MEETING PACKET APRIL 2017 APRIL` 2017
CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
120 WASHINGTON STREET,4111 FLOOR PUNCHeEfth
proms o[e
TEL. (978)741-1800 FAx(978) 745-0343
KIMBERLEY DRISCOLL lramdin@salem.com
LARRY RAMDIN,RS/REHS,CHO,CP-]
MAYOR HEALTH AGENT
NOTICE OF MEETING
You are hereby notified that the Salem Board of Health will hold its regularly scheduled meeting
Tuesday April 18, 2017 at 7.00 PM
City Hall Annex 120 Washington Street Room 313
MEETING AGENDA
1. Call to order
2. Approval of Minutes o6a:.
3. Chairperson Communications tn�
4. Public Health Announcements/Reports/Updates 3rn s
a. PHN Report x'
b. Health Agent
c. Administrative
d. Council Liaison Updates
5. Hearing 2nd Violation Vapor Outlet 103 Lafayette Street
6. Continue discussion on banning smoking in public parks and beaches
7. New Business/Scheduling of future agenda items
• Items that could not be anticipated prior to the posting of the agenda
Larry Ramdin
Health Agent
cc: Mayor Kimberley Driscoll, Board of Health, City Councilors
Next regularly scheduled meeting is May 9, 2017 at 7:00pm at City Hall Annex,
120 Washington Street 3'"Floor Room 313.
Know your,rights under the open meeting law MGL chapter 30A ss. 18-25 and City Ordinance
section 2-2028 through 2-2033
This notice posted on "Official Bulletin Board"
City Hall, Salem, Mass. on APR 12
�
at '4.�� in accordance witG� haP.3W.
Sections 18-25.
CITY OF SALEM
BOARD OF HEALTH
MEETING MINUTES
February 14, 2017
DRAFT
MEMBERS PRESENT: Paul Kirby, Chair,Nancy Crowder, Mary Lauby &Jeremy Schiller
OTHERS PRESENT: Larry Ramdin, Health Agent, Suzanne Doty, Public Health Nurse &Heather Lyons-Paul
Clerk of the Board
EXCUSED: Janet Greene
TOPIC DISCUSSION/ACTION n,;=
1. Call to Order 7:18pm
2.Minutes of Last Meeting Dr. Schiller motioned to accept th--draft minutes. N. Crowder
(January 17, 2017) 2nd by All m Favor. Motion passed
3. Reorganization of the Board Dr. Schiller motioned to,nominate Paul Kirby for Chair of The
Board. 2"a N. Crowder-;All h Favor. Motion.-passed.
Dr. Schiller motioned that Heather Lyons-Paul will remain the
Clerk 4the Board until the March 2017 meeting and Maureen
Davis wiWcontinue for the remaining of the year.N. Crowder
- F2"a All m�Favor.:Motion;passed
4. Chairperson Announcements `fi Y
5.Monthly Reports-Updates
A. Public Health +' , 1,O;piate discussion.'January 2017 there were 4 fatalities and 22
Nurse's Report overdoses.
Thu s�day nights at hospital there are Narcan trainings
f.. _ TM. ,,,Copy available at the BOH office
B. Health Agent's Report::' }?Needle exchange program discussion. This would create an avenue
tia help with people with a substance abuse problem.
`. "= •Budget discussion. Larry Ramdin is asking for another fulltime
clerk a program director, and to increase Janet's hours to 19 a
week.
Copy available at the BOH office
C. Administrative Update admin report for next month to include breakdown of types
Report of food permits
Copy available at the BOH office
Nancy Crowder motioned to accept the reports. 2nd by Dr.
Schiller All in favor. Motion passed.
D. City Council Liaison No updates this month
Updates
Deferred item to next month meeting.
6. Syringe exchange program— Topic will include:
Board will discuss approval of *Needle deposit fee/exchange program
syringe exchange program in *Data of towns/cities that have adopted this exchange
keeping with MGL Chapll s215 *Mary Wheeler will be asked to present next month
No updates from Councilor Liaison Beth Gerard.
7. Continue discussion on banning L. Ramdin will reach out to Park and Rec and the Police
smoking in public parks and Department to discuss enforcement responsibilities.
beaches
8.New Business/Scheduling of future Forward thinking goals
`{
agenda items Mass in Motion =+w
Mary Wheeler';needle exchange
r
Smoking ban`
Task Force
8. MEETING ADJOURNED: MjLaubynotioned to'adlourn the meeting. 2"d Dr Schiller by
All in favor Motion passed.'--,
9:05pm
ra Respectfully submitted,
t
9 T.
S
Heather Lyons-Paul
Clerk of the Board
�.
Next regularly scheduled meeting is March 14, 2017 at 7pm
AtY00,-Hall Annex, 12O.,Washzngton Street,Room 313 Salem.
Suzanne Doty RN BSN
• Salem Board of Health
Public Health Nurse
Public Health Nurse Report
Reporting on February 9, 2017 through March 9, 2017
Disease Prevention and Health Promotion
• Investigated reportable diseases and reported case information to MDPH.
• Coordinating follow up with North Shore Pulmonary Clinic on tuberculosis cases.
• Continually inputting flu doses and clinic information into the Massachusetts
Immunization Information System(MIIS) for up to date vaccine records and better
continuity of care between clinics and providers.
• Added post to the Board of Health Facebook page including information from the CDC
to show when antibiotics are necessary or not(as an effort to combat antibiotic
resistance)and a post with information to help differentiate between a cold and the flu
including a table to compare symptoms and know when to seek treatment.
Meetings/Trainings
• • Continued modules and Working on Wellness webinars, the beginning steps of creating a
program on wellness for city employees. Submitting on going assignments as plans
become more finalized and planning next committee meeting. First round of seed funding
of$2,000 awarded on December 15"and arrived mid-January. Second round of seed
funding for$7,000 has also been awarded and arrived mid-February. Currently
completing the task of creating encouraging signage to increase use of the stairs in our
buildings instead of the elevators.
• Attended the Salem Overdose and Substance Abuse Awareness Coalition on February
14`h for ongoing efforts to increase prevention and awareness of substance abuse.
• Completed a 2-day Emergency Preparedness training on February 151h and 16`h, a train
the trainer course for responding to a mass casualty incident and a hands-on Personal
Protective Equipment training where we learned to properly don and doff level C suits
required for a biological hazard.
• Attended a meeting with the North Shore public health nurses on February 28th to
collaborate on issues we are seeing within our communities such as food borne illnesses
reported and Tuberculosis education and treatment, this month's meeting also included a
presentation by Sanofi Pasteur,the company we order adult influenza vaccine from, to
discuss efficacy of the vaccines, future ordering and shipping changes and what to
anticipate for next season.
• Attended a CBRNE training on March Vt hosted by our Emergency Preparedness
• coalition which stands for Chemical, Biological, Radiological,Nuclear, and Explosives,
this presentation discussed how to prepare for these specific incidents, the incident
• command system and what our role is to assist Emergency Operations with the Fire
departments and other disciplines.
• Scheduled a training/presentation for the public health nurses and all recreational camp
directors on the Northshore with the Department of Public Health regarding camp
regulations. Letters and flyers were mailed and also e-mailed to all camp directors in
Salem regarding applying for a camp license in 2017, scheduling an inspection and
attending the training. The training will be held on March 30t'in Beverly.
• A local tattoo artist inquired about Microblading, a form of cosmetic tattooing, I have
been doing ongoing research on the procedure to help offer support,guidance and be
informed for licensing artists.
