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MEETING PACKET FEBRUARY 2016 • Health Agent report February 2016 Announcements • Elizabeth Gagakis has been promoted to Senior Sanitarian,replacing David Greenbaum. He first day in the new post was February 22 . • The vacant Sanitarian position has been advertised and interviews will be scheduled once we have a pool of qualified applicants • We will be advertising for a Part-Time Inspector to do food inspections Community Outreach • The Salem Opiate overdose awareness and use reduction resources webpage was launched Meetings and Trainings • I attended a Learn to Cope meeting and took Narcan administration training. • I attended the MEHA Onsite wastewater training that discussed current issues in wastewater Inspections Item Monthly Total YTD 2015 Total Certificate of Fitness 38 70 534 Inspection Certificate of Fitness 5 5 4 re-inspection Food Inspection 4 19 263 Food Re-inspections 6 11 55 Retail Food 4 4 18 Inspections Retail Food 0 0 1 re-inspection • General Nuisance 5 5 25 Inspections Food— 0 0 0 Administrative Hearings Housing Inspections 8 20 181 Housing re- 0 3 37 inspections Rodent Complaints 0 0 19 Court 1 2 7 Hearings/filings Trash Inspections 25 35 138 Orders served by 0 3 7 • Constable Tanning Inspections 0 0 7 Body Art 0 0 1 Swimming pools 0 0 17 Bathing Beach 0 0 106 Inspection/testing Recreational Camps 0 0 12 Lead Determination 1 1 1 Septic Abandonment 0 0 0 Septic System Plan 0 0 0 Review Soil Evaluation 0 0 0 Percolation tests 0 0 0 Total 89 179 1433 y CITY OF SALEM BOARD OF HEALTH MEETING MINUTES January 12, 2016 DRAFT MEMBERS PRESENT:, Dr. Shama Alam, Chair, Paul Kirby, Janet Greene, &Dr. Jeremy Schiller OTHERS PRESENT: Larry Ramdin, Health Agent, Council Liaison Beth Gerard, Eric Rampila, Public Health Nurse, Joyce Redford, Dir. NSATPP &Heather Lyons-Paul Clerk of the Board TOPIC DISCUSSION/ACTION 1. Call to Order 7:00pm P. Kirby motioned to take item#6 of the agenda out of order. J. Greene 2"d. All in favor 2. Minutes of Last Meeting J. Greene motioned to approve the minutes. P. Kirby 2"d All in (Dec 8, 2015) favor 3.Orginization of the Board Voting for Clerk and.Chair. Dr Alam motioned,•to nominate Heather Lyons-Paul as the Clerk ofthe Board. P..Kirby 2"d. No other nominations made. All hr Favor*, J. Greene motioned to nominated Dr. Alam as Chair of the .Board. Dr Schiller 2"d. No other nominations made. All in Favor 4. Chairperson Announcements Dr Alam discussed and reviewed meeting protocol with the Board and Department. 5. Monthly Reports-Updates A. Public Health Nurse's *The DPH, CDC and The W.H.O. sent notification stating there is Report no longer a need to monitor Ebola in the US at this time. *Latent TB is down. Copy available at the BOH office B. Health Agent's Report * D. Greenbaum, Sr. Sanitarian attended the Salem Hospital determination of need hearing. Factor 9 funding will be available. Another meeting will be scheduled on the near future. Dr. Alam provided an update on DPH public hearing in Salem on NSMC consolidation. *Dr. Alam met with the Mayor and the Mayor raised the issue of shared kitchens regulations and whether any are in place. *Dr. Alam requested that L. Ramdin post guidelines for a shared kitchen on the Department website. Copy available at the BOH office r C. Administrative Report L. Ramdin provided update on budget process. Dr. Alam requested, workload metrics vial email- to support 2"d Clerk Request. Copy available at the BOH office P. Kirby motioned to accept reports. Dr. Schiller 2"d All in favor. Motion Passed D. City Council Liaison *No update regarding home rule petition status. Updates *L. Ramdin opened up a discussion on prohibiting sale of bath salts, synthetic marijuana and drug paraphernalia. He suggested a City Ordinance might be the right step to take since the police and health inspectors do not have the authority over the selling of these items. Lynn has a City Ordinance that L. Ramdin will bring to the next meeting. *L. Ramdin also brought to the Boards attention concerns about smoking in places frequented by children and suggested that the Board may want to consider prohibiting the same as nearby communities::or similar. * Council'Liaison B. Gerard will invite the Opiate Coalition to present on their work to the City Council 6. Joyce Redford Director of *P. Kirby would lace aversion of the tobacco. inspection results North Shore/Cape Ann Alcohol an Excel file that J. Redford provided to the Board members. and Tobacco Policy Program— *Grant-'fop.the North Shore Alcohol and tobacco Policy Continued discussion on Program has been extended°to Dec 31, 2016. program policy and procedures *J. Redford provided update regarding tobacco 21 adoption. on the market Swampscott has adopted tobacco 21 to the regulations. . Peabody and'Vlarblehead are in the process of adopting tobacco 21.'Boston has now voted on tobacco 21. There is also &Bill at the state level for the entire state to increase the purchasing age to 21. *J. Redford gave a presentation on flavored tobacco products. She had samples of different flavored nicotine products that she;handed to the Board. At the federal level there is a flavor restriction on cigarettes. Flavors are still allowed in cigars and cigarillos. The Saugus Board of Health will be meeting on Feb 1, 2016 about drafting a regulation for flavor restrictions. There are 40 communities in the Commonwealth that have a flavor restriction in their regulations. The Board showed interested in looking into banning flavored tobacco and would like J. Redford to bring a draft regulation to the meeting in March. *J. Redford will provide data on flavors, draft language, and present the flavor survey for the Board. *Discussion on 2"d offense suspensions. J. Redford suggested to the Board that they not call in the 2nd offenses tobacco violations unless they request a hearing as this can be handled administratively by the Health Agent as is done in other communities. The Board asked for a copy of the tobacco violation letter template, and the motion made by Martin Fair to be brought to C. Administrative Report L. Ramdin provided update on budget process. Dr. Alam requeste workload metrics vial email-to support 2nd Clerk Request. Copy available at the BOH office P.Kirby motioned to accept reports. Dr. Schiller 2nd All in favor. Motion Passed D. City Council Liaison *No update regarding home rule petition status. Updates *L. Ramdin opened up a discussion on prohibiting sale of bath salt: synthetic marijuana and drug paraphernalia. He suggested a City Ordinance might be the right step to take since the police and healtl inspectors do not have the authority over the selling of these items. Lynn has a City Ordinance that L. Ramdin will bring to the next meeting. *L. Ramdin also brought to the Boards attention concerns about smoking in places tequerited by children and suggested that the Board may watt to consider prohibiting the same as nearby communities or similar. * Council..Liaison B. Gerard will invite the Opiate Coalition to present on their work to the City Council 6. Joyce Redford Director of V. Kirby would like a version of the tobacco. inspection results North Shore/Cape Ann Alcohol mi Excel file that J. Redford provided to the Board members. and Tobacco Policy Program— * ahttfar.the North Shore Alcohol and tobacco Policy Continued discussion on Program has been extended`to Dec 31, 2016. program policy and procedures *J. Redford provided update regarding tobacco 21 adoption. on the market Swampscott has iidopted tobacco 21 to the regulations. , Peabody and Marblehead are in the process of adopting tobacco 21-. Boston has now voted on tobacco 21. There is also a Bill at the'state level for the entire state to increase the puresing age to 21. *J. Redford gave a presentation on flavored tobacco products. She had samples of different flavored nicotine products that she.handed to the Board. At the federal level there is a flavor restriction on cigarettes. Flavors are still allowed in cigars and cigarillos. The Saugus Board of Health will be meeting on Feb 1, 2016 about drafting a regulation for flavor restrictions. There are 40 communities in the Commonwealth that have a flavor restriction in their regulations. The Board showed interested in looking into banning flavored tobacco and would like J. Redford to bring a draft regulation to the meeting in March *J. Redford will provide data on flavors, draft language, and present the flavor survey for the Board. *Discussion on 2nd offense suspensions. J. Redford suggested to the Board that they not call in the 2nd offenses tobacco violations unless they request a hearing as this can be handled administratively by the Health Agent as is done in other communities. The Board asked for a copy of the tobacco violation letter template, and the motion made by Martin Fair to be brought to I, the next meeting for discussion. Dr. Alam would also like to I meet with L. Ramdin and the City Solicitor regarding changing procedures to allow the Health Agent to enforce the suspensions for 2°a violations and whether a motion is needed to change this policy. *Salem Hospital has formed an overdose task force. 