Item #P4036 (3/02)
Pneumococcal vaccination
q I am 65 years of age or older, and I have never had a dose of pneumococcal vaccine, so I need this vaccination.
q I am 65 years of age or older, had a previous dose when I was under 65, and it has been at least 5 years since that dose, so I need a second dose now.
q I am less than 65 years old, and I have one of the following health problems listed below that puts me at high risk for pneumococcal disease and:
q I have never had a dose of pneumococcal vaccine, so I need two doses spaced 5 years apart.
q It has been at least 5 years since my first dose of pneumococcal vaccine, so I need a second dose now.
___ sickle cell disease ___ had my spleen removed ___ HIV/AIDS
___ leukemia
Tetanus-diphtheria (Td) vaccination
q I have not yet had at least 3 Td shots in my lifetime (usually given as DTP in childhood), so I need to be vaccinated now with one or more doses to bring me up to date, and then I will need one dose every 10 years.
q I have had at least 3 Td shots (or DTPs) in my lifetime, but I think it’s been 10 years or more since I received my last Td, so I need one dose now, and subsequently I will need one dose every 10 years.
Approximate date(s) that I had my last Td(s): _____________________
q I have no idea if I ever received Td vaccination in school, the military, or elsewhere, so I probably need to be vaccinated and will talk with my doctor about how many doses I should receive.
Immunization Action Coalition • 1573 Selby Avenue • St. Paul, MN 55104 • (651) 647-9009 • www.immunize.org ___ diabetes mellitus
___ kidney disease
___ organ or bone marrow transplant
___ lymphoma ___ multiple myeloma ___ generalized malignancy q I am not in one of the groups listed above, but I’d like a flu shot to avoid getting influenza this season.
___ alcoholism
Approximate date that I last had pneumococcal vaccine: _______________________
___ Hodgkin’s disease
___ on medication or receiving x-ray treatment that affects my immune system
___ I am a health care worker.
___ I provide essential community services.
___ I live in a nursing home or chronic care facility.
___ lung disease ___ heart disease ___ kidney disease ___ diabetes mellitus ___ HIV/AIDS
___ a disease that affects the immune system
___ lung disease (not asthma) ___ heart disease
q I am less than 65 years old, and I have one of the following health problems, and I have never had a dose of pneumococcal vaccine, so I need this vaccination.
___ liver disease ___ cerebrospinal fluid leak
To access the current, ready-to-copy version of this piece, visit www.immunize.org/catg.d/4036need.pdf
*Call your local travel clinic to find out if additional vaccines are recommended.
† Adults from these areas should be tested for hepatitis B infection prior to vaccination. Areas with high rates of hepatitis B include: Africa; China; Korea; Southeast Asia including Indonesia and the Philippines; the Middle East except Israel; South and Western Pacific Islands; interior Amazon Basin; and certain parts of the Caribbean, i.e., Haiti and the Dominican Republic. Areas of moderate endemicity include South Central and Southwest Asia, Israel, Japan, Eastern and Southern Europe, Russia, and most of Central and South America.
Hepatitis A vaccination
q I am in one of the following risk groups, but I do not wish to disclose which one, so I need to be vaccinated.
q I am in one of the following risk groups, so I need to be vaccinated:
___ I travel outside of the U.S., Western Europe, Canada, Japan, Australia, and New Zealand.*
___ I live in a community where cases of hepatitis A are occurring and I am 18 or younger.
___ I am a man who has sex with men.
___ I use street drugs.
___ I have chronic liver disease.
___ I have a clotting factor disorder.
Hepatitis B vaccination
q I am in one of the following risk groups, but I do not wish to disclose which one, so I need to be vaccinated.
q I am in one of the following risk groups, so I need to be vaccinated:
___ I live with a person who has hepatitis B.
___ I have a bleeding disorder that requires transfusion.
___ I am or will be on kidney dialysis.
___ I am an immigrant from an area of the world with moderate or high rates of hepatitis B.†
Measles-Mumps-Rubella (MMR) vaccination
q I was born after 1956 and never received a dose of MMR, so I need to be vaccinated.
q I am a woman thinking about a future pregnancy and do not know if I’m immune to rubella, so I need to be tested or vaccinated.
q I am included in one of the following groups for whom two doses of MMR are recommended, but I have only received one dose of MMR, so I need a second dose.