Monthly Report of Communicable Diseases: February 2017
Disease New Carry Over Discharged/ Total#Of Running Total for Total for4
Reported Cases this Total for 2016 2015`
Closed Month 2017
Tuberculosis 0 0 0 0 0 4 "
(Active)
Latent 1 0 1 1 3 31 47`
Tuberculosis*
Arbovirus* 0 0 0 0 0 0 0j
Babesiosis 0 0 0 0 0 0 I°
Calicivirus/No 0 0 0 0 0 0 1
rovirus
Campylobacte 0 0 0 0 0 15 Tl
riosis
Chikungunya 0 0 0 0 0 0 0.
Dengue* 0 0 0 0 0 0 0
Ehrlichiosis 0 0 0 0 0 0 01.
Enterovirus 0 0 0 0 0 0 1
Giardiasis 0 0 0 0 1 6 x2+
•
Group A 1 0 1 1 1 0
eptococcus
Group B* 3 0 3 3 3 2 ,71
Streptococcus
Human 0 0 0 0 0 1 1
Granulocytic
Anaplasmosis
Haemophilus 1 1 0 1 1 2 1;
Influenzae
Hansen's 0 0 0 0 0 0 10,
Disease
Hepatitis A 0 0 0 0 0 0 0.
Hepatitis B* 0 0 0 0 1 8
Hepatitis C* 4 0 4 4 10 30 r
Influenza* 17 0 17 17 28 199
gionellosis 0 0 0 0 0 2 1
Lyme 0 0 0 . 0 0 0 2,
Disease*
(27**)
(Probable)
Malaria 0 0 0 0 0 2 `0
Measles 0 0 0 0 0 1 0
Meningitis 0 0 0 0 0 0 0
Mumps 0 0 0 0 0 1 b
Pertussis 0 0 0 0 0 1 1,
Rocky 0 0 0 0 0 0 0°
Mountain
Spotted Fever
Salmonellosis 0 0 0 0 1 11 6
Shigatoxin 0 0 0 0 0 0 0,
Wroducing
Organism
Shigellosis 0 0 0 0 0 3 0'
Streptococcus 0 0 0 0 0 8 61
Pneumoniae*
Varicella* 0 0 0 0 0 1 08
Vibrio 0 0 0 0 0 1 01
West Nile 0 0 0 0 0 0 0
Yersoniosis 0 0 0 0 0 0 a'V
Zika Virus 0 0 0 0 0 1 6
Infection
Total 27 1 26 27 49 204 140
• January 2017
*Notifications only, LBOH not required to follow up or investigation per DPH.
**Total reflects cases that have also been reported as suspect cases.
All Communicable disease totals above are subject to change in the event that the follow up investigation
results in the revocation of the diagnosis.
Yearly totals for 2016 have been updated for year end with the number of CONFIRMED cases.
Summary of Current Communicable Diseases
Group A Streptococcus:
Case 1: This patient developed the infection as a pneumonia and was treated for 2 days in the
hospital, has since recovered.No further cases of invasive Group A streptococcus reported, this case is
complete and closed.
Giardia:
Case 1: This patient was treated outpatient after developing minor symptoms after recently
traveling out of the country, they have fully recovered. Does not work in a food establishment or in a
caregiver setting.No further follow up required, case is closed.
Haemophilus influenza:
• Case 1: This case is currently being worked on as I am continuing to make contact with the
patient to conduct an interview. This diagnosis is vaccine preventable and follow up with any household
contacts under the age of 4 regarding vaccine status will need to be completed. The patient was diagnosed
by in a lab in another state. I will continue to attempt follow up.
Norovirus:
Case 1: This patient was immunocompromised and therefor required testing to identify the source
of their symptoms. Case is a student in a private school in a neighboring town, that town was notified and
appropriate follow up completed. No further follow up necessary, case is closed.
Case 2: This patient contracted the virus while they were inpatient at a hospital outside of Salem
for an unrelated matter. They have since recovered. The hospitals infection control staff are continuing to
implement strategies to prevent spread of viruses in the hospital.No further follow up necessary, case is
closed.
Mumps (suspect): A suspected case of Mumps required follow up in the month of February.
This case was school aged and had developed parotitis (swollen salivary glands). The PCR for mumps
that came back negative. The patient and all household contacts are currently up to date on their Mumps
vaccinations. The patient was kept in isolation at home for 5 days post swelling onset to prevent
possibility of spread. Per the Department of Public Health, a heightened surveillance is required in the
school setting for only the students who are not immunized, no exclusions or notices necessary. I
communicated this with the Director of Nursing for the schools and directly to the nurse of the school the
patient attends, a fact sheet was provided. No further reports at this time. Per the epidemiologist at MDPH
this case is closed.
Zika Virus Infection:
31 cases of Zika Virus Infection previously listed as cases have been revoked after lab tests. In
the month of February, there were no new cases of testing and 5 revoked cases.
Confirmed Case(June 2016): Case not pregnant at time of diagnosis. Case traveled to
Dominican Republic and reported symptoms of fever and rash.
•
Recommended Immunization Schedule for
Children and Adolescents Aged 18 Years or Younger, UN ITED STATES, 2017
This schedule includes recommendations in effect as of January 1, 2017. Any dose not administered at the
recommended age should be administered at a subsequent visit, when indicated and feasible.The use of a
combination vaccine generally is preferred over separate injections of its equivalent component vaccines.
Vaccination providers should consult the relevant Advisory Committee on Immunization Practices (ACIP) statement
for detailed recommendations, available online at www.cdc.gov/vaccines/hcp/acip-recs/index.html. Clinically
significant adverse events that follow vaccination should be reported to the Vaccine Adverse Event Reporting
System (VAERS) online (www.vaers.hhs.gov) or by telephone (800-822-7967). Suspected cases of vaccine-
preventable diseases should be reported to the state or local health department. Additional information, including
precautions and contraindications for vaccination, is available from CDC online (www.cdc.gov/vaccines/hcp/admin/
contra indications.htm1) or by telephone (800-CDC-INFO [800-232-46361).
The Recommended Immunization Schedule for
Children and Adolescents Aged 18 Years or Younger area pproved by the
Advisory Committee on Immunization Practices
(www.cdc.gov/vaccines/acip)
American Academy of Pediatrics
(www.aap.org)
American Academy of Family Physicians
(www.aafp.org)
American College of Obstetricians and Gynecologists
(www.acog.org)
-..
n . . and Prevention
Figure 1.Recommended Immunization Schedule for Children and Adolescents Aged 18 Years or Younger—United States,2017.
(FOR THOSE WHO FALL BEHIND OR START LATE,SEETHE CATCH-UP SCHEDULE[FIGURE 2]).
These recommendations must be read with the footnotes that follow.For those who fall behind or start late,provide catch-up vaccination at the earliest opportunity as indicated by the green bars in Figure 1.
To determine minimum intervals between doses,see the catch-up schedule(Figure 2).School entry and adolescent vaccine age groups are shaded in gray.
Vaccine Birth 1 mo 2 mos 4 mos 6 mos 9 EJ:1:2 mos 15 mos 18 mos 19-2 2-3 yrs 4-6 yrs 7-10 yrs 11-12 yrs 13-15 yrs 16 yrs 17-18 yrs
mos
Hepatitis B'(HepB) tndose <---------2^d dose-------•- ------------------------------------3rd dose------------------------------------
3►
Rotavirus2(RV)RV1(2-dose See
series);RV5(3-dose series) 1'dose 2"d dose footnote 2
Diphtheria,tetanus,&acellular
pertussis3(DTaP:<7 yrs) 1 dose 2n1 dose 3`d dose ---4°^dose 5`h dose
Haemophiius influenza'type b^ d See 3'd or 4d dose,.,.. _( ;, } t s
(Hib) lndose 21 dose footnote 4 See footnote 4
Pneumococcal a con ate' d , s
f g 1"dose 2"dose 3 dose --------411 dose.........