7. Opioid epidemic prevention * On March 5, 2016, Salem State University will be offering measures discussion an in service update for social workers discussing the epidemic. *There are two community events that the city supports; Overdose Awareness Day,and an Awareness Walk. The general consensus is to continue these events. *Task force meeting discussed developing a tool for Human Resources to inform`:them and staff on dealing with this addiction. *L. Ramdin is:. i6eting with School Dept. about underage drinking problems. *The task forced encouraged building a grass roots organization end.Ramdin:will be working with the Mayor and Liaison on this 1amdin is also working on getting the Anonymous People video scrdened at the Salem Cinema. *Needle exchange program discussion. There is a state funded program available. The Worcester Board of Health Chair . discussed this„with P Kirby. L. Ramdin will get some data for the Board on'tius topic and will also find out if there is a need fior this type of program here. The Salem,Police has a prescription medication take back prograrn.that is:funded by the DEA. Medications can be dropped "tat the police station at any time. The city also offers a needle drop off at the main Fire Station on New Derby Street that is also open 24 hours a day. , s 8. Protocol for evaluating Health ' *Discussion on evaluation form. Agent The Mayor is also starting an evaluation process for Department Heads that will include goal settings to measure incentive programs and needs for departments. *Dr. Alam to discuss form and process with the Mayor, HR Director, and City Solicitor for input before next meeting *Vote on final evaluation form at next meeting * Discussed 360* feedback process Discussed proposal to ask select staff on a rotating basis for evaluation feedback. Is it helpful for staff to do these evaluations or should it being just Board members? P. Kirby motioned that Dr. Alam forward the evaluation form to key stake holders and request their input on the content and continue discussion on the process of a 360 review vs just the Board. Dr. Schiller 2"d All in Favor Motion passed. Next meeting evaluation tool and process to be approved for adoption in March. 9. New Business/Scheduling of future *Continuation of protocols for evaluating Health Agent. agenda items *Tobacco violation process to allow Health Agent to enforce suspensions for second violations *Invite J. Redford to March meeting to discuss tobacco flavor restrictions. 10. MEETING ADJOURNED: P. Kirby motioned to adjourn the meeting.J. Greene 2"d All in favor. Motion passed 9:51 pm Respectfully submitted, -ons Heather L Paul Y Clerk of the Board Next regularly scheduled meeting is February 9, 2016 at 7pm At City Hall Annex, 120 Washington Street;Room 313 Salem. s form to key stake holders and request their input on the content and continue discussion on the process of a 360 review vs just the Board. Dr. Schiller 2°d All in Favor Motion passed. Next meeting evaluation tool and process to be approved for adoption in March. 9. New Business/Scheduling of future *Continuation of protocols for evaluating Health Agent. agenda items *Tobacco violation process to allow Health Agent to enforce suspensions for second violations *Invite J. Redford to March meeting to discuss tobacco flavor restrictions. 10. MEETING ADJOURNED: P.Kirby motioned to adjourn the meeting.J. Greene 2°d All in favor. Motion passed 9:51pm Respectfully submitted, Heather Lyons-Paul Clerk of the Board Next regularly scheduled meeting is February 9,2016 at 7pm At City Hall Annex, 120 Washington Street,Room 313 Salem. i r Erica Rimpila RN BSN BA Salem Board of Health Public Health Nurse Public Health Nurse Report Reporting on January 13`h, 2016 to February 9th, 2016 Disease Prevention • As of January 28`h, currently covering MAVEN cases. Investigated reportable diseases and reported case information to MDPH. Suzanne Doty covered MAVEN cases prior to January 28th,2016. • Obtained tuberculin/PPD from Tewksbury State hospital for a TB contact investigation. On January 19t"started contact follow up TB Skin Tests for five contacts for DOT Case #1. Latent TB Infection cases were reported to MDPH and referred for follow up. • Beginning in January, the following disease events will also flow into the MAVEN LBOH Notification but no follow up needed workflow:Psittacosis,Invasive bacterial (other)Streptococcus pneumoniae (18 years and older), Cryptococcus neoformans, Encephalitis,Enterovirus, Group B streptococcus,Hepatitis D,Leptospirosis, Rickettsial po., Typhus Viral meningitis. Health Promotion • North Shore Pulmonary Clinic is following up on 2 current active tuberculosis cases. Boston Medical Center TB Pulmonary Clinic is following up on 1 current active tuberculosis case. • Offered one Flu Shot walk in time on Thursday, January 20 • Provided one flu shot clinic at the Fire Station on February 4`h. 3 flu shots were administered. Scheduled another flu clinic at the Fire Station for February 1 lth. • Flu activity is peaking. The 2015-16 vaccine is a good in tch. • Flu Shots are still available. Meetines/Trainines • On January 20th attended MEMA Emergency Operation Center Management and Operations training in Lawrence on organization, communications, operations and information management. • On January 27th attended North Shore/Cape Ann Emergency Preparedness meeting. • On January 28`h completed the required course of MAVEN training which included TB MAVEN training. Started covering MAVEN. • On February 9`h attended Salem Overdose Prevention Committee meeting. Monthly Report of Communicable Diseases: January 2016 0 Disease New Carry Over Discharged Total#Of Running Totaltfor Total, r Reported Cases this Total for 305a �014' Month 2016 Tuberculosis 0 3 0 3 3 4 (Active) Latent 6 0 0 6 6 5 3 1 Tuberculosis* Babesiosis 0 0 0 0 0 0 Calicivirus/No 0 0 0 0 0 1 rovirus Campylobacte 1 0 0 1 0 riosis ` i Chikungunya 0 0 0 0 0 0 „ i 1. Dengue 0 0 0 0 00 0 Ehrlichiosis 0 0 0 0 0 � 1 Enterovirus 0 0 0 0 0 Giardiasis 0 0 0 0 0 2 0 Group A 0 0 0 0 0 4' Streptococcus Group B 0 0 0 0 0 '` 6 Streptococcus Human 0 0 0 0 0 Granulocytic - h Ana lasmosis Haemophilus 0 0 0 0 0 1 '', 0' Influenzae Hansen's 0 0 0 0 0 0 0 Disease Hepatitis B* 0 0 0 0 0 0 2 Hepatitis C* 4 0 0 4 4 '20 37 Influenza* 0 0 0 0 029.; 27` Legionellosis 0 0 0 0 0 l 0 Lyme 0 0 0 0 0 2 7' Disease* Malaria 0 0 0 0 0 1 Meningitis 0 0 0 0 0 2 Pertussis 0 0 0 0 0 Salmonellosis 1 0 0 1 1 w I Shigatoxin 0 0 0 0 00� Producing Organism Shigellosis 0 0 0 0 0 Streptococcus 0 0 0 0 0 Pneumoniae Varicella* 0 0 0 0 0 Vibrio 0 0 0 0 04 -41 West Nile 0 0 0 0 0 § ate a " 8 Yersomosls 0 0 0 0 0 Total. 12 3 0 15 15 .,98 .`. 148 January 2016 *Notifications only, LBOH not required to follow up or investigate per DPH. MSummary of Current Communicable Diseases Active Tuberculosis: Case 1:Resident requires DOT at least 3 times a week. Resident has been compliant with medication and TB Clinic appointments. Resident has 3 children and a spouse living in the household. 3children are being treated prophylactically.5 contacts have completed their 2"d TB Skin Test. Individuals that have tested positive have been reported and referred for follow up. Case 2: Salem Public Health Nurse started assisting DOT with this case on 01/15/16. This resident also continues to receive DOT from an outreach worker. Resident has been compliant with medications and TB Clinic appointments. Case 3: This resident is almost complete with DOT.This resident currently receives DOT through an outreach worker. Campylobacter: Case was hospitalized and received antibiotics. Case is currently on leave from work due to an unrelated medical issue. Case is interested in returning to work at a restaurant and was informed that clearance is required from the Health Department prior to returning to work at any food establishment. Lab work results are still pending. Salmonellosis: This case is a minor and has no history of recent travel or contact with animals. Case does not work in a care setting or as a food worker. Suzanne Doty followed up with the guardian and symptoms have improved since treatment.No other cases of illness have been reported from contacts. Salmonellosis: • ( � This case is a minor and has no history of recent travel or contact with animals. Case does not work in a care setting or as a food worker. Suzanne Doty followed up with the guardian and symptoms have improved since treatment. No other cases of illness have been reported from contacts. i i Centers for Disease Control and Prevention ONMAWIM Morbidity and Mortality Weekly Report Early Release/Vol.65 February 2, 2016 Advisory Committee on Immunization Practices Recommended Immunization Schedule for Adults Aged 19 Years or Older — United States, 2016 David K.Kim,MDI;Carolyn B.Bridges,MDI;Kathleen H.Harriman,PhD2;Advisory Committee on Immunization Practices(ACIP), ACIP Adult Immunization Work Group3 In October 2015,the Advisory Committee on Immunization adult immunization schedule illustrate recommended vaccinations Practices (ACIP)* approved the Recommended Immunization that begin at age 19 years,the footnotes contain information on Schedule for Adults Aged 19 Years or Older,United States,2016. vaccines