Licensed combination vaccines may be used whenever any components of the combination are indicated and when the vaccine s other components are not contraindicated. For detailed recommendations on all vaccines, including those used primarily for travelers or that are issued during the year, consult the manufacturers package inserts and the complete statements from the Advisory Committee on Immunization Practices ( Use of trade names and commercial sources is for identification only and does not imply endorsement by the U.S. Department of Health and Human Services.

7 Footnotes Recommended Immunization Schedule for Adults Aged 9 Years and Older United States, 03. Additional information Additional guidance for the use of the vaccines described in this supplement is available at htm. Information on vaccination recommendations when vaccination status is unknown and other general immunization information can be found in the General Recommendations on Immunization at Information on travel vaccine requirements and recommendations (e.g., for hepatitis A and B, meningococcal, and other vaccines) are available at Influenza vaccination Annual vaccination against influenza is recommended for all persons aged 6 months and older. Persons aged 6 months and older, including pregnant women, can receive the inactivated influenza vaccine (IIV). Healthy, nonpregnant persons aged 49 years without high-risk medical conditions can receive either intranasally administered live, attenuated influenza vaccine (LAIV) (FluMist), or IIV. Health-care personnel who care for severely immunocompromised persons (i.e., those who require care in a protected environment) should receive IIV rather than LAIV. The intramuscularly or intradermally administered IIV are options for adults aged 8 64 years. Adults aged 65 years and older can receive the standard dose IIV or the high-dose IIV (Fluzone High-Dose). 3. Tetanus, diphtheria, and acellular pertussis (Td/Tdap) vaccination Administer one dose of Tdap vaccine to pregnant women during each pregnancy (preferred during 7 36 weeks gestation), regardless of number of years since prior Td or Tdap vaccination. Administer Tdap to all other adults who have not previously received Tdap or for whom vaccine status is unknown. Tdap can be administered regardless of interval since the most recent tetanus or diphtheria-toxoid containing vaccine. Adults with an unknown or incomplete history of completing a 3-dose primary vaccination series with Td-containing vaccines should begin or complete a primary vaccination series including a Tdap dose. For unvaccinated adults, administer the first doses at least 4 weeks apart and the third dose 6 months after the second. For incompletely vaccinated (i.e., less than 3 doses) adults, administer remaining doses. Refer to the Advisory Committee on Immunization Practices (ACIP) statement for recommendations for administering Td/Tdap as prophylaxis in wound management (see footnote #). 4. Varicella vaccination All adults without evidence of immunity to varicella (as defined below) should receive doses of single-antigen varicella vaccine or a second dose if they have received only dose. Special consideration for vaccination should be given to those who have close contact with persons at high risk for severe disease (e.g., health-care personnel and family contacts of persons with immunocompromising conditions) or are at high risk for exposure or transmission (e.g., teachers; child care employees; residents and staff members of institutional settings, including correctional institutions; college students; military personnel; adolescents and adults living in households with children; nonpregnant women of childbearing age; and international travelers). Pregnant women should be assessed for evidence of varicella immunity. Women who do not have evidence of immunity should receive the first dose of varicella vaccine upon completion or termination of pregnancy and before discharge from the health-care facility. The second dose should be administered 4 8 weeks after the first dose. Evidence of immunity to varicella in adults includes any of the following: documentation of doses of varicella vaccine at least 4 weeks apart; U.S.-born before 980 except health-care personnel and pregnant women; history of varicella based on diagnosis or verification of varicella disease by a health-care provider; history of herpes zoster based on diagnosis or verification of herpes zoster disease by a health-care provider; or laboratory evidence of immunity or laboratory confirmation of disease. 5. Human papillomavirus (HPV) vaccination Two vaccines are licensed for use in females, bivalent HPV vaccine (HPV) and quadrivalent HPV vaccine (HPV4), and one HPV vaccine for use in males (HPV4). For females, either HPV4 or HPV is recommended in a 3-dose series for routine vaccination at age or years, and for those aged 3 through 6 years, if not previously vaccinated. For males, HPV4 is recommended in a 3-dose series for routine vaccination at age or years, and for those aged 3 through years, if not previously vaccinated. Males aged through 6 years may be vaccinated. HPV4 is recommended for men who have sex with men (MSM) through age 6 years for those who did not get any or all doses when they were younger. Vaccination is recommended for immunocompromised persons (including those with HIV infection) through age 6 years for those who did not get any or all doses when they were younger. A complete series for either HPV4 or HPV consists of 3 doses. The second dose should be administered months after the first dose; the third dose should be administered 6 months after the first dose (at least 4 weeks after the first dose). HPV vaccines are not recommended for use in pregnant women. However, pregnancy testing is not needed before vaccination. If a woman is found to be pregnant after initiating the vaccination series, no intervention is needed; the remainder of the 3-dose series should be delayed until completion of pregnancy. Although HPV vaccination is not specifically recommended for health-care personnel (HCP) based on their occupation, HCP should receive the HPV vaccine as recommended (see above). 6. Zoster vaccination A single dose of zoster vaccine is recommended for adults aged 60 years and older regardless of whether they report a prior episode of herpes zoster. Although the vaccine is licensed by the Food and Drug Administration (FDA) for use among and can be administered to persons aged 50 years and older, ACIP recommends that vaccination begins at age 60 years. Persons aged 60 years and older with chronic medical conditions may be vaccinated unless their condition constitutes a contraindication, such as pregnancy or severe immunodeficiency. Although zoster vaccination is not specifically recommended for HCP, they should receive the vaccine if they are in the recommended age group. 7. Measles, mumps, rubella (MMR) vaccination Adults born before 957 generally are considered immune to measles and mumps. All adults born in 957 or later should have documentation of or more doses of MMR vaccine unless they have a medical contraindication to the vaccine, or laboratory evidence of immunity to each of the three diseases. Documentation of provider-diagnosed disease is not considered acceptable evidence of immunity for measles, mumps, or rubella. Measles component: A routine second dose of MMR vaccine, administered a minimum of 8 days after the first dose, is recommended for adults who are students in postsecondary educational institutions; work in a health-care facility; or plan to travel internationally. Persons who received inactivated (killed) measles vaccine or measles vaccine of unknown type during should be revaccinated with doses of MMR vaccine. Mumps component: A routine second dose of MMR vaccine, administered a minimum of 8 days after the first dose, is recommended for adults who are students in a postsecondary educational institution; work in a health-care facility; or plan to travel internationally. Persons vaccinated before 979 with either killed mumps vaccine or mumps vaccine of unknown type who are at high risk for mumps infection (e.g., persons who are working in a health-care facility) should be considered for revaccination with doses of MMR vaccine. Rubella component: For women of childbearing age, regardless of birth year, rubella immunity should be determined. If there is no evidence of immunity, women who are not pregnant should be vaccinated. Pregnant women who do not have evidence of immunity should receive MMR vaccine upon completion or termination of pregnancy and before discharge from the health-care facility. HCP born before 957: For unvaccinated health-care personnel born before 957 who lack laboratory evidence of measles, mumps, and/or rubella immunity or laboratory confirmation of disease, health-care facilities should consider vaccinating personnel with doses of MMR vaccine at the appropriate interval for measles and mumps or dose of MMR vaccine for rubella. 