Cuestionario de nombre del paciente …

1 Cuestionario de contraindicaciones para vacunaci n de adultosA los pacientes: Las siguientes preguntas nos ayudar n a determinar cu les vacunas le podemos dar hoy. Si contesta s a alguna pregunta, eso no siempre quiere decir que no lo deben vacunar. Simplemente quiere decir que hay que hacerle m s preguntas. Si alguna pregunta no est clara, pida a su profesional de la salud que se la explique. 1. Est enfermo hoy? 2. Es al rgico a alg n medicamento, alimento, a alg n componente de las vacunas o al l tex? 3. Tuvo alguna vez una reacci n seria despu s de vacunarse? 4. Tiene alg n problema de salud a largo plazo, como enfermedad del coraz n, enfermedad de los pulmones, asma, enfermedad de los ri ones, enfermedad metab lica (como la diabetes), anemia o alg n otro trastorno de la sangre?

2 5. Tiene c ncer, leucemia, VIH/SIDA o alg n otro problema del sistema inmunol gico? 6. En los ltimos 3 meses ha tomado medicamentos que afecten su sistema inmunol gico, como prednisona, otros esteroides o medicamentos contra el c ncer; medicamentos para el tratamiento de la artritis reumatoide, la enfermedad de Crohn o la psoriasis; o ha tenido tratamientos de radiaci n? 7. Tuvo alguna vez convulsiones o problemas del cerebro o alg n otro problema del sistema nervioso? 8. Durante el a o pasado, le hicieron una transfusi n de sangre o de productos de la sangre, o le dieron inmunoglobulina o gamaglobulina o un medicamento antiviral?

3 9. Para las mujeres: Est embarazada o hay alguna posibilidad de que quede embarazada en el pr ximo mes? 10. Le aplicaron alguna vacuna en las ltimas 4 semanas? formulario llenado por fecha formulario revisado por fecha Trajo su comprobante de vacunaci n hoy? s no Es importante que tenga un comprobante de vacunaci n personal. Si no lo tiene, p dale a su profesional de la salud que le d uno. Gu rdelo en un lugar seguro y ll velo todas las veces que reciba atenci n m dica. Aseg rese de que su profesional de la salud escriba all todas las vacunas que reciba. Screening Checklist for Contraindications to Vaccines for AdultsSaint Paul, Minnesota 651-647-9009 Item #P4065-01 Spanish (4/18)s nono sabenombre del paciente fecha de nacimiento / / mes d a a o 1.

4 Are you sick today? [all vaccines] There is no evidence that acute illness reduces vaccine efficacy or increases vac-cine adverse However, as a precaution with moderate or severe acute illness, all vaccines should be delayed until the illness has improved. Mild ill-nesses (such as upper respiratory infections or diarrhea) are NOT contraindica-tions to vaccination. Do not withhold vaccination if a person is taking antibiotics. 2. Do you have allergies to medications, food, a vaccine component, or latex? [all vaccines]An anaphylactic reaction to latex is a contraindication to vaccines that contain latex as a component or as part of the packaging ( , vial stoppers, prefilled syringe plungers, prefilled syringe caps).

5 If a person has anaphylaxis after eating gelatin, do not administer vaccines containing gelatin. A local reaction to a prior vaccine dose or vaccine component, including latex, is not a contraindica-tion to a subsequent dose or vaccine containing that component. For informa-tion on vaccines supplied in vials or syringes containing latex, see reference 2; for an extensive list of vaccine components, see reference with egg allergy of any severity can receive any IIV or RIV that is other-wise appropriate for the patient s age. The safety of LAIV in egg allergic people has not been established. For people with a history of severe allergic reaction to egg involving any symptom other than hives ( , angioedema, respiratory dis-tress), or who required epinephrine or another emergency medical intervention, the vaccine should be administered in a medical setting, such as a clinic, health department, or physician office.

6 Vaccine administration should be supervised by a healthcare provider who is able to recognize and manage severe allergic 3. Have you ever had a serious reaction after receiving a vaccination? [all vaccines]History of anaphylactic reaction (see question 2) to a previous dose of vaccine or vaccine component is a contraindication for subsequent Under normal circumstances, vaccines are deferred when a precaution is present. However, situations may arise when the benefit outweighs the risk ( , during a commu-nity pertussis outbreak). 4. Do you have a long-term health problem with heart disease, lung disease, asthma, kidney disease, metabolic disease ( , diabetes), anemia, or other blood disorder? [MMR, LAIV]A history of thrombocytopenia or thrombocytopenic purpura is a precaution to MMR vaccine.

7 The safety of intranasal live attenuated influenza vaccine (LAIV) in people with these conditions has not been established. These conditions, including asthma in adults, should be considered precautions for the use of LAIV. 5. Do you have cancer, leukemia, HIV/AIDS, or any other immune system problem? [LAIV, MMR, VAR, ZVL]Live virus vaccines ( , LAIV, measles-mumps-rubella [MMR], varicella [VAR], zoster vaccine live [ZVL]) are usually contraindicated in immunocompromised people. However, there are exceptions. For example, MMR vaccine is recom-mended and varicella vaccine should be considered for adults with CD4+ T-lym-phocyte counts of greater than or equal to 200 cells/ L. Immunosuppressed people should not receive LAIV.

8 For details, consult the ACIP ,5,6 6. In the past 3 months, have you taken medications that affect your immune system, such as cortisone, prednisone, other steroids, or anticancer drugs; drugs for the treatment of rheumatoid arthritis, Crohn s disease, or psoriasis; or have you had radiation treatments? [LAIV, MMR, VAR, ZVL]Live virus vaccines ( , LAIV, MMR, VAR, ZVL) should be postponed until after chemotherapy or long-term high-dose steroid therapy has ended. For details and length of time to postpone, consult the ACIP ,5 Some immune mediator and immune modulator drugs (especially the anti-tumor necrosis factor agents adalimumab, infliximab, etanercept, golimumab, and certolizumab Information for Healthcare Professionals about the Screening Checklist for Contraindications to Vaccines for AdultsAre you interested in knowing why we included a certain question on the screening checklist?)

9 If so, read the information below. If you want to find out even more, consult the references listed at the Action Coalition Saint Paul, Minnesota 651-647-9009 Item #P4065 page 2 (4/18)pegol) may be immunosuppressive. The use of live vaccines should be avoided in persons taking these drugs (see ). To find specific vaccination schedules for stem cell transplant (bone marrow transplant) patients, see reference 7. LAIV can be given only to healthy non-pregnant people ages 2 through 49 years. 7. Have you had a seizure or a brain or other nervous system problem? [influenza, Td/Tdap]Tdap is contraindicated in people who have a history of encephalopathy within 7 days following DTP/DTaP. An unstable progressive neurologic problem is a precaution to the use of Tdap.

10 For people with stable neurologic disorders (including seizures) unrelated to vaccination, or for people with a family history of seizure, vaccinate as usual. A history of Guillain-Barr syndrome (GBS) is a consideration with the following: 1) Td/Tdap: if GBS has occurred within 6 weeks of a tetanus-toxoid vaccine and decision is made to continue vaccina-tion, give Tdap instead of Td if no history of prior Tdap; 2) Influenza vaccine (IIV/LAIV): if GBS has occurred within 6 weeks of a prior influenza vaccine, vac-cinate with IIV if at increased risk for severe influenza complications. 8. During the past year, have you received a transfusion of blood or blood products, or been given immune (gamma) globulin or an antiviral drug?