(PCV13) a... m. •.x 1 ,Inactivated poliovirus6 1 n dose 2"d dose 3 dose------------------•---------------- 41'dose
(IPV:<18 yrs)
Influenza'(IIV) Annual vaccination(IIV)1 or 2 doses Annual vaccination(IIV)
1 dose only
4
Measles,mumps,rubella'(MMR) {d+5th`d -------1"dose--------- 21d dose
Varicella9(VAR) <---------1 1'dose-------- 21d dose
Hepatitis A10(HepA) ---------2-dose series,See footnote 10---------3► s1. '""_) _." ' }( '§^x•
Mening
enCY
6 weeks MenACWY-DM9 mos; =s )Sefbo][cst - ) ' f (� uf3 i 1"dose 2"d dose
MenACWY-CRM a2 mos)
Tetanus,diphtheria,&acellularMON"
pertussiS12(Tdap:>7 yrs) Tdap
See footnote
Human papillomavirust3(HPV) 13
Seefd6tfiote=11 i x
Meningococcal Bit
Pneumococcal polysaccharides t " _ 5('efaptnnt ;2 n $_
(PPSV23)
Range of recommended Range of recommended ages 17777 77l.Range of recommended ages Range of recommended ages for non-high-risk No recommendation
ages for all children for catch-up immunization for certain high-risk groups groups that may receive vaccine,subject to
individual clinical decision making
NOTE:The above recommendations must be read along with the footnotes of this schedule.
t 0 0
FIGURE 2.Catch-up immunization schedule for persons aged 4 months through 18 years who start late or who are more than 1 month behind—United States,2017.
The figure below provides catch-up schedules and minimum intervals between doses for children whose vaccinations have been delayed.A vaccine series does not need to be restarted,regardless of the time that has elapsed between
doses.Use the section a ro riate for the child's age.Alwa s use this table in coniunction with Fi ure 1 and the footnotes that follow.
Children age 4 months through 6 years
Minimum Minimum Interval Between Doses
Vaccine Agefor
Dose 1 Dose 1 to Dose 2 Dose 2 to Dose 3 Dose 3 to Dose 4 Dose 4 to Dose 5
8 weeks --
Hepatitis B1 Birth 4weeks and at least 16 weeks after first dose.
Minimu m age for the fi nal dose is 24 weeks.
Rotavirus2 6 weeks 4 weeks 4 weeks2
Diphtheria,tetanus,and 6 weeks 4 weeks 4 weeks 6 months 6 months3
acellular pertussis3
4 weeks'
if current age is younger than 12 months and first dose was administered at younger
than age 7 months,and at least 1 previous dose was PRP-T(ActHib,Pentacel,Hiberix)or
unknown.
4 weeks 8 weeks
iffirst dose was administered before the 1" and age 12 through 59 months(as final dose)'
birthday. ifcurrent age is younger than 12 months 8 weeks(as final dose)
and first dose was administered at age 7 through 11 months; This dose only Haemophilus inFluenzae 8 weeks(as final dose) y necessary for children age 12
type b' 6 weeks if first dose was administered at age 12 OR through 59 months who received 3 doses
through 14 months. ifcurrent age is 12 through 59 months before the 1It birthday.
and first dose was administered before the 1"birthday,and second dose ad minis-
No further doses needed if first dose was tered at younger than 15 months;
administered at age 15 months or older. OR
if both doses were PRP-OMP(PedvaxH1B;Comvax)
and were administered before the 1"birthday.
No further doses needed
if previous dose was administered at age 15 months or older.
4 weeks 4 weeks
if first dose administered before the 1" ifcurrent age is younger than 12 monthsand previous dose given at<7 months old
birthday. 8 weeks(as final dose)
8 weeks(as final dose for healthy children) 8 weeks(as final dose for healthy children) This dose only necessary for children aged
if previous dose given between 7-11 months(wait until at least 12 months old);
Pneumococcal6 6weeks if first dose was administered at the 1" OR 12 through 59 months who received 3 doses
birthday or after. ifcurrent age is 12 months or older and at least 1 dose was given before age 12 months. before age 12 months or for children at high
No further doses needed risk who received 3 doses at any age.
for heaher children iffirstdosewas admin- No further doses needed for healthy children if previous dose administered atage 24
hy
istered at age 24 months or older. months or older.
Inactivatedpoliovirus6 6weeks 4weeks6 4weeks6 6 months6(minimum age4yearsfor final dose).
Measles,mumps,rubella8 12 months 4 weeks
Varicella9 12 months 3 months
Hepatitis A10 12 months 6 months
Meningococcaltt
(Hib-MenCY>_6 weeks; 6 weeks 8 weeks' See footnote 11 See footnote 11
MenACWY-D>_9 mos;
MenACWY-CRM z2 mos)
Meningococcaltt Not Applicable
(MenACWY-D>_9 mos; (N/A) 8 weeks
MenACWY-CRM>_2 mos)
4 weeks
Tetanus,diphtheria; if first dose of DTaP/DT was administered before the 1"birthday. 6 months if first dose of DTaP/DT was
tetanus,diphtheria,and 7 yearsi� 4 weeks 6 months(asfinal dose) administered before the 1"birthday.
acellular pertussis
if first dose of DTaP/DT orTda /Td was administered at or after the 1"birthday,
Human papillomavirus13 9 years Routine dosing intervals are recommended.13
Hepatitis A10 N/A 6 months
Hepatitis Bi N/A 4 weeks 8 weeks and at least 16 weeks after first dose.
Inactivated poliovirus6 N/A 4 weeks 4 weeks6 6 months6
Measles,mumps,rubella8 N/A 4 weeks
Varicella9 N/A 3 months if younger than age 13 years.
4 weeks if age 13 years or older.
NOTE:The above recommendations must be read along with the footnotes of this schedule.
Figure 3.Vaccines that might be indicated for children and adolescents aged 18 years or younger based on medical indications
HIV infection
CD4+count
(cells/pL)
Immunocompromised <15%of >_15%of Kidney failure,end- CSF leaks/ Asplenia and persistent Chronic
status(excluding HIV total CD4 total CD4 stage renal disease,on Heart disease, cochlear complement component liver
VACCINE Y INDICATION ► Pregnancy infection) cell count€ cell count hemodialysis chronic lung disease implants deficiencies disease Diabetes
Hepatitis B'
Rotavirusz
Diphtheria,tetanus,&acellular pertussis3
(DTaP)
■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■
Haemophilus influenzae type b4 ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■
■ ■��_�■■■�■�■ ■ ■ 0.■J■0.■■-■-■- ■ ■ ■ ■■■. ■ ■ ■
■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■
Pneumococcal conjugates ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■
Inactivated poliovirus6
Influenza?
Measles,mumps,rubella8
Varicella9
Hepatitis A10 ■■■■■■■
■ ■ ■ ■ ■1ir0■■ ■iiriri`ire■
MeningococcalACWY11 ■■■■■r■■■■■■■■■ ■■■■■�■■■■■■■■■■
Tetanus,diphtheria,&acellularpertussisi2 •■■■■■■■
(Tdap) �■■■■■�■
■ ■■iri■i■i■i■i ti■�ri i i i■
Human papillomavirus13 ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■
MeningococcalBt1 ■�r�■�■�■�■�■�■�
33
•-■ ■—■r°—r�■ —■—■�ri—■—r—r�r°—■��■�°r—r^-■—�— r�r—■�r—■r—■—■r�■—r�■—r—�—r^—r^r—r—r—r r—°■--°■—■�r—■�■—
Pneumococcalpolysaccharides ■■■■■■■■■r■■■■■■■■■■■■■rr■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■r■■■■■■■■■■■■■r■■■■■■■■■■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■�■�■�■�■�■�■■_■■ ■■■r■■■ ■■■■�■■r■■■rrr■■■■■■■■■■■ ■■■rrr■ ■r■■■■■ ■ ■■■■■■■■■ r■■■■r■■
Vaccination is recommended,
Recommended for persons with
Vaccination according to the an additional risk factor for which and additional doses may No recommendation contraindicated Precaution for vaccination
routine schedule recommended the vaccine would be indicated necessary based on medicalal
condition.See footnotes.