8. Pneumococcal polysaccharide (PPSV3) vaccination Vaccinate all persons with the following indications: all adults aged 65 years and older; adults younger than age 65 years with chronic lung disease (including chronic obstructive pulmonary disease, emphysema, and asthma); chronic cardiovascular diseases; diabetes mellitus; chronic renal failure; nephrotic syndrome; chronic liver disease (including cirrhosis); alcoholism; cochlear implants; cerebrospinal fluid leaks; immunocompromising conditions; and functional or anatomic asplenia (e.g., sickle cell disease and other hemoglobinopathies, congenital or acquired asplenia, splenic dysfunction, or splenectomy [if elective splenectomy is planned, vaccinate at least weeks before surgery]); residents of nursing homes or long-term care facilities; and adults who smoke cigarettes. Persons with immunocompromising conditions and other selected conditions are recommended to receive PCV3 and PPSV3 vaccines. See footnote #0 for information on timing of PCV3 and PPSV3 vaccinations. Persons with asymptomatic or symptomatic HIV infection should be vaccinated as soon as possible after their diagnosis. When cancer chemotherapy or other immunosuppressive therapy is being considered, the interval between vaccination and initiation of immunosuppressive therapy should be at least weeks. Vaccination during chemotherapy or radiation therapy should be avoided. Routine use of PPSV3 is not recommended for American Indians/Alaska Natives or other persons younger than age 65 years unless they have underlying medical conditions that are PPSV3 indications. However, public health authorities may consider recommending PPSV3 for American Indians/Alaska Natives who are living in areas where the risk for invasive pneumococcal disease is increased. When indicated, PPSV3 should be administered to patients who are uncertain of their vaccination status and there is no record of previous vaccination. When PCV3 is also indicated, a dose of PCV3 should be given first (see footnote #0). 9. Revaccination with PPSV3 One-time revaccination 5 years after the first dose is recommended for persons aged 9 through 64 years with chronic renal failure or nephrotic syndrome; functional or anatomic asplenia (e.g., sickle cell disease or splenectomy); and for persons with immunocompromising conditions. Persons who received or doses of PPSV3 before age 65 years for any indication should receive another dose of the vaccine at age 65 years or later if at least 5 years have passed since their previous dose. No further doses are needed for persons vaccinated with PPSV3 at or after age 65 years. 0. Pneumococcal conjugate 3-valent vaccination (PCV3) Adults aged 9 years or older with immunocompromising conditions (including chronic renal failure and nephrotic syndrome), functional or anatomic asplenia, CSF leaks or cochlear implants, and who have not previously received PCV3 or PPSV3 should receive a single dose of PCV3 followed by a dose of PPSV3 at least 8 weeks later. Adults aged 9 years or older with the aforementioned conditions who have previously received one or more doses of PPSV3 should receive a dose of PCV3 one or more years after the last PPSV3 dose was received. For those that require additional doses of PPSV3, the first such dose should be given no sooner than 8 weeks after PCV3 and at least 5 years since the most recent dose of PPSV3. When indicated, PCV3 should be administered to patients who are uncertain of their vaccination status history and there is no record of previous vaccination. Although PCV3 is licensed by the Food and Drug Administration (FDA) for use among and can be administered to persons aged 50 years and older, ACIP recommends PCV3 for adults aged 9 years and older with the specific medical conditions noted above.. Meningococcal vaccination Administer doses of meningococcal conjugate vaccine quadrivalent (MCV4) at least months apart to adults with functional asplenia or persistent complement component deficiencies. HIV-infected persons who are vaccinated also should receive doses. Administer a single dose of meningococcal vaccine to microbiologists routinely exposed to isolates of Neisseria meningitidis, military recruits, and persons who travel to or live in countries in which meningococcal disease is hyperendemic or epidemic. First-year college students up through age years who are living in residence halls should be vaccinated if they have not received a dose on or after their 6th birthday. MCV4 is preferred for adults with any of the preceding indications who are aged 55 years and younger; meningococcal polysaccharide vaccine (MPSV4) is preferred for adults aged 56 years and older. Revaccination with MCV4 every 5 years is recommended for adults previously vaccinated with MCV4 or MPSV4 who remain at increased risk for infection (e.g., adults with anatomic or functional asplenia or persistent complement component deficiencies).. Hepatitis A vaccination Vaccinate any person seeking protection from hepatitis A virus (HAV) infection and persons with any of the following indications: men who have sex with men and persons who use injection or noninjection illicit drugs; persons working with HAV-infected primates or with HAV in a research laboratory setting; persons with chronic liver disease and persons who receive clotting factor concentrates; persons traveling to or working in countries that have high or intermediate endemicity of hepatitis A; and unvaccinated persons who anticipate close personal contact (e.g., household or regular babysitting) with an international adoptee during the first 60 days after arrival in the United States from a country with high or intermediate endemicity. (See footnote # for more information on travel recommendations). The first dose of the -dose hepatitis A vaccine series should be administered as soon as adoption is planned, ideally or more weeks before the arrival of the adoptee. Single-antigen vaccine formulations should be administered in a -dose schedule at either 0 and 6 months (Havrix), or 0 and 6 8 months (Vaqta). If the combined hepatitis A and hepatitis B vaccine (Twinrix) is used, administer 3 doses at 0,, and 6 months; alternatively, a 4-dose schedule may be used, administered on days 0, 7, and 30, followed by a booster dose at month. 3. Hepatitis B vaccination Vaccinate persons with any of the following indications and any person seeking protection from hepatitis B virus (HBV) infection: sexually active persons who are not in a long-term, mutually monogamous relationship (e.g., persons with more than one sex partner during the previous 6 months); persons seeking evaluation or treatment for a sexually transmitted disease (STD); current or recent injection-drug users; and men who have sex with men; health-care personnel and public-safety workers who are potentially exposed to blood or other infectious body fluids; persons with diabetes younger than age 60 years as soon as feasible after diagnosis; persons with diabetes who are age 60 years or older at the discretion of the treating clinician based on increased need for assisted blood glucose monitoring in long-term care facilities, likelihood of acquiring hepatitis B infection, its complications or chronic sequelae, and likelihood of immune response to vaccination; persons with end-stage renal disease, including patients receiving hemodialysis; persons with HIV infection; and persons with chronic liver disease; household contacts and sex partners of hepatitis B surface antigen-positive persons; clients and staff members of institutions for persons with developmental disabilities; and international travelers to countries with high or intermediate prevalence of chronic HBV infection; and all adults in the following settings: STD treatment facilities; HIV testing and treatment facilities; facilities providing drug-abuse treatment and prevention services; health-care settings targeting services to injection-drug users or men who have sex with men; correctional facilities; end-stage renal disease programs and facilities for chronic hemodialysis patients; and institutions and nonresidential daycare facilities for persons with developmental disabilities. Administer missing doses to complete a 3-dose series of hepatitis B vaccine to those persons not vaccinated or not completely vaccinated. The second dose should be administered month after the first dose; the third dose should be given at least months after the second dose (and at least 4 months after the first dose). If the combined hepatitis A and hepatitis B vaccine (Twinrix) is used, give 3 doses at 0,, and 6 months; alternatively, a 4-dose Twinrix schedule, administered on days 0, 7, and 30 followed by a booster dose at month may be used. Adult patients receiving hemodialysis or with other immunocompromising conditions should receive dose of 40 μg/ml (Recombivax HB) administered on a 3-dose schedule at 0,, and 6 months or doses of 0 μg/ml (Engerix-B) administered simultaneously on a 4-dose schedule at 0,,, and 6 months. 4. Selected conditions for which Haemophilus influenzae type b (Hib) vaccine may be used dose of Hib vaccine should be considered for persons who have sickle cell disease, leukemia, or HIV infection, or who have anatomic or functional asplenia if they have not previously received Hib vaccine. 5. Immunocompromising conditions Inactivated vaccines generally are acceptable (e.g., pneumococcal, meningococcal, and influenza [inactivated influenza vaccine]), and live vaccines generally are avoided in persons with immune deficiencies or immunocompromising conditions. Information on specific conditions is available at

