Screening Checklist patient name
for Contraindications date of birth
month
/
day
/
year
to Vaccines for Children and Teens
For parents/guardians: The following questions will help us determine which vaccines your child may
be given today. If you answer “yes” to any question, it does not necessarily mean your child should not be
vaccinated. It just means additional questions must be asked. If a question is not clear, please ask your
healthcare provider to explain it.
don’t
yes no know
1. Is the child sick today? □ □ □
2. Does the child have allergies to medications, food, a vaccine component, or latex? □ □ □
3. Has the child had a serious reaction to a vaccine in the past? □ □ □
4. Has the child had a health problem with lung, heart, kidney or metabolic disease
(e.g., diabetes), asthma, or a blood disorder? Is he/she on long-term aspirin therapy? □ □ □
5. If the child to be vaccinated is 2 through 4 years of age, has a healthcare provider
told you that the child had wheezing or asthma in the past 12 months? □ □ □
6. If your child is a baby, have you ever been told he or she has had intussusception? □ □ □
7. Has the child, a sibling, or a parent had a seizure; has the child had brain or other
nervous system problems? □ □ □
8. Does the child or a family member have cancer, leukemia, HIV/AIDS, or any other
immune system problems? □ □ □
9. In the past 3 months, has the child taken medications that affect the immune system
such as prednisone, other steroids, or anticancer drugs; drugs for the treatment of □ □ □
rheumatoid arthritis, Crohn’s disease, or psoriasis; or had radiation treatments?
10. In the past year, has the child received a transfusion of blood or blood products,
or been given immune (gamma) globulin or an antiviral drug? □ □ □
11. Is the child/teen pregnant or is there a chance she could become pregnant
during the next month? □ □ □
12. Has the child received vaccinations in the past 4 weeks? □ □ □
form completed by date
form reviewed by date
Did you bring your immunization record card with you? yes □ no □
It is important to have a personal record of your child’s vaccinations. If you don’t have one, ask the child’s
healthcare provider to give you one with all your child’s vaccinations on it. Keep it in a safe place and bring
it with you every time you seek medical care for your child. Your child will need this document to enter day
care or school, for employment, or for international travel.
Technical content reviewed by the Centers for Disease Control and Prevention
Saint Paul, Minnesota • 651- 647- 9009 • www.immunize.org • www.vaccineinformation.org
www.immunize.org/catg.d/p4060.pdf • Item #P4060 (9/17)
Information for Healthcare Professionals about the Screening Checklist
for Contraindications (Children and Teens)
Are you interested in knowing why we included a certain question on the screening checklist? If so, read
the information below. If you want to find out even more, consult the references listed at the end.
1. Is the child sick today? [all vaccines]
There is no evidence that acute illness reduces vaccine efficacy or increases vaccine adverse note: Live attenuated influenza vaccine (LAIV4; FluMist) is not recommended by
events.1,2 However, as a precaution with moderate or severe acute illness, all vaccines should be CDC’s Advisory Committee on Immunization Practices for use in the U.S. for the
delayed until the illness has improved. Mild illnesses (such as otitis media, upper respiratory 2017–18 influenza season.
infections, and diarrhea) are NOT contraindications to vaccination. Do not withhold vaccination
if a person is taking antibiotics. occurred within 6 weeks of a tetanus-containing vaccine and decision is made to continue vacci-
nation, give Tdap instead of Td if no history of prior Tdap; 2) Influenza vaccine (IIV or LAIV):
2. Does the child have allergies to medications, food, a vaccine component, or latex? [all if GBS has occurred within 6 weeks of a prior influenza vaccination, vaccinate with IIV if at high
vaccines] risk for severe influenza complications.
