Recommendation of the Immunization Practices Advisory Committee General Recommendations on Immunization

This revision of the "General Recommendations on Immunization" updates the 1980 statement.* Changes from that statement clarify information on possible interference with the immune response by spacing immunobiologics. Recommendations for vaccinating persons with allergies are revised. New sections dealing with many aspects of immunization procedures have been added. INTRODUCTION

Recommendations for immunization of infants, children, and adults are based on facts about immunobiologics and scientific knowledge about the principles of active and passive immunization and on judgments by public health officials and specialists in clinical and preventive medicine. Benefits and risks are associated with the use of all products--no vaccine is completely safe or completely effective. The benefits range from partial to complete protection from the consequences of disease, and the risks range from common, trivial, and inconvenient side effects to rare, severe, and life-threatening conditions. Thus, recommendations on immunization practices balance scientific evidence of benefits, costs, and risks to achieve optimal levels of protection against infectious or communicable diseases.

These recommendations describe this balance and attempt to minimize the risk by providing specific advice regarding dose, route, and spacing of immunobiologics and by delineating situations warranting precautions or contraindicating their use. These recommendations may apply only in the United States, as epidemiological circumstances and vaccines may differ in other countries. The relative balance of benefits and risks may change as diseases are brought under control or eradicated. For example, because smallpox has been eradicated throughout the world, the very small risk from smallpox vaccine now exceeds the risk of smallpox; consequently, smallpox vaccination of civilians is now indicated only for laboratory workers directly involved with smallpox or closely related orthopox viruses (e.g., monkeypox, vaccinia, and others). *Replaces previous recommendations on this subject in MMWR 1980;29:76,81-83. DEFINITIONS

1. Immunobiologic: Immunobiologics include vaccines, toxoids,

and antibody containing preparations from human or animal donors, including globulins and antitoxins. These products are used for immunization.

1. Vaccine: A suspension of attenuated live or killed microorganisms (bacteria, viruses, or rickettsiae), or fractions thereof administered to induce immunity and thereby prevent infectious disease.

2. Toxoid: A modified bacterial toxin that has been rendered nontoxic but that retains the ability to stimulate the formation of antitoxin.

3. Immune globulin (IG): A sterile solution containing antibody from human blood. It is a 15%-18% protein obtained by cold ethanol fractionation of large pools of blood plasma. It is primarily indicated for routine maintenance of certain immunodeficient persons, and for passive immunization against measles and hepatitis A.

4. Specific immune globulin: Special preparations obtained from donor pools preselected for a high antibody content against a specific disease, e.g., Hepatitis B Immune Globulin (HBIG), Varicella Zoster Immune Globulin (VZIG), Rabies Immune Globulin (RIG), and Tetanus Immune Globulin (TIG).

5. Antitoxin: A solution of antibodies derived from the serum of animals immunized with specific antigens (diphtheria, tetanus) used to achieve passive immunity or to effect a treatment. B. Vaccination and immunization: Today, these terms are often

used interchangeably. The words vaccination and vaccine derive from vaccinia, the cowpox virus once used as smallpox vaccine. Thus, vaccination originally meant the inoculation of vaccinia virus to render individuals immune to smallpox. Some people still prefer that the term vaccination be restricted to this use, but many have come to use the term in a more general sense, to denote the administration of any vaccine or toxoid without regard to whether the recipient is successfully made immune.

Immunization is a more inclusive term denoting the process of inducing or providing immunity artificially by administering an immunobiologic. Immunization can be active or passive.

Active immunization denotes the production of antibody or antitoxin in response to the administration of a vaccine or toxoid. Passive immunization denotes the provision of temporary immunity by the administration of preformed antitoxin or antibodies (e.g., immunoglobulin, maternal antibodies). Three types of immunobiologics are used for passive immunization: (1) pooled human IG, (2) specific IG preparations, and (3) antitoxin.

Although there is lack of consensus that vaccination and immunization are completely synonymous, these words are used interchangeably in ACIP statements when referring to active immunization. Regardless of which term is used, it must be emphasized that administration of an immunobiologic cannot be automatically equated with the development of (or conferring of) adequate immunity because of a variety of specific factors, many of which are discussed in this statement.