___ I am a health care worker.
___ I travel internationally.
___ I am entering college or a post–high-school educational institution.
___ I had a rubella titer that shows I do not have immunity.
___ I travel outside of the U.S.*† and plan to stay for 6 months or longer.
___ I inject street drugs.
___ I am a sex partner of a person with hepatitis B.
___ I’ve been treated for a sexually transmitted disease.
___ I have or had more than one sex partner during a 6-month time period.
___ I am a man who has sex with men.
___ I am a health care or public safety worker who is exposed to blood.
___ I provide direct services for people with develop-mental disabilities.
Chickenpox (Varicella) vaccination
q I have never had chickenpox, so I need to be tested or vaccinated.
q I’m not sure if I’ve had chickenpox or not, so I need to be tested or vaccinated.
q I may become pregnant and do not know if I’m immune to chickenpox, so I need to be tested or vaccinated.
Meningococcal vaccination
q I am (or I’ll be) a college freshman living in a dorm, so tell me more about the meningococcal vaccine.
q I am traveling to an area of the world where meningococcal disease is common, so I need to be vaccinated.*
q I have sickle cell disease, or a spleen that isn’t working or has been removed, so I need to be vaccinated.
Haemophilus influenzae type b (Hib) vaccination
q I have one of the following health conditions: HIV infection, bone marrow transplant, sickle cell disease or a spleen that isn’t working or has been removed, so I need to be vaccinated.
Page 113 Appendix B: Patient Materials
Adults Only Vaccination: A Step-by-Step Guide Immunization Action Coalition www.immunize.org www.vaccineinformation.org
To access the current, ready-to-copy version of this piece, visit www.immunize.org/catg.d/p4065scr.pdf
1. Are you sick today?
2. Do you have allergies to medications, food, or any vaccine?
3. Have you ever had a serious reaction after receiving a vaccination?
4. Do you have cancer, leukemia, AIDS, or any other immune system problem?
5. Do you take cortisone, prednisone, other steroids, or anticancer drugs, or
have you had x-ray treatments?
6. During the past year, have you received a transfusion of blood or blood
products, or been given a medicine called immune (gamma) globulin?
7. For women: Are you pregnant or is there a chance you could become
pregnant during the next month?
8. Have you received any vaccinations in the past 4 weeks?
Item #P4065 (1/02)
Immunization Action Coalition • 1573 Selby Avenue • St. Paul, MN 55104 • (651) 647-9009 • www.immunize.org Form completed by: _____________________________________ Date: _____________
For patients: The following questions will help us determine which vaccines may be given today.
If a question is not clear, please ask your health care provider to explain it.
No
Yes Don’t Know
Screening Questionnaire for Adult Immunization
Patient name: Date of birth:
(mo.) (day) (yr.)
Did you bring your immunization record card with you? yes no
It is important for you to have a personal record of your vaccinations. If you don’t have a record card, ask your health care provider to give you one! Bring this record with you every time you seek medical care.
Make sure your health care provider records all your vaccinations on it.
To access the current, ready-to-copy version of this piece, visit www.immunize.org/catg.d/p4065scr.pdf
Understanding the Screening Questionnaire for Adult Immunization
1. Are you sick today?
There is no evidence that acute illness reduces vaccine efficacy or increases vaccine adverse events (1, 2). However, with moderate or severe acute illness, all vaccines should be delayed until the ill-ness has improved. Mild illill-nesses (such as upper respiratory infec-tions or diarrhea) are NOT contraindicainfec-tions to vaccination. Do not withhold vaccination if a person is taking antibiotics.