*Severe Combined Immunodeficiency
NOTE:The above recommendations must be read along with the footnotes of this schedule.
Footnotes—Recommended Immunization Schedule for Children and Adolescents Aged 18 Years or Younger,UNITED STATES,2017
For further guidance on the use of the vaccines mentioned below,see:www.cdc.gov/vaccines/hcp/acip-recs/index.html.
For vaccine recommendations for persons 19 years of age and older,see the Adult Immunization Schedule.
Additional information
• For information on contraindications and precautions for the use of a vaccine and for additional information regarding that vaccine,vaccination providers should consult the ACIP General
Recommendations on Immunization and the relevant ACIP statement,available online at www.cdc.gov/vaccines/hcp/acip-recs/index.htmi.
• For purposes of calculating intervals between doses,4 weeks=28 days.Intervals of 4 months or greater are determined by calendar months.
• Vaccine doses administered<_4 days before the minimum interval are considered valid.Doses of any vaccine administered>_5 days earlier than the minimum interval or minimum age should not
be counted as valid doses and should be repeated as age-appropriate.The repeat dose should be spaced after the invalid dose by the recommended minimum interval.For further details,see
Table 1,Recommended and minimum ages and intervals between vaccine doses,in MMWR,General Recommendations on Immunization and Reports/Vol.60/No.2,available online at www.cdc.gov/
m mwr/pdf/rr/rr6002.pdf.
• Information on travel vaccine requirements and recommendations is available at wwwnc.cdc.gov/travel/.
• For vaccination of persons with primary and secondary immunodeficiencies,see Table 13,Vaccination ofpersons with primaryand secondary immunodeficiencies,in General Recommendations
on Immunization(ACIP),available at www.cdc.gov/mmwr/pdf/rr/rr6002.pdf.;and Immunization in Special Clinical Circumstances,(American Academy of Pedatrics).In:Kimberlin DW,Brady MT,
Jackson MA,Long SS,eds.Red Book:2015 report ofthe Committee on Infectious Diseases.30th ed.Elk Grove Village,IL:American Academy of Pediatrics,2015:68-107.
• The National Vaccine Injury Compensation Program(VICP)is a no-fault alternative to the traditional legal system for resolving vaccine injury petitions.Created by the National Childhood Vaccine
Injury Act of 1986,it provides compensation to people found to be injured by certain vaccines.All vaccines within the recommended childhood immunization schedule are covered byVICP
except for pneumococcal polysaccharide vaccine(PPSV23).For more information;see www.hrsa.ciov/vaccinecomi2ensation/index.html.
1. Hepatitis B(HepB)vaccine.(Minimum age:birth) Administration of a total of 4 doses of HepB vaccine is provided at least 6 months have elapsed since the third
Routine vaccination: permitted when a combination vaccine containing HepB dose.
At birth: is administered after the birth dose. Inadvertent administration of fourth DTaP dose early:
• Administer monovalent HepB vaccine to all newborns Catch-up vaccination: If the fourth dose of DTaP was administered at least 4
within 24 hours of birth. Unvaccinated persons should complete a 3-dose series. months after the third dose of DTaP and the child was 12
• For infants born to hepatitis B surface antigen(HBsAg)- A 2-dose series(doses separated by at least 4 months)of months of age or older,it does not need to be repeated.
positive mothers,administer HepB vaccine and 0.5 mL adult formulation Recombivax HB is licensed for use in Catch-up vaccination:
of hepatitis B immune globulin(HBIG)within 12 hours children aged 11 through 15 years. The fifth dose of DTaP vaccine is not necessary if the
of birth.These infants should be tested for HBsAg and For other catch-up guidance,see Figure 2. fourth dose was administered at age 4 years or older.
antibodyto HBsAg(anti-HBs)at age 9 through 12 months 2, Rotavirus(RV)vaccines.(Minimum age:6 weeks for both For other catch-up guidance,see Figure 2.
(preferably at the next well-child visit)or 1 to 2 months RV1 [Rotarix]and RV5[RotaTeq]) 4. Haemophilus influenzae type b(Hib)conjugate vaccine.
after completion of the HepB series if the series was Routine vaccination: (Minimum age: 6 weeks for PRP T[ActHIB,DTaP-IPV/Hib
delayed. Administer a series of RV vaccine to all infants as follows: (Pentacel),Hiberix,and Hib-MenCY(MenHibrix)],PRP-
• If mother's HBsAg status is unknown,within 12 hours of 1.If Rotarix is used,administer a 2-dose series at ages 2 OMP[PedvaxHIB])
birth,administer HepB vaccine regardless of birth weight. and 4 months.
For infants weighing less than 2,000 grams,administer Routinevacci a 2-o
2.If RotaTeq is used,administer a 3-dose series at ages 2, Administer a 2-or
3-dose Hib vaccine primary series
HBIG in addition to HepB vaccine within 12 hours of birth. 4,and 6 months.
Determine mother's HBsAg status as soon as possible and a booster dose(dose 3 or 4,depending on vaccine
3.If anydose in the series was RotaTeq or vaccine product primary used in series)at age 12 through 15 months to
and,if mother is HBsAg-positive,also administer HBIG to is unknown for any dose in the series,a total of 3 doses p y g g
infants weighing 2,000 grams or more as soon as possible, complete a full Hib vaccine series.
v of R vaccine should be administered. The series with ActHIB,MenHibrix,Hiberix,
but no later than age 7 days.
Catch-up vaccination: primary� Y
Doses following the birth dose: or Pentacel consists of 3 doses and should be
• The second dose should be administered at age 1 or 2 The maximum age for the first dose in the series is 14 administered at ages 2,4,and 6 months.The primary
months.Monovalent Hep6 vaccine should be used for weeks,6 days;vaccination should not be initiated for infants aged 15 weeks,0 days,or older. series with PedvaxHlB consists of 2 doses and should be
doses administered before age 6 weeks. administered at ages 2 and 4 months;a dose at age 6
• Infants who did not receive a birth dose should receive 3 The maximum age for the final dose in the series is 8 months is not indicated.
doses of a HepB-containing vaccine on a schedule of 0, months,0 days.
p g For other catch-up guidance,see Figure 2. One booster dose(dose 3 or 4,depending on vaccine
1 to 2 months,and 6 months,starting as soon as feasible used in primary series)of any Hib vaccine should be
(see figure 2). 3. Diphtheria and tetanus toxoids and acellular pertussis
• Administer the second dose 1 to 2 months after the first (DTaP)vaccine.(Minimum age:6 weeks.Exception:DTaP- administered at age 12 through 15 months.
IPV[Kinrix,Quadracel]:4 years) For recommendations on the use of MenHibrix in patients
dose(minimum interval of 4 weeks);administer the third at increased risk for meningococcal disease,refer to the
dose at least 8 weeks after the second dose AND at least Routine vaccination:
16 weeks after the first dose.The final(third or fourth) Administer a 5-dose series of DTaP vaccine at ages 2,4,6, F e February
8,20occal vaccine footnotes and also to MMWR
dose in the HepB vaccine series should be administered 15 through 18 months,and 4 through 6 years.The fourth February 28,2014/ r6301.1):1 13,available at www.cdc.
no earlier than age 24 weeks. dose may be administered as early as age 12 months, qov/mmwrlPDF/rr/rr6301.pdf.