that are recommended for adults that may begin at age This schedule provides a summary of ACIP recommendations younger than age 19 years.The footnotes also contain vaccine for the use of vaccines routinely recommended for adults aged dosing,intervals between doses,and other important information 19 years or older in two figures,footnotes for each vaccine,and a and should be read with the figures. table that describes primary contraindications and precautions for Changes in the 2016 adult immunization schedule from the 2015 commonly used vaccines for adults.Although the figures in the schedule included the following new ACIP recommendations: • Interval change for 13-valent pneumococcal conjugate *http://wwwcdc.gov/vaccines/acip/committee/members-azchive.html. vaccine (PCV13) followed by 23-valent pneumococcal polysaccharide vaccine(PPSV23)from"6 to 12 months"to • Recommendations for routine use of vaccines in children, "at least 1 year" for adults aged >_65 years who do not have adolescents, and adults are developed by the Advisory immunocompromising conditions,anatomical or functional Committee on Immunization Practices (ACID). ACID is asplenia,cerebrospinal fluid leaks,or cochlear implants(1). chartered as a federal advisory committee to provide expert The interval for adults aged >_19 years with any of these external advice and guidance to the Director of the Centers conditions is at least 8 weeks(2). for Disease Control and Prevention(CDC)on use of vaccines • Serogroup B meningococcal(Meng)vaccine series should be and related agents for the control of vaccine preventable administered to certain groups of persons aged>_10 years who diseases in the civilian population of the United States. are at increased risk for serogroup B meningococcal disease(3). Recommendations for routine use of vaccines in children • MenB vaccine series maybe administered to adolescents and and adolescents are harmonized to the greatest extent young adults aged 16 through 23 years (preferred age is 16 possible with recommendations made by the American through 18 years) to provide short-term protection against Academy of Pediatrics (AAP), the American Academy of most strains of serogroup B meningococcal disease(4). Family Physicians (AAFP), and the American College of • Nine-valent human papillomavirus(HPV)vaccine(9vHPV) Obstetricians and Gynecologists(ACOG).Recommendations has been added to the schedule and can be used for routine for routine use of vaccines in adults are harmonized with vaccination of females and males against HPV(5). recommendations of AAFP, ACOG, the American College These recommendations were also reviewed and approved by of Physicians (ACP), and the American College of Nurse- the American College of Physicians, the American Academy of Midwives(ACNM).ACIP recommendations adopted by the Family Physicians, the American College of Obstetricians and CDCDirector become agencyguidelines on the date published Gynecologists,and the American College of Nurse-Midwives. in the Morbidity and Mortality Weekly Report(MMWR). The 2016 adult immunization schedule contains the following Additional information regardingACIP is available at http:// changes from the 2015 schedule: www.cdcgov/vaccines/acip. In Figures 1 ("Recommended adult immunization schedule, by vaccine and age group") and 2 ("Vaccines • ► U.S.Department of Health and Human Services Centers for Disease Control and Prevention Early Release that might be indicated for adults based on medical and MenB-4C or a 3-dose series of MenB-FHbp vaccine to other indications"), the row for "Meningococcal" was provide short-term protection against most strains of 0 retitled Meningococcal 4-valent conjugate(MenACWY) serogroup B meningococcal disease(4). or polysaccharide (MPSV4)" and a new row for — The use of 9vHPV vaccine for HPV vaccination of young "Meningococcal B (MenB)" was added; additional text adult females and males was added(4).For females,2vHPV, was added in indication bars to describe reasons for 4vHPV, or 9vHPV may be used; for males, 4vHPV or alternate dosing schedules for vaccines where such 9vHPV may be used as indicated. designations were appropriate. For example, the measles, • In the table ofcontraindications and precautions to commonly mumps, and rubella (MMR) indication bar that stated used vaccines in adults, rows for MenACWY/MPSV4 and "1 or 2 doses" in the 2015 schedule was revised to "1 or MenB vaccines replaced the single row for meningococcal 2 doses depending on indication" in the 2016 schedule. vaccine in the 2016 table. • In Figure 2, the text in the PPSV23 indication bar was Details on these updates and information on other vaccines recom- revised from"1 or 2 doses"to"1,2,or 3 doses depending mended for adults are available online under Adult Immunization on indication" to account for the recommendation that Schedule, United States, 2016 (www.cdc.gov/vaccines/schedules/ adults aged >-19 years with immunocompromising hcp/adult.html)and in the Annals of Internal Medicine(8).Thefull conditions or anatomical or functional asplenia can receive ACIP recommendations for each vaccine are also available online up to 3 doses of PPSV23. The text in the Haemophilus (wwwcdc.gov/vaccines/hcp/adp-recs/index.hm-d). influenzae type b (Hib) indication bar was revised from Immunization Services Division, National Center for Immunization and "I or 3 doses" to "3 doses, post-HSCT recipients only' Respiratory Diseases,CDC;2Cabfornia Department of Public Health;3Advisory because adults who have received hematopoietic stem cell Committee on Immunization Practices,Adult Immunization Work Group. transplants are the only group for which a 3-dose series of Corresponding author:David K.Kim,dkim@cdc.gov,404-639-0969. Hib vaccination is recommended;for the other groups of adults for which Hib vaccination is recommended, the References text in the indication bar has been revised to "1 dose." 1.Kobayashi M,Bennett NM,Gierke R,et al. Intervals between PCV13 and PPSV23 vaccines:recommendations of the Advisory Committee on • In Footnotes, the sections on influenza, neumococcal, • P Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep meningococcal,and HPVvaccination were changed as follows: 2015;64:944-7.http://dx.doi.org/10.15585/mmwr.mm6434a4. — The language on vaccinating persons with egg allergies 2.Bennett NM,Whitney CG,Moore M,Pilishvili T,Dooling KL.Use of 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal was clarified to state: "Persons aged>_18 years with egg polysaccharide vaccine for adults with immunocompromising conditions: allergy of any severity may receive the recombinant recommendations of the Advisory Committee on Immunization Practices influenza vaccine (RIV) because it does not contain (ACIP).MMWR Morb Mortal Wkly Rep 2012;61:816-9. any egg protein.Persons with hives-only allergy to eggs 3.Folaranmi T, Rubin L, Martin SW, Patel M, MacNeil JR. Use of serogroup B meningococcal vaccines in persons aged>40 years at increased may receive the inactivated influenza vaccine(IIV)with risk for serogroup B meningococcal disease: recommendations of the additional safety measures." (6). Advisory Committee on Immunization Practices,2015.MMWR Morb — Two errata in the 2015 footnotes on pneumococcal Mortal Wkly Rep 2015;64:608-12. 4.MacNeil JR,Rubin L,Folaranmi T,Ortega-Sanchez IR,Patel M,Martin vaccination were corrected: 1) "Adults aged >-19 years" SW.Use of serogroup B meningococcal vaccines in adolescents and young replaced"adults aged 19 through 64 years" as the age at adults:recommendations of the Advisory Committee on Immunization which adults with immunocompromising conditions, Practices, 2015. MMWR Morb Mortal VMy Rep 2015;64:1171-6. anatomical or functional asplenia, cerebrospinal fluid http://dx.doi.org/10.15585/mmwr.mm6441a3. 5.Petrosky E, Bocchini JA Jr, Harid S, et al. Use of 9-valent human leaks,or cochlear implants should receive PCV13 followed papiflomavirus(HPV)vaccine:updated HPV vaccination recommendations by PPSV23 at least 8 weeks later(/7);and 2) "Adults aged of the advisory committee on immunization practices. MMWR Morb 19 through 64 years who are residents of nursing homes Mortal VMy Rep 2015;64:300-4. 6.GrohskopfLA,Sokolow LZ,Olsen SJ,Bresee JS,Broder KR,Karron RA. and other long-term care facilities"was removed from the Prevention and control of influenza with vaccines:recommendations of list of persons for whom PPSV23 is recommended.These the Advisory Committee on Immunization Practices, United States, adults should be assessed for pneumococcal vaccination 2015-16 influenza season. MMWR Morb Mortal Wkly Rep 2015;64:818-25.http://dx.doi.org/10.15585/mmwr.mm6430a3. status and vaccinated as appropriate on the basis of age or 7,CDC. Prevention of pneumococcal disease: recommendations of the medical indications(). Advisory Committee on Immunization Practices (ACIP). MMWR — Recommendations for the use ofMenB vaccine for persons Morbid Mortal VMy Rep 1997;46(RR-08). aged>10 years with certain Conditions were included (3). m 8.Kim DK,Bridges CB,Harriman KH;AdvisoryComittee on Immunization Practices.Advisory Committee on Immunization Practices recommended Information was also included to indicate that persons aged immunization schedule for adults aged 19 years or older:United States,2016. • 16 through 23 years (preferred age range is 16 through Ann Intern Med 2016;164:184-94.http://dx.doi.org/l0.7326/M15-3005. 