2. Do you have allergies to medications, food, or any vaccine?
History of anaphylactic reaction such as hives (urticaria), wheezing or difficulty breathing, or circulatory collapse or shock (not fainting) from a previous dose of vaccine or vaccine component is a con-traindication for further doses. For example, if a person experi-ences anaphylaxis after eating eggs, do not administer influenza vaccine, or if a person has anaphylaxis after eating gelatin, do not administer MMR or varicella vaccine. Local reactions (e.g., a red eye following instillation of ophthalmic solution) are not contraindications. For an extensive table of vaccine components, see reference 3.
3. Have you ever had a serious reaction after receiving a vaccination?
History of anaphylactic reaction (see question 2) to a previous dose of vaccine or vaccine component is a contraindication for subsequent doses (4). Under normal circumstances, vaccines are deferred when a precaution is present. However, situations may arise when the benefit outweighs the risk (e.g., community measles outbreak).
4. Do you have cancer, leukemia, AIDS, or any other immune system problem?
Live virus vaccines (e.g., MMR, varicella) are usually contraindi-cated in immunocompromised people. However, there are ex-ceptions. For example, MMR is recommended for asymptomatic HIV-infected individuals who do not have evidence of severe im-munosuppression. For details, consult the ACIP recommenda-tions (5, 6).
5. Do you take cortisone, prednisone, other steroids, or anticancer drugs, or have you had x-ray treatments?
Live virus vaccines (e.g., MMR, varicella) should be postponed un-til after chemotherapy or long-term high-dose steroid therapy has ended. For details and length of time to postpone, consult the ACIP statement (1). To find specific vaccination schedules for stem cell transplant (bone marrow transplant) patients, see
reference 7.
The information below has been adapted from Epidemiology & Prevention of Vaccine-Preventable Diseases, WL Atkinson et al., editors, CDC, 6th edition, Jan. 2000, and CDC’s Guide to Contraindications to Childhood Vaccinations, Oct. 2000.
6. During the past year, have you received a transfusion of blood or blood products, or been given a medicine called immune (gamma) globulin?
Live virus vaccines (e.g., MMR, varicella) may need to be de-ferred, depending on several variables. Consult the ACIP State-ment “General Recommendations on Immunization” (1) or 2000 Red Book, p. 390 (2), for the most current information on intervals between immune globulin or blood product administration and MMR or varicella vaccination.
7. For women: Are you pregnant or is there a chance you could become pregnant during the next month?
Live virus vaccines (e.g., MMR, varicella) are contraindicated prior to and during pregnancy due to the theoretical risk of virus trans-mission to the fetus. Sexually active women in their child-bearing years who receive MMR or varicella vaccination should be in-structed to practice careful contraception for one month following receipt of either vaccine (8, 9). Inactivated vaccines may be given to a pregnant woman whenever indicated.
8. Have you received any vaccinations in the past 4 weeks?
If two live virus vaccines (e.g., MMR, varicella, yellow fever) are not given on the same day, the doses must be separated by at least 28 days. Inactivated vaccines may be given at any spacing interval if they are not administered simultaneously. (For travelers, consult the Yellow Book (10).
1. CDC. General recommendations on immunization. MMWR 1994; 34 (RR-1).
2. AAP. 2000 Red Book: Report of the Committee on Infectious Diseases. 25th ed. Elk Grove Village, IL: AAP, 2000.
3. Visit the website: www.cdc.gov/nip/publications/pink/vaxcont.pdf 4. CDC. Guide to contraindications to childhood vaccinations. Oct. 2000.
Available online at: www.cdc.gov/nip/recs/contraindications.pdf 5. CDC. Measles, mumps, and rubella—vaccine use and strategies for
elimination of measles, rubella, and congenital rubella syndrome and con-trol of mumps. MMWR 1998; 47 (RR-8).
6. CDC. Prevention of varicella: updated recommendations of the ACIP.
MMWR 1999; 48 (RR-6).
7. CDC. Guidelines for preventing opportunistic infections among hematopoi-etic stem cell transplant recipients. MMWR 2000; 49 (RR-10).