8 Figure. Recommended immunization schedule for persons aged 0 through 8 years 03. (FOR THOSE WHO FALL BEHIND OR START LATE, SEE THE CATCH-UP SCHEDULE [FIGURE ]). These recommendations must be read with the footnotes that follow. For those who fall behind or start late, provide catch-up vaccination at the earliest opportunity as indicated by the green bars in Figure. To determine minimum intervals between doses, see the catch-up schedule (Figure ). School entry and adolescent vaccine age groups are in bold. Vaccines Birth mo mos 4 mos 6 mos 9 mos mos 5 mos 8 mos 9 3 mos -3 yrs 4-6 yrs 7-0 yrs - yrs 3 5 yrs 6 8 yrs Hepatitis B (HepB) st dose nd dose 3 rd dose Rotavirus (RV) RV- (-dose series); RV-5 (3-dose series) Diphtheria, tetanus, & acellular pertussis 3 (DTaP: <7 yrs) st dose nd dose See footnote st dose nd dose 3 rd dose 4 th dose 5 th dose Tetanus, diphtheria, & acellular pertussis 4 (Tdap: >7 yrs) (Tdap) Haemophilus influenzae type b 5 (Hib) st dose nd dose See footnote 5 3 rd or 4 th dose, see footnote 5 Pneumococcal conjugate 6a,c (PCV3) st dose nd dose 3 rd dose 4 th dose Pneumococcal polysaccharide 6b,c (PPSV3) Inactivated Poliovirus 7 (IPV) (<8years) Influenza 8 (IIV; LAIV) doses for some : see footnote 8 Measles, mumps, rubella 9 (MMR) st dose nd dose 3 rd dose 4 th dose Annual vaccination (IIV only) Annual vaccination (IIV or LAIV) st dose nd dose Varicella 0 (VAR) st dose nd dose Hepatitis A (HepA) dose series, see footnote Human papillomavirus (HPV: females only; HPV4: males and females) Meningococcal 3 (Hib-MenCY > 6 weeks; MCV4-D>9 mos; MCV4-CRM > yrs.) (3-dose series) see footnote 3 st dose booster Range of recommended ages for all children Range of recommended ages for catch-up immunization Range of recommended ages for certain high-risk groups Range of recommended ages during which catch-up is encouraged and for certain high-risk groups Not routinely recommended This schedule includes recommendations in effect as of January, 03. Any dose not administered at the recommended age should be administered at a subsequent visit, when indicated and feasible. The use of a combination vaccine generally is preferred over separate injections of its equivalent component vaccines. Vaccination providers should consult the relevant Advisory Committee on Immunization Practices (ACIP) statement for detailed recommendations, available online at Clinically significant adverse events that follow vaccination should be reported to the Vaccine Adverse Event Reporting System (VAERS) online ( or by telephone ( ).Suspected cases of vaccine-preventable diseases should be reported to the state or local health department. Additional information, including precautions and contraindications for vaccination, is available from CDC online ( or by telephone (800-CDC-INFO [ ]). This schedule is approved by the Advisory Committee on Immunization Practices ( the American Academy of Pediatrics ( the American Academy of Family Physicians ( and the American College of Obstetricians and Gynecologists ( NOTE: The above recommendations must be read along with the footnotes of this schedule. Footnotes Recommended immunization schedule for persons aged 0 through 8 years United States, 03 For further guidance on the use of the vaccines mentioned below, see: Hepatitis B (HepB) vaccine. (Minimum age: birth) At birth Administer monovalent HepB vaccine to all newborns before hospital discharge. For infants born to hepatitis B surface antigen (HBsAg) positive mothers, administer HepB vaccine and 0.5 ml of hepatitis B immune globulin (HBIG) within hours of birth. These infants should be tested for HBsAg and antibody to HBsAg (anti-hbs) to months after completion of the HepB series, at age 9 through 8 months (preferably at the next well-child visit). If mother s HBsAg status is unknown, within hours of birth administer HepB vaccine to all infants regardless of birth weight. For infants weighing <,000 grams, administer HBIG in addition to HepB within hours of birth. Determine mother s HBsAg status as soon as possible and, if she is HBsAg-positive, also administer HBIG for infants weighing,000 grams (no later than age week). Doses following the birth dose The second dose should be administered at age or months. Monovalent HepB vaccine should be used for doses administered before age 6 weeks. Infants who did not receive a birth dose should receive 3 doses of a HepB-containing vaccine on a schedule of 0, to months, and 6 months starting as soon as feasible. See Figure. The minimum interval between dose and dose is 4 weeks and between dose and 3 is 8 weeks. The final (third or fourth) dose in the HepB vaccine series should be administered no earlier than age 4 weeks, and at least 6 weeks after the first dose. Administration of a total of 4 doses of HepB vaccine is recommended when a combination vaccine containing HepB is administered after the birth dose. Unvaccinated persons should complete a 3-dose series. A -dose series (doses separated by at least 4 months) of adult formulation Recombivax HB is licensed for use in children aged through 5 years.. Rotavirus (RV) vaccines. (Minimum age: 6 weeks for both RV- [Rotarix] and RV-5 [RotaTeq]). Administer a series of RV vaccine to all infants as follows:. If RV- is used, administer a -dose series at and 4 months of age.. If RV-5 is used, administer a 3-dose series at ages, 4, and 6 months. 3. If any dose in series was RV-5 or vaccine product is unknown for any dose in the series, a total of 3 doses of RV vaccine should be administered. The maximum age for the first dose in the series is 4 weeks, 6 days. Vaccination should not be initiated for infants aged 5 weeks 0 days or older. The maximum age for the final dose in the series is 8 months, 0 days. If RV-(Rotarix) is administered for the first and second doses, a third dose is not indicated. 3. Diphtheria and tetanus toxoids and acellular pertussis (DTaP) vaccine. (Minimum age: 6 weeks) Administer a 5-dose series of DTaP vaccine at ages, 4, 6, 5 8 months, and 4 through 6 years. The fourth dose may be administered as early as age months, provided at least 6 months have elapsed since the third dose. The fifth (booster) dose of DTaP vaccine is not necessary if the fourth dose was administered at age 4 years or older. 4. Tetanus and diphtheria toxoids and acellular pertussis (Tdap) vaccine. (Minimum age: 0 years for Boostrix, years for Adacel). Administer dose of Tdap vaccine to all adolescents aged through years. Tdap can be administered regardless of the interval since the last tetanus and diphtheria toxoid-containing vaccine. Administer one dose of Tdap vaccine to pregnant adolescents during each pregnancy (preferred during 7 through 36 weeks gestation) regardless of number of years from prior Td or Tdap vaccination. Persons aged 7 through 0 years who are not fully immunized with the childhood DTaP vaccine series, should receive Tdap vaccine as the first dose in the catch-up series; if additional doses are needed, use Td vaccine. For these children, an adolescent Tdap vaccine should not be given. Persons aged through 8 years who have not received Tdap vaccine should receive a dose followed by tetanus and diphtheria toxoids (Td) booster doses every 0 years thereafter. An inadvertent dose of DTaP vaccine administered to children aged 7 through 0 years can count as part of the catch-up series. This dose can count as the adolescent Tdap dose, or the child can later receive a Tdap booster dose at age years. 5. Haemophilus influenzae type b (Hib) conjugate vaccine. (Minimum age: 6 weeks) Administer a Hib vaccine primary series and a booster dose to all infants. The primary series doses should be administered at, 4, and 6 months of age; however, if PRP-OMP (PedvaxHib or Comvax) is administered at and 4 months of age, a dose at age 6 months is not indicated. One booster dose should be administered at age through5 months. Hiberix (PRP-T) should only be used for the booster (final) dose in children aged months through 4 years, who have received at least dose of Hib. If dose was administered at ages -4 months, administer booster (as final dose) at least 8 weeks after dose. If the first doses were PRP-OMP (PedvaxHIB or Comvax), and were administered at age months or younger, the third (and final) dose should be administered at age through 5 months and at least 8 weeks after the second dose. If the first dose was administered at age 7 through months, administer the second dose at least 4 weeks later and a final dose at age through 5 months, regardless of Hib vaccine (PRP-T or PRP-OMP) used for first dose. For unvaccinated children aged 5 months or older, administer only dose.

9 For further guidance on the use of the vaccines mentioned below, see: Vaccination of persons with high-risk conditions: Hib vaccine is not routinely recommended for patients older than 5 years of age. However one dose of Hib vaccine should be administered to unvaccinated or partially vaccinated persons aged 5 years or older who have leukemia, malignant neoplasms, anatomic or functional asplenia (including sickle cell disease), human immunodeficiency virus (HIV) infection, or other immunocompromising conditions. 6a. Pneumococcal conjugate vaccine (PCV). (Minimum age: 6 weeks) Administer a series of PCV3 vaccine at ages, 4, 6 months with a booster at age through 5 months. For children aged 4 through 59 months who have received an age-appropriate series of 7-valent PCV (PCV7), administer a single supplemental dose of 3-valent PCV (PCV3). Administer dose of PCV3 to all healthy children aged 4 through 59 months who are not completely vaccinated for their age. Vaccination of persons with high-risk conditions: For children aged 4 through 7 months with certain underlying medical conditions (see footnote 6c), administer dose of PCV3 if 3 doses of PCV were received previously, or administer doses of PCV3 at least 8 weeks apart if fewer than 3 doses of PCV were received previously. A single dose of PCV3 may be administered to previously unvaccinated children aged 6 through 8 years who have anatomic or functional asplenia (including sickle cell disease), HIV infection or an immunocompromising condition, cochlear implant or cerebrospinal fluid leak. See MMWR 00;59 (No. RR-), available at Administer PPSV3 at least 8 weeks after the last dose of PCV to children aged years or older with certain underlying medical conditions (see footnotes 6b and 6c). 6b. Pneumococcal polysaccharide vaccine (PPSV3). (Minimum age: years) Vaccination of persons with high-risk conditions: Administer PPSV3 at least 8 weeks after the last dose of PCV to children aged years or older with certain underlying medical conditions (see footnote 6c). A single revaccination with PPSV should be administered after 5 years to children with anatomic or functional asplenia (including sickle cell disease) or an immunocompromising condition. 