18 years)may be vaccinated with either a 2-dose series of 2 MMWR / February 2,2016 / Vol.65 Early Release ACIP Adult Immunization Work Group Work Group Chair:Kathleen Harriman,PhD,Richmond,California. Work Group Members:John Epling, MD, Syracuse, New York; Sandra Fryhofer, MD,Atlanta, Georgia; Robert H. Hopkins,Jr., MD, Little Rock, Arkansas;Jane Kim,MD,Durham,North Carolina;Laura Pinkston Koenigs,MD,Springfield,Massachusetts;Maria Lanzi,ANP,Hamilton,New Jersey; Marie-Michele Leger,PA-C,Alexandria,Virginia;Susan M.Lett,MD,Boston,Massachusetts;Robert Palinkas,MD,Urbana,Illinois;Gregory Poland,MD, Rochester,Minnesota;Joni Reynolds,MPH,Denver,Colorado;Laura E.Riley,MD,Boston,Massachusetts;Charles Rittle,DNP,Pittsburgh,Pennsylvania; William Schaffner, MD,Nashville,Tennessee; Kenneth Schmader,MD, Durham, North Carolina; Rhoda Sperling,MD,New York, New York; Richard Zimmerman,MD,Pittsburgh,Pennsylvania. Work Group Contributors:Anna Acosta,MD,Atlanta,Georgia;Carolyn B.Bridges,MD,Atlanta,Georgia;Elizabeth Briere,MD,Atlanta,Georgia;Lisa Grohskopf,MD,Atlanta,Georgia;Rafael Harpaz,MD,Atlanta,Georgia;Charles LeBaron,MD,Atlanta,Georgia;Jennifer L.Liang,DVM,Atlanta,Georgia; Jessica MacNeil,MPH,Atlanta, Georgia;Mona Marin,MD,Atlanta,Georgia;Lauri Markowitz, MD,Atlanta, Georgia; Matthew Moore,MD,Atlanta, Georgia;Tamara Pilishvili,MPH,Atlanta,Georgia;Mona Saraiya,MD,Atlanta,Georgia;Sarah Schillie,MD,Atlanta,Georgia;Raymond A Strikas,MD, Atlanta,Georgia;Walter W.Williams,MD,Atlanta,Georgia. Work Group Consultants:Tamers Coyne-Beasley,MD,Chapel Hill,North Carolina;Molly Howell,MPH,Bismarck,North Dakota;Linda Kinsinger,MD, Durham,North Carolina;Terri Murphy,MSN,Durham,North Carolina;Diane Peterson,Saint Paul,Minnesota;Litjen Tan,PhD,Chicago,Illinois. Work Group Secretariat:David K Kim,MD,Atlanta,Georgia. • Readers who have difficulty accessing this PDF file may access the HTML file at http://www.cdc.gov/mmwr/volumes/65/wr/ mm6504a5er.htm?s_cid=mm6504a5er_w Address all inquiries about the MMWR Series, including material to be considered for •publication,to Editor,MMWR Series,Mailstop E-90,CDC, 1600 Clifton Rd.,N.E.,Atlanta,GA 30329-4027 or to mmwrq@cdc.gov. MMWR / February 2,2016 / Vol.65 3 f ' Recommended Adult Immunization Schedule United States - 2016 The 2016 Adult Immunization Schedule was approved by the Centers for Disease Control and Prevention's (CDC) Advisory Committee on Immunization Practices (ACIP), the American Academy of Family Physicians (AAFP), the American College of Physicians (ACP), the American College of Obstetricians and Gynecologists (ACOG), and the American College of Nurse-Midwives (ACNM). On February 2, 2016, the adult immunization schedule and a summary of changes from 2015 were published in the Annals of Internal Medicine, and the availability of the schedule was announced in the Morbidity and Mortality Weekly Report(MMWR) on February 4, 2016. All clinically significant postvaccination reactions should be reported to the Vaccine Adverse Event Reporting System (VAERS). Reporting forms and instructions on filing a VAERS report are available at www.vaers.hhs.gov or by telephone, 800-822-7967. Additional.details regarding ACIP recommendations for each of the vaccines listed in the schedule can be found at www.cdc.gov/vaccines/hcp/acip-recs/index.html. American Academy of Family Physicians (AAFP) www.aafp.org/ American College of Physicians (ACP) www.acponline.org/ American College of Obstetricians and Gynecologists (ACOG) www.acog.org/ American College of Nurse-Midwives (ACNM) www.midwife.org/ • rrlI,,��iU.S.Department rem. Recommended Adult Immunization Schedule—United States-2016 Note:These recommendations must be read with the footnotes that follow containing number of doses,intervals between doses,and other important information. Figure 1.Recommended immunization schedule for adults aged 19 years or older,by vaccine and age group' VACUNE♦ AGE GROUP b- 19-21years 22.26years 27-49years SO.59years 60-64years t65years uenza'' 1 dose annually nus,diphtheria,pertussis(Td/ldap)'•' substitute Tdap forTd once,then Td booster every 10 yrs Varicella'•' 2 doses Human papillomavirus(HPV)Female.' 3 doses Human papillomavirus(HPV)Male'-' 3 d Zosterb 1 dose Measles,mumps,rubella(MMR)'•' 1,or 2-doses depending on indication Pneumococcal 13-valent conjugate(PCV13)'•' se Pneumococcal 23-valent polysaccharide(PPSV23)a 1 dose Hepatitis A'•' Hepatitis B'•10 Meningococcal4-valent conjugate(MenACWY)or polysaccharide(MP5V4)'," Meningococcal B(MenB)" Haemophilus in(luenzae type b(Hib)'1' I gin *Covered by the Vaccine Injury Compensation Program Report all clinical)ysignificant postvaccination reactions to the Vaccine Adverse Event Reporting System(VAERS).Reporting forms and instructions on filing a VAERS Recommendedforall persons who report are available at www.vaers.hhs.gov or by telephone,800-822-7967. meet theage requirement lack Information on how to file a Vaccine Injury Compensation Program claim is available at www.hrsa.gov/vaccinecompensation or by telephone,800-338-2382.To file a documentation of vaccination,or claim for vaccine injury,contact the U.S.Court of Federal Claims,717 Madison Place,N.W,Washington,D.C.20005;telephone,202-357-6400. lack evidence of past infection;zoster vacdneisrecommended regardless of Additional information about the vacci nes in this schedu 1p-extent of avai lable data,and contrainclications for vacci nation is also available at past episode of zoster www.cdcgov/vaccines or from the CDC-INFO Contact Center at 800-CDC-INFO(800-232-4636)in English and Spanish,8:00 a.m.-8:00 p.m.Eastern Time,Monday- ® Recommended for persons witharisk Friday,excluding holidays. factor(medical,occupational,lifestyle, Use of trade names and commercial sources is for identification only and does not imply endorsement by the U.S.Department of Health and Human Services. or other indication) The recommendations in this schedule were approved by the Centers for Disease Control and Prevention's(CDC)Advisory Committee on Immunization Practices O No recommendation (ACIP),the American Academy of Family Physicians(AAFP),the America College of Physicians(ACP),the American College of Obstetricians and Gynecologists(ACOG) and the American College of Nurse-Midwives(ACNM). re 2.Vaccines that might be indicated for adults aged 19 years or older based on medical and other indications' Immuno- HIVinfection Men who Kidneyfailure, Heart disease, compromising CD4+count havesex end-stage renal chroniclung Asplenia and persistent Chronic conditions(excluding (cells/pl.)"'''°'" with men disease,an disease,chronic complement component liver Healthcare VACCINE♦ INDICATION► Pregnancy HIVinfection)",rA" <200 I 2200 (MSM) hemodialysis alcoholism deficiencies,",' disease Diabetes personnel Influenza*,' 1 dose annually, Tetanus,diphtheria,pertussis(Td/Tdap)',' 'pwraip each SubstttuteTdap for once,then Td booster every 10 yrs Varicella'/ 2 doses Human papillomavirus(HPV)Female*,' 3 doses through age 26 yrs 3 doses through age 26 yrs Human papillomavirus(HPV)Male',' 3 doses through age 26 yrs 3 doses through age 21 yrs Zosterb 1 dose Measles,mumps,rubella(MMR)'' Contrainclicated1 or 2 doses depending on indication Pneumococcall3-valent conjugate(P(V13)'s 1 d Pneumococcal polysaccharide(PPSV23)8 3r,3 doses depending on indication Hepatitis A'•' 2 Hepatitis B'•10 3 d Meningococcal4-valent conjugate(MenACWY) on indication or polysaccharicle(MPSV4)' Meningococcal B(MenB)" on vaccine Hoemophilus influenzoetype b(Hib)'•1' 3 doses post-HSCT se red ients ont d by the Recommended for all persons who meet the age requirement,lack ®Recommended for persons with a risk No recommendation Contraindicated Injury documentation of vaccination,or lack evidence of past infection; factor(medical,occupational,lifestyle,or cation zoster vaccine is recommended regardless of past episode of zoster other indication) These schedules indicate the recommended age groups and medical indications for which administration of currently licensed vaccines is commonly recommended for adults aged a 19 years,as of February 2016.For all vaccines being recommended on the Adult Immunization Schedule:a vaccine series does {� U.S.Department of not need to be restarted,regardless of the time that has elapsed between doses.Licensed combination vaccines may be used whenever any components of the Health and Human Services a combination are indicated and when the vaccine's other components are not contraindicated.For detailed recommendations on all vaccines,includingthose used Centers for Disease primarily for travelers or that are issued during the year,consult the manufacturerspackage inserts and the complete statements from the Advisory Committee on Control and Prevention ,lImmunizationPractices(www.cdc.govtvaccines/hcp/acip-recsfindex.html).Useoftradenamesandcommercialsourcesisforidentificationonlyanddoesnot imply endorsement by the U.S.Department of Health and Human Services. Footnotes—Recommended Immunization Schedule for Adults Aged 19 Years or Older:United