An anaphylactic reaction to latex is a contraindication to vaccines that contain latex as a compo-
nent or as part of the packaging (e.g., vial stoppers, prefilled syringe plungers, prefilled syringe 8. Does the child or a family member have cancer, leukemia, HIV/AIDS, or any other
caps). If a person has anaphylaxis after eating gelatin, do not administer vaccines containing gel- immune system problem? [LAIV, MMR, MMRV, RV, VAR]
atin. A local reaction to a prior vaccine dose or vaccine component, including latex, is not a con- Live virus vaccines (e.g., MMR, MMRV, varicella, rotavirus, and LAIV) are usually contraindicated
traindication to a subsequent dose or vaccine containing that component. For information on in immunocompromised children. However, there are exceptions. For example, MMR is recom-
vaccines supplied in vials or syringes containing latex, see reference 3; for an extensive list of mended for asymptomatic HIV-infected children who do not have evidence of severe immuno-
vaccine components, see reference 4. People with egg allergy of any severity can receive any rec- suppression. Likewise, varicella vaccine should be considered for HIV-infected children with
ommended influenza vaccine (i.e., any IIV or RIV) that is otherwise appropriate for the patient’s age-specific CD4+ T-lymphocyte percentage at 15% or greater, or for children 6–7 years with
age. For people with a history of severe allergic reaction to egg involving any symptom other CD4+ T-lymphocyte counts of greater than or equal to 200 cell/µL. Varicella vaccine may be con-
than hives (e.g., angioedema, respiratory distress), or who required epinephrine or another emer- sidered for HIV-infected children with age-specific CD4+ T-lymphocyte percentage of greater than
gency medical intervention, the vaccine should be administered in a medical setting, such as or equal to 200 cells/µL. Varicella and MMR vaccines should not be given to a child or teen with
a clinic, health department, or physician office. Vaccine administration should be supervised by a family history of congenital or hereditary immunodeficiency in first-degree relatives (e.g., par-
a healthcare provider who is able to recognize and manage severe allergic conditions.5 ents, siblings) unless the immune competence of the potential vaccine recipient has been clini-
cally substantiated or verified by a laboratory. Immunosuppressed children should not receive
3. Has the child had a serious reaction to a vaccine in the past? [all vaccines] LAIV. Infants who have been diagnosed with severe combined immunodeficiency (SCID) should
History of anaphylactic reaction (see question 2) to a previous dose of vaccine or vaccine com- not be given a live virus vaccine, including rotavirus (RV) vaccine. Other forms of immunosup-
ponent is a contraindication for subsequent doses.1 History of encephalopathy within 7 days pression are a precaution, not a contraindication, to rotavirus vaccine. For details, consult ACIP
following DTP/DTaP is a contraindication for further doses of pertussis-containing vaccine. Pre- recommendations.1,6,7,8
cautions to DTaP (not Tdap) include the following: (a) seizure within 3 days of a dose, (b) pale
or limp episode or collapse within 48 hours of a dose, (c) continuous crying for 3 or more hours 9. In the past 3 months, has the child taken medications that affect the immune system
within 48 hours of a dose, and (d) fever of 105°F (40°C) within 48 hours of a previous dose. such as prednisone, other steroids, or anticancer drugs; drugs for the treatment
There are other adverse events that might have occurred following vaccination that constitute of rheumatoid arthritis, Crohn’s disease, or psoriasis; or had radiation treatments?
contraindications or precautions to future doses. Under normal circumstances, vaccines are [LAIV, MMR, MMRV, VAR]
deferred when a precaution is present. However, situations may arise when the benefit outweighs Live virus vaccines (e.g., LAIV, MMR, MMRV, VAR) should be postponed until after chemotherapy
the risk (e.g., during a community pertussis outbreak). or long-term high-dose steroid therapy has ended. For details and length of time to postpone,
consult the ACIP statement.1 Some immune mediator and immune modulator drugs (especially
4. Has the child had a health problem with lung, heart, kidney, or metabolic disease (e.g., the antitumor-necrosis factor agents adalimumab, infliximab, and etanercept) may be immuno-
diabetes), asthma, or a blood disorder? Is he/she on long-term aspirin therapy? [MMR, suppressive. The use of live vaccines should be avoided in persons taking these drugs.1 To find
MMRV, LAIV] specific vaccination schedules for stem cell transplant (bone marrow transplant) patients, see
A history of thrombocytopenia or thrombocytopenic purpura is a precaution to MMR and reference 9. LAIV, when recommended, can be given only to healthy non-pregnant people ages
MMRV vaccines. The safety of live, attenuated influenza vaccine (LAIV) in children and teens 2 through 49 years.