C. Antigen(s): Substance(s) inducing the formation of antibodies. In some vaccines, the antigen is highly defined (e.g., pneumococcal polysaccharide, hepatitis B surface antigen, tetanus or diphtheria toxoids); in others, it is complex or incompletely defined (e.g., killed pertussis bacteria, live, attenuated viruses). IMMUNOBIOLOGICS

The specific nature and content of immunobiologics may differ. When immunobiologics against the same infectious agents are produced by different manufacturers, active and inert ingredients among the various products may differ. Practitioners are urged to become familiar with the constituents of the products they use. The constituents of immunobiologics include:

1. Suspending fluid: This frequently is as simple as sterile

water or saline, but it may be a complex fluid containing small amounts of proteins or other constituents derived from the medium or biologic system in which the vaccine is produced (serum proteins, egg antigens, cell-culture-derived antigens).

B. Preservatives, stabilizers, antibiotics: These components of vaccines are used to inhibit or prevent bacterial growth in viral culture or the final product, or to stabilize the antigen. They include such materials as mercurials and specific antibiotics. Allergic reactions may occur if the recipient is sensitive to one of these additives.

C. Adjuvants: An aluminum compound is used in some vaccines to enhance the immune response to vaccines containing inactivated microorganisms or their products (e.g., toxoids and hepatitis B virus vaccine). Vaccines with such adjuvants must be injected deeply in muscle masses, since subcutaneous or intracutaneous administration may cause local irritation, inflammation, granuloma formation, or necrosis. ROUTE, SITE, AND TECHNIQUE OF IMMUNIZATION

1. Route: There is a recommended route of administration for

each immunobiologic. To avoid unnecessary local or systemic effects and/or ensure optimal efficacy, the practitioner should not deviate from the recommended route of administration.

B. Site: Injectable immunobiologics should be administered in an area where there is minimal opportunity for local, neural, vascular, or tissue injury. Subcutaneous injections are usually administered into the thigh of infants and in the deltoid area of older children and adults. Intradermal injections are generally given on the volar surface of the forearms, except for human diploid cell rabies vaccine, with which reactions are less severe in the deltoid area.

In the past, the upper, outer quadrant of the buttocks was the usual site of intramuscular vaccination. The buttocks should not be routinely used as a vaccination site for infants and children; and, to avoid injury to the sciatic nerves, they are generally not used in adults, The central region of the buttocks should be avoided for all injections; the upper, outer quadrant should be used only for the largest volumes of injection or when multiple doses need to be given, such as when large doses of IG must be administered. The site selected should be well into the upper, outer mass of the gluteus maximus and away from the central region of the buttocks.

Currently, preferred sites for intramuscular injections are the anterolateral aspect of the upper thigh and the deltoid muscle of the upper arm. In most infants, the anterolateral aspect of the thigh provides the largest muscle mass and, therefore, is the preferred site. In older children, the deltoid mass is of sufficient size for intramuscular injection. An individual decision must be made for each child, based on the volume of the injected material and the size of the muscle into which it is to be injected. Many practitioners prefer to continue using the anterolateral thigh until age 3 years before switching to the deltoid area. In adults, the deltoid is generally used for routine intramuscular vaccine administration.

C. Techniques: Before giving the injection, the needle is inserted in the site, and the syringe plunger is pulled back to see if blood appears; if so, the needle should be withdrawn and a new site selected. The same procedure is followed until no blood appears. A separate needle and syringe should be used for each injection. Disposable needles and syringes should be discarded in labeled containers to prevent accidental inoculation or theft. If more than one vaccine preparation is administered, each should be given at a different site. DOSAGE

The recommended doses of immunobiologics are derived from theoretical considerations, experimental trials, and clinical experience. Administration of dose volumes smaller than those recommended, such as split doses or intradermal administration (unless specifically recommended), may result in inadequate protection. Exceeding the recommended dose volumes might be hazardous because of excessive local or systemic concentrations of antigens.