8. CDC. Notice to readers: Revised ACIP recommendation for avoiding pregnancy after receiving a rubella-containing vaccine. MMWR 2001;
50 (49).
9. CDC. Prevention of varicella. MMWR 1996; 45 (RR-11).
10. CDC. Health Information for International Travel, 1999-2000, DHHS, Atlanta, GA.
Page 115 Appendix B: Patient Materials
Adults Only Vaccination: A Step-by-Step Guide Immunization Action Coalition www.immunize.org www.vaccineinformation.org
To access the current, ready-to-copy version of this piece, visit www.immunize.org/catg.d/p4115.pdf
Get vaccinated
This brochure was developed in cooperation with the Youth and AIDS Projects, a service program of the University of Minnesota. This brochure has been reviewed by the Centers for Disease Control and Prevention. It may be reproduced without permission. If you alter it, please acknowledge that it was adapted from the Immunization Action Coalition. Item #P4115 (5/01) Immunization Action Coalition 1573 Selby Avenue, Suite 234 St. Paul, Minnesota 55104 (651) 647-9009 website: www.immunize.org
For more information on where to get vaccinated against hepatitis B, call:
Vaccinations protect your health!
Hepatitis B 100 times easier to catch than HIV!
against this disease!These people are called “chronically infected.” Chronically infected people usually do not have symptoms, but are at increased risk for liver failure and liver cancer and need ongoing medical care. How do I know if I have or have had hepatitis B? The only way to know for sure is to have your blood tested. Up to 70% of gay and bisexual men have already been infected with HBV. Will hepatitis B vaccine protect me from hepatitis A or hepatitis C? NO. Hepatitis A and hepatitis C are different diseases caused by different viruses. Hepatitis A occurs often in men who have sex with men. There is a vaccine for hepatitis A. Talk to your doctor about whether you need this vaccine. There is no vaccine for hepatitis C. Where can I receive hepatitis B shots? Talk to your health care provider or your local public health department.
If you can’t afford a doctor, call your city or county health department.
To access the current, ready-to-copy version of this piece, visit www.immunize.org/catg.d/p4115.pdf
What is hepatitis B? Hepatitis B is a sexually transmitted liver disease caused by the hepatitis B virus (HBV). HBV is spread much like HIV, the virus that causes AIDS. HBV, however, is easier to catch than HIV because it is over 100 times more concentrated in an infected person’s blood and it can exist on surfaces outside the body. How serious is hepatitis B? HBV infection can cause severe liver disease, including liver failure (cirrhosis) and liver cancer. Over 5,000 people die every year from hepatitis B-related liver disease. How great is my risk for getting HBV infection? HBV infects one out of every 20 people living in the United States. Gay and bisexual men who have multiple partners are 10 to 15 times more likely to acquire HBV than the general population. How do I protect myself from HBV infection? •Get the hepatitis B shots •Continue to practice “safer” sex •Put a barrier between you and another person’s body fluids and blood (e.g., condom, dental dam) •Tell your friends at risk to get vaccinated with hepatitis B vaccine!
HBV can be spread by: •unprotected anal or vaginal sex •sharing needles used for drugs, body piercing, or tattooing •contact with open sores •sharing toothbrushes, razors, nail clippers, or washcloths •living in a household with a person with ongoing HBV infection. •human bites You do not get HBV from sneezing, coughing, or holding hands. What are the symptoms of HBV? •extreme tiredness •joint pain •loss of appetite •nausea, vomiting •fever •dark-colored urine •bloated and tender belly •yellowish tinged skin and eyes Only about half of people who are infected with HBV get symptoms. People who are infected with HBV, whether they have symp- toms or not, can spread the disease to others! Do people fully recover from HBV? Approximately 6% of adults who become infected will carry HBV in their bodies for years or for life and remain contagious.
