5/8"* needle (newborns only), 1" (older infants),

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1 How to Administer Intramuscular (IM) Injections Administer these vaccines via intramuscular (IM) route: Diphtheria-tetanus (DT, Td) with pertussis (DTaP, Tdap); Hib; hepatitis A; hepatitis B; human papillomavirus (HPV); inactivated influenza; meningococcal conjugate (MCV4); and pneumococcal conjugate (PCV). Administer inactivated polio (IPV) and pneumococcal polysaccharide (PPV) either IM or SC. Patient age Site Needle size Needle insertion Birth to 12 mos. 12 mos. to 10 yrs. Children and adults 11 yrs. and older Anterolateral thigh muscle Thickest portion of deltoid muscle above level of axilla and below acromion (if adequate muscle mass). The anterolateral thigh may also be used. Thickest portion of deltoid muscle above level of axilla and below acromion 5/8"* needle (newborns only), 1" (older infants), gauge 5/8"* to 1" needle, gauge 1" 1½"* needle, gauge Use a needle long enough to reach deep into the muscle. Insert needle at a 90 angle to the skin with a quick thrust. (Before administering an injection, it is not 90 angle necessary to aspirate, i.e., to pull back on the syringe plunger after needle insertion. ) skin Multiple injections given in the same extremity should be separated by a minimum of 1", if subcutaneous tissue possible. muscle *A 5/8" needle can be used if the skin is stretched tight and the subcutaneous tissue is not bunched. A 5/8" needle may be used in the deltoid muscle in children ages 12 mos. or older and in adults weighing less than 130 lbs. IM site for infants CDC. ACIP General Recommendations on Immunization at IM site for children (after the 1st birthday) and adults level of axilla acromion IM injection site (shaded area) elbow IM injection site area (shaded area) Insert needle at a 90 angle into the anterolateral thigh muscle. Technical content reviewed by the Centers for Disease Control and Prevention, Jan Insert needle at a 90 angle into thickest portion of deltoid muscle above the level of the axilla and below the acromion. Item #P2020 (1/07) Immunization Action Coalition 1573 Selby Ave. St. Paul, MN (651) admin@immunize.org

2 How to Administer Subcutaneous (SC) Injections Administer these vaccines via subcutaneous (SC) route: MMR, varicella, meningococcal polysaccharide (MPSV), and zoster (shingles). Administer inactivated polio (IPV) and pneumococcal polysaccharide (PPV) vaccines either SC or IM. Patient age Site Needle size Needle insertion Birth to 12 mos. 12 mos. and older Fatty tissue over the anterolateral thigh Fatty tissue over the triceps 5/8" needle, gauge 5/8" needle, gauge Pinch up on SC tissue to prevent injection into muscle. Insert needle at 45 angle to the skin. (Before administering an injection, it is not necessary to aspirate, i.e., to pull back on the syringe plunger after needle insertion.*) Multiple injections given in the same extremity should be separated by a minimum of 1". skin subcutaneous tissue 45 angle *CDC. ACIP General Recommendations on Immunization at muscle SC site for infants SC site for children (after the 1st birthday) and adults acromion SC injection site area (shaded area) SC injection site area (shaded area) elbow Insert needle at a 45 angle into fatty tissue of the anterolateral thigh. Make sure you pinch up on SC tissue to prevent injection into the muscle. Insert needle at a 45 angle into the fatty tissue over the triceps muscle. Make sure you pinch up on the SC tissue to prevent injection into the muscle. Technical content reviewed by the Centers for Disease Control and Prevention, Jan Item #P2020 (1/07) Immunization Action Coalition 1573 Selby Ave. St. Paul, MN (651) admin@immunize.org

3 Revision Date Reviewer POST ON OUTSIDE OF REFRIGERATOR FOR ALL STAFF Practice Name: Primary Person Responsible: Secondary Person Responsible: Person with 24 hour access: PIN: Phone: Phone: Phone: WHAT TO DO IN THE EVENT OF A POWER OUTAGE (FILL IN THE BLANKS) Electrical Power Company Phone How will the primary/secondary person be notified of an outage after business hours? Dry Ice Vendor: Phone Who lives closest to the clinic location that would know about an outage during the weekend? Name of Facility with Generator Address Name of Point of Contact for Generator Phone 1. If possible, do not open the refrigerator or freezer during a power outage. An unopened unit will keep colder longer. 2. Call the power company and ask how long the power will be out. How long will power be out? 3. Monitor the storage temperatures once the power goes out and record on the back of this sheet or a temperature log. 4. If it looks like the power outage will last for several hours, prepare vaccines for alternate storage. Label the vaccine boxes VFC or place them in a separate bag for easy identification. 5. ALTERNATE STORAGE PLAN: E.g., Put vaccines in a cooler surrounded by ice with a thermometer, move to location with a generator. 6. If the temperatures are out of range for several hours and vaccines are not moved to another functional storage unit, spoilage may have occurred. Mark the affected vaccine for identification. Do not administer these vaccines until manufacturers have been contacted. Do not automatically discard the affected vaccine. 7. Collect essential data on the reverse side of this sheet. Notify Virginia Vaccines For Children (VVFC) at WHAT TO DO IN EVENT OF STORAGE UNIT MALFUNCTION / PROBLEM The refrigerator door was left open, the plug was pulled, the temperature dial was set too cold or too warm Refrigerator Repair Company: Phone Location of Circuit Breaker: Circuit # for Storage Unit 1. Record the current temperature of the refrigerator/freezer when the incident is discovered (see back of this sheet). 2. Close the refrigerator door and/or plug in the refrigerator to restore appropriate temperatures. Adjust the thermostat dial. Check your circuit breaker to see if the circuit for the refrigerator was tripped. 3. If the refrigerator cannot achieve appropriate temperatures within an hour, prepare vaccines for alternate storage. ALTERNATE STORAGE PLAN: 4. The unit may be malfunctioning if temperatures do not change after several hours. Call the refrigerator repair company. 5. Do not automatically discard the affected vaccine. Mark the affected vaccine for identification. Do not administer these vaccines until the manufacturers have been contacted. See the back of this sheet for manufacturers phone numbers. 6. Collect essential data on back of this sheet. Notify VVFC at Turn over for Emergency Response Worksheet /13/08