Some practioners use divided doses of vaccine (particularly diphtheria and tetanus toxoids and pertussis vaccine (DTP)) to reduce reaction rates. There has not been adequate study of the efficacy of such practices by serologic confirmation or clinical efficacy or of the effects on the subsequent frequency and severity of adverse reactions. The Committee does not recommend dividing doses of any vaccine. AGE AT WHICH IMMUNOBIOLOGICS ARE ADMINISTERED

Several factors influence recommendations concerning the age at which vaccine is administered (Tables 1-3). These include: age-specific risks of disease, age-specific risks of complications, ability of individuals of a given age to respond to the vaccine(s), and potential interference with the immune response by passively transferred maternal antibody. In general, vaccines are recommended for the youngest age group at risk with an acceptable level of antibody response following vaccine administration. For example, while infants as young as 6 months of age may be at risk for measles, most are protected by maternal antibody, which may inhibit successful active immunization at this age. In the United States, measles vaccine is routinely administered at 15 months of age, by which time maternal antibody is no longer detectable.

In certain measles epidemics, public health officials may recommend measles vaccine for infants as young as 6 months of age. Although a smaller proportion of those given vaccine before the first birthday develop antibody to measles, compared with older infants, the higher risk of disease during an epidemic may justify earlier immunization. Such infants should be reimmunized at the recommended age for measles vaccination to achieve protection. SPACING OF IMMUNOBIOLOGICS

1. Multiple doses of same antigen: Some products require more

than one dose for full protection. In addition, it is necessary to give periodic reinforcement (booster) doses of some preparations to maintain protection. In recommending the ages and/or intervals for age for measles vaccination to achieve protection. SPACING OF IMMUNOBIOLOGICS

1. Multiple doses of same antigen: Some products require more

than one dose for full protection. In addition, it is necessary to give periodic reinforcement (booster) doses of some preparations to maintain protection. In recommending the ages and/or intervals for multiple doses, the Committee takes into account current risks from disease and the objective of inducing satisfactory protection. Intervals between doses that are longer than those recommended do not lead to a reduction in final antibody levels. Therefore, it is unnecessary to restart an interrupted series of an immunobiologic or to add extra doses. By contrast, giving doses of a vaccine or toxoid at less than recommended intervals may lessen the antibody response; doses given at less than recommended intervals should not be counted as part of a primary series.

B. Different antigens: Experimental evidence and extensive clinical experience have strengthened the scientific basis for giving certain vaccines at the same time. Most of the widely used antigens can safely and effectively be given simultaneously. This knowledge is particularly helpful in circumstances that include imminent exposure to several infectious diseases, preparation for foreign travel, or uncertainty that the patient will return for further doses of vaccine.

In general, inactivated vaccines can be administered simultaneously at separate sites. It should be noted, however, that when vaccines commonly associated with local or systemic side effects (such as cholera, typhoid, and plague vaccines) are given simultaneously, the side effects theoretically might be accentuated. When practical, these vaccines should be given on separate occasions.

Field observations indicate that simultaneous administration (on the same day) of the most widely used live-virus vaccines has not resulted in impaired antibody response or increased rates of adverse reactions. Observation of children indicates that antibody responses to trivalent oral polio vaccine (OPV) given simultaneously with licensed combination measles-mumps-rubella (MMR) vaccine are comparable to those obtained when the same vaccines are given at separate visits. It is reasonable to expect equivalent immunologic responses when other licensed combination or live, attenuated-virus vaccines or their component antigens are given simultaneously with OPV. While data are lacking on potential interference with antibody responses to measles, mumps, rubella, and/or trivalent oral polio vaccines administered at different times within 1 month of one another, there are theoretical concerns and data showing that the immune response to a live virus vaccine might be impaired if the vaccine is administered within the month following another live virus vaccine. When feasible, live virus vaccines not administered on the same day should be given at least 1 month apart.

No data indicate that simultaneous administration of individual measles, mumps, or rubella antigens at different sites yields different results from administration of the combined vaccines in a single site.