6c. Medical conditions for which PPSV3 is indicated in children aged years and older and for which use of PCV3 is indicated in children aged 4 through 7 months: Immunocompetent children with chronic heart disease (particularly cyanotic congenital heart disease and cardiac failure); chronic lung disease (including asthma if treated with high-dose oral corticosteroid therapy), diabetes mellitus; cerebrospinal fluid leaks; or cochlear implant. Children with anatomic or functional asplenia (including sickle cell disease and other hemoglobinopathies, congenital or acquired asplenia, or splenic dysfunction); Children with immunocompromising conditions: HIV infection, chronic renal failure and nephrotic syndrome, diseases associated with treatment with immunosuppressive drugs or radiation therapy, including malignant neoplasms, leukemias, lymphomas and Hodgkin disease; or solid organ transplantation, congenital immunodeficiency. 7. Inactivated poliovirus vaccine (IPV). (Minimum age: 6 weeks) Administer a series of IPV at ages, 4, 6 8 months, with a booster at age 4 6 years. The final dose in the series should be administered on or after the fourth birthday and at least 6 months after the previous dose. In the first 6 months of life, minimum age and minimum intervals are only recommended if the person is at risk for imminent exposure to circulating poliovirus (i.e., travel to a polio-endemic region or during an outbreak). If 4 or more doses are administered before age 4 years, an additional dose should be administered at age 4 through 6 years. A fourth dose is not necessary if the third dose was administered at age 4 years or older and at least 6 months after the previous dose. If both OPV and IPV were administered as part of a series, a total of 4 doses should be administered, regardless of the child s current age. IPV is not routinely recommended for U.S. residents aged 8 years or older. 8. Influenza vaccines. (Minimum age: 6 months for inactivated influenza vaccine [IIV]; years for live, attenuated influenza vaccine [LAIV]) Administer influenza vaccine annually to all children beginning at age 6 months. For most healthy, nonpregnant persons aged through 49 years, either LAIV or IIV may be used. However, LAIV should NOT be administered to some persons, including ) those with asthma, ) children through 4 years who had wheezing in the past months, or 3) those who have any other underlying medical conditions that predispose them to influenza complications. For all other contraindications to use of LAIV see MMWR 00; 59 (No. RR-8), available at Administer dose to persons aged 9 years and older. For children aged 6 months through 8 years: For the 0 3 season, administer doses (separated by at least 4 weeks) to children who are receiving influenza vaccine for the first time. For additional guidance, follow dosing guidelines in the 0 ACIP influenza vaccine recommendations, MMWR 0; 6: 63 68, available at pdf/wk/mm63.pdf. For the 03 4 season, follow dosing guidelines in the 03 ACIP influenza vaccine recommendations. 9. Measles, mumps, and rubella (MMR) vaccine. (Minimum age: months for routine vaccination) Administer the first dose of MMR vaccine at age through 5 months, and the second dose at age 4 through 6 years. The second dose may be administered before age 4 years, provided at least 4 weeks have elapsed since the first dose. Administer dose of MMR vaccine to infants aged 6 through months before departure from the United States for international travel. These children should be revaccinated with doses of MMR vaccine, the Additional information For contraindications and precautions to use of a vaccine and for additional information regarding that vaccine, vaccination providers should consult the relevant ACIP statement available online at For the purposes of calculating intervals between doses, 4 weeks = 8 days. Intervals of 4 months or greater are determined by calendar months. Information on travel vaccine requirements and recommendations is available at cdc.gov/travel/page/vaccinations.htm. For vaccination of persons with primary and secondary immunodeficiencies, see Table 3, Vaccination of persons with primary and secondary immunodeficiencies, in General Recommendations on Immunization (ACIP), available at mmwrhtml/rr600a.htm; and American Academy of Pediatrics. Immunization in Special Clinical Circumstances. In: Pickering LK, Baker CJ, Kimberlin DW, Long SS eds. Red book: 0 report of the Committee on Infectious Diseases. 9th ed. Elk Grove Village, IL: American Academy of Pediatrics. first at age through 5 months ( months if the child remains in an area where disease risk is high), and the second dose at least 4 weeks later. Administer doses of MMR vaccine to children aged months and older, before departure from the United States for international travel. The first dose should be administered on or after age months and the second dose at least 4 weeks later. Ensure that all school-aged children and adolescents have had doses of MMR vaccine; the minimum interval between the doses is 4 weeks. 0. Varicella (VAR) vaccine. (Minimum age: months) Administer the first dose of VAR vaccine at age through 5 months, and the second dose at age 4 through 6 years. The second dose may be administered before age 4 years, provided at least 3 months have elapsed since the first dose. If the second dose was administered at least 4 weeks after the first dose, it can be accepted as valid. Ensure that all persons aged 7 through 8 years without evidence of immunity (see MMWR 007;56 [No. RR-4], available at have doses of varicella vaccine. For children aged 7 through years the recommended minimum interval between doses is 3 months (if the second dose was administered at least 4 weeks after the first dose, it can be accepted as valid); for persons aged 3 years and older, the minimum interval between doses is 4 weeks.. Hepatitis A vaccine (HepA). (Minimum age: months) Initiate the -dose HepA vaccine series for children aged through 3 months; separate the doses by 6 to 8 months. Children who have received dose of HepA vaccine before age 4 months, should receive a second dose 6 to 8 months after the first dose. For any person aged years and older who has not already received the HepA vaccine series, doses of HepA vaccine separated by 6 to 8 months may be administered if immunity against hepatitis A virus infection is desired. The minimum interval between the two doses is 6 months. Special populations: Administer doses of Hep A vaccine at least 6 months apart to previously unvaccinated persons who live in areas where vaccination programs target older children, or who are at increased risk for infection.. Human papillomavirus (HPV) vaccines. (HPV4 [Gardasil] and HPV [Cervarix]). (Minimum age: 9 years) Administer a 3-dose series of HPV vaccine on a schedule of 0, -, and 6 months to all adolescents aged - years. Either HPV4 or HPV may be used for females, and only HPV4 may be used for males. The vaccine series can be started beginning at age 9 years. Administer the second dose to months after the first dose and the third dose 6 months after the first dose (at least 4 weeks after the first dose). Administer the vaccine series to females (either HPV or HPV4) and males (HPV4) at age 3 through 8 years if not previously vaccinated. Use recommended routine dosing intervals (see above) for vaccine series catch-up. 3. Meningococcal conjugate vaccines (MCV). (Minimum age: 6 weeks for Hib-MenCY, 9 months for Menactra [MCV4-D], years for Menveo [MCV4-CRM]). Administer MCV4 vaccine at age years, with a booster dose at age 6 years. Adolescents aged through 8 years with human immunodeficiency virus (HIV) infection should receive a -dose primary series of MCV4, with at least 8 weeks between doses. See MMWR 0; 60:08 09 available at: For children aged months through 0 years with high-risk conditions, see below. Administer MCV4 vaccine at age 3 through 8 years if not previously vaccinated. If the first dose is administered at age 3 through 5 years, a booster dose should be administered at age 6 through 8 years with a minimum interval of at least 8 weeks between doses. If the first dose is administered at age 6 years or older, a booster dose is not needed. Vaccination of persons with high-risk conditions: For children younger than 9 months of age with anatomic or functional asplenia (including sickle cell disease), administer an infant series of Hib-MenCY at, 4, 6, and -5 months. For children aged through 8 months with persistent complement component deficiency, administer either an infant series of Hib-MenCY at, 4, 6, and through 5 months or a -dose primary series of MCV4-D starting at 9 months, with at least 8 weeks between doses. For children aged 9 through 3 months with persistent complement component deficiency who have not received a complete series of Hib-MenCY or MCV4-D, administer primary doses of MCV4-D at least 8 weeks apart. For children aged 4 months and older with persistent complement component deficiency or anatomic or functional asplenia (including sickle cell disease), who have not received a complete series of Hib- MenCY or MCV4-D, administer primary doses of either MCV4-D or MCV4-CRM. If MCV4-D (Menactra) is administered to a child with asplenia (including sickle cell disease), do not administer MCV4-D until years of age and at least 4 weeks after the completion of all PCV3 doses. See MMWR 0;60:39, available at For children aged 9 months and older who are residents of or travelers to countries in the African meningitis belt or to the Hajj, administer an age appropriate formulation and series of MCV4 for protection against serogroups A and W-35. Prior receipt of Hib-MenCY is not sufficient for children traveling to the meningitis belt or the Hajj. See MMWR 0;60:39, available at mm6040.pdf. For children who are present during outbreaks caused by a vaccine serogroup, administer or complete an age and formulation-appropriate series of Hib-MenCY or MCV4. For booster doses among persons with high-risk conditions refer to acip-list.htm#mening.

