Microsoft word - flu immunization screening tool rev oct 2009 intranasal.doc

Department of State Health Services, Immunization Branch
Screening Questionnaire for Intranasal 2009 H1N1 Influenza Vaccine
1. Is the person to be vaccinated younger than 2 years of age or older than 49 years of age? If YES, person is not eligible for Intranasal Influenza vaccine. Please consider injectable influenza vaccine. 2. Have you read the vaccine information statement(s) for the vaccine(s) you plan to receive today? If YES, “Do you have any questions”? If NO, “Please take a few moments to read it/them now”. 3. Is the person to be vaccinated moderately or severely ill today? If YES, please describe the illness. (Mild illness, such as colds or seasonal allergies, even if accompanied by a low-grade fever, is not a contraindication to vaccination. Vaccination should always be delayed if illness is moderate to severe). 4. Has the person to be vaccinated ever had a serious reaction after receiving a vaccination? If YES, please describe the vaccine involved and the reaction. (Anaphylactic reaction to any vaccine contraindicates further doses of that vaccine). 5. Has the person to be vaccinated ever been paralyzed with Guillain-Barré syndrome (an illness with sudden muscle weakness and some loss of senses in the fingers and toes)? If YES, defer immunization and consult with your doctor. Flu vaccine may slightly increase your risk for recurrence. 6. Does the person to be vaccinated have a serious allergy to eggs? If YES, please clarify with the recipient that the allergy is “serious”. In general, persons who can eat eggs or egg product without reaction can be vaccinated. A history of anaphylactic or anaphylactic-like allergy to eggs or egg product is a contraindication to flu vaccination. 7. Does the person to be vaccinated have a long-term health problem with heart disease, lung disease, asthma, kidney disease, neurologic or neuromuscular disease, liver disease, metabolic disease (e.g., diabetes), or anemia or another blood disorder? If YES, the person is not eligible for vaccination with the intranasal influenza vaccine, please consider using injectable influenza vaccine. DSHS Immunization Branch • PO Box 149347 • Austin, TX 78714-9347 • (800) 252-9152 8. If the person to be vaccinated is less than 5 years of age, in the past 12 months has a healthcare provider ever told you that he or she had wheezing or asthma? If YES, the person is not eligible for vaccination with the intranasal influenza vaccine, please consider using injectable influenza vaccine. 9. Does the person to be vaccinated have a weakened immune system due to illness or long-term treatment? If YES, the person is not eligible for vaccination with the intranasal influenza vaccine, please consider using injectable influenza vaccine. 10. If the person to be vaccinated is a child or teen, is he or she receiving aspirin therapy or aspirin-containing If YES, the person is not eligible for vaccination with the intranasal influenza vaccine, please consider using injectable influenza vaccine. 11. Is the person to be vaccinated pregnant or planning to become pregnant within the next month? If YES, the person is not eligible for vaccination with the intranasal influenza vaccine, please consider using injectable influenza vaccine. 12. Has the person to be vaccinated taken anti-viral (such as Tamiflu or Relenza) agent within the last 48 hours? If YES, the person is not eligible for vaccination with the intranasal influenza vaccine at this time, please consider using injectable influenza vaccine, or they will have to return 48 hours after completing the anti-viral. 13. Does the person to be vaccinated live with or expect to have close contact with a person whose immune system is severely compromised and who must in a protective isolation (such as in a hospital room with reverse air flow)? If YES, the person is not eligible for vaccination with the intranasal influenza vaccine, please consider using injectable influenza vaccine. 14. Have you received any other vaccination in the past 4 weeks? If the individuals states that have received a live virus vaccine (such as MMR, varicella, and Flu Mist) within the last 4 weeks, then they are not a candidate for intranasal vaccine at this time; please consider using injectable vaccine. Note: Two live vaccines (such as MMR, varicella, and Flu Mist) must be separated by 4 weeks if not given at the same time (exception - nasal vaccines cannot be given at the same time), but live and inactivated vaccines can be given at any time. DSHS Immunization Branch • PO Box 149347 • Austin, TX 78714-9347 • (800) 252-9152

Source: http://www.pediatricassociates.net/H1N1ScreeningTool-Intranasal.pdf