4 Emergency Response Worksheet TEMPERATURE LOG Date: Refrigerator Temperature Freezer Temperature Time Required Range: 2-8 Celsius or Fahrenheit Required Range: -15 Celsius or 5 Fahrenheit or colder Number of hours that temperature was outside required range: Max/Min Temperature Reached: Refrigerator Freezer REFRIGERATOR Vaccine Type Lot # Manufacturer Expiration Date Number of Doses Manufacturers Comments FREEZER Vaccine Type Lot # Manufacturer Expiration Date Number of Doses Manufacturers Comments CALL ALL MANUFACTURER(S) OF AFFECTED VACCINE(S): Vaccine Manufacturer Telephone Number ADACEL (Tdap), IPV (Polio), Tripedia (DTaP), Daptacel (DTaP), TriHIBit (DTaP- HIB), DT, Td, ActHIB, Fluzone (Flu), IG, Rabies, Menactra Aventis Pasteur Recombivax (Hep B), MMR, Varivax (Varicella), Pedvax-HIB, COMVAX (HIB- Hep B), Pneumovax (pneumonia), ProQuad (MMRV), VAQTA (Hep A), Gardasil, Merck Rotateq Boostrix (Tdap), Infanrix (DTaP), Pediarix (DTaP-Hep B-IPV), Engerix B (Hep B), Havrix (Hep A) GlaxoSmithKline Pnu-Immune (23-Valent Pneumococcal Polysaccharide), Prevnar (PCV7) Wyeth H-BIG (Hep B Immune Globulin) Bayer H-B (Hep B Immune Globulin) North American Biologics, Inc Rabies, FluVirin Chiron Flumist MedImmune Vaccines

5 Emergency Response Worksheet What to do in case of a power failure or another event that results in vaccine storage outside of the recommended temperature range Follow these procedures: 1. Close the door tightly and/or plug in the refrigerator/freezer. 2. Store the vaccines at appropriate temperatures. Make sure the refrigerator/freezer is working properly or move the vaccines to a unit that is. Do not discard the affected vaccines. Mark the vaccines so that the potentially compromised vaccines can be easily identified. 3. Call the manufacturer(s) and notify the local or state health department (see manufacturers phone numbers below). 4. Record action taken. Record this information*: 1. Temperature of refrigerator: current max. min. 2. Temperature of freezer: current max. min. 3. Air temperature of room where refrigerator is located: 4. Estimated amount of time the unit s temperature was outside normal range: refrigerator freezer 5. Vaccines in the refrigerator/freezer during the event (use the table below) * Using a recording thermometer is the most effective method of tracking the refrigerator and freezer temperatures over time. Visually checking thermometers twice a day is another effective method to identify inconsistent or fluctuating termperatures in a refrigerator and freezer. Vaccines Stored in Refrigerator Vaccine, manufacturer, and lot # Expiration date # of doses # of affected vials Action taken Vaccines Stored in Freezer Vaccine, manufacturer, and lot # Expiration date # of doses # of affected vials Action taken Other Conditions 1. Prior to this event, was the vaccine exposed to temperatures outside the recommended range? Y N 2. Were water bottles in the refrigerator and ice packs in the freezer at the time of this event? Y N 3. Other: Manufacturers CSL Biotherapies, Inc. (888) GlaxoSmithKline (866) MedImmune, Inc. (877) Merck & Co., Inc. (800) Novartis Vaccines (800) sanofi pasteur (800) Wyeth Vaccines (800) Other Resources Local health department phone number State health department phone number Adapted by the Immunization Action Coalition, courtesy of the Michigan Department of Community Health Technical content reviewed by the Centers for Disease Control and Prevention, May Item #P3051 (5/08) Immunization Action Coalition 1573 Selby Ave. St. Paul, MN (651)