States,2016 1.Additional information • HPV vaccines are not recommended for use in pregnant women.However, • Additional guidance for the use of the vaccines described in this supplement is pregnancy testing is not needed before vaccination.If a woman is found to be available at www.cdc.gov/vaccines/hcp/acip-recs/index.htmi. pregnant after initiating the vaccination series,no intervention is needed;the • Information on vaccination recommendations when vaccination status is remainder of the 3-dose series should be delayed until completion or termination unknown and other general immunization information can be found in the of pregnancy. General Recommendations on Immunization at 6.Zooter vaccination www.cdc.gov/mmwr/preview/mmwrhtmi/rr6002al.htm. •A single dose of zoster vaccine is recommended for adults aged z60 years 'Information on travel vaccine requirements and recommendations(e.g.,for regardless of whether they report a prior episode of herpes zoster.Although hepatitis A and B,meningococcal,and other vaccines)is available at the vaccine is licensed by the U.S.Food and Drug Administration for use among wwwnc.cdc.gov/travel/destinations/list. and can be administered to persons aged z50 years,ACIP recommends that • Additional information and resources regarding vaccination of pregnant women vaccination begin at age 60 years. can be found atwww.cdc.gov/vaccines/adults/rec-vac/pregnant.htmi. • Persons aged 2t60years with chronic medical conditions may be vaccinated 2.Influenza vaccination unless their condition constitutes a contraindication,such as pregnancy or severe • Annual vaccination against influenza is recommended for all persons aged z6 immunodeficiency. months.A list of currently available influenza vaccines can be found at http:// 7.Measles,mumps,rubella(MMR)vaccination www.cdc.gov/flu/protect/vaccine/vaccines.htm. • Adults born before 1957 are generally considered immune to measles and mumps. • Per aged z6 months,including pregnant women,can receive the inactivated All adults born in 1957 or later should have documentation of 1 or more doses influenza vaccine(IIV).An age-appropriate IlVformulation should be used. of MMR vaccine unless they have a medical contraindication to the vaccine or • Intradermal IIV is an option for persons aged 18 through 64 years. laboratory evidence of immunity to each of the three diseases.Documentation of • High-dose IIV is an option for persons aged>_65 years. provider-diagnosed disease is not considered acceptable evidence of immunity for • Live attenuated influenza vaccine(LAIV[FluMist])is an option for healthy,non- measles,mumps,or rubella. pregnant persons aged 2 through 49 years. Measles component • Recombinant influenza vaccine(RIV[Flublok])is approved for persons aged z18 . A routine second dose of MMR vaccine,administered a minimum of 28 days after years. the first dose,is recommended for adults who: •RIV,which does not contain any egg protein,may be administered to persons — are students in postsecondary educational institutions, aged 2t18 years with egg allergy of any severity;IIV may be used with additional — work in a healthcare facility,or safety measures for persons with hives-only allergy to eggs. — plan to travel internationally. • Health care personnel who care for severely immunocompromised persons . Persons who received inactivated(killed)measles vaccine or measles vaccine of who require care in a protected environment should receive IIV or RIV;health unknown type during 1963-1967 should be revaccinated with 2 doses of MMR care personnel who receive LAIV should avoid providing care for severely vaccine. immunosuppressed persons for 7 days after vaccination. Mumps component: 3.Tetanus,diphtheria,and acellular pertussis(Td/Tdap)vaccination .A routine second dose of MMR vaccine,administered a minimum of 28 days after •Administer 1 dose of Tdap vaccine to pregnant women during each pregnancy the first dose,is recommended for adults who: (preferably during 27-36 weeks'gestation)regardless of interval since priorTd or — are students in a postsecondary educational institution, Tdap vaccination. — work in a healthcare facility,or • Persons aged z 11 years who have not received Tdap vaccine or for whom — plan to travel internationally. vaccine status is unknown should receive a dose of Tdap followed by tetanus . Persons vaccinated before 1979 with either killed mumps vaccine or mumps and diphtheria toxoids(Td)booster doses every 10 years thereafter.Tdap can be vaccine of unknown type who are at high risk for mumps infection(e.g.,persons administered regardless of interval since the most recent tetanus or diphtheria- who are working in a health care facility)should be considered for revaccination toxoid-containing vaccine. with 2 doses of MMR vaccine. •Adults with an unknown or incomplete history of completing a 3-dose primary Rubella component vaccination series with Td-containing vaccines should begin or complete a primary • For women of childbearing age,regardless of birth year,rubella immunity should vaccination series including a Tdap dose. be determined.If there is no evidence of immunity,women who are not pregnant • For unvaccinated adults,administer the first 2 doses at least 4 weeks apart and the should be vaccinated.Pregnant women who do not have evidence of immunity third dose 6-12 months after the second. should receive MMR vaccine upon completion or termination of pregnancy and or incompletely vaccinated(i.e.,less than 3 doses)adults,administer remaining before discharge from the health care facility. oses. Health care personnel born before 1957. Refer to the ACIP statement for recommendations for administering TdfTdap as • For unvaccinated health care personnel born before 1957 who lack laboratory prophylaxis in wound management(see footnote 1). evidence of measles,mumps,and/or rubella immunity or laboratory confirmation 4.Varicella vaccination of disease,health care facilities should consider vaccinating personnel with 2 • All adults without evidence of immunity to varicella(as defined below)should doses of MMR vaccine at the appropriate interval for measles and mumps or 1 receive 2 doses of single-antigen varicella vaccine or a second dose if they have dose of MMR vaccine for rubella. received only 1 dose. 8.Pneumococcal vaccination •Vaccination should be emphasized for those who have close contact with persons .General information at high risk for severe disease(e.g.,health care personnel and family contacts of — Adults are recommended to receive 1 dose of 13-valent pneumococcal persons with immunocompromising conditions)or are at high risk for exposure or conjugate vaccine(PCV13)and 1,2,or 3 doses(depending on indication)of transmission(e.g.,teachers;child care employees;residents and staff members of 23-valent pneumococcal polysaccharide vaccine(PPSV23). institutional settings,including correctional institutions;college students;military — PCV13 should be administered at least 1 year after PPSV23. personnel;adolescents and adults living in households with children;nonpregnant — PPSV23 should be administered at least 1 year after PCV13,except among women of childbearing age;and international travelers). adults with immunocompromising conditions,anatomical orfunctional • Pregnant women should be assessed for evidence of varicella immunity.Women asplenia,cerebrospinal fluid leak,or cochlear implant,for whom the interval who do not have evidence of immunity should receive the first dose of varicella should be at least 8 weeks;the interval between PPSV23 doses should be at vaccine upon completion or termination of pregnancy and before discharge from least 5 years. the health care facility.The second dose should be administered 4-8 weeks after — No additional dose of PPSV23 is indicated for adults vaccinated with PPSV23 the first dose. at age 2t65 years. • Evidence of immunity to varicella in adults includes any of the following: — When both PCV13 and PPSV23 are indicated,PCV13 should be administered — documentation of 2 doses of varicella vaccine at least 4 weeks apart; first;PCV13 and PPSV23 should not be administered during the same visit. — U.S.