For further guidance on the use of the vaccines mentioned below,see:www.cdc.gov/vaccines/hcp/acip-recs/index.html.
Catch-up vaccination: (including sickle cell disease)and unimmunized*persons 2.If PCV13 has been received previously but PPSV23 has
• If dose 1 was administered at ages 12 through 14 months, 5 through 18 years of age with HIV infection. not,administer 1 dose of PPSV23 at least 8 weeks after
administer a second(final)dose at least 8 weeks after *Patients who have not received a primary series and the most recent dose of PCV13.
dose 1,regardless of Hib vaccine used in the primary booster dose orat least I dose of Hib vaccine after 14 3.If PPSV23 has been received but PCV13 has not,admin-
series. months ofage are considered unimmunized. ister 1 dose of PCV13 at least 8 weeks after the most
• If both doses were PRP-OMP(PedvaxHlB or COMVAX)and 5. Pneumococcal vaccines.(Minimum age:6 weeks for recent dose of PPSV23.
were administered before the first birthday,the third(and PCV13,2 years for PPSV23) For children aged 6 through 18 years with chronic heart
final)dose should be administered at age 12 through 59 Routine vaccination with PCV13: disease(particularly cyanotic congenital heart disease
months and at least 8 weeks after the second dose. Administer a 4-dose series of PCV13 at ages 2,4,and 6 and cardiac failure),chronic lung disease(including
• If the first dose was administered at age 7 through 11 months and at age 12 through 15 months.
9 9 asthma if treated with high-dose oral corticosteroid
months,administer the second dose at least 4 weeks later Catch-up vaccination with PCV13: therapy),diabetes mellitus,alcoholism,or chronic liver
and a third(and final)dose at age 12 through 15 months Administer 1 dose of PCV13 to all healthy children
9 9 disease,who have not received PPSV23,administer 1
or 8 weeks after second dose,whichever is later. aged 24 through 59 months who are not completely dose of PPSV23.If PCV13 has been received previously,
• If first dose is administered before the first birthdayand vaccinated for their age.
For other catch-up guidance, Figure then PPSV23 should be administered at least 8 weeks
second dose administered at younger than 15 months, p g ,see g ure 2. after any prior PCV13 dose.
a third(and final)dose should be administered 8 weeks Vaccination of persons with high-risk conditions with
PCV73 and PPSV23: A single revaccination with PPSV23 should be
later. administered ears after the first dose to children
• For unvaccinated children aged 15-59 months, All recommended PCV13 doses should be administered y
administer only 1 dose. prior to PPSV23 vaccination if possible. with sickle cell disease or other hemoglobinopathies;
• For other catch-up guidance,see Figure 2.For catch-up For children aged 2 through 5 years with any of the anatomic or functional asplenia;congenital or acquired
guidance related to MenHibrix,see the meningococcal following conditions:chronic heart disease(particularly immunodeficiencies;HIV infection;chronic renal failure;
vaccine footnotes and also MMWR February 28,2014/ cyanotic congenital heart disease and cardiac failure); nephrotic syndrome;diseases associated with treatment
63(RR01):1-13,available at www.cdc.gov/mmwr/PDF/rr/ chronic lung disease(including asthma if treated with with immunosuppressive drugs or radiation therapy,
rr6301.pdf. high-dose oral corticosteroid therapy);diabetes mellitus; including malignant neoplasms,leukemias,lymphomas,
Vaccination of persons with high-risk conditions: cerebrospinal fluid leak;cochlear implant;sickle cell and Hodgkin disease;generalized malignancy;solid
Children aged 12 through 59 months who are at increased disease and other hemoglobinopathies;anatomic or organ transplantation;or multiple myeloma.
risk for Hib disease,including chemotherapy recipients functional asplenia;HIV infection;chronic renal failure; 6. Inactivated poliovirus vaccine(IPV).(Minimum age:6
and those with anatomic or functional asplenia(including nephrotic syndrome;diseases associated with treatment weeks)
sickle cell disease),human immunodeficiency virus(HIV) with immunosuppressive drugs or radiation therapy, Routine vaccination:
infection,immunoglobulin deficiency,or early component including malignant neoplasms,leukemias,lymphomas, Administer a 4-dose series of IPV at ages 2,4,6through
y
complement deficiency,who have received either no g
and Hodgkin disease;solid organ transplantation;or 18 months,and 4 through 6 ears.The final dose in the
doses or only 1 dose of Hib vaccine before age 12 months,
congenital immunodeficiency: series should be administered on or after the fourth should receive 2 additional doses of Hib vaccine,8 weeks 1.Administer 1 dose of PCV13 if any incomplete schedule birthday and at least 6 months after the previous dose.
of 3 doses of PCV13 was received previously. Catch-upvaccination:
apart;children who received 2 or more doses of Hib vaccine 2.Administer 2 doses of PCV13 at least 8 weeks apart if
before age 12 months should receive 1 additional dose. unvaccinated or anyincomplete schedule offewerthan In the first 6 months of life,minimum age and minimum
• For patients younger than age 5 years undergoing 3 doses of PCV13 was received previously. intervals are only recommended if the person is at risk of
chemotherapy or radiation treatment who received a 3.The minimum interval between doses of PCV13 is 8 imminent exposure to circulating poliovirus(i.e.,travel to
Hib vaccine dose(s)within 14 days of starting therapy weeks. a polio-endemic region or during an outbreak).
or during therapy,repeat the close(s)at least 3 months 4.For children with no history of PPSV23 vaccination, If 4 or more doses are administered before age 4 years,an
following therapy completion. administer PPSV23 at least 8 weeksafterthe most recent additional dose should be administered at age 4through
• Recipients of hematopoietic stem cell transplant dose of PCV13. 6 years and at least 6 months after the previous dose.
(HSCT)should be revaccinated with a 3-dose regimen For children aged 6 through 18 years who have A fourth dose is not necessary if the third dose was
of Hib vaccine starting 6 to 12 months after successful cerebrospinal fluid leak;cochlear implant;sickle cell administered at age 4 years or older and at least 6 months
transplant,regardless of vaccination history;doses should disease and other hemoglobinopathies;anatomic after the previous dose.
be administered at least 4 weeks apart. or functional asplenia;congenital or acquired If both oral polio vaccine(OPV)and IPV were
• A single dose of any Hib-containing vaccine should be immunodeficiencies;HIV infection;chronic renal failure; administered as part of a series,a total of 4 doses should
administered to unimmunized*children and adolescents nephrotic syndrome;diseases associated with treatment be administered,regardless of the child's current age.
15 months of age and older undergoing an elective with immunosuppressive drugs or radiation therapy, If only OPV was administered,and all doses were given
splenectomy;if possible,vaccine should be administered including malignant neoplasms,leukemias,lymphomas, prior to age 4 years,1 dose of IPV should be given at 4
at least 14 days before procedure. and Hodgkin disease;generalized malignancy;solid years or older,at least 4 weeks after the last OPV dose.
• Hib vaccine is not routinely recommended for patients organ transplantation;or multiple myeloma: IPV is not routinely recommended for U.S.residents aged
5 years or older.However,I dose of Hib vaccine should 1.If neither PCV13 nor PPSV23 has been received previ- 18 years or older.
be administered to unimmunized*persons aged 5 ously,administer 1 dose of PCV13 now and 1 dose of For other catch-up guidance,see Figure 2.
years or older who have anatomic or functional asplenia PPSV23 at least 8 weeks later.
• 0
For further guidance on the use of the vaccines mentioned below,see:www.cdc.gov/vaccines/hcp/acip-recs/index.html.