6 Don t Be Guilty of These Errors in Vaccine Storage and Handling The following are frequently reported errors in vaccine storage and handling. Some of these errors are much more serious than others, but none of them should occur. Be sure your clinic or practice is not making errors such as these. Error #1: Designating only one person in the office to be responsible for storage and handling of vaccines, instead of a minimum of two. It s important to train at least one back-up person to learn proper storage and handling of vaccines. The back-up person should be familiar with all aspects of vaccine storage and handling, including knowing how to handle vaccines when they arrive, how to properly record refrigerator and freezer temperatures, and what to do in case of an equipment problem or power outage. Error #2: Recording temperatures only once per day. Temperatures fluctuate throughout the day. Temperatures in the refrigerator and freezer should be checked at the beginning and end of the day to determine if the unit is getting too cold or too warm. Ideally, you should have continuous thermometers that measure and record temperatures all day and all night. A less expensive alternative is to purchase maximum/minimum thermometers. Only certified thermometers should be used for vaccine storage. It s also a good idea to record the room temperature on your temperature log in case there is a problem with the refrigerator or freezer temperature. This information may be helpful to the vaccine company s telephone consultant in determining whether your vaccine can still be used. Error #3: Recording temperatures for only the refrigerator or freezer. If your facility administers varicella, MMRV, or zoster (shingles) vaccine, you should have certified thermometers in both the refrigerator and freezer. Rather than buying cheap thermometers that may not accurately measure the temperature, buy quality thermometers that will last for years. Error #4: Documenting out-of-range temperatures on vaccine temperature logs but not taking action. Documenting temperatures is not enough. Acting on the information is even more important! So, what should you do? Notify your supervisor whenever you have an out-of-range temperature. Safe-guard your vaccines by moving them to another location and then determine if they are still useable. Check the condition of the unit for problems. Are the seals tight? Is there excessive lint or dust on the coils? After you have made the adjustment, document the date, time, temperature, the nature of the problem, the action you took, and the results of your action. Recheck the temperature every two hours. Call maintenance or a repair person if the temperature is still out of range. Error #5: Discarding temperature logs at the end of every month. It s important that you keep your temperature logs for at least three years. As the refrigerator ages, you can track recurring problems. If out-of-range temperatures have been documented, you can determine how long this has been happening and take appropriate action. It s also a great way to lobby for a new refrigerator. Error #6: Refrigerating vaccine in a manner that could jeopardize its quality. The temperature in the vegetable bins, on the floor, next to the walls, in the door, and near the cold air outlet from the freezer may differ significantly from the temperature in the body of the refrigerator. Always store vaccines in their original packaging in the body of the refrigerator away from these locations. Place vaccine packages in such a way that air can circulate around the compartment. Never overpack a refrigerator compartment. Error #7: Storing frozen vaccines in a dorm-style refrigerator. Varicella, MMRV, and zoster (shingles) vaccines must be stored in a freezer that has its own external door separate from the refrigerator. No matter how hard you try to adjust the temperature in a dormstyle refrigerator s freezer to +5 F, you won t be able to reach this low freezer temperature, and you ll probably freeze the vaccines in the refrigerator compartment! Temp Log Error #8: Inadvertently leaving the refrigerator or freezer door open or having inadequate seals. Remind staff to close the unit doors tightly each time they open them. Also, check the seals on the doors on a regular schedule, and if there is any indication the door seal may be cracked or not sealing properly, have it replaced. The cost of replacing a seal is much less than replacing a box of pneumococcal conjugate or varicella vaccine. Error #9: Discarding multi-dose vials 30 days after they are opened. Don t discard your vaccines prematurely. Almost all multi-dose vials of vaccine contain a preservative and can be used until the expiration date on the vial unless there is visible contamination. However, you must discard multi-dose vials of reconstituted vaccine (e.g., meningococcal polysaccharide, yellow fever) if they are not used within a defined period after reconstitution. Refer to the vaccine package inserts for additional information. Error #10: Not having emergency plans for a power outage or natural disaster. Every clinic should have a written Disaster Recovery Plan that identifies a refrigerator with a back-up generator in which to store vaccine in the event of a power outage or natural disaster. Consider contacting a local hospital or similar facility to be your back-up location if you should need it. Error #11: Storing food and drinks in the vaccine refrigerator. Frequent opening of the refrigerator door to retrieve food items can adversely affect the internal temperature of the unit and damage vaccines. Technical content reviewed by the Centers for Disease Control and Prevention, June Item #P3036 (6/08) Immunization Action Coalition 1573 Selby Ave. St. Paul, MN (651)

7 Guide to Contraindications and Precautions to Commonly Used Vaccines Vaccine Contraindications Precautions 1 Hepatitis B (HepB) Rotavirus (RV5 [RotaTeq], RV1 [Rotarix]) Severe allergic reaction (e.g., anaphylaxis) after a previous Moderate or severe acute illness with or without fever vaccine dose or to a vaccine component Infant weighing less than 2000 grams 2 Severe allergic reaction (e.g., anaphylaxis) after a previous vaccine dose or to a vaccine Moderate or severe acute illness with or without fever component Immunosuppression Preexisting gastrointestinal disease Previous history of intussusception Diphtheria, tetanus, pertussis (DTaP) Severe allergic reaction (e.g., anaphylaxis) after a previous vaccine dose or to a vaccine component Encephalopathy (e.g., coma, decreased level of consciousness, and prolonged seizures) not attributable to another identifiable cause within 7 days of administration of previous dose of DTP or DTaP Progressive neurologic disorder, including infantile spasms, uncontrolled epilepsy, progressive encephalopathy: defer DTaP until neurologic status clarified and stabilized Moderate or severe acute illness with or without fever Temperature of 105 or higher (40.5 C or higher) within 48 hours after vaccination with a previous dose of DTP or DTaP Collapse or shock-like state (i.e., hypotonic hyporesponsive episode) within 48 hours after receiving a previous dose of DTP/DTaP Seizure within 3 days after receiving a previous dose of DTP/DTaP 3 Persistent, inconsolable crying lasting 3 or more hours within 48 hours after receiving a previous dose of DTP/DTaP Guillain-Barré syndrome (GBS) within 6 weeks after a previous dose of tetanus toxoid-containing vaccine History of Arthus-type hypersensitivity reactions following a previous dose of tetanus toxoid-containing vaccine: defer vaccination until at least 10 years have elapsed since the last tetanus toxoid-containing vaccine Tetanus, diphtheria (DT, Td) Severe allergic reaction (e.g., anaphylaxis) after a previous vaccine dose or to a vaccine component GBS within 6 weeks after a previous dose of tetanus Moderate or severe acute illness with or without fever toxoid-containing vaccine History of Arthus-type hypersensitivity reactions following a previous dose of tetanus toxoid-containing vaccine: defer vaccination until at least 10 years have elapsed since the last tetanus toxoid-containing vaccine Tetanus, diphtheria, pertussis (Tdap) Haemophilus influenzae type b (Hib) Severe allergic reaction (e.g., anaphylaxis) after a previous vaccine dose or to a vaccine component Encephalopathy (e.g., coma, decreased level of consciousness, and prolonged seizures) not attributable to another identifiable cause within 7 days of administration of previous dose of DTP, DTaP, or Tdap Severe allergic reaction (e.g., anaphylaxis) after a previous vaccine dose or to a vaccine component Age younger than 6 weeks Moderate or severe acute illness with or without fever GBS within 6 weeks after a previous dose of tetanus toxoid-containing vaccine Progressive or unstable neurologic disorder, uncontrolled seizures or progressive encephalopathy until a treatment regimen has been established and the condition has stabilized History of Arthus-type hypersensitivity reactions following a previous dose of tetanus toxoid-containing vaccine: defer vaccination until at least 10 years have elapsed since the last tetanus toxoid-containing vaccine Moderate or severe acute illness with or without fever Inactivated poliovirus vaccine (IPV) Influenza, injectable trivalent (TIV) Influenza, live attenuated (LAIV) Severe allergic reaction (e.g., anaphylaxis) after a previous vaccine dose or to a vaccine component Severe allergic reaction (e.g., anaphylaxis) after a previous Moderate or severe acute illness with or without fever vaccine dose or to a vaccine component History of GBS within 6 weeks of previous TIV Severe allergic reaction (e.g., anaphylaxis) after a previous vaccine dose or to a vaccine component Pregnancy Known severe immunodeficiency (e.g., hematologic and solid tumors; receiving chemotherapy; congenital immunodeficiency; long-term immunosuppressive therapy 4 ; or patients with HIV infection who are severely immunocompromised) Certain chronic medical conditions 5 Pregnancy Moderate or severe acute illness with or without fever Moderate or severe acute illness with or without fever History of GBS within 6 weeks of previous influenza vaccination Adapted from Contraindications and Precautions to Commonly Used Vaccines found in: CDC. General Recommendations on Immunization: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2006; 55(No. RR-15). Technical content reviewed by the Centers for Disease Control and Prevention, August Item #P3072a (8/08) Immunization Action Coalition 1573 Selby Ave. St. Paul, MN (651)

