Approximately 11 ,000 infants are born each day in the United States. According to the recommended childhood immunization schedule, they require approximately 24 doses of vaccine (18 to 19 injections, if using combination vaccines) before age 2 to protect them from 13 vaccine-preventable diseases.1
During the pediatrie visit, immunizations are an important and often complicated issue. Vaccination is complex and ever changing, necessitating nurses and other medical staff to review and incorporate frequent changes into their daily practice. Today, with most vaccinations given in the private provider's office, it is increasingly important that office practice nurses who provide immunizations incorporate successful strategies that will help achieve optimal vaccination coverage and protection among our nation's children.
Immunization recommendations change frequently, so it is imperative that health care providers know where to find current immunization recommendations. One of the best places to start is the Recommended Childhood and Adolescent Immunization Schedule, which is developed and distributed by the Centers for Disease Control and Prevention (CDC) National Immunization Program (NIP) every January. (As of April 3, 2006, the NIP's name changed to the National Center for Immunization and Respiratory Diseases [NCIRD].) The current Childhood and Adolescent Immunization Schedule is provided on pages 485-486 in English and pages 487-488 in Spanish. This immunization schedule should be considered the roadmap and guide to optimal vaccine administration. Following the recommended age ranges provides optimal vaccine responses. Equally important are the footnotes, located on the bottom or reverse side of the childhood immunization schedule. The footnotes contain critical pieces of information for the administration, spacing and timing of the recommended vaccines and must be read carefully to fully understand and correctly interpret the schedule.
There are times when the spacing of vaccines may be shortened or the schedule may be accelerated due to a late start or if a child is behind schedule. This accelerated schedule, using shortened intervals between vaccines is commonly referred to as the "catch-up" schedule and can be found on page 485. The schedules also can be downloaded in a number of different formats from the CDC Web site at http://www.cdc. gov/nip/recs/child-schedule.htm.
Before any vaccination can be given, the healthcare provider must determine if there are valid contraindications or precautions that will dictate whether or not a vaccine is administered. The key to preventing serious adverse reactions is screening. Although generally rare, serious adverse events after vaccination do occur. Nursing staff should screen every patient for medical contraindications and precautions before giving any dose of vaccine and never assume screening questions were asked by another staff member.
Screening should happen at every vaccination visit. If a valid contraindication or precaution is identified, the affected vaccine should not be given at that time. Office staff must be aware there are both permanent contraindications and temporary precautions to vaccination. The CDC's comprehensive guide to contraindications can be found at http://www.cdc.gov/nip/recs/contraindications.htm.
Screening may be accomplished by asking a series of questions, distributing a screening questionnaire, or both. A physical examination is not required before vaccination. Optimally, the patient should be provided with a screening questionnaire when first arriving to the office's waiting room and should be given time to complete the questionnaire. The questionnaire should be reviewed with the patient, and all questions and concerns discussed and answered. Screening can be covered safely and easily using the six questions listed in the Sidebar.
Screening questions may be modified by individual practices. Standardized screening forms with rationales for each question are available from the Immunization Action Coalition at http.7/www. immunize.org/catg.aVp4060scr.pdf.
KEEPING ON TARGET
To keep children on schedule for appropriate immunizations, it may be necessary to administer up to four or five injections at a visit. For children with delayed immunization, more injections might be necessary. There is no decrease in safety or efficacy when multiple vaccines are given on the same day or in the same limb. It is recommended, however, that vaccines given in the same limb be separated by at least 1 inch. Vaccines approved for subcutaneous administration - measles, mumps, rubella, varicella, and the inactivated polio vaccine - may be given in the upper outer arm even in infants. It is important to give all vaccines that are due. Parents accept the practice of multiple injections when its safety is explained.
KEEPING COMMUNICATION OPEN
Effectively communicating with patients and their parents about ine current recommended vaccinations is a challenge. With only a handful of minutes to spend with each patient, it is absolutely necessary for Healthcare providers to give the most accurate and sound, yet clear and concise, information to the patient. All healthcare providers who administer vaccinations to children and adolescents have the responsibility of educating the patient or parent on the risks and benefits of vaccines.