7. Influenza vaccines.(Minimum age:6 months for inacti- Catch-up vaccination: vaccination of persons with high-risk conditions and other
vated influenza vaccine[IIV],18 years for recombinant Ensure that all persons aged 7 through 18 years without persons at increased risk of disease"below.
influenza vaccine[RIV]) evidence of immunity(see MMWR 2007;56[No.RR-4], Catch-up vaccination:
Routine vaccination: available at www.cdc.gov/mmwr/pdf/rr/rr5604.pdf)have Administer Menactra or Menveo vaccine at age 13 through
• Administer influenza vaccine annually to all children 2 doses of varicella vaccine. For children aged 7 through 18 years if not previously vaccinated.
beginning at age 6 months.For the 2016-17 season, 12 years,the recommended minimum interval between If the first dose is administered at age 13 through 15 years,
use of live attenuated influenza vaccine(LAIV)is not doses is 3 months(if the second dose was administered a booster dose should be administered at age 16 through
recommended. at least 4 weeks after the first dose,it can be accepted as 18 years,with a minimum interval of at least 8 weeks
For children aged 6 months through 8 years: valid);for persons aged 13 years and older,the minimum between doses.
For the 2016-17 season,administer 2 doses(separated by interval between doses is 4 weeks. If the first dose is administered at age 16 years or older,a
at least 4 weeks)to children who are receiving influenza 10. Hepatitis A(HepA)vaccine.(Minimum age:12 months) booster dose is not needed.
vaccine for the first time or who have not previously Routine vaccination:
P Y For other catch-up guidance,see Figure 2.
received>_2 doses of trivalent or quadrivalent influenza Initiate the 2-dose HepA vaccine series at ages 12 through Clinical discretion:
vaccine before Jul 1,2016.For additional guidance, 23 months;separate the 2 doses by 6 to 18 months.
Y g Young adults aged 16 through 23 years(preferred age
follow dosingguidelines in the 2016-17 ACIP influenza Children who have received of vaccine g Child h h id 1 d f HA cie range is 16 through 18 years)who are not at increased
vaccine recommendations(see MMWR August 26, before age 24 months should receive a second dose 6 to
2016;65(5):1-54,available at 18 months after the first dose. risk for meningococcal disease may be vaccinated with a
www.cdc.gov/mmwr/volumes/65/rr/pdfs/rr6505.pdf). For any person aged 2 years and older who has not (-dose series of either o provide
a >_1 month)o protection
nba
• For the 2017-18 season,follow dosing guidelines in the already received the HepA vaccine series,2 doses of (0,6 months)vaccine to provide short-term protection
2017-18 ACIP influenza vaccine recommendations. HepA vaccine separated by 6 to 18 months may be against most strains of serogroup B meningococcal
For persons aged 9 years and older: administered if immunity against hepatitis A virus disease.The two MenB vaccines are not interchangeable;
• Administer 1 dose. infection is desired. the same vaccine product must be used for all doses.
8. Measles,mumps,and rubella(MMR)vaccine.(Minimum Catch-up vaccination: If the second dose ofTrumenba is given at an interval of
age:12 months for routine vaccination) • The minimum interval between the 2 doses is 6 months. <6 months,a third dose should be given at least 6 months
Routine vaccination: Special populations: after the first dose;the minimum interval between the
• Administer a 2-dose series of MMRvaccine at ages 12 Administer 2 doses of HepA vaccine at least 6 months apart second and third doses is 4weeks.
through 15 months and 4 through 6 years.The second to previously unvaccinated persons who live in areas where Meningococcal conjugate ACWY vaccination of persons
dose may be administered before age 4 years,provided at vaccination programs target older children,or who are at with high-risk conditions and other persons at increased
least 4 weeks have elapsed sincethe first dose. increased risk for infection.This includes persons traveling risk:
• Administer 1 dose of MMR vaccine to infants aged 6 to or working in countries that have high or intermediate Children with anatomic or functional asplenia(including
through 11 months before departure from the United endemicity of infection;men having sex with men;users sickle cell disease),children with HIV infection,or children
States for international travel.These children should be of injection and non-injection illicit drugs;persons who with persistent complement component deficiency
revaccinated with 2 doses of MMR vaccine,the first at age work with HAV-infected primates or with HAV in a research (includes persons with inherited or chronic deficiencies
12 through 15 months(12 months if the child remains in laboratory;persons with clotting-factor disorders;persons in C3,C5-9,properdin,factor D,factor H,or taking
an area where disease risk is high),and the second dose at with chronic liver disease;and persons who anticipate eculizumab[Soliris)l:
least 4 weeks later. close,personal contact(e.g.,household or regular Menveo
• Administer 2 doses of MMR vaccine to children aged babysitting)with an international adoptee during the first o Children who initiate vaccinationat8 weeks.Administer
60 days after arrival in the United States from a country
12 months and older before departure from the United with high or intermediate endemicityThe first dose should doses at ages 2,4,6,and 12 months.
.
States for international travel.The first dose should be o Unvaccinated children who initiate vaccination at 7
be administered as soon as the adoption is planned,ideally,
administered on or after age 12 months and the second 2 or more weeks before the arrival of the doptee. through 23 months.Administer 2 primary doses,with
a
dose at least 4 weeks later. 11. Meningococcal vaccines.(Minimum age: weeks for the second dose at least 12 weeks after the first dose
Catch-up vaccination: Hib-MenCY[MenHibrix],2 months for MenACWY-CRM AND after the first birthday.
• Ensure that all school-aged children and adolescents [Menveo],9 months for MenACWY-D[Menactra],10 years o Children 24 months and older who have not received a
have had 2 doses of MMR vaccine;the minimum interval for serogroup B meningococcal[MenB]vaccines:MenB- complete series.Administer 2 primary doses at least 8
between the 2 doses is 4 weeks. 4C[Bexsero]and MenB-FHbp[Trumenba]) weeks apart.
9. Varicella(VAR)vaccine.(Minimum age:12 months) Routine vaccination:
Routine vaccination: MenHibrix
• Administer a single dose ofMenactraorMenveovaccine o Children who initiate vaccinationat6 weeks.Administer
• Administer a 2-dose series of VAR vaccine at ages 12 at age 11 through 12 years,with a booster dose at age 16
through 15 months and 4 through 6 years.The second doses at ages 2,4,6,and 12 through 15 months.
years. If the first dose of MenHibrix is given at or after age 12
dose may be administered before age 4 years,provided For children aged 2 months through 18 years with high- o g g
at least 3 months have elapsed since the first dose.If the risk conditions,see"Meningococcal conjugate ACWY months,a total of 2 doses should be given at least 8
second dose was administered at least 4 weeks after the vaccination of persons with high-risk conditions and
weeks apart to ensure protection against serogroups
first dose,it can be accepted as valid. other persons at increased risk"and"Meningococcal B C and Y meningococcal disease.
For further guidance on the use of the vaccines mentioned below,see:www.cdc.gov/vaccines/hcp/acip-recs/index.htmi.
• Menactra For serogroup B:Administer a 2-dose series of Bexsero, 13. Human papillomavirus(HPV)vaccines. (Minimum age:9
o Children with anatomic or or with doses t least 1 h art or a 3-close series of years for 4vHPV Gard it V functional asplema os a eas month apart, yea [ asi]and 9vHP [Gardasil 9))
HIV infection Trumenba,with the second dose at least 1-2 months Routine and catch-up vaccination:
— Children24 months and older who have not receivedo after the first and the third dose at least 6 months after Administer a 2-dose series of HPV vaccine on a schedule
completeseries.Administer 2 primary doses at least thefirst.Thetwo MenB vaccines are not interchangeable; of 0,6-12 months to all adolescents aged 11 or 12 years.