How is HBV spread? HBV is not just a sexually transmitted disease. It is a hardy virus that can exist on almost any surface for up to one month. HBV is found in the blood, semen, and vaginal secretions of infected people, and low concentrations can be found in saliva.
Hepatitis B vaccination is your best protection against this disease. “I’ll have to tell Jack to go in for his hepatitis B shots, too.” (continued)
Page 117 Appendix B: Patient Materials
Adults Only Vaccination: A Step-by-Step Guide Immunization Action Coalition www.immunize.org www.vaccineinformation.org
To access the current, ready-to-copy version of this piece, visit www.immunize.org/catg.d/p4090.pdf
1573 Selby Avenue, Suite 234 St. Paul, MN 55104 (651) 647-9009 • Fax (651) 647-9131 www.immunize.org • www.vaccineinformation.org
What is hepatitis B?
Hepatitis B is a serious public health problem that affects people of all ages in the United States and around the world.
In 2001, an estimated 78,000 people contracted hepatitis B virus (HBV) infection in the United States. Hepatitis B is caused by a highly infectious virus that attacks the liver and can lead to severe illness, liver damage, and in some cases, death.
The best way to be protected from hepatitis B is to be vaccinated with hepa-titis B vaccine, a vaccine used in the U.S. for more than two decades and proven safe and effective.
Who is at risk for HBV infection?
About 5% of people in the U.S. will get infected with HBV sometime during their lives. If you engage in certain behaviors, your risk may be much higher. You may be at risk if you:
• have a job that exposes you to human blood
• share a household with someone who has lifelong HBV infection
• inject drugs
• have sex with a person infected with HBV
• have sex with more than one partner during a six-month period
• received blood transfusions in the past before excellent blood testing was available (1975)
• are a person whose parents were born in Asia, Africa, the Amazon Basin in South America, the Pacific Islands, Eastern Europe, or the Middle East
• were born in an area listed above
• were adopted from an area listed above
• are an Alaska native
• have hemophilia
• are a patient or worker in an institution for the developmentally disabled
• are an inmate of a long-term correc-tional facility
• travel internationally to areas with a high prevalence of hepatitis B
The largest outbreak of hepatitis B in the U.S. occurred in 1942 in military personnel who were given vaccine to protect them from yellow fever. It was unknown at the time that this vaccine contained a human blood component that was contaminated with HBV. The outbreak caused 28,585 cases of hepati-tis B with jaundice.
How is HBV spread?
HBV is found in blood and certain body fluids—such as serum, semen, and vagi-nal secretions—of people infected with HBV. HBV is not found in sweat, tears, urine, or respiratory secretions. Contact with even small amounts of infected blood can cause infection.
Hepatitis B virus can be spread by:
• unprotected sex
• injecting drug use
• an infected mother to her child during birth
• contact with the blood or open sores of an infected person
• human bites
• sharing a household with a chronically infected person
• sharing items such as razors, tooth-brushes, or washcloths
• pre-chewing food for babies or sharing chewing gum
• using unsterilized needles in ear or body piercing, tattooing, or acupunc-ture
• using the same immunization needle on more than one person
Hepatitis B virus IS NOT spread by:
• casual contact like holding hands
• eating food prepared by an infected person
• kissing or hugging
• sharing silverware, plates, or cups
• visiting an infected person’s home
• sneezing or coughing
What are the symptoms of hepatitis B?
Most people who get HBV infection as babies or children don’t look or feel sick at all. Similarly, almost half of adults who get infected don’t have any symp-toms or signs of the disease. If people do have signs or symptoms, they may experience any or all of the following:
• loss of appetite
• yellowing of skin and eyes (jaundice)
• nausea, vomiting
• fever
• weakness, tiredness, inability to work for weeks or months
• abdominal pain and/or joint pain
• dark urine
I’m not in a risk group. How did I get HBV infection?
Many people don’t know when or how they acquired the infection. When they get the blood test results indicating they’ve been infected with HBV, they are
Many people don’t know when or how they acquired the infection. When they get the blood test results indicating they’ve been infected with HBV, they are