-born before 1980,except health care personnel and pregnant women; — When indicated,PCV13 and PPSV23 should be administered to adults whose — history of varicella based on diagnosis or verification of varicella disease by a pneumococcal vaccination history is incomplete or unknown. health care provider; •Adults aged z65 years(immunocompetent)who: — history of herpes zoster based on diagnosis or verification of herpes zoster _ have not received PCV13 or PPSV23:administer PCV13 followed by PPSV23 at disease by a health care provider;or least 1 year after PCV13. — laboratory evidence of immunity or laboratory confirmation of disease. — have not received PCV13 but have received a dose of PPSV23 at age 2.'65 years: 5.Human papillomavirus(HPV)vaccination administer PCV13 at least 1 year after PPSV23. •Three HPV vaccines are licensed for use in females(bivalent HPV vaccine[2vHPV], _ have not received PCV13 but have received 1 or more doses of PPSV23 at quadrivalent HPV vaccine[4vHPV],and 9-valent HPV vaccine[9vHPV])and two age<65 years:administer PCV13 at least 1 year after the most recent dose of HPV vaccines are licensed for use in males(4vHPV and 9vHPV). PPSV23.Administer a dose of PPSV23 at least 1 year after PCV13 and at least 5 • For females,2vHPV,4vHPV,or 9vHPV is recommended in a 3-dose series for years after the most recent dose of PPSV23. routine vaccination at age 11 or 12 years and forthose aged 13 through 26 years,if — have received PCV13 but not PPSV23 at age<65 years:administer PPSV23 at not previously vaccinated. least 1 year after PCV13. • For males,4vHPV or 9vHPV is recommended in a 3-dose series for routine — have received PCV13 and 1 or more doses of PPSV23 at age<65 years: vaccination at age 11 or 12 years and for those aged 13 through 21 years,if not administer PPSV23 at least 1 year after PCV13 and at least 5 years after the previously vaccinated.Males aged 22 through 26 years may be vaccinated. most recent dose of PPSV23. PV vaccination is recommended for men who have sex with men through age 26 .Adults aged z19 years with immunocompromising conditions or anatomical or Fears who did not get any or all doses when they were younger. functional asplenia(defined below)who: Vaccination is recommended for immunocom promised persons(including those — have not received PCV13 or PPSV23:administer PCV13 followed by PPSV23 at with HIV infection)through age 26 years who did not get any or all doses when least 8 weeks after PCV13.Administer a second dose of PPSV23 at least 5 years they were younger. after the first dose of PPSV23. • A complete HPV vaccination series consists of 3 doses.The second dose should — have not received PCV13 but have received 1 dose of PPSV23:administer be administered 4-8 weeks(minimum interval of weeks)after the first dose;the PCV13 at least 1 year after the PPSV23.Administer a second dose of PPSV23 at third dose should be administered 24 weeks after the first dose and 16 weeks after least 8 weeks after PCV13 and at least 5 years after the first dose of PPSV23. the second dose(minimum interval of 12 weeks). (Continued on next page) IFootnotes—Recommended Immunization Schedule for Adults Aged 19 Years or Older:United States,2016 — have not received PCV13 but have received 2 doses of PPSV23:administer programs and facilities for chronic hemodialysis patients,and institutions and PCV13 at least 1 year after the most recent dose of PPSV23. nonresidential day care facilities for persons with developmental disabilities. — have received PCV13 but not PPSV23:administer PPSV23 at least 8 weeks after • Administer missing doses to complete a 3-dose series of hepatitis B vaccine to PCV13.Administer a second dose of PPSV23 at least 5 years after the first dose those persons not vaccinated or not completely vaccinated.The second dose of PPSV23. should be administered at least 1 month after the first dose;the third dose should — have received PCV13 and 1 dose of PPSV23:administer a second dose of be administered at least 2 months after the second dose(and at least 4 months PPSV23 at least 8 weeks after PCV13 and at least 5 years after the first dose of after the first dose).If the combined hepatitis A and hepatitis B vaccine(Twinrix) PPSV23. is used,give 3 doses at 0,1,and 6 months;alternatively,a 4-dose Twinrix schedule — If the most recent dose of PPSV23 was administered at age<65 years,at age may be used,administered on days 0,7,and 21-30,followed by a booster dose at a65 years,administer a dose of PPSV23 at least 8 weeks after PCV13 and at 12 months. least 5 years after the last dose of PPSV23. •Adult patients receiving hemodialysis or with other immunocompromising — Immunocom prom ising conditions that are indications for pneumococcal conditions should receive 1 dose of40 mcg/mL(Recombivax HB)administered vaccination are:congenital or acquired immunodeficiency(including B-or on a 3-dose schedule at 0,1,and 6 months or 2 doses of 20 mcg/mL(Engerix-B) T-lymphocyte deficiency,complement deficiencies,and phagocytic disorders administered simultaneously on a 4-dose schedule at 0,1,2,and 6 months. excluding chronic granulomatous disease),HIV infection,chronic renal failure, 11.Meningococcal vaccination nephrotic syndrome,leukemia,lymphoma,Hodgkin disease,generalized •General information malignancy,multiple myeloma,solid organ transplant,and iatrogenic — Serogroup A,C,W,and Y meningococcal vaccine is available as a conjugate immunosuppression(including long-term systemic corticosteroids and (MenACWY[Menactra,Menveo])or a polysaccharide(MPSV4[Menomune]) radiation therapy). vaccine. — Anatomical or functional asplenia that are indications for pneumococcal — Serogroup B meningococcal(MenB)vaccine is available as a 2-dose series of vaccination are:sickle cell disease and other hemoglobinopathies,congenital MenB-4C vaccine(Bexsero)administered at least 1 month apart or a 3-dose or acquired asplenia,splenic dysfunction,and splenectomy.Administer series of MenB-FHbp(Trumenba)vaccine administered at 0,2,and 6 months; pneumococcal vaccines at least 2 weeks before immunosuppressive therapy the two MenB vaccines are not interchangeable,i.e.,the same MenB vaccine or an elective splenectomy,and as soon as possible to adults who are newly product must be used for all doses. diagnosed with asymptomatic or symptomatic HIV infection. — MenACWY vaccine is preferred for adults with serogroup A,C,W,and Y • Adults aged Z19 years with cerebrospinal fluid leaks or cochlear implants: meningococcal vaccine indications who are aged s55 years,and for adults administer PCV13 followed by PPSV23 at least 8 weeks after PCV13;no additional aged 2!56 years:1)who were vaccinated previously with MenACWY vaccine dose of PPSV23 is indicated if aged<65 years.If PPSV23 was administered at age and are recommended for revaccination or 2)for whom multiple doses of <65 years,at age 2t65 years,administer another dose of PPSV23 at least 5 years vaccine are anticipated;MPSV4 vaccine is preferred for adults aged>-56 years after the last dose of PPSV23. who have not received MenACWY vaccine previously and who require a single • Adults aged 19 through 64 years with chronic heart disease(including congestive dose only(e.g.,persons at risk because of an outbreak). heart failure and cardiomyopathies,excluding hypertension),chronic lung disease — Revaccination with MenACWY vaccine every 5 years is recommended for (including chronic obstructive lung disease,emphysema,and asthma),chronic adults previously vaccinated with MenACWY or MPSV4 vaccine who remain at liver disease(including cirrhosis),alcoholism,or diabetes mellitus,or who smoke increased risk for infection(e.g.,adults with anatomical or functional asplenia cigarettes:administer PPSV23.At age z65 years,administer PCV13 at least 1 year or persistent complement component deficiencies,or microbiologists who after PPSV23,followed by another dose of PPSV23 at least 1 year after PCV13 and are routinely exposed to isolates of Neisseria meningitidis). at least 5 years after the last dose of PPSV23. — MenB vaccine is approved for use in persons aged 10 through 25 years; • Routine pneumococcal vaccination is not recommended for American Indian/ however,because there is no theoretical difference in safety for persons aged Alaska Native or other adults unless they have an indication as above;however, >25 years compared to those aged 10 through 25 years,MenB vaccine is public health authorities may consider recommending the use of pneumococcal recommended for routine use in persons aged>10 years who are at increased vaccines for American Indians/Alaska Natives or other adults who live in areas with risk for Serogroup B meningococcal disease. increased risk for invasive pneumococcal disease. — There is no recommendation for MenB revaccination at this time. 9.Hepatitis A vaccination — MenB vaccine may be administered concomitantly with MenACWY vaccine •Vaccinate any person seeking protection from hepatitis A virus(HAV)infection and but at a different anatomic site,if feasible. persons with any of the following indications: — HIV infection is not an indication for routine vaccination with MenACWY men who have sex with men; or MenB vaccine;if an HIV-infected person of any age is to be vaccinated, persons who use injection or noninjection illicit drugs; administer 2 doses of MenACWY vaccine at least 2 months apart. — persons working with HAV-infected primates or with HAV in a research •Adults with anatomical or functional asplenia or persistent complement laboratory setting; component deficiencies:administer 2 doses of MenACWY vaccine at least 2 persons with chronic liver disease and persons who receive clotting factor months apart and revaccinate every 5 years.Also administer a series of MenB concentrates; vaccine. persons traveling to or working in countries that have high or intermediate • Microbiologists who are routinely exposed to isolates of Neisseria meningitidis: endemicity of hepatitis A(see footnote 1);and administer a single dose of MenACWY vaccine;revaccinate with MenACWY unvaccinated persons who anticipate close personal contact(e.g.,household vaccine every 5 years if remain at increased risk for infection.Also administer a or regular babysitting)with an international adoptee during the first 60 days series of MenB