10 FIGURE. Catch-up immunization schedule for persons aged 4 months through 8 years who start late or who are more than month behind United States 03 The figure below provides catch-up schedules and minimum intervals between doses for children whose vaccinations have been delayed. A vaccine series does not need to be restarted, regardless of the time that has elapsed between doses. Use the section appropriate for the child s age. Always use this table in conjunction with Figure and the footnotes that follow. Vaccine Minimum Age for Dose Hepatitis B Birth 4 weeks Persons aged 4 months through 6 years Minimum Interval Between Doses Dose to dose Dose to dose 3 Dose 3 to dose 4 Dose 4 to dose 5 8 weeks and at least 6 weeks after first dose; minimum age for the final dose is 4 weeks Rotavirus 6 weeks 4 weeks 4 weeks Diphtheria, tetanus, pertussis 3 6 weeks 4 weeks 4 weeks 6 months 6 months 3 Haemophilus influenzae type b 5 6 weeks 4 weeks if first dose administered at younger than age months 8 weeks (as final dose) if first dose administered at age 4 months No further doses needed if first dose administered at age 5 months or older 4 weeks 5 if current age is younger than months 8 weeks (as final dose) 5 if current age is months or older and first dose administered at younger than age months and second dose administered at younger than 5 months No further doses needed if previous dose administered at age 5 months or older 8 weeks (as final dose) This dose only necessary for children aged through 59 months who received 3 doses before age months Pneumococcal 6 6 weeks 4 weeks if first dose administered at younger than age months 8 weeks (as final dose for healthy children) if first dose administered at age months or older or current age 4 through 59 months No further doses needed for healthy children if first dose administered at age 4 months or older 4 weeks if current age is younger than months 8 weeks (as final dose for healthy children) if current age is months or older No further doses needed for healthy children if previous dose administered at age 4 months or older 8 weeks (as final dose) This dose only necessary for children aged through 59 months who received 3 doses before age months or for children at high risk who received 3 doses at any age Inactivated poliovirus 7 6 weeks 4 weeks 4 weeks 6 months 7 minimum age 4 years for final dose Meningococcal 3 6 weeks 8 weeks 3 see footnote 3 see footnote 3 Measles, mumps, rubella 9 months 4 weeks Varicella 0 months 3 months Hepatitis A months 6 months Tetanus, diphtheria; tetanus, diphtheria, pertussis 4 7 years 4 4 weeks Persons aged 7 through 8 years 4 weeks if first dose administered at younger than age months 6 months if first dose administered at months or older 6 months if first dose administered at younger than age months Human papillomavirus 9 years Routine dosing intervals are recommended Hepatitis A months 6 months Hepatitis B Birth 4 weeks 8 weeks (and at least 6 weeks after first dose) Inactivated poliovirus 7 6 weeks 4 weeks 4 weeks 7 6 months 7 Meningococcal 3 6 weeks 8 weeks 3 Measles, mumps, rubella 9 months 4 weeks Varicella 0 months 3 months if person is younger than age 3 years 4 weeks if person is aged 3 years or older NOTE: The above recommendations must be read along with the footnotes of this schedule. Footnotes Recommended immunization schedule for persons aged 0 through 8 years United States, 03 For further guidance on the use of the vaccines mentioned below, see: Hepatitis B (HepB) vaccine. (Minimum age: birth) At birth Administer monovalent HepB vaccine to all newborns before hospital discharge. For infants born to hepatitis B surface antigen (HBsAg) positive mothers, administer HepB vaccine and 0.5 ml of hepatitis B immune globulin (HBIG) within hours of birth. These infants should be tested for HBsAg and antibody to HBsAg (anti-hbs) to months after completion of the HepB series, at age 9 through 8 months (preferably at the next well-child visit). If mother s HBsAg status is unknown, within hours of birth administer HepB vaccine to all infants regardless of birth weight. For infants weighing <,000 grams, administer HBIG in addition to HepB within hours of birth. Determine mother s HBsAg status as soon as possible and, if she is HBsAg-positive, also administer HBIG for infants weighing,000 grams (no later than age week). Doses following the birth dose The second dose should be administered at age or months. Monovalent HepB vaccine should be used for doses administered before age 6 weeks. Infants who did not receive a birth dose should receive 3 doses of a HepB-containing vaccine on a schedule of 0, to months, and 6 months starting as soon as feasible. See Figure. The minimum interval between dose and dose is 4 weeks and between dose and 3 is 8 weeks. The final (third or fourth) dose in the HepB vaccine series should be administered no earlier than age 4 weeks, and at least 6 weeks after the first dose. Administration of a total of 4 doses of HepB vaccine is recommended when a combination vaccine containing HepB is administered after the birth dose. Unvaccinated persons should complete a 3-dose series. A -dose series (doses separated by at least 4 months) of adult formulation Recombivax HB is licensed for use in children aged through 5 years.. Rotavirus (RV) vaccines. (Minimum age: 6 weeks for both RV- [Rotarix] and RV-5 [RotaTeq]). Administer a series of RV vaccine to all infants as follows:. If RV- is used, administer a -dose series at and 4 months of age.. If RV-5 is used, administer a 3-dose series at ages, 4, and 6 months. 3. If any dose in series was RV-5 or vaccine product is unknown for any dose in the series, a total of 3 doses of RV vaccine should be administered. The maximum age for the first dose in the series is 4 weeks, 6 days. Vaccination should not be initiated for infants aged 5 weeks 0 days or older. The maximum age for the final dose in the series is 8 months, 0 days. If RV-(Rotarix) is administered for the first and second doses, a third dose is not indicated. 3. Diphtheria and tetanus toxoids and acellular pertussis (DTaP) vaccine. (Minimum age: 6 weeks) Administer a 5-dose series of DTaP vaccine at ages, 4, 6, 5 8 months, and 4 through 6 years. The fourth dose may be administered as early as age months, provided at least 6 months have elapsed since the third dose. The fifth (booster) dose of DTaP vaccine is not necessary if the fourth dose was administered at age 4 years or older. 4. Tetanus and diphtheria toxoids and acellular pertussis (Tdap) vaccine. (Minimum age: 0 years for Boostrix, years for Adacel). Administer dose of Tdap vaccine to all adolescents aged through years. Tdap can be administered regardless of the interval since the last tetanus and diphtheria toxoid-containing vaccine.

11 For further guidance on the use of the vaccines mentioned below, see: Administer one dose of Tdap vaccine to pregnant adolescents during each pregnancy (preferred during 7 through 36 weeks gestation) regardless of number of years from prior Td or Tdap vaccination. Persons aged 7 through 0 years who are not fully immunized with the childhood DTaP vaccine series, should receive Tdap vaccine as the first dose in the catch-up series; if additional doses are needed, use Td vaccine. For these children, an adolescent Tdap vaccine should not be given. Persons aged through 8 years who have not received Tdap vaccine should receive a dose followed by tetanus and diphtheria toxoids (Td) booster doses every 0 years thereafter. An inadvertent dose of DTaP vaccine administered to children aged 7 through 0 years can count as part of the catch-up series. This dose can count as the adolescent Tdap dose, or the child can later receive a Tdap booster dose at age years. 5. Haemophilus influenzae type b (Hib) conjugate vaccine. (Minimum age: 6 weeks) Administer a Hib vaccine primary series and a booster dose to all infants. The primary series doses should be administered at, 4, and 6 months of age; however, if PRP-OMP (PedvaxHib or Comvax) is administered at and 4 months of age, a dose at age 6 months is not indicated. One booster dose should be administered at age through5 months. Hiberix (PRP-T) should only be used for the booster (final) dose in children aged months through 4 years, who have received at least dose of Hib. If dose was administered at ages -4 months, administer booster (as final dose) at least 8 weeks after dose. If the first doses were PRP-OMP (PedvaxHIB or Comvax), and were administered at age months or younger, the third (and final) dose should be administered at age through 5 months and at least 8 weeks after the second dose. If the first dose was administered at age 7 through months, administer the second dose at least 4 weeks later and a final dose at age through 5 months, regardless of Hib vaccine (PRP-T or PRP-OMP) used for first dose. For unvaccinated children aged 5 months or older, administer only dose. Vaccination of persons with high-risk conditions: Hib vaccine is not routinely recommended for patients older than 5 years of age. However one dose of Hib vaccine should be administered to unvaccinated or partially vaccinated persons aged 5 years or older who have leukemia, malignant neoplasms, anatomic or functional asplenia (including sickle cell disease), human immunodeficiency virus (HIV) infection, or other immunocompromising conditions. 6a. Pneumococcal conjugate vaccine (PCV). (Minimum age: 6 weeks) Administer a series of PCV3 vaccine at ages, 4, 6 months with a booster at age through 5 months. For children aged 4 through 59 months who have received an age-appropriate series of 7-valent PCV (PCV7), administer a single supplemental dose of 3-valent PCV (PCV3). Administer dose of PCV3 to all healthy children aged 4 through 59 months who are not completely vaccinated for their age. Vaccination of persons with high-risk conditions: For children aged 4 through 7 months with certain underlying medical conditions (see footnote 6c), administer dose of PCV3 if 3 doses of PCV were received previously, or administer doses of PCV3 at least 8 weeks apart if fewer than 3 doses of PCV were received previously. A single dose of PCV3 may be administered to previously unvaccinated children aged 6 through 8 years who have anatomic or functional asplenia (including sickle cell disease), HIV infection or an immunocompromising condition, cochlear implant or cerebrospinal fluid leak. See MMWR 00;59 (No. RR-), available at cdc.gov/mmwr/pdf/rr/rr59.pdf. Administer PPSV3 at least 8 weeks after the last dose of PCV to children aged years or older with certain underlying medical conditions (see footnotes 6b and 6c). 