Policies,Clinical,UWMF Clinical,UWMF-wide,Clinical Policies and Procedures,Medications, Drug-Specific

Immunization Administration (102.079)

Immunization Administration (102.079) - Policies, Clinical, UWMF Clinical, UWMF-wide, Clinical Policies and Procedures, Medications, Drug-Specific




Effective Date: August, 2002 Approval: See Authorization
Supersedes Policy: None Contact: Clinical Staff Education

Reviewed Nov. 2003 April 2010

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
 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)

UWMF staff will promote and follow the current Recommended Immunization Schedules,
unless otherwise instructed by the UW Health Immunization Task Force.


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 which 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.

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 with the exception of MMRV first dose where either MMRV or MMR and
varicella vaccines are both considered acceptable.

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
medical, 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.

UWMF 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
UWMF 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 

See Guide to Contraindications and Precautions to Commonly Used Vaccines
(Immunization Action Coalition)

UWMF 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 Guillain-Barre Syndrome (GBS) within 6 weeks after a previous dose of


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

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.

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

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

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

17. Follow the UWMF 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


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.

1. Center for Disease Control. www.cdc.gov
2. http://www.immunize.org
3. UW Health Immunization Task Force

UW Health Immunization Task Force

REVISED BY: Sandy Jacobson, Clinic Operations Manager, April 9, 2010

UW Health Immunization Task Force, Chaired by James Conway, M.D, 2010
LaVay Morrison, RN, BSN, Clinical Staff Educator, 2010


UWMF, Medical Director Date

UWMF, Director of Specialty Care Date

UWMF, Director of Primary Care Date


Appendix 1


Standard 1
Immunization services are readily available.
Standard 2
There are no barriers or unnecessary prerequisites to the receipt of vaccines.
Standard 3
Immunization services are available free or for a minimal fee.
Standard 4
Providers utilize all clinical encounters to screen for needed vaccines and, when indicated, vaccinate
Standard 5
Providers educate parents and guardians about immunization in general terms.
Standard 6
Providers question parents or guardians about contraindications and, before vaccinating a child, inform
them in specific terms about the risks and benefits of the vaccinations their child is to receive.
Standard 7
Providers follow only true contraindications.
Standard 8
Providers administer simultaneously all vaccine doses for which a child is eligible at the time of each visit.
Standard 9
Providers use accurate and complete recording procedures.
Standard 10
Providers co-schedule immunization appointments in conjunction with appointments for other child health
Standard 11
Providers report adverse events following vaccination promptly, accurately, and completely.
Standard 12
Providers operate a tracking system.
Standard 13
Discussion: Providers adhere to appropriate procedures for vaccine management.
Standard 14
Providers conduct semi-annual audits to assess immunization coverage levels and to review immunization
records in the patient populations they serve.
Standard 15
Providers maintain up-to-date, easily retrievable medical protocols at all locations where vaccines are
Standard 16
Providers practice patient-oriented and community-based approaches.
Standard 17
Vaccines are administered by properly trained persons.
Standard 18
Providers receive ongoing education and training regarding current immunization recommendations.