One of the best ways to begin is with Vaccine Information Statements (VIS). The VIS, produced by the CDC, are information sheets explaining the benefits and risks of vaccines. There are several important points to know about the VIS. The National Childhood Vaccine Injury Act of 1986 mandates VIS use. Every healthcare provider is required by law to provide a copy of the most current edition of the VIS to the vaccine recipient or the recipient's parent or legal representative each time a vaccine is administered. The current edition dates are found on the bottom margin of each VIS.
The VIS must be given out at the time of each vaccination, before administration of the vaccine. The VIS edition date, the date the VIS was given, and which VIS was given must be recorded in the patient's permanent record. Note that the VIS is not an "informed consent" document, as there is no federal requirement for informed consent. Nurses should check individual state laws to determine if there are specific informed consent requirements within their state.
Staff should provide patients and families adequate time to review each VIS. The VIS may be given to patients while they are still in the waiting room, with questions addressed once patients have been called in for their appointments. Detailed information, including VIS translated into 33 languages, is available at http://www.immunize.org/vis.
Vaccine storage and handling are critical components of a safe and effective vaccine practice. Vaccines are fragile, valuable, and extremely temperature sensitive. Improperly storing and handling vaccines will result in damaged and inactivated vaccines, causing children to have decreased protection against vaccine-preventable diseases. A recent study of office-based practices demonstrated that an estimated 17% to 37% of providers expose vaccines to improper storage temperatures.2
One of the best strategies for protecting an office practice against vaccine failure due to mishandled vaccine is to designate one staff member to be the primary vaccine coordinator. This person would be responsible for ensuring that all vaccines are handled and stored correctly. Each office ideally should have a second staff member named as backup, to ensure that vaccines are monitored on a daily basis and that vaccine storage and handling guidelines are followed by all office staff. A detailed review of suggested responsibilities for a vaccine coordinator is available through the CDC Web site at http://www2a.cdc. gov/nip/isd/shtoolkit/splash.html.
Vaccines to be stored in the refrigerator include DTaP and Tdap (diphtheria, tetanus, and pertussis); DT and Td (tetanus and diphtheria); Hib (Haemophilus influenzae type B); hepatitis A and hepatitis B; influenza (TIV), polio (IPV), meningococcal, and pneumoccocal (PPV or PCV). Vaccines to be stored in the freezer include varicella, MMRV (measles, mumps, rubella, and varicella), and liveattenuated influenza vaccine. MMR (measles, mumps, and rubella) may be stored in either the freezer or the refrigerator.
The refrigerator temperature range must be maintained between 35° to 46° F (2° to 8° C). Ideal is an average refrigerator temperature of 40° F (5° C). The freezer temperature range must be maintained at 5° F (-15° C) or colder.
The temperature should be measured using certified calibrated thermometers, kept in the refrigerator and freezer. The refrigerator may be a residential or a commercial-style refrigerator with two separate outside doors, one for refrigerator and one for freezer. Small, dorm-style refrigerators are not to be used, as they cannot maintain the proper temperature range required for vaccine storage.
The CDC recommends that the temperature of the refrigerator and freezer mat stores vaccines be checked twice per day to ensure proper temperature is maintained. A temperature log with both the refrigerator and freezer temperature should be posted on the refrigerator/freezer. The log should be reviewed weekly and be kept on file for at least 3 years.
Immediate action must be taken if a temperature is out of range. The affected vaccine must be stored as quickly as possible in the proper conditions and calls must be made to the vaccine manufacturers to determine if the potency of the vaccine has been affected. Contacting the local or state health department will provide further vaccine guidance. The CDC provides a complete guide on vaccine storage and handling at http:// www.cdc.gov/nip/publications/vac_ mgt_book.htm.
1. Centers for Disease Control and Prevention. Recommended childhood and adolescent schedule - United States 2006. MAfWR Morb Mortal Wkly Rep. 2006;54:Q1-4.
2. Gazmararian JA, Oster NV, Green DC, et al. Vaccine storage practices in primary care physician offices: assessment and intervention. Am J Prev Med. 2002;3(4)246-253.