8 Guide to Contraindications and Precautions to Commonly Used Vaccines (continued) Vaccine Contraindications Precautions 1 Pneumococcal (PCV or PPV) Severe allergic reaction (e.g., anaphylaxis) after a previous vaccine dose Moderate or severe acute illness with or or to a vaccine component without fever Measles, mumps, rubella (MMR) 6 Varicella (Var) 6 Severe allergic reaction (e.g., anaphylaxis) after a previous vaccine dose or to a vaccine component Pregnancy Known severe immunodeficiency (e.g., hematologic and solid tumors; receiving chemotherapy; congenital immunodeficiency; long-term immunosuppressive therapy 4 ; or patients with HIV infection who are severely immunocompromised) Severe allergic reaction (e.g., anaphylaxis) after a previous vaccine dose or to a vaccine component Substantial suppression of cellular immunity Pregnancy Moderate or severe acute illness with or without fever Recent (within 11 months) receipt of antibody-containing blood product (specific interval depends on product) 7 History of thrombocytopenia or thrombocytopenic purpura Moderate or severe acute illness with or without fever Recent (within 11 months) receipt of antibody-containing blood product (specific interval depends on product) 7 Hepatitis A (HepA) Human papillomavirus (HPV) Meningococcal, conjugate (MCV4) Meningococcal, polysaccharide (MPSV) Zoster (Zos) Severe allergic reaction (e.g., anaphylaxis) after a previous vaccine dose Moderate or severe acute illness with or or to a vaccine component without fever Pregnancy Severe allergic reaction (e.g., anaphylaxis) after a previous vaccine dose Moderate or severe acute illness with or or to a vaccine component without fever Pregnancy Severe allergic reaction (e.g., anaphylaxis) after a previous vaccine dose Moderate or severe acute illness with or or to a vaccine component without fever History of GBS (if not at high risk for meningococcal disease) Severe allergic reaction (e.g., anaphylaxis) after a previous vaccine dose Moderate or severe acute illness with or or to a vaccine component without fever Severe allergic reaction (e.g., anaphylaxis) after a previous vaccine dose or to a vaccine component Primary cellular or acquired immunodeficiency, including leukemia, lymphomas, or other malignant neoplasms affecting the bone marrow or lymphatic system; AIDS or other clinical manifestations of HIV, including persons with CD4+ T-lymphocyte values <200 per mm 3 or <15% of total lymphocytes; current immunosuppressive therapy 4 ; clinical or laboratory evidence of other unspecified cellular immunodeficiency; receipt of recombinant hematopoietic stem cell transplantation; current receipt of recombinant human immune mediators and immune modulators, especially the antitumor necrosis factor agents adalimumab, infliximab, and etanercept Pregnancy Moderate or severe acute illness with or without fever Footnotes 1. Events or conditions listed as precautions should be reviewed carefully. Benefits of and risks for administering a specific vaccine to a person under these circumstances should be considered. If the risk from the vaccine is believed to outweigh the benefit, the vaccine should not be administered. If the benefit of vaccination is believed to outweigh the risk, the vaccine should be administered. Whether and when to administer DTaP to children with proven or suspected underlying neurologic disorders should be decided on a case-by-case basis. 2. Hepatitis B vaccination should be deferred for infants weighing less than 2000 g if the mother is documented to be hepatitis B surface antigen (HBsAg)-negative at the time of the infant s birth. Vaccination can commence at chronological age 1 month. For infants born to HBsAg-positive women, hepatitis B immunoglobulin and hepatitis B vaccine should be administered at or soon after birth, regardless of weight. 3. Acetaminophen or other appropriate antipyretic can be administered to infants and children with a history of previous seizures at the time of DTaP vaccination and every 4 hours for 24 hours thereafter to reduce the possibililty of postvaccination fever (Source: American Academy of Pediatrics. Red Book: Report of the Committee on Infectious Diseases, 2006: page 512). 4. Substantially immunosuppressive steroid dose is considered to be 2 weeks or more of daily receipt of 20 mg or more (or 2 mg/kg body weight or more) of prednisone or equivalent. 5. For details, see CDC. Prevention and Control of Influenza: Recommendations of the Advisory Committee on Immunization Practices (ACIP) at 6. MMR and varicella vaccines can be administered on the same day. If not administered on the same day, these vaccines should be separated by at least 28 days. 7. For details, see CDC. General Recommendations on Immunization: Recommendations of the Advisory Committee on Immunization Practices (ACIP) at