Data on the response to simultaneous administration of diphtheria and tetanus toxoids and pertussis vaccine (DTP), OPV, and MMR vaccine are lacking. However, field experience and antibody data regarding simultaneous administration of either DTP and measles vaccine or DTP and OPV indicate that the protective response is satisfactory and adverse reactions do not increase. Therefore, simultaneous administration of all these antigens is recommended when individuals require multiple antigens and there is doubt that the recipient will return to receive further doses of vaccine. Children l5 months of age or older who have received fewer than the recommended number of DTP and OPV doses fall into this category (Table 2). Simultaneous administration of pneumococcal polysaccharide vaccine and whole-virus influenza vaccine gives satisfactory antibody response without increasing the occurrence of adverse reactions. Simultaneous administration of the pneumococcal vaccine and split-virus influenza vaccine may also be expected to yield satisfactory results. However, it should be kept in mind that influenza vaccine should be administered annually to the target population, whereas, under current recommendations, pneumococcal polysaccharide vaccine should only be administered in a single dose.

An inactivated vaccine and a live, attenuated-virus vaccine can be administered simultaneously at separate sites, with the precautions that apply to the individual vaccines. Some data suggest that the simultaneous administration of cholera and yellow fever vaccines may interfere with the immune response to each other. Decreased levels of antibodies have been observed when the vaccines are administered within 3 weeks of each other, compared with administration of the vaccines at longer intervals. However, there is no evidence that protection to either of these diseases diminishes when these vaccines are administered simultaneously. Therefore, the Committee believes that yellow fever and cholera vaccines can be administered simultaneously, if necessary.

C. Immune globulin: Immune globulin (IG, formerly called Immune Serum Globulin, ]ISG^) and various specific immune globulins contain antibodies common to the population from which the pooled plasma used in their preparation was obtained. These antibodies may interfere with the effectiveness of live, attenuated vaccines administered shortly after IG or specific IG has been given.

In general, such interference is of little practical importance with inactivated products. They can, therefore, be given anytime after IG use. With live, attenuated vaccines, passively acquired antibody may interfere with replication of vaccine virus and thus with the antibody response of the patient. Parenterally administered live vaccines (e.g., MMR or other combinations) should, therefore, not be given for at least 6 weeks, but preferably 3 months, after the administration of IG. Preliminary data indicate that IG does not interfere with the immune response either to OPV or yellow fever vaccine.

If IG administration becomes necessary after a live vaccine has been given, interference may occur. In general, vaccine virus replication and stimulation of immunity will occur within 7 to 10 days. Thus, if the interval between vaccine and IG is less than 14 days, vaccine should be repeated about 3 months after IG was given, unless serologic testing indicates that antibodies have been produced; if the interval was longer, vaccine need not be readministered. If administration of IG becomes necessary because of imminent exposure to disease, live virus vaccines may be administered simultaneously with IG, with the recognition that vaccine-induced immunity may be compromised. The vaccine should be administered in a site remote from that chosen for IG inoculation. Vaccination should be repeated about 3 months later, unless serologic testing indicates antibodies have been produced. HYPERSENSITIVITY TO VACCINE COMPONENTS

Vaccine antigens produced in systems or with substrates containing allergenic substances, e.g., antigens derived from growing microorganisms in embryonated chicken eggs, may cause hypersensitivity reactions. These reactions may include anaphylaxis when the final vaccine contains a substantial amount of the allergen. Yellow fever vaccine is such an antigen. Vaccines with such characteristics should not be given to persons with known hypersensitivity to components of the substrates. Contrary to this generalization, influenza vaccine antigens (whole or split), although prepared from viruses grown in embryonated eggs, are highly purified during preparation and have only very rarely been reported to be associated with hypersensitivity reactions.

Live virus vaccines prepared by growing viruses in cell cultures are essentially devoid of potentially allergenic substances related to host tissue. On very rare occasions, hypersensitivity reactions to measles vaccine have been reported in persons with anaphylactic hypersensitivity to eggs. Measles vaccine, however, can be given safely to egg-allergic individuals provided the allergies are not manifested by anaphylactic symptoms. Since mumps vaccine is grown in similar cell cultures, the same precautions apply.

Screening persons by history of ability to eat eggs without adverse effects is a reasonable way to identify those possibly at risk from receiving measles, mumps and influenza vaccine. Individuals with anaphylactic hypersensitivity to eggs (hives, swelling of the mouth and throat, difficulty breathing, hypotension, or shock)* should not be given these vaccines.