8weeks apart.If Menactra is administered to a child the same vaccine product must be used for all doses. The vaccination series can start at age 9 years.
with as lenia(including sickle cell disease)or HIV For MenACWY booster doses among persons with high-risk Administer HPV vaccine to all adolescents through
infection,do not administer Menactra until age 2 conditions,refer to MMWR 2013;62(RR02):1-22,at age 18 years who were not previously adequately
th
ears and at least 4 weeks after the completion of www.cdc.gov/mmwr/preview/mmwrhtm/rr6202a . tm, vaccinated.The number of recommended i i
all PCV13 doses. p MMWR June 20,2014/63(24):527-530,at www.cdc.gov/ rdoses s
mmwr/ df/wk/mm6324. df,and MMWR November 4,2016 based on age i t administration of the first dose.
o Children with persistent complement component P P For persons initiating vaccination before age 15,the
deficiency /65(43):1189-1194,at www.cdc.gov/mmwr/volumes/65/ recommended immunization schedule is 2 doses of HPV
/df/psm m6543a3.pdf.
—Children 9 through 23 months.Administer 2 primary wr vaccine at 0,6-12 months. �I
doses at least 12 weeks apart. For other catch-up recommendations for these persons and For persons initiating vaccination at age 15 years or
-Children 24 months and older who have not received complete information on use of meningococcal vaccines,
including guidance related to vaccination of persons at older,the recommended immunization schedule is 3
a complete series.Administer 2 primary doses at increased risk of infection see meningococcal MMWR doses of HPV vaccine at 0,1-2,6 months.
,
least 8 weeks apart. A vaccine dose administered at a shorter interval should
o All high-risk children publications,available at:www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/mening.html. be readministered at the recommended interval.
—If Menactra is to be administered to a child at high Ina 2-dose schedule of HPV vaccine,the minimum
riskfor meningococcal disease,it is recommended 12. Tetanus and diphtheria toxoids and acellular pertussis interval is 5 months between the first and second dose.
that Menactra be given either before or atthe same (Tdap)vaccine.(Minimum age:10 years for both Boostrix If the second dose is administered at a shorter interval,
time as DTaP. and Adacel) a third dose should be administered a minimum of
Meningococcal B vaccination of persons with high-risk Routine vaccination: 12 weeks after the second dose and a minimum of 5
conditions and other persons at increased risk of disease: Administer 1 dose of Tdap vaccine to all adolescents aged months after the first dose.
Children with anatomic or functional as lenia(including 11 through 12 years.
p � Ina 3-dose schedule of HPV vaccine,the minimum
sickle cell disease)or children with persistent complement Tdap may be administered regardless of the interval since
component deficiency(includes persons with inherited or the last tetanus and diphtheria toxoid-containing vaccine. intervalsare4weeks between thefirstand second dose,
chronic deficiencies in C3,C5-9,properdin,factor D,factor Administer 1 dose of Tdap vaccine to pregnant 12 weeks between the second and third dose,and 5
H,or taking eculizumab[Soliris)): adolescents during each pregnancy(preferably during months between the first and third dose. If a vaccine
• Bexsero or Trumenba the early part of gestational weeks 27 through 36), dose is administered at a shorter interval,it should be
o Persons 10 years or older who have not received a corn-. regardless of time since priorTd orTdap vaccination. readministered after another minimum interval has
pleteseries.Administer a 2-dose series of Bexsero,with Catch-up vaccination: been met since the most recent dose.
doses at least 1 month apart,or a 3-dose series of Persons aged 7 years and older who are not fully Special populations:
Trumenba,with the second dose at least 1-2 months immunized with DTaP vaccine should receive Tdap For children with history of sexual abuse or assault,
after the first and the third dose at least 6 months vaccine as 1 dose(preferablythe first)in the catch-up administer HPV vaccine beginning at age 9 years.
after the first.The two MenB vaccines are not inter- series;if additional doses are needed,useTd vaccine.For Immunocompromised persons*,including those
changeable;the same vaccine product must be used children 7 through 10 years who receive a dose of Tdap with human immunodeficiency virus(HIV)infection,
for all doses. as part of the catch-up series,an adolescentTdap vaccine should receive a 3-dose series at 0,1-2,and 6 months,
dose at age 11 through 12 years may be administered. regardless of age at vaccine initiation.
For children who travel to or reside in countries in which persons aged 11 through 18 ears who have not received g g
meningococcal disease is hyperendemic or epidemic, g g y Note:HPV vaccination is not recommended during
including countries in the African meningitis belt or the
Tdap vaccine should receive a dose,followed by tetanus Pre although there is no evidence that the
pregnancy, 9
Haii• and diphtheria toxoids(Td)booster doses every 10 years vaccine poses harm.If a woman is found to be pregnant
thereafter.• Administeran age-appropriate formulation and series of therea after initiating the vaccination series,no intervention is
•
Menactra or Menveofor protection against serogroups A Inadvertent doses of DTaP vaccine: needed;the remaining vaccine doses should be delayed
and W meningococcal disease.PriorreceiptofMenHibrix If administered inadvertently to a child aged 7 through until after the pregnancy.Pregnancy testing is not
is not sufficient for children traveling to the meningitis 10 years,the dose may count as part of the catch-up needed before HPV vaccination.
belt or the Hajj because it does not contain serogroups series.This dose may count asthe adolescentTdap dose, *See MMWR December 16,2016;65(49):1405-1408,
A or W. or the child may receive a Tdap booster dose at age 11 available at www.cdc.gov/mmwr/volumes/65/wr/pdfs/
For children at risk during an outbreak attributable to a through 12 years. mm6549a5.pdf.
vaccine serogroup: If administered inadvertently to an adolescent aged 11
• For serogroup A,C,W,or Y:Administer or complete an through 18 years,the dose should be counted as the
age-and formulation-appropriate series of MenHibrix, adolescentTdap booster.
Menactra,or Menveo. For other catch-up guidance,see Figure 2. CS270457-c
Recommended Immunization Schedule for Adults Aged 19 Years or Older, United States, 2017
In February 2017,the Recommended Immunization Schedule forAdults Aged 19 Years or Older, Vaccine Information Statements that explain benefits and risks of vaccines are available at
United States,2017 became effective,as recommended by the Advisory Committee on www.cdc.gov/vaccines/hcp/vis/index.html.
Immunization Practices(ACIP)and approved by the Centers for Disease Control and Prevention Information and resources regarding vaccination of pregnant women are available at www.
(CDC).The 2017 adult immunization schedule was also reviewed and approved by the following cdc.gov/vaccines/adults/rec-vac/pregnant.html.
professional medical organizations: Information on travel vaccine requirements and recommendations is available at
• American College of Physicians(www.acponline.org) wwwnc.cdc.gov/travel/destinations/list.
• American Academy of Family Physicians(www.aafp.org) CDC Vaccine SchedulesApp for clinicians and other immunization service providers to
• American College of Obstetricians and Gynecologists(www.acog.org) download is available at www.cdc.gov/vaccines/schedules/hcp/schedule-app.htmi.
• American College of Nurse-Midwives(www.midwife.org) Recommended Immunization Schedule for Children and Adolescents Aged 18 Years or Younger is
available at www.cdc.gov/vaccines/schedules/hcp/index.html.
CDC announced the availability of the 2017 adult immunization schedule at www.cdc.gov/ Report suspected cases of reportable vaccine-preventable diseases to the local or state health
vaccines/schedules/hcp/index.html in the Morbidity and Mortality Weekly Report(MMWR).1The
schedule is published in its entirety in the Annals oflnternal Medicine? department.