vaccine. after arrival in the United States from a country with high or intermediate • Persons at risk because of a meningococcal disease outbreak:if the outbreak endemicity of hepatitis A(see footnote 1).The first dose of the 2-dose is attributable to Serogroup A,C,W,or Y,administer a single dose of MenACWY hepatitis A vaccine series should be administered as soon as adoption is vaccine;if the outbreak is attributable to serogroup B,administer a series of MenB planned,ideally 2 or more weeks before the arrival of the adoptee, vaccine. • Single-antigen vaccine formulations should be administered in a 2-dose schedule • Persons who travel to or live in countries in which meningococcal disease is at either 0 and 6-12 months(Havrix),or 0 and 6-18 months(Vagta).If the hyperendemic or epidemic:administer a single dose of MenACWY vaccine combined hepatitis A and hepatitis B vaccine(Twinrix)is used,administer 3 doses and revaccinate with MenACWY vaccine every 5 years if the increased riskfor at 0,1,and 6 months,alternatively,a 4-dose schedule may be used,administered infection remains(see footnote 1);MenB vaccine is not recommended because on days 0,7,and 21-30 followed by a booster dose at 12 months. meningococcal disease in these countries is generally not caused by serogroup B. 10.Hepatitis B vaccination • Military recruits:administer a single dose of MenACWY vaccine. •Vaccinate any person seeking protection from hepatitis B virus(HBV)infection and • First-year college students aged s21 years who live in residence halls:administer a persons with any of the following indications: single dose of MenACWY vaccine if they have not received a dose on or after their — sexually active persons who are not in a long-term,mutually monogamous 16"'birthday. relationship(e.g.,persons with more than 1 sex partner during the previous 6 •Young adults aged 16 through 23 years(preferred age range is 16 through 18 months);persons seeking evaluation or treatment for a sexually transmitted years):may be vaccinated with a series of MenB vaccine to provide short-term disease(STD);current or recent injection drug users;and men who have sex protection against most strains of Serogroup B meningococcal disease. with men; 12.Haemophilus influenzae type b(Hib)vaccination — health care personnel and public safety workers who are potentially exposed •One dose of Hib vaccine should be administered to persons who have anatomical to blood or other infectious body fluids; or functional asplenia or sickle cell disease or are undergoing elective splenectomy — persons who are aged<60 years with diabetes as soon as feasible after if they have not previously received Hib vaccine.Hib vaccination 14 or more days diagnosis;persons with diabetes who are aged>-60 years at the discretion before splenectomy is suggested. of the treating clinician based on the likelihood of acquiring HBV infection, • Recipients of a hematopoietic stem cell transplant(HSCT)should be vaccinated including the risk posed by an increased need for assisted blood glucose with a 3-dose regimen 6-12 months after a successful transplant,regardless of monitoring in long-term care facilities,the likelihood of experiencing chronic vaccination history;at least 4 weeks should separate doses. sequelae if infected with HBV,and the likelihood of immune response to •Hib vaccine is not recommended for adults with HIV infection since their risk for vaccination; Hib infection is low. — persons with end-stage renal disease(including patients receiving 13.Immunocompromising conditions hemodialysis),persons with HIV infection,and persons with chronic liver •Inactivated vaccines(e.g.,pneumococcal,meningococcal,and inactivated disease; influenza vaccines)generally are acceptable and live vaccines generally should household contacts and sex partners of hepatitis B surface antigen- be avoided in persons with immune deficiencies or immunocompromising positive persons,clients and staff members of institutions for persons with conditions.Information on specific conditions is available at www.cdc.gov/ developmental disabilities,and international travelers to regions with high or vaccines/hcp/acip-recs/index.html. intermediate levels of endemic HBV infection(see footnote 1);and — all adults in the following settings:STD treatment facilities,HIV testing and treatment facilities,facilities providing drug abuse treatment and prevention services,health care settings targeting services to injection drug users or men who have sex with men,correctional facilities,end-stage renal disease TABLE.Contraindications and precautions to commonly used vaccines in adults''? Vaccine Contraindications Precautions ;Influenza,Ina ted OWY Severe alley icreaction' ana ' n t w ,. ' .- 9 (eg.,_ PfiY, 1 afteCpranous?joss of any ,1 Moderate or severe acute ilin�ess•with o"without fever influenza vaccine;or fb a vaccine corttponefttincludrng egg proteuti Htstgry of GuiAain Barre 5yndoriae wdtht¢weeks of previous:inftueoia vaccination '•Adyh�wrth egg allergy of any seveRy m reserve RIV adutswith hives- on all to" gs'mayreceive IlV with addltion5(s et measure3' uenza,recombinant(RIV) Severe allergic reaction(e.g.,anaphylaxis)after previous dose of RIV orto a Moderate or severe acute illness with or without fever vaccine component.RIV does not contain any egg protein' History of Guillain-Barre Syndrome within 6 weeks of previous influenza vaccination influenza,five attenuated(LAIV)'3 Severe allergic reaction(e.g:,anaphylaxis)to any component of the vaccine, Moderate or severe acute illness with orwithout fever. or to a previous dose of any influenza,vaccine History of Guillain-Barr,Syndrome within 6 weeks of previous influenza In addition,ACIP recommends that LAIV riot be used in thefollowing vaccination population Asthma n pertonsaged S�years and older pregnantwomen • Other chfomcmedical 2ondrtions gg,.other chronic lungdiseases chronic immurlosuppressedactult cardlovaFcular dtse"asp(exduiling isofatet�hypgrteris�on)diabetes'cRror_iic aduks with egg ailergyoJiy seventy renal or hepatic disease,hemtologiGdisease,neuri3togrc disease,and, dultswhallauetakei�influertzaantnnrafineili,aligns{amantadine meta'boiicdisoiders nmarnadine,zanam'tvir,or osehamivfrTcvitbin the previous 48 hoursavoid use`ofthese ante irat drtigsfor 14 days aftervaccination Tetanus,diphtheria,pertussis Severe allergic reaction(e.g.,anaphylaxis)after a previous dose or to a Moderate or severe acute illness with or without fever (Tdap);tetanus,diphtheria(Td) vaccine component Guillain-Barre Syndrome within 6 weeks after a previous dose of tetanus For pertussis-containing vaccines:encephalopathy(e.g.,coma,decreased toxoid-containing vaccine level of consciousness,or prolonged seizures)not attributable to another History of Arthus-type hypersensitivity reactions after a previous dose of identifiable cause within 7 days of administration of a previous dose of tetanus or diphtheria toxoid-containing vaccine;defer vaccination until at Tdap,diphtheria and tetanus toxoids and pertussis(DTP),or diphtheria and least 10 years have elapsed since the last tetanus toxoid-containing vaccine tetanus toxoids and acellular pertussis(DTaP)vaccine For pertussis-containing vaccines:progressive or unstable neurologic disorder,uncontrolled seizures,or progressive encephalopathy until a treatment regimen has been established and the condition has stabilized Varicella' Severe allergic reaethori(e g,a" il;*is)after a previousdoseoit0 a Recent{within 11 months)receipt of antibody,,,,corna,lrlingbtood product , vaccine component (specific interval depends on product); Known severe immunodefider"(e.g„from hematologic and solid tumors, Moderate or severe acute illness with or without fever receipt of chemotherapy,congenital immunodeficiency,or long-term Receipt of specific antivirals(i.e.,acyclovir,famciclovir,or valacyclovir)24 immunosuppressive therapy,'or patients with human immunodeficiency hours before vaccination;avoid use of these antiviral drugs for 14 days after+ virus(HIV)infection who are severely immunocompromised) vaccination Pregnancy Human papillomavirus(HPV) Severe allergic reaction(e.g.,anaphylaxis)after a previous dose or to a Moderate or severe acute illness with or without fever vaccine component Pregnancy T — - - - _ Fste SevereaileglcYeactiori(ega'rtaphylxts}toavacanecamnt M Herat'eorsevQfe..acuterNnesswt�lotlofever Knb vn save a linmunodeficrency(eg„fromhematol,grc a solid:tuMors, Receipt of specific antix4rals(fe acyde,i rr fainciclovir,qr valacy6t6Vt)24 receipt of Chem"o llerapy,or long-term immtsn suppressive Yherap 4 or hours before vatciriation:avoid use of`these antivtrai drugs for 14 days after Oki ents with HIV infection who are severely imrllunocontpromised) vaccination Pregnancy les,mumps,rubella(MMR)' Severe allergic reaction(e.g.,anaphylaxis)after a previous dose or to a Moderate or severe acute illness with or without fever vaccine component Recent(within 11 months)receipt of antibody-containing blood product Known severe immunodeficiency(e.g.,from hematologic and solid tumors, (specific interval depends on product)' receipt of chemotherapy,congenital immunodeficiency,or long-term History of thrombocytopenia or thrombocytopenic purpura