9 Designated person to order VFC vaccines: Back-up person to order VFC vaccines: How to Order Vaccines Use a copy of the most updated VFC Order Form every time you order so the VVFC Order Center can correctly identify the vaccines you want in the package sizes available. The order form can be found on the VFC website ( and as it changes, it is mailed to you from the Richmond office along with the Backpage newsletter. Vaccine orders can be mailed, faxed ( ), ed (vvfc@vdh.virginia.gov), or phoned in ( VVFC). All orders are processed on Thursdays at 4 pm. Orders received after 4 pm will be processed the following order period. During holidays, order processing and delivery schedules may change. When completing the order form, make sure to complete ALL of the information at the top of the form including your PIN number, facility name, contact person, address, phone number, fax number, address, and shipping instructions. If any of this information has changed and is new, please circle it. Make sure to write in the number of DOSES needed, not boxes, and use the information provided on the order form to figure out how vaccines are packaged. Unless approved otherwise, you should order on a quarterly basis, predicting a 3-month supply for your facility. It is suggested not to wait until you are out of vaccine before ordering and to keep at least a 2-3 week supply on hand. Varicella vaccine is ordered on the same form, but is shipped directly from Merck due to storage requirements and will therefore arrive separately and not at the same time as the rest of your order. Flu vaccine is ordered on a separate order form which is mailed to your facility from the VFC Order Center in late winter/early spring for pre-booking for the following flu season. The flu order form due date is always included on the form. VFC can place ordering holds on your facility due to storage/temperature problems, excessive wastage, or other program violations such as not submitting yearly registration updates or tally reports. You must contact the VFC program in order to arrange for holds to be lifted once certain conditions have been met.

10 VVFC monitors all requests and may adjust orders due to demand, shortages, or volume ordered if it exceeds enrollment numbers. Every effort is made to honor your brand preferences but we may need to substitute brands due to availability issues. If your vaccine fails to arrive within 3 weeks of placing your order, or if the order is incomplete or inaccurate, please contact the VFC order center immediately. VFC Covered Diseases/Vaccines: Diptheria Hepatitis A Hepatitis B Hib HPV Influenza Measles Meningococcal Mumps Pertussis Pneumococcal Polio Rotavirus Rubella Tetanus Varicella

11 Medical Management of Vaccine Reactions in Children and Teens All vaccines have the potential to cause an adverse reaction. To minimize adverse reactions, patients should be carefully screened for precautions and contraindications before vaccine is administered. Even with careful screening, reactions can occur. These reactions can vary from trivial and inconvenient (e.g., soreness, itching) to severe and life threatening (e.g., anaphylaxis). If reactions occur, staff should be prepared with procedures for their management. The table below describes procedures to follow if various reactions occur. Reaction Symptoms Management Localized Psychological fright and syncope (fainting) Soreness, redness, itching, or swelling at the injection site Slight bleeding Continuous bleeding Fright before injection is given Extreme paleness, sweating, coldness of the hands and feet, nausea, light-headedness, dizziness, weakness, or visual disturbances Fall, without loss of consciousness Loss of consciousness Apply a cold compress to the injection site. Consider giving an analgesic (pain reliever) or antipruritic (anti-itch) medication. Apply an adhesive compress over the injection site. Place thick layer of gauze pads over site and maintain direct and firm pressure; raise the bleeding injection site (e.g., arm) above the level of the patient s heart. Have patient sit or lie down for the vaccination. Have patient lie flat or sit with head between knees for several minutes. Loosen any tight clothing and maintain an open airway. Apply cool, damp cloths to patient s face and neck. Examine the patient to determine if injury is present before attempting to move the patient. Place patient flat on back with feet elevated. Check the patient to determine if injury is present before attempting to move the patient. Place patient flat on back with feet elevated. Call 911 if patient does not recover immediately. Anaphylaxis Sudden or gradual onset of generalized itching, erythema (redness), or urticaria (hives); angioedema (swelling of the lips, face, or throat); severe bronchospasm (wheezing); shortness of breath; shock; abdominal cramping; or cardiovascular collapse See Emergency Medical Protocol for Management of Anaphylactic Reactions in Children and Teens on the next page for detailed steps to follow in treating anaphylaxis. Supplies Needed! Aqueous epinephrine 1:1000 dilution, in ampules, vials of solution, or prefilled syringes, including epinephrine autoinjectors (e.g., EpiPen). If EpiPens are to be stocked, both EpiPen Jr. (0.15 mg) and adult EpiPens (0.30 mg) should be available.! Diphenhydramine (Benadryl) injectable (50 mg/ml solution) and oral (12.5 mg/5 ml suspension) and 25 mg or 50 mg capsules or tablets! Syringes: 1 3 cc, 22 25g, 1", 1½", and 2" needles for epinephrine and diphenhydramine (Benadryl)! Pediatric & adult airways (small, medium, and large)! Sphygmomanometer (child, adult & extra-large cuffs) and stethoscope! Pediatric & adult size pocket masks with one-way valve! Alcohol swabs! Tongue depressors! Flashlight with extra batteries (for examination of mouth and throat)! Wrist watch! Tourniquet! Cell phone or access to an on-site phone (Page 1 of 2) Item #P3082a (8/06) Immunization Action Coalition 1573 Selby Ave. St. Paul, MN (651)

