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Did you know that healthcare providers can receive federally-funded vaccines for low-income and uninsured children at no cost? Visit the Vaccines for Children (VFC) program for more information.

Incomplete immunization records

Patients without written, dated vaccination records should be considered susceptible to disease. Vaccination should be the first approach when a patient's immunity is unknown, even if the patient suspects s/he has already been immunized.
No. Only written and dated vaccination records should be entered in WAIIS or your clinic's EMR.
You do not need to repeat the full series. Give the remaining doses according to schedule and document accordingly.


Titers can be used to test serologic immunity when no vaccination records are available and the patient/parent is vaccine hesitant. However, revaccination is almost always the best first approach. Repeating vaccinations is safe and acceptable and prevents the time and resources involved with obtaining and interpreting serologic tests. Your clinic may already have a standard protocol in place for titers. Consult this helpful table:

MMR Can get titer if status is unknown. IgG may be difficult to interpret if exposed. When deciding whether or not to use a titer and when interpreting results, consider recent exposure to disease.
Hep A Can get titer.
Hep B YES! Use reference.
Polio Can get titer. Patients need protective level titers for ALL three types of polio. If titers show protection for only one or two types, the patient should be revaccinated.
DTaP Can get titer if > 3 doses given, or give a dose and get a titer.  There is no titer for pertussis.

Not all titers are sufficiently sensitive or standardized for detection of vaccine-induced immunity (with the exception of hepatitis B vaccination at one to two months after the final dose). Additionally, laboratory testing might not be readily available.

Yes, but only if they can be done one to two months after the final dose of vaccine has been given. If the patient is HBsAg positive, infection is present. If the patient is Anti-HepBSAb positive, s/he is immune. Read more about Hep B testing and vaccination and refer to this table for additional guidance.

Administering vaccines off-schedule

In both circumstances, infants between six and twelve months can receive a dose of MMR. However, they will still need two full doses given according to schedule.
Giving HPV to an adult over 26 is an off-label use, and doing so is at the provider's discretion. The immune response may not be as strong as in a younger adult or adolescent, and insurance may not cover vaccination.

Administering vaccines to a different age or population group than indicated on the label is at the provider's discretion. One should consider the risks and benefits along with other treatments for a patient's condition or situation. If the patient presents with particular symptoms or concerns, you may want consult with a specialist and make a plan with the patient prior to vaccination.

In certain situations, vaccines may be recommended off-label. For example, Hib is typically a vaccine for very young children, but may be recommended for adults with specific medical conditions.

Catch-up schedules

Immunization catch-up schedules for children and adolescents and for adults should answer the majority of your questions. You can also use WAIIS's forecast tool to figure out what vaccines are needed.  If your EMR has a forecast or catch-up tool, make sure to use the CDC schedule and WAIIS forecast tool to verify accuracy.
No routinely recommended vaccines need to be restarted because of a delayed schedule. You can deliver the next dose in the series regardless of the interval since the last dose. However, the oral typhoid vaccine, recommended for travel to certain areas abroad, may need to be restarted if the vaccine series isn't completed within the recommended timeframe.


Yes, DTaP counts for a catch-up schedule. It may also count for the adolescent Tdap. Alternatively, the child can receive a Tdap booster at age 11 or 12.

Consult the DTaP catch-up guide for more information.

If the wound is dirty and it's been more than five years since the last Td/Tdap dose, give a booster.
If the wound is clean and it's been more than 10 years since the last Td/Tdap dose, give a booster. Consult the table below for more information.

Tetanus wound management
Vaccination history Clean, minor wounds All other wounds
Td/Tdap TIG Td/Tdap TIG
Unknown or fewer than 3 doses Yes No Yes Yes
3 or more doses No* No No** No

*Yes, if more than 10 years since the last tetanus toxoid-containing vaccine dose.
**Yes, if more than 5 years since the last tetanus toxoid-containing vaccine dose.

In the table above, you can see that both Td and TIG are needed for a person who has:

  • A wound that is neither clean nor minor.
  • An unknown vaccination history or a history of fewer than 3 doses of a tetanus-containing vaccine.

Wounds that are other than clean and minor might include, but are not limited to:

  • Wounds contaminated with dirt, feces, soil, and saliva
  • Puncture wounds.
  • Avulsions.
  • Wounds resulting from missiles, crushing, burns, and frostbite.

If the person is 11 years of age or older, Tdap can be given for 1 of the doses, preferably the first dose. TIG provides temporary passive immunity by directly providing antitoxin (antibody) to eliminate the disease-producing toxins produced by C. tetani. The antitoxin provides protection before the body produces its own antitoxins (antibodies) in response to Td or Tdap vaccine.

Medical indications

Patients with HIV/AIDS whose CD4 counts are below 200 and pregnant women should not receive live vaccine. In addition, patients receiving immune medications, such as Prednisone, should be evaluated on a case-by-case basis. Consult this algorithm for guidance.

Vaccine errors

Treat vaccine errors like a medical error or near miss.

  1. Notify and assess the patient/family
  2. Review corrections needed.
  3. Determine cause, factors, influences, and defects in process
  4. Follow your institution's policies for reporting errors
  5. Report to VERP (the Vaccine Errors Reporting Program)
  6. Report to VAERS (the Vaccine Adverse Events Reporting System) as needed
  7. Document
  8. Put steps in place to avoid repetition of errors, including retraining of staff

For more specific guidance, consult this guide on Vaccination Errors and How to Prevent Them.