with lung, heart, kidney, or metabolic disease (e.g., diabetes), or a blood disorder has not been
established. These conditions, including asthma in children ages 5 years and older, should be con- 10. In the past year, has the child received a transfusion of blood or blood products, or
sidered precautions for the use of LAIV. Children on long-term aspirin therapy should not be been given immune (gamma) globulin or an antiviral drug? [LAIV, MMR, MMRV, VAR]
given LAIV; instead, they should be given IIV. Certain live virus vaccines (e.g., LAIV, MMR, MMRV, varicella) may need to be deferred, depend-
ing on several variables. Consult the most current ACIP recommendations or the current Red
5. If the child to be vaccinated is 2 through 4 years of age, has a healthcare provider Book for the most current information on intervals between antiviral drugs, immune globulin or
told you that the child had wheezing or asthma in the past 12 months? [LAIV] blood product administration and live virus vaccines.1,2
Children ages 2 through 4 years who have had a wheezing episode within the past 12 months
should not be given LAIV. Instead, these children should be given IIV. 11. Is the child/teen pregnant or is there a chance she could become pregnant during
the next month? [HPV, IPV, LAIV, MMR, MMRV, VAR]
6. If your child is a baby, have you ever been told that he or she has had intussusception? Live virus vaccines (e.g., MMR, MMRV, varicella, LAIV) are contraindicated one month before and
[Rotavirus] during pregnancy because of the theoretical risk of virus transmission to the fetus.1,2 Sexually
Infants who have a history of intussusception (i.e., the telescoping of one portion of the intestine active young women who receive a live virus vaccine should be instructed to practice careful con-
into another) should not be given rotavirus vaccine. traception for one month following receipt of the vaccine.7,10 On theoretical grounds, inactivated
poliovirus vaccine should not be given during pregnancy; however, it may be given if risk of
7. Has the child, a sibling, or a parent had a seizure; has the child had brain or other exposure is imminent (e.g., travel to endemic areas) and immediate protection is needed. Inac-
nervous system problem? [DTaP, Td, Tdap, IIV, LAIV, MMRV] tivated influenza vaccine and Tdap are both recommended during pregnancy. HPV vaccine is
not recommended during pregnancy.
DTaP and Tdap are contraindicated in children who have a history of encephalopathy within 7 days
following DTP/DTaP. An unstable progressive neurologic problem is a precaution to the use
of DTaP and Tdap. For children with stable neurologic disorders (including seizures) unrelated 12. Has the child received vaccinations in the past 4 weeks? [LAIV, MMR, MMRV, VAR,
to vaccination, or for children with a family history of seizures, vaccinate as usual (exception: yellow fever]
children with a personal or family [i.e., parent or sibling] history of seizures generally should not Children who were given either LAIV or an injectable live virus vaccine (e.g., MMR, MMRV, vari-
be vaccinated with MMRV; they should receive separate MMR and VAR vaccines). A history of cella, yellow fever) should wait 28 days before receiving another vaccination of this type. Inacti-
Guillain-Barré syndrome (GBS) is a consideration with the following: 1) Td/Tdap: if GBS has vated vaccines may be given at the same time or at any spacing interval.
references
4. Table of Vaccine Components: www.cdc.gov/ 6. CDC. Measles, mumps, and rubella – vaccine use 9. Tomblyn M, Einsele H, et al. Guidelines for prevent-
1. CDC. General best practice guidelines for and strategies for elimination of measles, rubella, ing infectious complications among hematopoietic
immunization. Best Practices Guidance of the vaccines/pubs/pinkbook/downloads/appendices/
B/excipient-table-2.pdf. and congenital rubella syndrome and control of stem cell transplant recipients: a global perspective.
Advisory Committee on Immunization Practices mumps. MMWR 1998; 47 (RR-8). Biol Blood Marrow Transplant 15:1143–1238;
(ACIP) at www.cdc.gov/vaccines/hcp/acip-recs/ 5. CDC. Prevention and control of seasonal influenza
7. CDC. Prevention of varicella: Recommendations 2009 at www.cdc.gov/vaccines/pubs/hemato-cell-
downloads/general-recs.pdf. with vaccines: Recommendations of the Advisory
of the Advisory Committee on Immunization transplts.htm.
2. AAP. Red Book: Report of the Committee on Committee on Immunization Practices – United
States, 2017–18 Influenza Season at www.cdc.gov/ Practices. MMWR 2007; 56 (RR-4). 10. CDC. Notice to readers: Revised ACIP recommen-
Infectious Diseases at www.aapredbook.org. dation for avoiding pregnancy after receiving a
mmwr/volumes/66/rr/pdfs/rr6602.pdf 8. Rubin LG, Levin MJ, Ljungman P. 2013 IDSA
3. Latex in Vaccine Packaging: www.cdc.gov/vaccines/ Clinical practice guideline for vaccination of the rubella-containing vaccine. MMWR 2001; 50 (49).
pubs/pinkbook/downloads/appendices/B/latex- immunocompromised host. Clinical Infectious
table.pdf Diseases 2014;58(3):e44–100.
Immunization Action Coalition • Saint Paul, Minnesota • 651- 647- 9009 • www.immunize.org • www.vaccineinformation.org
www.immunize.org/catg.d/p4060.pdf • Item #P4060 – page 2 (9/17)