12 Emergency Medical Protocol for Management of Anaphylactic Reactions in Children and Teens Signs and Symptoms of Anaphylactic Reaction Sudden or gradual onset of generalized itching, erythema (redness), or urticaria (hives); angioedema (swelling of the lips, face, or throat); bronchospasm (wheezing); shortness of breath; shock; abdominal cramping; or cardiovascular collapse. Treatment in Children and Teens a. If itching and swelling are confined to the injection site where the vaccination was given, observe patient closely for the development of generalized symptoms. b. If symptoms are generalized, activate the emergency medical system (EMS; e.g., call 911) and notify the on-call physician. This should be done by a second person, while the primary nurse assesses the airway, breathing, circulation, and level of consciousness of the patient. c. Administer aqueous epinephrine 1:1000 dilution (i.e., 1 mg/ml) intramuscularly; the standard dose is 0.01 mg/kg body weight, up to 0.3 mg maximum single dose in children and 0.5 mg maximum in adolescents (see chart below). d. In addition, for anaphylaxis, administer diphenhydramine either orally or by intramuscular injection; the standard dose is 1 mg/kg body weight, up to 30 mg maximum dose in children and 100 mg maximum dose in adolescents (see chart below). e. Monitor the patient closely until EMS arrives. Perform cardiopulmonary resuscitation (CPR), if necessary, and maintain airway. Keep patient in supine position (flat on back) unless he or she is having breathing difficulty. If breathing is difficult, patient s head may be elevated, provided blood pressure is adequate to prevent loss of consciousness. If blood pressure is low, elevate legs. Monitor blood pressure and pulse every 5 minutes. f. If EMS has not arrived and symptoms are still present, repeat dose of epinephrine every minutes for up to 3 doses, depending on patient s response. g. Record all vital signs, medications administered to the patient, including the time, dosage, response, and the name of the medical personnel who administered the medication, and other relevant clinical information. h. Notify the patient s primary care physician. Suggested Dosing of Epinephrine and Diphenhydramine Age Group Weight * Weight (lbs)* Epinephrine Dose Diphenhydramine (Benadryl) Dose in kg in lbs 1 mg/ml injectable 12.5 mg/5 ml liquid (1:1000 dilution) 25 and 50 mg capsules or tabs intramuscular 50 mg/ml injectable 1 6 mos 4 7 kg 9 15 lbs 0.05 mg (0.05 ml) 5 mg 7 18 mos 7 11 kg lbs 0.1 mg (0.1 ml) 10 mg mos kg lbs 0.15 mg (0.15 ml) 15 mg mos kg lbs 0.15 mg (0.15 ml) mos kg lbs 0.2 mg (0.2 ml) 20 mg 5 7 yrs kg lbs 0.2 mg (0.2 ml) 8 10 yrs kg lbs 0.3 mg (0.3 ml) 30 mg yrs kg lbs 0.4 mg (0.4 ml) 40 mg 13 yrs & older 45+ kg 99+ lbs 0.5 mg (0.5 ml) mg *Dosing by body weight is preferred. These standing orders for the medical management of vaccine reactions in child and teenage patients shall remain in effect for patients of the until rescinded or until. name of clinic date Medical Director s signature Effective date Sources: American Academy of Pediatrics. Passive Immunization. In: Pickering LK, ed. Red Book: 2006 Report of the Committee on Infectious Diseases. 27th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2006: American Pharmacists Association, Grabenstein, JD, Pharmacy-Based Immunization Delivery, (Page 2 of 2) Item #P3082a (8/06) Immunization Action Coalition 1573 Selby Ave. St. Paul, MN (651)

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

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

15 Checklist for Safe Vaccine Handling and Storage Here are the 20 most important things you can do to safeguard your vaccine supply. Are you doing them all? Reviewing this list can help you improve your clinic s vaccine management practices. Yes No 1. We have a designated person in charge of the handling and storage of our vaccines. 2. We have a back-up person in charge of the handling and storage of our vaccines. 3. A vaccine inventory log is maintained that documents: Vaccine name and number of doses received Date the vaccine was received Arrival condition of vaccine Vaccine manufacturer and lot number Vaccine expiration date 4. Our refrigerator for vaccines is either household-style or commercial-style, NOT dormitory-style. The freezer compartment has a separate exterior door. Alternatively, we use two storage units: a free-standing refrigerator and a separate, free-standing freezer. 5. We do NOT store any food or drink in the refrigerator or freezer. 6. We store vaccines in the middle of the refrigerator or freezer, and NOT in the door. 7. We stock and rotate our vaccine supply so that the newest vaccine of each type (with the longest expiration date) is placed behind the vaccine with the shortest expiration date. 8. We check vaccine expiration dates and we first use those that will expire soonest. 9. We post a sign on the refrigerator door showing which vaccines should be stored in the refrigerator and which should be stored in the freezer. 10. We always keep a thermometer in the refrigerator. 11. The temperature in the refrigerator is maintained at 35 46ºF (2 8ºC). 12. We keep extra containers of water in the refrigerator to help maintain cold temperatures. 13. We always keep a thermometer in the freezer. 14. The temperature in the freezer is maintained at +5ºF (-15ºC) or colder. 15. We keep ice packs and other ice-filled containers in the freezer to help maintain cold temperatures. 16. We post a temperature log on the refrigerator door on which we record the refrigerator and freezer temperatures twice a day first thing in the morning and at clinic closing time and we know whom to call if the temperature goes out of range. 17. We have a Do Not Unplug sign next to the refrigerator s electrical outlet. 18. In the event of a refrigerator failure, we take the following steps: We assure that the vaccines are placed in a location with adequate refrigeration. We mark exposed vaccines and separate them from undamaged vaccines. We note the refrigerator or freezer temperature and contact the vaccine manufacturer or state health department to determine how to handle the affected vaccines. We follow the vaccine manufacturer s or health department s instructions as to whether the affected vaccines can be used, and, if so, we mark the vials with the revised expiration date provided by the manufacturer or health department. 19. We have obtained a detailed written policy for general and emergency vaccine management from our local or state health department. 20. If all above answers are yes, we are patting ourselves on the back. If not, we have assigned someone to implement needed changes! Technical content reviewed by the Centers for Disease Control and Prevention, July Item #P3035 (7/08) Immunization Action Coalition 1573 Selby Ave. St. Paul, MN (651)

