DFM Policy & Procedure Manual
□ Clinical Operations
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Title:
Immunization Policy
PURPOSE
The purpose of this policy is to uphold:
 Recommended Immunization Schedules for Persons Aged 0 through 18
Years as approved by the American Academy of Pediatrics (AAP), the Advisory
Committee on Immunization Practices (ACIP)and the American Academy of
Family Physicians (AAFP).
 Recommended Adult Immunization Schedule as approved by the Advisory
Committee on Immunization Practices (ACIP), the American Academy of Family
Physicians (AAFP), the American College of Obstetricians and Gynecologists
(ACOG), and the American College of Physicians (ACP)
DFM staff will promote and follow the current Recommended Immunization Schedules,
unless otherwise instructed by the UW Health Immunization Task Force.
PRINCIPLES
The UW Health Immunization Task Force discourages any practice that deviates from the
ACIP Recommended Immunization Schedules.
Vaccination providers should adhere to the following immunization principles:
INTERVALS: Intervals between doses of multidose antigens provide optimal protection
and/or have the best evidence of efficacy.
AGE: Vaccines are recommended for members of the youngest age group at risk for
experiencing the disease for whom efficacy and safety have been demonstrated. Delaying
administration of vaccines leaves patients at risk for infection during their most
vulnerable ages.
SIMULTANEOUS ADMINISTRATION: Simultaneously administering all vaccines
for which a person is eligible is critical, because simultaneous administration increases
the probability that a child will be vaccinated fully at the appropriate age.
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DFM Policy & Procedure Manual
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Immunization Policy
COMBINATION VACCINES: Use of licensed combination vaccines is preferred to
separate injection of their equivalent component vaccines to reduce the number of
injections and missed opportunities.
ALTERNATE PRODUCTS: Medication errors and patient safety are of increasingly
concern and every effort must be made to prevent them. Stocking multiple brands of the
same or similar medications increases the likelihood of errors.
INTERCHANGEABILITY: Certain vaccines are available from different
manufacturers, and these vaccines usually are not identical. Whenever possible, the same
brand of vaccine should be used for all doses of the vaccination series. If vaccination
providers do not know or have available the type of vaccine previously administered to a
child, any age-appropriate vaccine containing the appropriate antigens should be used to
continue or complete the series.
LAPSES: Longer-than-recommended intervals between doses do not reduce final
antibody concentrations. An interruption in the vaccination schedule generally does not
require restarting the entire series of a vaccine.
VACCINATION STATUS: Providers should only accept written, dated records as
evidence of vaccination. Self-reported doses of vaccine without written documentation
should not be accepted. If records cannot be located, these persons should be considered
susceptible and should be started on the age-appropriate vaccination schedule. Serologic
testing for immunity is an alternative to vaccination if there is a history of disease.
VIS: CDC Vaccine Information Statements must be provided for all vaccines offered and
an opportunity to ask questions offered.
REFUSALS/DECLINATION DOCUMENTATION: A limited number of persons
will have religious or personal objections to vaccinations. For patients and parents who
refuse immunization for other reasons (personal conviction waivers),
declination/responsibility refusal forms should be used. For providers who do choose to
offer alternative immunization schedules, obtaining informed consent from families
indicating that they have been counseled on the recommended schedule and declining to
follow those recommendations is advised. Parents should be advised of state laws
pertaining to school or child-care entry, which might require that unvaccinated children
be excluded from school or child care during outbreaks.
DFM Policy & Procedure Manual
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□ Clinical Operations
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Immunization Policy
STANDARDS
DFM staff will adhere to the CDC/ACIP/AAP Standard for Childhood Immunizations
(Appendix 1) and as distinguished below in the components of accessibility, education,
vaccine precautions, administration, documentation and follow up.
ACCESSIBILITY: All children will have every opportunity and encouragement to
receive immunizations in accordance with the Recommended Immunization Schedules
for Persons Aged 0 through 18 Years. Accessibility to these vaccines may include the
Vaccines for Children Program (VFC), a federally funded vaccine supply program in
which the providers throughout UWMF participate. In this program vaccines are
provided through the Wisconsin Immunization Program to public and private providers to
vaccinate eligible children at no cost to providers. Eligible children for the VFC program
are those from birth through 18 years old who: a) Are eligible for Medicaid, b) Have no
health insurance c) Are Native American or Alaska Native, d) Have health insurance that
does not cover immunizations. A supplemental component of the VFC program includes
the availability of free hepatitis B vaccine to all newborn infants, regardless of payor
status, who are delivered at VFC participating birthing hospitals where DFM physicians
practice.
EDUCATION: Education about the use of immunizations and their benefits and risks
will be provided to the parent or legal guardian of any child to whom the provider intends
to administer a vaccine. This includes the use of, but is not limited to, the federally
mandated use of Vaccine Information Statements (VIS). Vaccine Information Statements
(VIS’s) are information sheets produced by the CDC to explain vaccines to recipients,
their parents, or their legal guardian. VIS’s explain the benefits and risks of a vaccine and
are required by Federal law to be given out either before each dose of a vaccine covered
under the National Childhood Vaccine Injury Act or by a mechanism approved by the
Attorney General of the State of Wisconsin.