6b. Pneumococcal polysaccharide vaccine (PPSV3). (Minimum age: years) Vaccination of persons with high-risk conditions: Administer PPSV3 at least 8 weeks after the last dose of PCV to children aged years or older with certain underlying medical conditions (see footnote 6c). A single revaccination with PPSV should be administered after 5 years to children with anatomic or functional asplenia (including sickle cell disease) or an immunocompromising condition. 6c. Medical conditions for which PPSV3 is indicated in children aged years and older and for which use of PCV3 is indicated in children aged 4 through 7 months: Immunocompetent children with chronic heart disease (particularly cyanotic congenital heart disease and cardiac failure); chronic lung disease (including asthma if treated with high-dose oral corticosteroid therapy), diabetes mellitus; cerebrospinal fluid leaks; or cochlear implant. Children with anatomic or functional asplenia (including sickle cell disease and other hemoglobinopathies, congenital or acquired asplenia, or splenic dysfunction); Children with immunocompromising conditions: HIV infection, chronic renal failure and nephrotic syndrome, diseases associated with treatment with immunosuppressive drugs or radiation therapy, including malignant neoplasms, leukemias, lymphomas and Hodgkin disease; or solid organ transplantation, congenital immunodeficiency. 7. Inactivated poliovirus vaccine (IPV). (Minimum age: 6 weeks) Administer a series of IPV at ages, 4, 6 8 months, with a booster at age 4 6 years. The final dose in the series should be administered on or after the fourth birthday and at least 6 months after the previous dose. In the first 6 months of life, minimum age and minimum intervals are only recommended if the person is at risk for imminent exposure to circulating poliovirus (i.e., travel to a polio-endemic region or during an outbreak). If 4 or more doses are administered before age 4 years, an additional dose should be administered at age 4 through 6 years. A fourth dose is not necessary if the third dose was administered at age 4 years or older and at least 6 months after the previous dose. If both OPV and IPV were administered as part of a series, a total of 4 doses should be administered, regardless of the child s current age. IPV is not routinely recommended for U.S. residents aged 8 years or older. 8. Influenza vaccines. (Minimum age: 6 months for inactivated influenza vaccine [IIV]; years for live, attenuated influenza vaccine [LAIV]) Administer influenza vaccine annually to all children beginning at age 6 months. For most healthy, nonpregnant persons aged through 49 years, either LAIV or IIV may be used. However, LAIV should NOT be administered to some persons, including ) those with asthma, ) children through 4 years who had wheezing in the past months, or 3) those who have any other underlying medical conditions that predispose them to influenza complications. For all other contraindications to use of LAIV see MMWR 00; 59 (No. RR-8), available at Additional information For contraindications and precautions to use of a vaccine and for additional information regarding that vaccine, vaccination providers should consult the relevant ACIP statement available online at pubs/acip-list.htm. For the purposes of calculating intervals between doses, 4 weeks = 8 days. Intervals of 4 months or greater are determined by calendar months. Information on travel vaccine requirements and recommendations is available at page/vaccinations.htm. For vaccination of persons with primary and secondary immunodeficiencies, see Table 3, Vaccination of persons with primary and secondary immunodeficiencies, in General Recommendations on Immunization (ACIP), available at and American Academy of Pediatrics. Immunization in Special Clinical Circumstances. In: Pickering LK, Baker CJ, Kimberlin DW, Long SS eds. Red book: 0 report of the Committee on Infectious Diseases. 9th ed. Elk Grove Village, IL: American Academy of Pediatrics. Administer dose to persons aged 9 years and older. For children aged 6 months through 8 years: For the 0 3 season, administer doses (separated by at least 4 weeks) to children who are receiving influenza vaccine for the first time. For additional guidance, follow dosing guidelines in the 0 ACIP influenza vaccine recommendations, MMWR 0; 6: 63 68, available at For the 03 4 season, follow dosing guidelines in the 03 ACIP influenza vaccine recommendations. 9. Measles, mumps, and rubella (MMR) vaccine. (Minimum age: months for routine vaccination) Administer the first dose of MMR vaccine at age through 5 months, and the second dose at age 4 through 6 years. The second dose may be administered before age 4 years, provided at least 4 weeks have elapsed since the first dose. Administer dose of MMR vaccine to infants aged 6 through months before departure from the United States for international travel. These children should be revaccinated with doses of MMR vaccine, the first at age through 5 months ( months if the child remains in an area where disease risk is high), and the second dose at least 4 weeks later. Administer doses of MMR vaccine to children aged months and older, before departure from the United States for international travel. The first dose should be administered on or after age months and the second dose at least 4 weeks later. Ensure that all school-aged children and adolescents have had doses of MMR vaccine; the minimum interval between the doses is 4 weeks. 0. Varicella (VAR) vaccine. (Minimum age: months) Administer the first dose of VAR vaccine at age through 5 months, and the second dose at age 4 through 6 years. The second dose may be administered before age 4 years, provided at least 3 months have elapsed since the first dose. If the second dose was administered at least 4 weeks after the first dose, it can be accepted as valid. Ensure that all persons aged 7 through 8 years without evidence of immunity (see MMWR 007;56 [No. RR-4], available at have doses of varicella vaccine. For children aged 7 through years the recommended minimum interval between doses is 3 months (if the second dose was administered at least 4 weeks after the first dose, it can be accepted as valid); for persons aged 3 years and older, the minimum interval between doses is 4 weeks.. Hepatitis A vaccine (HepA). (Minimum age: months) Initiate the -dose HepA vaccine series for children aged through 3 months; separate the doses by 6 to 8 months. Children who have received dose of HepA vaccine before age 4 months, should receive a second dose 6 to 8 months after the first dose. For any person aged years and older who has not already received the HepA vaccine series, doses of HepA vaccine separated by 6 to 8 months may be administered if immunity against hepatitis A virus infection is desired. The minimum interval between the two doses is 6 months. Special populations: Administer doses of Hep A vaccine at least 6 months apart to previously unvaccinated persons who live in areas where vaccination programs target older children, or who are at increased risk for infection.. Human papillomavirus (HPV) vaccines. (HPV4 [Gardasil] and HPV [Cervarix]). (Minimum age: 9 years) Administer a 3-dose series of HPV vaccine on a schedule of 0, -, and 6 months to all adolescents aged - years. Either HPV4 or HPV may be used for females, and only HPV4 may be used for males. The vaccine series can be started beginning at age 9 years. Administer the second dose to months after the first dose and the third dose 6 months after the first dose (at least 4 weeks after the first dose). Administer the vaccine series to females (either HPV or HPV4) and males (HPV4) at age 3 through 8 years if not previously vaccinated. Use recommended routine dosing intervals (see above) for vaccine series catch-up. 3. Meningococcal conjugate vaccines (MCV). (Minimum age: 6 weeks for Hib-MenCY, 9 months for Menactra [MCV4-D], years for Menveo [MCV4-CRM]). Administer MCV4 vaccine at age years, with a booster dose at age 6 years. Adolescents aged through 8 years with human immunodeficiency virus (HIV) infection should receive a -dose primary series of MCV4, with at least 8 weeks between doses. See MMWR 0; 60:08 09 available at: For children aged months through 0 years with high-risk conditions, see below. Administer MCV4 vaccine at age 3 through 8 years if not previously vaccinated. If the first dose is administered at age 3 through 5 years, a booster dose should be administered at age 6 through 8 years with a minimum interval of at least 8 weeks between doses. If the first dose is administered at age 6 years or older, a booster dose is not needed. Vaccination of persons with high-risk conditions: For children younger than 9 months of age with anatomic or functional asplenia (including sickle cell disease), administer an infant series of Hib-MenCY at, 4, 6, and -5 months. For children aged through 8 months with persistent complement component deficiency, administer either an infant series of Hib-MenCY at, 4, 6, and through 5 months or a -dose primary series of MCV4-D starting at 9 months, with at least 8 weeks between doses. For children aged 9 through 3 months with persistent complement component deficiency who have not received a complete series of Hib-MenCY or MCV4-D, administer primary doses of MCV4-D at least 8 weeks apart. For children aged 4 months and older with persistent complement component deficiency or anatomic or functional asplenia (including sickle cell disease), who have not received a complete series of Hib-MenCY or MCV4-D, administer primary doses of either MCV4-D or MCV4-CRM. If MCV4-D (Menactra) is administered to a child with asplenia (including sickle cell disease), do not administer MCV4-D until years of age and at least 4 weeks after the completion of all PCV3 doses. See MMWR 0;60:39, available at mmwr/pdf/wk/mm6040.pdf. For children aged 9 months and older who are residents of or travelers to countries in the African meningitis belt or to the Hajj, administer an age appropriate formulation and series of MCV4 for protection against serogroups A and W-35. Prior receipt of Hib-MenCY is not sufficient for children traveling to the meningitis belt or the Hajj. See MMWR 0;60:39, available at For children who are present during outbreaks caused by a vaccine serogroup, administer or complete an age and formulation-appropriate series of Hib-MenCY or MCV4. For booster doses among persons with high-risk conditions refer to htm#mening.