Rubella vaccine is grown in human diploid cell culture and can be safely given, regardless of a history of allergy to eggs or egg proteins.

Bacterial vaccines, such as cholera, DTP, plague, and typhoid, are frequently associated with local or systemic adverse effects; these common reactions do not appear to be allergic.

Some vaccines contain preservatives (e.g., thimerosal, a mercurial) or trace amounts of antibiotics (e.g., neomycin) to which patients may be hypersensitive. Those administering vaccines should carefully review the information provided with the package insert before deciding whether the rare patients with known hypersensitivity to such preservatives or antibiotics should be given the vaccine(s). No currently recommended vaccine contains penicillin or its derivatives. *Any of these signs or symptoms constitutes a systemic anaphylactic response.

Some vaccines (e.g., MMR vaccine or its individual component vaccines) contain trace amounts of neomycin. This amount is less than would usually be used for the skin test to determine hypersensitivity. Persons who have experienced anaphylactic reactions to neomycin should not receive these vaccines. Most often, neomycin allergy is a contact dermatitis, a manifestation of a delayed-type (cell-mediated) immune response rather than anaphylaxis. In such individuals, the adverse reaction, if any, to neomycin in the vaccines would be an erythematous, pruritic papule at 48-96 hours. A history of delayed-type reactions to neomycin is not a contraindication to receiving these vaccines. ALTERED IMMUNOCOMPETENCE

Virus replication after administration of live, attenuated-virus vaccines may be enhanced in persons with immune deficiency diseases, and in those with suppressed capability for immune response, as occurs with leukemia, lymphoma, generalized malignancy, or therapy with corticosteroids, alkylating agents, antimetabolites, or radiation. Patients with such conditions should not be given live, attenuated-virus vaccines. Because of the possibility of familial immunodeficiency, live, attenuated-virus vaccines should not be given to a member of a household in which there is a family history of congenital or hereditary immunodeficiency until the immune competence of the potential recipient is known. OPV should not be given to a member of a household in which there is a family history of immunodeficiency or immunosuppression, regardless whether acquired or hereditary, until the immune status of the recipient and the other family members is known. Individuals residing in the household of a immunocompromised individual should not receive OPV, because vaccine viruses are excreted by the recipient of the vaccine and may be communicable to other persons. SEVERE FEBRILE ILLNESSES

Minor illnesses, such as mild upper-respiratory infections, should not postpone vaccine administration. However, immunization of persons with severe febrile illnesses should generally be deferred until they have recovered. This precaution is to avoid superimposing adverse effects from the vaccine on the underlying illness or mistakenly identifying a manifestation of the underlying illness as a result of the vaccine. In persons whose compliance with medical care cannot be assured, it is particularly important to take every opportunity to provide appropriate vaccinations. VACCINATION DURING PREGNANCY

On the grounds of a theoretical risk to the developing fetus, live, attenuated-virus vaccines are not generally given to pregnant women or to those likely to become pregnant within 3 months after receiving vaccine(s). With some of these vaccines--particularly rubella, measles, and mumps--pregnancy is a contraindication. Both yellow fever vaccine and OPV can be given to pregnant women at substantial risk of exposure to natural infection. When vaccine is to be given during pregnancy, waiting until the second or third trimester to minimize any concern over teratogenicity is a reasonable precaution. If a pregnant woman receives a live, attenuated-virus vaccine, there is not necessarily any real risk to the fetus. In particular, although there are theoretical risks in giving rubella vaccine during pregnancy, data on previously and currently available rubella vaccines indicate that the risk, if any, of teratogenicity from live rubella vaccine is quite small. There has been no evidence of congenital rubella syndrome in infants born to susceptible mothers who received rubella vaccine during pregnancy.

Since persons given measles, mumps, or rubella vaccine viruses do not transmit them, these vaccines may be administered with safety to children of pregnant women. Although live polio virus is shed by children recently immunized with OPV (particularly following the first dose), this vaccine can also be administered to children of pregnant women. Polio immunization of children should not be delayed because of pregnancy in close adult contacts. Experience to date has not revealed any risks of poliovaccine virus to the fetus.