CLINICAL STAFF EDUCATION: Clinical staff must maintain currency of an
immunization services knowledge base that includes the review of the following
immunization curriculum:
 Teaching
Immunization
Delivery
and
Evaluation

http://www2.edserv.musc.edu/tide/menu.lasso
and/or
 Understanding the Basics: General Recommendations on Immunization
2005

http://www.cdc.gov/vaccines/ed/youcalltheshots.htm
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Immunization Policy
VACCINE CONTRAINDICATIONS AND PRECAUTIONS
See Guide to Contraindications and Precautions to Commonly Used Vaccines
(Immunization Action Coalition)
DFM staff will screen prospective vaccine recipients for the following conditions and
consult with the provider if these exist:
 Severe allergic reaction (e.g. anaphylaxis) after a previous vaccine dose or to a
vaccine component.
 Pregnancy
 Known severe immunodeficiency (hematologic and solid tumors; receiving
chemotherapy; congenital immunodeficiency; long-term immunosuppressive
therapy,; or patients with HIV infection who are severely immunocompromised.
 Moderate to severe acute illness with or without fever. History of GuillainBarre Syndrome (GBS) within 6 weeks after a previous dose of vaccine.
PROCEDURE: VACCINE ADMINISTRATION
1. Physician, PA, NP must be present in the clinic before administering
immunizations.
2. Obtain a patient’s past immunization history by referring to the patient’s
clinical record and Wisconsin Immunization Registry (WIR).
3. Obtain/review a history of allergies or other disease conditions proper to
initiation of immunization of any patient; if there is a history of allergies
in the family (i.e. latex) or of previous reaction to the same
immunization, refer the patient to a physician or provider.
4. Provide a patient or responsible party the appropriate Vaccine Information
Statement (VIS) from the Centers for Disease Control, or provide the
equivalent information in another form if necessary.
5. Inform parents, guardians, legal representatives, and adolescent and adult
patients about the benefits and risks of vaccines in an understandable
language. Provide an opportunity for questions and the provision of
answers by the nurse or physician before each vaccination.
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Immunization Policy
6. Administer immunizations according to a provider’s active order or by
protocol..
7. Administer immunizations using standard precautions and vaccine
administration procedures, including the use of OSHA approved needle
protection systems.
8. Follow specific instructions of each vaccine. Check expiration date,
appearance, and color of vaccine, if appropriate. Review package inserts
regarding dosage, administration (including specifications for needle
length for SQ or IM injections) and contraindications for immunization.
9. Prepare skin area appropriately if immunization will be injected. If
immunization is delivered via oral or nasal route, administer according to
directions on package insert.
10. Check medication label and verify with order, drawing up appropriate
dose (if applicable)
11. Confirm with patient immunization to be given prior to administration.
12. Give medication by route (IM, SQ, Orally, ID) as appropriate – per
package insert.
13. Instruct patient or caregiver about expected reaction, possible side effects
and if appropriate, time interval between immunization. Information is
given regarding the time interval during which reaction is likely to occur,
symptoms, action to alleviate symptoms, duration of symptoms, and time
interval between immunizations, if the immunization is part of a series.
Provide Health Facts For You #5240- Immunizations for Children and
Adults.
14. Observe patient for 15 minutes following injection and observe for any
untoward reaction.
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Immunization Policy
15. Notify physician immediately in the event of respiratory distress,
anaphylaxis or angioneurotic edema (swelling of throat and pharynx) or
call a ‘code blue’ if necessary. Refer to UWMF Anaphylactic Protocol
for treatment guide.
16. Report all untoward reaction to immunizations, such as fever, rash,
abscesses to the physician.
17. Follow the DFM Vaccine Refusal Policy and Procedure, should a patient
or responsible party refuse a routinely recommended vaccine for their
child, after educating the patient or responsible party of the benefits and
risks of the vaccine, and the risks of refusing the vaccine.
HealthLink or other type of patient medical record, document the following items:
 vaccine used
 date of immunization
 name of the person giving the immunization
 publication date of the VIS which was given
 in Progress Note area type in .npwimm and complete text (HealthLink)
 signed refusal, if warranted
Wisconsin Immunization Registry (WIR):
 Immunization given
 Dose given
 Injection site
 Route of administration
 Lot number
 Manufacturer
 Expiration date
 Name of ordering clinician
 Name of person administering immunization
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DFM Policy & Procedure Manual
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Immunization Policy
AFTER INJECTION PROCEDURE
1. Before discharge from the clinical area, advise the patient and/or family regarding
possible reactions and their treatment.
2. Report any adverse reactions to the provider and record them in the patient’s medical
record. Report all significant adverse reactions to the federal Vaccine Adverse Event
Reporting System at www.vaers.hhs.gov or (800)-822-7967.
3. Activate a process or system in place to remind and recall those patients who are
overdue for recommended immunizations.
REFERENCES
1. Center for Disease Control. www.cdc.gov
2. http://www.immunize.org
3. UW Health Immunization Task Force
WRITTEN BY:
UW Health Immunization Task Force
REVISED BY: Sandy Jacobson, Clinic Operations Manager, April 9, 2010
For DFM specific clinics – Sue Kaletka, Director of Clinical Care
Services, December 17, 2010
REVIEWED BY:
UW Health Immunization Task Force, Chaired by James Conway, M.D, 2010
LaVay Morrison, RN, BSN, Clinical Staff Educator, 2010
Authorization:
Date: 12/20/2010
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