immunosuppressive therapy,4 or patients with HIV infection who are severely immunocompromised) Need for tuberculin skin testinge Pregnancy Pneumococcalconjugate(PCV13)' i Severe allergic reaction(e.g.anaphylaxis]after a previoirsdose or`to a Moderate or severe acute illness.witR 6r,�ithoi(t fever vaccine componeni,including to any vaccine containing diphtheria toxoid Pneumococcal polysaccharide Severe allergic reaction(e.g.,anaphylaxis)after a previous dose or to a Moderate or severe acute illness with or without fever (PPSV23) vaccine component Hepatitis A Severe allergic reaction(e g„anaphylaxis)after a previous dose or to a Moderate or severe acute illness with or without fever vaccine component Hepatitis B Severe allergic reaction(e.g.,anaphylaxis)after a previous dose or to a Moderate or severe acute illness with or without fever vaccine component Meningococcal,conjugate Severe allergic reaction(e:g.,anaphylaxis)after a previous dose or to a Moderate or severe acute illness with or without fever (MinkWY);meningococcal, vaccinecomponent olysacch arid e(MPSV4) Meningococcal serogroup B Severe allergic reaction(e.g.,anaphylaxis)after a previous dose or to a Moderate or severe acute illness with or without fever (MenB) vaccine component Haemophilus influenzae Type b Severe allergic reaction(e.g.,anaphylaxis)after a previous dose or to a Moderate or severe acute illness with or without fever (Hib) vaccine component I.Vaccine package inserts and the full ACIP recommendations for these vaccines should be consulted for additional information on vaccine-related contraindications and precautions and for more information on vaccine excipients.Events or conditions listed as precautions should be reviewed carefully.Benefits of and risks for administering a specific vaccine to a person under these circumstances should be considered.If the riskfrom the vaccine is believed to outweigh the benefit,the vaccine should not be administered.If the benefit of vaccination is believed tooutweigh the risk,the vaccine should be administered.A contraindication is a condition in a recipient that increasesthe chanceof a serious adverse reaction.Therefore,a vaccine should not be administered when a contraindication is present. 2.For more information on use of influenza vaccines among persons with egg allergies and a complete list of conditions that CDC considers to be reasons to avoid receiving LAIV,see CDC.Prevention and control of seasonal influenza with vaccines:recommendations of the Advisory Committee on Immunization Practices(ACIP)—United States,2015-16Influenza Season.MMWR2015;64(30):818-25. 3.LAIV,MMR varicella,or zoster vaccines can be administered on the same day.If not administered on the same day,live vaccines should be separated by at least 28 days. 4.Immunosuppressive steroid dose is consideredto be>2 weeksof daily receipt of 20 mg of prednisone orthe equivalent.Vaccination should be deferred forat least 1 month after discontinuation of such therapy. Providers should consult ACIP recommendations for complete information on the use of specific live vaccines among persons on immune-suppressing medications or with immune suppression because of other reasons. 5.Vaccine should be deferredforthe appropriate interval if replacement immune globulin products are being administered.See CDC.General recommendations on immunization:recommendations of the Advisory ittee on Immunization Practices(ACIP).MMWR 2011;60(No.RR-2).Available atwww.cdc.gov/vaccines/pubs/pinkbookfndex.html. �mm sles vaccination might suppress tuberculin reactivity temporarily.Measles-containing vaccine may be administered on the same dayas tuberculin skin testing.If testing cannot be performed until afterthe day AMR vaccination,the test should be postponed for at least 4 weeks after the vaccination.If an urgent need exists to skin test,do so with the understanding that reactivity might be reduced by the vaccine. 'Adapted from CDC.Table 6.Contraindications and precautions to commonly used vaccines.General recommendations on immunization: recommendations of the Advisory Committee on Immunization Practices.MMWR 2011;60(No.RR-2):40-41 and from HamborskyJ,Kroger,A, Wolfe C,eds.Appendix A.Epidemiology and prevention of vaccine preventable diseases.13`"ed.Washington,DC:Public Health Foundation,2015. Department of D U.S.D Available at www.cdc.gov/vaccines/pubs/pinkbook/index.html, U.S U.SHealt and Human Services Regarding latex allergy,consult the package insert for any vaccine administered. Centers for Disease Control and Prevention C526093}D ZIKA Script for Salem Board of Health Department: Practice enhanced travel precautions for the following locations: Caribbean, Pacific Islands, South America, Central America and Cape Verde. • Prevention: There is no vaccine to prevent Zika virus disease. Prevent Zika by avoiding mosquito bites (see below). Prevent sexual transmission of Zika by using condoms or not having sex with persons that have recently traveled to an area with an outbreak. • Recommendations for women that are pregnant, planning pregnancy or are breastfeeding: Talk with a physician prior to travel to and when returning from an area with an outbreak. • Please understand that this remains a rapidly evolving situation and that new guidance will continue to come out as more is learned about specific risks linked to Zika virus infection. You should continue to remain alert for and follow the most up-to-date information. For the most current information about the Zika virus visit one of the following websites: o Salem Board of Health at www.salem.com/health o Center for Disease Control at www.cdc. ov,'zika o Massachusetts Department of Public Health at www.mass.cov/eohhs/ og v/departments/dph/ Steps to prevent mosquito bites: When traveling to countries where Zika virus or other viruses spread by mosquitoes are found, • take the following steps: • Understand that mosquitoes that spread Zika virus bite mostly during the daytime. • Cover exposed skin by wearing long-sleeved shirts, long pants,and hats. • Stay in places with air conditioning or that use window and door screens. • Sleep under a mosquito bed net if you are overseas or outside and are not able to protect yourself from mosquito bites. • Use insect repellent, follow product directions and reapply as directed. • If you are also using sunscreen, apply sunscreen first and insect repellent second. • If you have a baby or child: Follow instructions closely when using an insect repellent product. After Travel: • Talk to your health care provider if you develop a fever with a rash,joint pain, or red eyes. Tell your health care provider about your travel. • Persons with Guillain-Bane Syndrome(neurological disorder)should follow up with their health care provider regarding recent travel. • For males: If your partner is pregnant, either use condoms the right way every time you have vaginal, anal,and oral(mouth-to-penis)sex or do not have sex during the pregnancy. • For females: If you are pregnant or planning to get pregnant, discuss concerns with a physician. You can use condoms the right way every time you have vaginal, anal, and oral(mouth-to-penis) sex. Not having sex is the best way to be sure that you do not get sexually transmitted Zika virus. All pregnant travelers returning from areas with ongoing Zika transmission can be tested for Zika virus infection. • Information from:http://www.cdc.gov/zika/prevention/index.html taken February 25th,2016, http://www.health.gov.au/internet/"main/publishing.nsf/Content/ohp-zika-countries.htm taken February 25, 2016. MDPH Bureau of Infectious Disease Public Health Fact Sheet January 2016. Created:02/25/16 I Health Dept. Clerical Report • - p p rt FY 16 Burial Permits Certificate of $25 Permits Plan Reviews Fitness $50 Copies / Fines Revenue Permit Fees July-14 $475.00 $2,210.00 $1,950.00 $4,635.00 Food Service Est. <25 seats $140 August $700.00 $985.00 $1,500.00 $3,185.00 �5-99 seats $280 >gg seats $420 September $1,475.00 $2,165.00 $4,300.00 $300 00 <"#. $8,240.00 Retail Food <l000sq' $70 October $725.00 $3,295.00 $1,400.00 $5,420.00 l000-so,000 $280 >10,000 $420 November m $600.00 $2,384.14 $180.00 $1,400.00 $200.00 $4,764.14 Temp Food , 13d6ys $360 December $1,375.00 $52,268.00 $2,600.00 $56,243.00 47d6ys $600'; >7days� s - January-15 $325.00 $10,780.00 r Exampleof>7.daytempfoodpermit. $650.00 m $11,755.00a. (dqs)divided b 7.=2 x$600=:$iioo February Frozen Desserts g25 $0.00 March $0.00 Mobile Food $210 April Plan Reviews NQW'q s .e'4n gjF s zr $0.00 #180. : _ w May $0.00 Remodelsgo w June a � $ r Zoo '00 g catering kitchen Body Art Est. 315 Total $5,675.00 $74,087.14 $180.00 $13,800.00 Body Art Practitioner 13S $500.00 :� $94,242.14 Review Plans $i8o Fiscal Year Budget 2014 Suntan Est. $140 Rec. Day Camp $10 Salary Starting Ending Expenses/Budget Ext.Paint Removal $35 Full Time $357,223.00 $160,388.69 Starting Ending Transport 0 Subst. $10 p ff. 5 Part Time $16,545.00 $12,172.50 $18,300.00 $8,721.18 Tobacco Vendors $135 Overtime $2,000.00 $0.00 Swimming Pools Seasonal $140 Balance $375,768.00 $172,561.19 Health Clinic Revolving Account AnnUai$210 Nonprofit$40 $S,720.09 Title V Review s18o Well Application s18o Disposal works $225/i8o