There is no convincing evidence of risk to the fetus from immunization of pregnant women using inactivated virus vaccines, bacterial vaccines, or toxoids. Tetanus and diphtheria toxoid (Td) should be given to inadequately immunized pregnant women because it affords protection against neonatal tetanus. There is no risk to the fetus from passive immunization of pregnant women with IG (see below). For further information regarding immunization of pregnant women, refer to the American College of Obstetricians and Gynecologists (ACOG) Technical Bulletin Number 14, May 1982. ADVERSE EVENTS FOLLOWING IMMUNIZATION*

Modern vaccines are extremely safe and effective, but not completely so. Adverse events following immunization have been reported with all vaccines. These range from frequent, minor, local reactions to extremely rare, severe, systemic illness such as paralysis associated with OPV. To improve knowledge about adverse reactions, all temporally associated events severe enough to require the recipient to seek medical attention should be evaluated and reported in detail to local or state health officials and to the vaccine manufacturer. It is frequently impossible to establish cause-and-effect relationships when untoward events occur after receiving vaccine(s) since temporal association alone does not necessarily indicate causation. DISEASE CONTROL THROUGH CONTINUING PROGRAMS

The best means of reducing the occurrence of vaccine-preventable diseases of childhood (diphtheria, pertussis, tetanus, polio, measles, mumps, and rubella) is by having a highly immune population. Universal immunization is an important part of good health care and should be accomplished through routine and intensive programs carried out in physicians' offices and public health clinics. Programs aimed at ensuring that all children are immunized at the recommended age should be established and maintained in all communities. In addition, all other susceptible persons (regardless of age) should be immunized, unless vaccine is otherwise contraindicated. *More complete information on adverse reactions to a specific vaccine may be found in the ACIP recommendations for specific vaccines.

Official health agencies should take whatever steps are necessary, including development and enforcement of school immunization requirements, to assure that all persons in schools at all grade levels and those in day-care centers are protected against the vaccine-preventable diseases of childhood.

Official personal immunization record cards have been adopted by every state and the District of Columbia to encourage uniformity of records and to facilitate the assessment of immunization status by schools and day-care centers. In many states, these cards are distributed to new mothers while they are still in the hospital following delivery. The records are used as one teaching tool in immunization education programs aimed at increasing parental awareness of the need for vaccines. The Committee recommends the use of these standard records by all health care providers.

A permanent, comprehensive immunization record should be established for each newborn infant and maintained by the parent. Physicians should encourage parents to use the record and should record all immunization data. Parents or guardians should be urged to bring the record every time the child sees a health care provider. Health care providers should review the immunization status of children at each visit. At a minimum, the type of immunobiologic administered and the date of administration should be entered into the patient's immunization record.

Maintenance of personal immunization records is very important, since persons in this country relocate frequently. This will facilitate accurate record-keeping for the patient, assist with physician encounters, and fulfill the need for documentation of immunization in schools and other institutions and organizations.

Every health care provider should maintain a permanent record of the immunization history of each patient so information can be updated when subsequent vaccine(s) are administered, and patients in need of immunization can easily be identified and recalled. These records should contain the type of vaccine or other immunobiologic administered, date of administration, manufacturer, and lot number.

Recall or tickler systems have been developed to identify children who are due for immunizations or behind schedule for immunizations so parents can be contacted to have them immunized. The Committee recommends the use of these systems by all health care providers.

Dates of immunization (at least month and year) should be required on institutional immunization records, such as those kept in schools and day-care centers, to assure that children have received vaccines at an acceptable age and according to an appropriate schedule. This will facilitate assessment that a primary vaccine series has been completed and that any needed boosters have been obtained at the appropriate time. Measles, mumps, and rubella immunizations should be considered adequate only if they were administered on or after the and day-care centers, to assure that children have received vaccines at an acceptable age and according to an appropriate schedule. This will facilitate assessment that a primary vaccine series has been completed and that any needed boosters have been obtained at the appropriate time. Measles, mumps, and rubella immunizations should be considered adequate only if they were administered on or after the first birthday (the currently recommended age for routine measles immunization is 15 months). Administration of MMR vaccine at 15 months is desirable for use in routine infant-child immunization programs. SOURCES OF VACCINE INFORMATION

Apart from these general recommendations, which are published at approximately 2-year intervals, the practitioner can draw on a variety of sources for specific data and updated information including:

1. Official package circular--Manufacturers provide

product-specific information along with each vaccine; some of these are reproduced in their entirety in the Physician's Desk Reference (PDR) and dated.