12 VACCINES REQUIRED FOR CHILD CARE/PRESCHOOL ATTENDANCE July, 03 June 30, 04 VACCINE By 3 Months (on or before last day of mo ) By 5 Months (on or before last day of mo 4) By 7 Months (on or before last day of mo 6) By 6 Months (on or before last day of mo 5) By 9 Months (on or before last day of mo 8) Hepatitis B dose May get dose at birth. doses May get dose as early as month. 3 doses Diphtheria, Tetanus, Pertussis (DTaP/DT) dose doses 3 doses May get as early as 6 months. 4 doses May get 4 th dose as early as months as long as 6 months separate Dose 3 and Dose 4. Haemophilus influenzae type B (Hib) dose doses 3 doses 4 doses Polio (IPV or OPV) dose doses May get as early as 4 months. 3 doses Pneumococcal Conjugate (PCV7 or PCV3) dose doses 3 doses 4 doses* Measles, Mumps, Rubella Varicella Not given before months of age. Not given before months of age. dose dose OR Healthcare provider verifies disease. *Some children may get 5 total doses. A single supplemental dose of PCV3 is recommended, but not required, for all children aged 4 59 months who got 4 doses of PCV7. Available online only at: School-aged children (K-) in before and after-school programs must meet the immunization requirements for their grade in school. Find information on other recommended vaccines not required for child care/preschool attendance: Review the Individual Vaccine Requirements Summary for more detailed information: IndividualVaccineRequirements.pdf Page of

13 Minimum Age & Interval for Valid Vaccine Doses Vaccine Dose # Minimum Age Minimum Interval Between Doses Notes Hepatitis B (HepB) Diphtheria, Tetanus, and Pertussis (DTaP/DT) Haemophilus influenzae type B (Hib) Pneumococcal Conjugate (PCV7 or PCV3) Polio (IPV or OPV) Measles, Mumps, and Rubella (MMR or MMRV) Varicella (chickenpox) (VAR) Dose Birth 4 weeks between Dose & Dose 4 weeks 8 weeks between Dose & 3 Dose 3 4 weeks 6 weeks between Dose & 3 Dose 6 weeks 4 weeks between Dose & Dose 0 weeks 4 weeks between Dose & 3 Dose 3 4 weeks 6 months between Dose 3 & 4 Dose 4 months 6 months between Dose 4 & 5 The final dose in the series should be given at age >4 weeks. Typical vaccine schedule:, 4, 6, and 5-8 months of age. Recommended: 6 months between Dose 3 and Dose 4, but >4 months is acceptable. Dose 6 weeks 4 weeks between Dose & Three doses total for catch-up if doses given before months Dose 0 weeks 4 weeks between Dose & 3 and Dose 3 given > months of age. Two doses total for catch-up if Dose given before months and Dose given >5 months of Dose 3 4 weeks 8 weeks between Dose 3 & 4 age. Dose 4 months One dose required if the dose given >5 months. If all 3 doses of PedvaxHIB given, only need 3 doses total. Dose 6 weeks 4 weeks between Dose & Three doses total for catch-up if only doses given before Dose 0 weeks 4 weeks between Dose & 3 months and Dose 3 given > months of age. Two doses required if both received between -4 months at least 8 weeks apart. Dose 3 4 weeks 8 weeks between Dose 3 & 4 One dose required if the dose given >4 months of age. Dose 4 months A single supplemental dose of PCV3 recommended for all children 4 59 months of age who got 4 doses of PCV7. Dose 6 weeks 4 weeks between Dose & Dose 0 weeks 4 weeks between Dose & 3 Dose 3 4 weeks 6 months between Dose 3 & 4 Dose months 4 weeks between Dose & Dose months 3 months between Dose & If you have a disability and need this document in another format, please call (TDD/TTY call 7). Three doses acceptable if child got Dose 3 >4 th birthday. MMRV (MMR + varicella) may be used in place of separate MMR and varicella vaccines. 4-day grace DOES apply between doses of the same live vaccine such as MMR/MMR or MMRV/MMRV. The 4 day grace period DOES NOT apply between Dose and Dose of different live vaccines, such as between MMR and Varicella or between MMR and live flu vaccine. Recommended: 3 months between varicella doses, but >8 days acceptable. Must get the same day as MMR OR > 8 days apart (4-day grace DOES NOT apply). Page of DOH January 03

14 VACCINES REQUIRED FOR SCHOOL ATTENDANCE, GRADES K- July, 03 June 30, 04 VACCINE Kindergarten- nd Grade 3 rd -5 th Grade 6 th Grade 7 th - th Grade Hepatitis B 3 doses See minimum intervals on page Dose 3 must be given >4 weeks of age 3 doses See minimum intervals on page Dose 3 must be given >4 months of age Diphtheria, Tetanus, and Pertussis (DTaP/DT/Td/Tdap) 5 doses (4 doses required IF 4 th dose given >4 th birthday) plus dose Tdap required for 6 th - th grade IF > years old Polio (IPV or OPV) 4 doses (3 doses only IF 3 rd dose given >4 th birthday) The final dose given on or after August 7, 009 must be given at a minimum of 4 years of age AND a minimum interval of 6 months from the previous dose. 4 doses (3 doses only IF 3 rd dose given >4 th birthday) Measles, Mumps, and Rubella doses doses dose Varicella OR OR Recommended, but not required. Healthcare provider verifies disease Parent verifies disease Look at the Minimum Age and Interval Table on page for recommended minimum age and spacing information. Review the Individual Vaccine Requirements Summary for more detailed information: IndividualVaccineRequirements.pdf Page of

15 Hepatitis B HepB Minimum Age & Interval for Valid Vaccine Doses Vaccine Dose # Minimum Age Minimum Interval Between Doses Notes Diphtheria, Tetanus, and Pertussis DTaP/DT Tetanus, Diphtheria, and Pertussis Tdap Dose Birth 4 weeks between Dose & (K- th ) Dose 4 weeks 8 weeks between Dose & 3 (K- th ) Dose 3 4 weeks (K-6 th ) 4 months (7 th - th ) 6 weeks between Dose & 3 (K-6 th ) No minimum interval between Dose & 3 (7 th - th ) Dose 6 weeks 4 weeks between Dose & Dose 0 weeks 4 weeks between Dose & 3 Dose 3 4 weeks 6 months between Dose 3 & 4 Dose 4 months 6 months between Dose 4 & 5 Dose 5 4 years Dose 0 years (minimum age depends on vaccine brand) Note minimum age and interval changes for 03-4 school year. doses valid if adult Recombivax HB given between ages and 5 and doses separated by >4 months. DTaP: for children through age 6. Recommended to have 6 months between Dose 3 and Dose 4, but >4 months acceptable. Boostrix : licensed for >0 year olds; Adacel : licensed for > year olds. Can be given regardless of the interval between DTaP or Td. Students 7-0 years of age not fully immunized with DTaP or Td should get one Tdap followed by additional doses of Td if needed. Tetanus and Diphtheria Td Polio IPV or OPV Measles, Mumps, and Rubella MMR Dose 7 years 5 years Dose 6 weeks 4 weeks between Dose & Dose 0 weeks 4 weeks between Dose & 3 Dose 3 4 weeks 6 months between Dose 3 & 4 Dose 4 4 years Dose months 4 weeks between Dose & Dose 3 months Td: for children >7 years of age. 3 doses of Td required, if starting series >7 years, with a single dose of Tdap preferred as the first dose. Not required for students 8 years and older. If a student got all doses before August 7, 009: 4 week minimum interval must separate all doses and minimum age must be >8 weeks. MMRV (MMR + varicella) may be used instead of separate MMR and varicella vaccines. 4-day grace DOES apply between doses of the same live vaccine such as MMR/MMR or MMRV/MMRV. The 4 day grace period DOES NOT apply between Dose and Dose of different live vaccines, such as between MMR and Varicella or between MMR and live flu vaccine. Varicella (chickenpox) VAR Dose months Dose 5 months 3 months between Dose & Recommended: 3 months between varicella doses, but >8 days acceptable. Must get the same day as MMR OR > 8 days apart. (4-day grace DOES NOT apply). 4-day grace DOES apply between doses of the same live vaccine such as VAR and VAR). If you have a disability and need this document in another format, please call (TDD/TTY call 7) DOH January 03 Page of

16 Certificate of Immunization Status (CIS) DOH January 00 Please print. See back for instructions on how to fill out this form or get it printed from the Immunization Registry. Child s Last Name: First Name: Middle Initial: Birthdate (mm/dd/yyyy): Sex: I certify that the information provided on this form is correct and verifiable. Symbols below: Required for School and Child Care/Preschool Required for Child Care/Preschool Only Vaccine Dose Hepatitis B (Hep B) 3 Date Month Day Year or Hep B - dose alternate schedule for teens Rotavirus (RV, RV5) 3 Diphtheria, Tetanus, Pertussis (DTaP, DTP, DT) Tetanus, Diphtheria, Pertussis (Tdap, Td) Haemophilus influenzae type b (Hib) 3 4 Pneumococcal (PCV, PPSV) 3 4 Vaccine Parent/Guardian Name (please print): Dose Polio (IPV, OPV) 3 4 Influenza (flu, most recent) Date Month Day Year Measles, Mumps, Rubella (MMR) Varicella (chickenpox) or verify disease -4 Hepatitis A (Hep A) Meningococcal (MCV, MPSV) Human Papillomavirus (HPV) 3 Office Use Only: Immunization information updated and verified with parent/guardian permission: Printed Staff Name Date Printed Staff Name Date Printed Staff Name Date Printed Staff Name Date Office Use Only: Reviewed by: Date: Signed Cert. of Exemption on file? Yes No Parent/Guardian Signature Required Date If the child named on this CIS had chickenpox disease (and not the vaccine), disease history must be verified. Mark option,, 3, OR 4 below see, back #5. ) Chickenpox disease verified by printout from CHILD Profile Immunization Registry Must be marked by printout (not by hand) to be valid. ) Chickenpox disease verified by Health Care Provider (HCP) If you choose this box, mark A OR B below. A) Signed note from HCP attached OR B) HCP signed here and print name below: Licensed health care provider (HCP) Signature Date (MD, DO, ND, PA, ARNP) HCP Printed Name: 3) Chickenpox disease verified by school staff from CHILD Profile Immunization Registry If you choose this box, staff must initial that parent or guardian approves: (initial) (date) 4) Chickenpox disease verified by parent* If you choose this box, fill in the date or child s age when he or she had the disease: Age/Date of disease: *Can ONLY verify for some grades, see back #5 (4). If the child can show immunity by blood test (titer) and hasn t had the vaccine, ask your HCP to fill in this box. Documentation of Disease Immunity I certify that the child named on this CIS has laboratory evidence of immunity (titer) to the diseases marked. Signed lab report(s) MUST also be attached. Diphtheria Hepatitis A Hepatitis B Hib Measles Mumps Polio Rubella Tetanus Varicella Other: Licensed health care provider (HCP) Signature Date (MD, DO, ND, PA, ARNP) HCP Printed Name:

17 Instructions for completing the Certificate of Immunization Status (CIS): printing it from the Immunization Registry or filling it in by hand. # To print with info filled in: First, ask if your health care provider s office puts vaccination history into the CHILD Profile Immunization Registry (Washington s statewide database). If they do, ask them to print the CIS from CHILD Profile and your child s information will fill in automatically. Be sure to review all the information, sign and date the CIS in the upper right hand box, and return it to school or child care. If your provider s office does not use CHILD Profile, ask for a copy of your child s vaccine record so you can fill it in by hand using steps #-7 (below): EXAMPLE Vaccine Dose Date Month Day Year Diphtheria, Tetanus, Pertussis (DTaP, DTP, DT) DTaP 0 0 DTaP DTaP # To fill in by hand: Print your child s name, birthdate, sex, and your own name in the top box. #3 Write each vaccine your child received under the correct disease. Write the vaccine type under the Vaccine column and the date each dose was received in the Month, Day, and Year columns (as mm/dd/yyyy). For example, if DTaP was received Jan, March 0, June,, fill in as shown here #4 If your child receives a combination vaccine (one shot that protects against several diseases), use the Reference Guide below to record each vaccine correctly. For example, record Pediarix under Diphtheria, Tetanus, Pertussis as DTaP, Hepatitis B as Hep B, and Polio as IPV. #5 If your child has had chickenpox (varicella) disease and not the vaccine, use only one of these four options to record this on the CIS: ) If your child s CIS is printed directly from the CHILD Profile Immunization Registry (by your health care provider or school system), and disease verification is found, box is automatically marked. To be valid, this box must be marked by the Immunization Registry printout (not by hand). ) If your health care provider (HCP) can verify that your child has had chickenpox, mark box. Then mark either A to attach a signed note from your HCP, or B if your HCP signs and dates in the space provided. Be sure your HCP s full name is also printed. 3) If school staff access the CHILD Profile Immunization Registry and see verification that your child has had chickenpox, they will mark box 3. Then, they must initial and date that they got parent or guardian approval to mark this box (i.e. make this change) to the CIS. 4) If your child started kindergarten in the school year or later, you CANNOT use this box. If your child started kindergarten before the school year, mark this box if you know he or she has had chickenpox. If you mark box 4, you must also write the approximate age or date your child had chickenpox. To find out which grades require chickenpox vaccine (or history), visit: #6 Documentation of Disease Immunity: If your child can show immunity by blood test (titer) and has not had the vaccine, have your health care provider (HCP) fill in this box. Ask your HCP to mark the disease(s), sign, date, print his or her name in the space provided, and attach signed lab reports. #7 Be sure to sign and date the CIS in the upper right hand box, and return to school or child care. #8 If a school or child care makes a change to your CIS, staff will print their name in the middle bottom box and date to show that you gave approval. Vaccine Trade Names in alphabetical order (For updated lists, visit Trade Name Vaccine Trade Name Vaccine Trade Name Vaccine Trade Name Vaccine Trade Name Vaccine ActHIB Hib Engerix-B Hep B Ipol IPV Pentavalente DTaP + Hep B + Hib TriHIBit DTaP + Hib Adacel Tdap Fluarix Flu (TIV) Infanrix DTaP Pneumovax PPSV or PPV3 Tripedia DTaP Afluria Flu (TIV) FluLaval Flu (TIV) Kinrix (Knrx) DTaP + IPV Prevnar PCV or PCV7 or PCV3 Twinrix (Twnrx) Hep A + Hep B Boostrix Tdap FluMist Flu (LAIV) Menactra MCV or MCV4 ProQuad (PrQd) MMR + Varicella Vaqta Hep A Cervarix HPV Fluvirin Flu (TIV) Menomune MPSV or MPSV4 Quadracel (Qdrcl) DTaP + IPV Varivax Varicella Comvax (Cmvx) Hep B + Hib Fluzone Flu (TIV) Pediarix (Pdrx) DTaP + Hep B + IPV Recombivax HB Hep B Daptacel DTaP Gardasil HPV4 PedvaxHIB Hib Rotarix Rotavirus (RV) Decavac Td Havrix Hep A Pentacel (Pntcl) DTaP + Hib + IPV RotaTeq Rotavirus (RV5) Vaccine Abbreviations in alphabetical order (For updated lists, visit Abbreviations Full Vaccine Name Abbreviations Full Vaccine Name Abbreviations Full Vaccine Name Abbreviations Full Vaccine Name DT Diphtheria, Tetanus Hep A (HAV) Hepatitis A Meningococcal Rota MPSV or MPSV4 Hep B (HBV) Hepatitis B Polysaccharide Vaccine (RV or RV5) Rotavirus DTaP Diphtheria, Tetanus, Haemophilus influenzae Measles, Mumps, Rubella / Hib MMR / MMRV acellular Pertussis type b with Varicella Td Tetanus, Diphtheria DTP Diphtheria, Tetanus, Tetanus, Diphtheria, acellular HPV Human Papillomavirus OPV Oral Poliovirus Vccine Tdap Pertussis Pertussis Flu (TIV or LAIV) HBIG Influenza Hepatitis B Immune Globulin IPV MCV or MCV4 Inactivated Poliovirus Vaccine Meningococcal Conjugate Vaccine PCV or PCV7 or PCV3 PPSV or PPV3 Pneumococcal Conjugate Vaccine Pneumococcal Polysaccharide Vaccine TIG VAR or VZV Tetanus immune globulin If you have a disability and need this document in another format, please call (TDD/TTY ). DOH January 00 Varicella

18 DOH June 0 Certificate of Exemption For School, Child Care and Preschool Immunization Requirements DIRECTIONS: All exemptions must have a licensed health care provider sign & date Box ( Provider Statement ). Exception: Box is not required for religious exemptions when Box ( Demonstration of Religious Membership ) is completed. All exemptions must also have a parent/guardian sign & date Box 3 ( Parent/Guardian Statement ). Child s Last Name: First Name: Middle Initial: Birthdate (mm/dd/yyyy): Sex: Parent/Guardian Name (please print): Parent/Guardian, please choose the exemption(s) that apply to your child below. Temporary Medical Exemption Permanent Medical Exemption Until Vaccine(s) Date (or Permanent) Print Name of Licensed Health Care Provider (MD, DO, ND, PA, ARNP) X X Signature of Licensed Health Care Provider Date Personal/Philosophical Exemption (see Box ) Religious Exemption (see Box ) Religious Membership Exemption (see Box ) I do not want my child to get the following vaccine(s): Diphtheria Hepatitis B Hib Measles Mumps Pertussis (whooping cough) Pneumococcal Polio Rubella Tetanus Varicella (chickenpox) Other (indicate): Box Box Provider Statement : I,, am a qualified provider (MD, DO, ND, PA, ARNP) licensed under Title 8 RCW. I confirm that the parent or guardian signing in Box 3 (Parent/Guardian Statement) has received information on the benefits and risks of immunization to their child as a condition for exempting their child for medical, religious, personal, or philosophical reasons. X Signature of Licensed Health Care Provider (MD, DO, ND, PA, ARNP) X Date Parent/Guardian Demonstration of Religious Membership: I am a member of a church or religious body whose beliefs or teachings do not allow for medical treatment from a health care practitioner. By supplying the information requested below, no further proof or signed provider statement in Box is required for this religious exemption. X Name of Church or Religious Body X X Signature of Parent or Guardian Date Box 3 Parent/Guardian Statement: I certify that all the information provided on this certificate is correct and verifiable. I understand that if there is an outbreak of a vaccine-preventable disease my child has not been fully immunized against (as indicated above, for medical, personal/philosophical or religious reasons), my child may be at risk for disease and can be excluded from school, child care, or preschool until the outbreak is over. X X Signature of Parent or Guardian Date If you have a disability and need this document in a different format, please call (TDD/TTY ). RCW 8A states that before or on the first day of every child s attendance at any public and private school or licensed child care center in Washington State, the parent or guardian must present proof of either: () full immunization, () the initiation of and compliance with a schedule of immunization, as required by rules of the State Board of Health, or (3) a certificate of exemption, signed by a parent or guardian and a licensed health care provider. A letter may substitute for a signed Provider Statement on this certificate. To be accepted, the letter must reference the child s name on this certificate, confirm that the child s parent or guardian got information on the risks and benefits of immunization to their child, and be signed by a licensed health care provider.