16 Suggested Supplies Checklist for Pediatric and Adult Immunization Clinic Frozen Vaccines*! Diphtheria, tetanus, and pertussis (DTaP)! DTaP-HepB-IPV (Pediarix )! DTaP-Hib (Trihibit )! Haemophilus influenzae type b (Hib)! Hepatitis A! Hepatitis B! Hep B-Hib (Comvax )! Hep A-Hep B (Twinrix )! Human papillomavirus (HPV)! Influenza, trivalent injectable (TIV) (in season)! Measles, mumps, rubella (MMR) and diluent! Meningococcal and diluent! Pneumococcal conjugate (PCV)! Pneumococcal polysaccharide (PPV)! Polio, inactivated (IPV)! Rotavirus! Tetanus-diphtheria, adult (Td)! Tetanus, diphtheria, and pertussis (Tdap)! Influenza, live attenuated intranasal (LAIV) (in season)! Measles, mumps, rubella, varicella (MMRV) and diluent! Varicella and diluent! Zoster (shingles) and diluent Note: do not place diluent in container with dry ice. For instructions on how to pack and transport vaccines, go to Emergency Kit*! Standing orders for medical emergencies! Aqueous epinephrine USP (1:1000), in ampules, vials of solution, or prefilled syringes (including Epi-Pens)! Diphenhydramine (Benadryl) injectable (50 mg/ml solution) and oral in 25 or 50 mg tablets! 1 3 cc syringes with 1", 1½", and 2" needles for epinephrine or Benadryl! Pediatric and adult airways (small, medium, large)! Sphygmomanometer (child, adult & extra-large cuffs) and stethoscope! Pediatric & adult size pocket masks with one-way valve! Cell phone or access to an on-site phone! Flashlight & extra batteries (for examination of mouth & throat)! Wrist watch! Alcohol swabs! Tourniquet! Tongue depressors Miscellaneous Office Supplies! Calendar! Stapler/staples! Pens, black and red! Rubber bands! Files! Tape! Scissors! Paper clips! Pad of paper Technical content reviewed by the Centers for Disease Control and Prevention, Oct Vaccine Information Statements (VISs)*! DTaP! Polio! Hepatitis A! PCV! Hepatitis B! PPV! HPV! Rotavirus! Hib! Td! Influenza (TIV)! Tdap! Influenza (LAIV)! Varicella! MMR! Zoster (shingles)! Meningococcal Clinic Charts! Immunization clinic standing orders and protocols! Vaccination administration records (medical charts)! Billing forms! Screening Questionnaire for Childhood Immunization **! Screening Questionnaire for Adult Immunization **! Summary of Recommendations for Childhood and Adolescent Immunization **! Summary of Recommendations for Adult Immunization **! Immunization record cards for patients! Release of information forms! Notification of vaccination letter (to send to primary clinic)! Vaccine Adverse Events Reporting (VAERS) forms! List of clinics, phone #s, and other referral sources! This Suggested Supplies Checklist for Pediatric &Adult Immunization Clinic **! Schedules with dates for future clinics Vaccine Supplies*! 2 Sharps disposal containers! 1 box of 3 cc syringes! 22 25g needles! 5/8";! 1";! 1½";! 2"! 1 box of latex gloves! Alcohol wipes! Spot bandaids! Rectangular bandaids! 1" gauze pads or cotton balls! Thermometers! Probe covers for thermometer! Certified calibrated thermometer for vaccine cooler! One cloth towel! Paper towels! Bleach solution in spray bottle * Always check the expiration dates of all vaccines, medications, and medical supplies before using! In addition, be sure to check that you have the most current versions of the VISs. To learn more about VISs, visit **These materials are available at Item #P3046 (10/06) Immunization Action Coalition 1573 Selby Ave. St. Paul, MN (651)

17 Vaccine Benefits and Risk Communications Educational materials are available in all waiting areas Educational materials are available in the patient s native language if patient does not understand English Benefits of each vaccine to be administered are reviewed with each client/legal guardian and include oral review of vaccine and the VIS (Vaccine Information Statement) Risks of vaccines are reviewed with each client/legal guardian prior to administration (local, systemic reactions, possible side effects, etc.) Client/legal guardian is advised of timing (oral and written) for next vaccine Client/legal guardian is advised of when/where to receive medical care in the event of any adverse events due to vaccination Medical staff will document any adverse events on VAERS forms and alert doctor of the adverse event. Information will be documented in the client s chart Client/legal guardian is made aware of National Vaccine Injury Compensation Program, as necessary, and will be provided with written information on the program

18 Vaccine Record Maintenance and Accessibility Office will update patient s immunization history (if have received any vaccines elsewhere) and pertinent information will be entered into patient s chart with each patient visit. Medical staff, after having administered vaccine(s), will enter the vaccine into patient s chart including vaccine name, lot number, manufacturer, medical staff person s name and title who administered the vaccine, and the VIS publication date. Client/legal guardian is given a copy of the immunization record if requested. Client/legal guardian is advised of time of the next vaccine and appointment time is given (verbal and written) Immunization records will be shared with other medical providers/schools as requested to benefit client s needs. Update Initials