Download an immunization app to easily access recommendations and guidance.

Additional resources

How many vaccine storage errors can you find?

How many vaccine storage errors can you find?

See enlarged image then click on link shown to see the full list.

  • There Never Was An Age of Reason - Vaccines, Vaccine Hesitancy, and Vaccine Decision Making
    Presented by: Dr. Edgar K. Marcuse, MD, MPH, FPIDS Emeritus Professor, Pediatrics University of Washington
    What impact does vaccine hesitancy have on vaccine-preventable diseases? How do parents make decisions about vaccines? What role do health care providers play in getting parents to vaccinate? Register today to hear about the history, origins, current status, and impact of vaccine hesitancy on our vaccination rates and outbreaks of disease across Washington state and beyond.

  • You Are the Key to HPV Cancer Prevention
    Produced by WithinReach and Cardea through funding provided by the Washington State Department of Health, this free course provides the most up-to-date information on HPV infection, related disease and cancers, vaccine recommendations, safety and impact, and evidence-based suggestions for successful HPV vaccine communication with patients and parents. Upon successful completion of this CE activity, 1 contact hour (including 1 hour pharmacology credit) will be awarded. Learn more about this training.

  • Coursera
    Keep an eye out for future sessions of Dr. Paul Offit’s popular six week Coursera course on vaccines.The course, administered through the University of Pennsylvania, covers the following topics: a history of vaccines, schedules and common questions, vaccines and the media, case studies, exemptions, recently licensed vaccines, and disease outbreaks. The course is free and learners can earn a verified certificate statement of accomplishment. Add the course to your watch list.

  • Children's Hospital of Philadelphia Vaccine webinar
    Register for Dr. Paul Offit's "Current Issues in Vaccines" webinar series and view archived presentations. Each 40-45 minute webinar presents topics being addressed by the Advisory Committee on Immunization Practices (ACIP), covered by the media, or asked by parents. Archived topics include: the serogroup B meningococcal vaccine, the 9-valent HPV vaccine and the measles epidemic. Continuing education credits (CME, CEU, or CPE) can be obtained after viewing the archived events.

  • "You Call the Shots": HPV online training module
    CDC has added a module on human papillomavirus (HPV) vaccine to the web-based training course, "You Call the Shots." This module discusses diseases related to infection with HPV, the groups at highest risk, basic vaccination recommendations, the characteristics of the two HPV vaccines, and more. Continuing Education (CE) credit is available. Learn more about this trainingSee additional information about other modules in the "You Call the Shots" training series.

  • "You Call the Shots": Influenza training module
    CDC's Immunization: You Call the Shots series of web-based training materials now offers an updated self-study Influenza Module. This Module provides information on influenza disease, the influenza vaccine, and recommendations for vaccine use including information on vaccinating children ages 6 months through 8 years. The Module is free of charge and is intended for healthcare professionals. The training can be found on the You Call the Shots website.

  • California Distance Learning Health Network

  • Distance learning opportunities through the CDC

The Vaccine Adverse Event Reporting System (VAERS) is a national vaccine safety surveillance program co-sponsored by the Centers for Disease Control and Prevention (CDC) and the Food and Drug Administration (FDA). VAERS collects and analyzes information from reports of adverse events following immunization. VAERS encourages the reporting of any clinically significant adverse event that occurs after the administration of any vaccine licensed in the United States. You should report clinically significant adverse events even if you are unsure whether a vaccine caused the event.

The National Childhood Vaccine Injury Act (NCVIA) requires health care providers to report:

  • Any event listed by the vaccine manufacturer as a contraindication to subsequent doses of the vaccine.
  • Any event listed in the Reportable Events Table that occurs within the specified time period after vaccination.

A copy of the Reportable Events Table can be obtained by calling VAERS at 1-800-822-7967 or by downloading online.

Who can report to VAERS?

Anyone can report to VAERS. The majority of VAERS reports are sent in by vaccine manufacturers (42%) and health care providers (30%). The remaining reports are obtained from state immunization programs (12%), vaccine recipients (or their parent/guardians, 7%) and other sources (9%). Vaccine recipients or their parents or guardians are encouraged to seek the help of their health care professional in filling out the VAERS form.

How do I report to VAERS?

You can report by mail, fax or online. You can access the online reporting portal via the link above. If reporting by mail, you can obtain pre-addressed postage paid report forms by calling VAERS at 1-800-822-7967. You may use photocopies of the form to submit reports by mail or fax. You may also download printable copies of the VAERS form as well as other information about the VAERS Program.

Q&A about new HPV vaccine recommendations by awardees and providers, CDC

Books and other publications:

Newsletters and other publications:

Public health agencies:

Related immunization sites

Order HPV vaccine reminder magnets

3.5" square HPV vaccine reminder magnets available free of charge for Seattle clinics that administer HPV vaccine.

3.5" square HPV vaccine reminder magnets available free of charge for Seattle clinics that administer HPV vaccine

HPV Vaccine Campaign

Tools for School-Based Health Center staff and students to develop an HPV Vaccine Campaign in their schools.

HPV Vaccine Campaign Toolkit for SBHC staff and students.

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