B. Morbidity and Mortality Weekly Report (MMWR)--This report is published weekly by CDC and contains vaccine recommendations, reports of specific disease activity, policy statements, and the regular and special recommendations of this Committee. The MMWR will contain any necessary updated information on the ACIP recommendations. Subscription price for domestic (United States, Canada, and Mexico) is $70.00 (third class) and $90.00 (first class), and the foreign price is $140 (airmail printed matter) and $155 (airmail letter). Write: MMWR, National Technical Information Services, 5282 Port Royal Road, Springfield, Virginia 22161.

C. Health Information for International Travel--This booklet is published annually by CDC as a guide to requirements and recommendations for specific immunizations and health practices for travel to various countries. It can be obtained for $5 from the Superintendent of Documents, U. S. Government Printing Office, Washington, D.C. 20402.

D. Advisory memoranda--Memoranda are published when necessary by CDC to advise international travelers or those who provide information to travelers about specific outbreaks of communicable diseases abroad. These memoranda include health information for prevention and specific recommendations for immunization and may be obtained at the present time at no cost by writing the Division of Quarantine, Centers for Disease Control, Atlanta, Georgia 30333, to request placement on the mailing list.

E. The Report of the Committee on Infectious Diseases of the American Academy of Pediatrics (Red Book)--The full report containing recommendations on all licensed vaccines is usually updated every 4-5 years. The most recent Red Book was published in 1982. The cost is $15.00, plus mailing. It may be ordered from: American Academy of Pediatrics, P. O. Box 1034, Evanston, Illinois 60204.

F. Red Book Update--The Committee on Infectious Diseases of the American Academy of Pediatrics publishes its recent positions and specific recommendations in Pediatrics after each quarterly meeting. A yearly subscription costs $37.50. It may be ordered from the address listed in E above.

G. Control of Communicable Diseases in Man--This manual is published by the American Public Health Association at approximately 5-year intervals. The thirteenth edition (1980) is available now. The manual contains valuable information concerning infectious diseases, their occurrence worldwide, immunization, diagnostic and therapeutic information, and up-to-date recommendations on isolation and other control measures for each disease presented. It may be ordered at a cost of $7.50 from: The American Public Health Association, 1015 Fifteenth Street, N.W., Washington, D.C. 20005.

H. Technical Bulletins of the American College of Obstetricians and Gynecologists (ACOG)--These bulletins, which are updated periodically, contain important information on immunization of pregnant women. A set may be ordered at a cost of $7.50 from: American College of Obstetricians and Gynecologists, Attention: Distribution Center, 600 Maryland Avenue, S.W., Suite 300 East, Washington, D.C. 20024.

1. Most state and many local health departments provide routine

immunizations, immunization cards, and schedules to patients. They also send out routine reports of disease incidence.

J. Additional information can also be obtained from city, county, or state health departments, medical schools, and large hospitals. Specific questions may be addressed to the Division of Immunization, Centers for Disease Control, Atlanta, Georgia 30333, telephone, (404) 329-3311. PATIENT INFORMATION

Parents and patients should be informed about the benefits and risks of vaccines. It is essential that the patient or responsible person be given information concerning the risks of vaccines as well as the major benefits from vaccines in preventing disease in both individuals and the community. Benefit and risk information should be presented in terminology that is as simple as possible. No formal and legally acceptable statement has been universally adopted for the private medical sector. CDC has developed "Important Information Statements" for use with federally purchased vaccines given in public health clinics. Practitioners may wish to consider these or similar materials for parents and patients. The Committee recommends that there be ample opportunity for questions before each immunization.

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