19 Vaccine Handling Tips Outdated or improperly stored vaccines won t protect patients! Maintain freezer temperature at 5 F (-15 C) or colder g MMR* MMRV Varicella Zoster Maintain refrigerator temperature at F (2 8 C) g Hib Hepatitis A Hepatitis B Human papillomavirus DTaP, DT, Td,Tdap Influenza (TIV/LAIV) Polio (IPV) MMR* Meningococcal (MCV4 & MPSV4) Pneumococcal (PPV & PCV) Rotavirus Order vaccine carefully. Inventory your vaccine at least monthly and before placing an order. Expired vaccine must never be used and is money wasted! Store vaccine correctly. Refrigerate or freeze immediately upon receiving shipment. Do not store vaccine in the door of the refrigerator or freezer. Inactivated vaccines should always be placed in the middle of the refrigerator far enough away from the freezer compartment to protect them from freezing. Always use the vaccine with the earliest expiration date first. Move vaccine with the earliest expiration date to the front and mark it to be used first. Keep vials in their boxes. Never use outdated vaccine. Stabilize temperatures. Store ice packs in the freezer and large jugs of water in the refrigerator along with the vaccine. This will help maintain a stable, cold temperature in case of a power failure or if the refrigerator or freezer doors are opened frequently or left open. Frequent opening of the refrigerator unit s doors can lead to temperature variations inside, which could affect vaccine efficacy. For this reason you should not store food or beverages in the refrigerator or freezer. Safeguard the electrical supply to the refrigerator. Make sure the refrigerator is plugged into an outlet in a protected area where it cannot be disconnected accidentally. Label the refrigerator, electrical outlets, fuses, and circuit breakers on the power circuit with information that clearly identifies the perishable nature of vaccines and the immediate steps to be taken in case of interruption of power (use DO NOT UNPLUG stickers). If your building has auxiliary power, use the outlet supplied by that system. *MMR may be stored in either the freezer or the refrigerator. Refer to package insert for specific instructions on the storage of each vaccine. If you have questions about the condition of the vaccine, you should immediately place the vaccine in recommended storage and call the vaccine manufacturer(s) to determine whether the potency of the vaccine(s) has been affected. For other questions, call the immunization program at your state or local health department. Record your health department s phone number here: Adapted by the Immunization Action Coalition, courtesy of the Minnesota Department of Health Technical content reviewed by the Centers for Disease Control and Prevention, May Item #P3048 (5/07) Immunization Action Coalition 1573 Selby Ave. St. Paul, MN (651)

20 Maintaining the Cold Chain During Transport When transporting vaccines, think about how each vaccine was packed when you first received it from the manufacturer or distributor. Use this as a model for how to repack the individual vaccines in order to transport them at their appropriate temperature. Keep a temperature log. Record the temperature during transport and periodically (e.g., at least once each hour) during the entire time the vaccine is kept in the transport container to ensure it remains within the recommended range. Vaccines Special Instructions Inactivated vaccines Live virus vaccines Diphtheria-tetanuspertussis (DTaP, DT, Tdap, Td) Haemophilus influenzae type b Human papillomavirus Hepatitis A Hepatitis B Influenza, inactivated Meningococcal Pneumococcal Poliovirus, inactivated Combination products of these vaccines Measles, mumps, rubella (MMR) Rotavirus Varicella (VAR) MMR+VAR (MMRV) Zoster (shingles) Influenza, live Keep cold at F (2 8 C) and do not freeze. Use refrigerated or frozen packs depending on the time of the year and the situation (e.g., frozen packs for hot weather while transporting outdoors, refrigerated packs for cold weather). Make sure vaccines are kept in their original boxes. Place some insulation (e.g., crumpled paper, bubble wrap) between the vaccine boxes and the refrigerated or frozen packs to prevent the inactivated vaccine from directly touching the refrigerated or frozen packs. Put crushed paper in the cooler to keep the vaccines from shifting during transport. During hot weather, keep the insulated container in a cool place (air-conditioned interior of car). Do not leave the vaccine container unattended or in the trunk of a parked car. During cold weather, do not leave the container in an unheated area because vaccine must not freeze. In cold weather, include a freeze indicator in the vaccine container. Keep cold at F (2 8 C). MMR may be frozen. If MMR is transported with inactivated vaccines, follow the packing instructions for inactivated vaccines indicated above. If you are transporting diluent in the same cooler with the MMR, refrigerate the diluent in advance to help maintain the cold temperature in the cooler. Transport only the quantity needed in a special freezer unit or in an insulated container with dry ice; clearly mark the vaccine with the date and time it was removed from the original freezer unit. It is extremely important to include a thermometer in the container with the vaccine. If using dry ice, pack the container with enough to ensure the temperature is maintained at 5 F (-15 C) or colder. If dry ice is not available, you may transport VAR (not MMRV or zoster) with frozen packs. If the temperature within the container exceeds 5 F (-15 C) but doesn t go above 46 F (8 C), the expiration date of the VAR vaccine is reduced to 72 hours. VAR vaccine that has reached temperatures above 46 F (8 C) or has exceeded the 72 hour limit cannot be used. Note: MMRV and zoster vaccines must always be transported with dry ice or in a special freezer unit that can reliably maintain temperatures of 5 F (-15 C) or colder. For this reason, transport of MMRV or zoster to off-site clinics is not advised. For information on transporting live, attenuated intranasal influenza vaccine (FluMist ), refer to the package insert. Adapted by the Immunization Action Coalition, courtesy of the Minnesota Department of Health Technical content reviewed by the Centers for Disease Control and Prevention, Nov Item #P3049 (11/06) Immunization Action Coalition 1573 Selby Ave. St. Paul, MN (651)