The adult immunization schedule describes the age groups and medical conditions and other Report all clinically significant post-vaccination reactions to the Vaccine Adverse Event Reporting
indications for which licensed vaccines are recommended.The 2017 adult immunization schedule System at www.vaers.hhs.govor by telephone,800-822-7967.All vaccines included in the 2017
consists of: adult immunization schedule except herpes zoster and 23-valent pneumococcal polysaccharide
vaccines are covered by the Vaccine Injury Compensation Program.Information on how to file a
• Figure 1.Recommended immunization schedule for adults by age group vaccine injury claim is available at www.hrsa.gov/vaccinecompensation or by telephone,800-338-
• Figure 2.Recommended immunization schedule for adults by medical condition and other 2382.
indications Submit questions and comments regarding the 2017 adult immunization schedule to CDC
• Footnotes that accompany each vaccine containing important general information and through www.cdcgov/cdc-info or by telephone,800-CDC-INFO(800-232-4636),in English and
considerations for special populations
• Table.Contraindications and precautions for vaccines routinely recommended for adults Spanish,8:OOam-8:OOpm ET,Monday—Friday,excluding holidays.
Consider the following information when reviewing the adult immunization schedule: The following acronyms are used for vaccines recommended for adults:
• The figures in the adult immunization schedule should be read with the footnotes that HepA hepatitis A vaccine
contain important general information and information about vaccination of special HepA-HepB hepatitis A and hepatitis B vaccines
populations. HepB hepatitis B vaccine
• When indicated,administer recommended vaccines to adults whose vaccination history is Hib Haemophilus influenzae type b conjugate vaccine
incomplete or unknown. HPV vaccine human papillomavirus vaccine
• Increased interval between doses of a multi-dose vaccine does not diminish vaccine HZV herpes zoster vaccine
effectiveness;therefore,it is not necessary to restart the vaccine series or add doses to the IIV inactivated influenza vaccine
series because of an extended interval between doses. LAIV live attenuated influenza vaccine
• Adults with immunocompromising conditions should generally avoid live vaccines, MenACWY serogroups A,C,W,and Y meningococcal conjugate vaccine
e.g.,measles,mumps,and rubella vaccine.Inactivated vaccines,e.g.,pneumococcal or MenB serogroup B meningococcal vaccine
inactivated influenza vaccines,are generally acceptable. MMR measles,mumps,and rubella vaccine
• Combination vaccines may be used when any component of the combination is indicated MPSV4 serogroups A,C,W,and Y meningococcal polysaccharide vaccine
and when the other components of the combination vaccine are not contraindicated. PCV13 13-valent pneumococcal conjugate vaccine
• The use of trade names in the adult immunization schedule is for identification purposes PPSV23 23-valent pneumococcal polysaccharide vaccine
only and does not imply endorsement by the ACIP or CDC. RIV recombinant influenza vaccine
Details on vaccines recommended for adults and complete ACIP statements are available at www. Td tetanus and diphtheria toxoids
cdc.gov/vaccines/hcp/acip-recs/index.html.Additional CDC resources include: Tdap tetanus toxoid,reduced diphtheria toxoid,and acellular pertussis vaccine
• A summary of information on vaccination recommendations,vaccination of persons VAR varicella vaccine
with immunodeficiencies,preventing and managing adverse reactions,vaccination MMWR Morb Mortal Wkly Rep.2017;66(5).Available atwww.cdc.gov/mmwr/volumes/66/wr/mm6605e2.htm?s_
contraindications and precautions,and other information can be found in General cid=mm6605e2_w.
Recommendations on Immunization at www.cdc.gov/mmwr/preview/mmwrhtmi/rr6002a1.htm. 2 Ann Intern Med.2017;166:209-218.Available at annals.org/aim/article/doi/l0.7326/M16-2936.
av_ U.S.Department
Figures 1 and 2 should be read with the footnotes that contain important general information and considerations for special populations.
Figure 1.Recommended immunization schedule for adults aged 19 years or older by age group,United States,2017
Vaccine 19-21 years 22-26 years 27-59 years 60-64 years >—65 years
Influenza' 1 dose annually
Td/TdaP1 Substitute Tdap forTd once,then Td booster every 10 yrs
MMR3 1 or 2 doses depending on indication
VAR 2 doses
HZV5 1 dose
I
HPV—Female6 f 3 doses
HPV—Maleb 3 dosses f
- - -
PCV13' adose
PPSV237 1o2 mndication 1 dose
" € =
HepA$ }= 2 or 3 douses dependingaonvaccne y . r
. . ..�
He g€ sra'3 .g s 3a s 5' 3SC�OSES v' az t ?uxgPM
p B9 3,
a•,
MenACWY or MPSV410 1 ormoredo'ses depending'onandication
Men610 2 or 3doses depending on vaccine
s r ,f _ a ,
Hib" Al "` _" -'1 ow3"do`s"es depending o 'indication = x
Recommended for adults who meet the Recommended for adults with additional
age requirement,lack documentation of No recommendation
vaccination,or lack evidence of past infection medical conditions or other indications
• 0 .
0
Figure 2.Recommended immunization schedule for adults aged 19 years or older by medical condition and other indications,United States,2017
Immuno- HlVinfection Asplenia, Kidney failure, Heart or
compromised CD4+count persistent end-stage renal lung disease, Men who
(excluding HIV (cells/NL)3-7''-" complement disease,on chronic Chronic liver Healthcare have sex
Vaccine Pregnancy'-",' infection)3-'•" <200 >t 200 deficiencies7•70•" hemodialysis7,9 alcoholism' disease'-9 Diabetes" personnel3A9 with men" ,9
Influenza' 1 dose annually
1 dose
Td/Tdap2 Tdap each Substitute Tdap for Td once,then Td booster every 10 yrs
pregnancy
MMR3 1 or 2 doses depending on indication
VAR 2 doses
HZV5 1 dose
HPV-Female" 3 doses through age 26 yrs
3 doses
HPV-Male" 3 doses through age 26 yrs 3 doses through age 21 yrs through age
26 yrs
PCV13' 1 dose
3.._Mav - :,•,
PPSV237 1,2,or 3 doses depending on indication
e�
HepA' 2 or 3:doses depending on vaccine
n ,;
•'
Hep 69 3,doses
MenACWY or MPSV41O 1 or more doses depending on indication
a -
a ,s a s
MenB10 2 or 3 doses depending on vaccine
jxumv
3 doses �13 -
Hib" post-HSCT 1 dose
recipients only
Recommended for adults who meet the Recommended for adults with additional
age requirement,lack documentation of ®medical conditions or other indications Contraindicated No recommendation
vaccination,or lack evidence of past infection
Footnotes.l�ecommended immunization schedule for adults aged 19 years Oder,United States,2017 •
1. Influenza vaccination Special populations Adults with human immunodeficiency virus(HIV)infection and CD4+
General information Pregnant women who do not have evidence of immunity to rubella T-lymphocyte count>:200 cells/NI may receive 2 doses of VAR 3 months
• All persons aged 6 months or older who do not have a should receive 1 dose of MMR upon completion ortermination of apart Adults with HIV infection and CD4+T-lymphocytecount<200
pregnancy and before dischargefrom the healthcare facility;non- cells/NI should not receive VAR.
Contra ind icatio n should receive annual influenza vaccination with an pregnant women ofchildbearing age without evidence ofrubella
immunity should receive 1 dose of MMR. 5. Herpes zoster vaccination
age-appropriate formulation of inactivated influenza vaccine(IIV)or P
recombinant influenza vaccine(RIV). Adults with primary oracquired immunodeficiency including malignant General information
In addition to standard-dose IIV,available options for adults in conditions affecting the bone marrow or lymphatic system,systemic Adults aged 60 years or older should receive 1 dose of herpes zoster
specific age groups include:high-dose or adjuvanted IIV for adults immunosuppressive therapy,or cellular immunodeficiency should not vaccine(HZV),regardless of whether they had a prior episode of herpes
aged 65 years or older,intradermal IIV for adults aged 18 through 64 receive MMR. zoster.
years,and RIV for adults aged 18 years or older. Adults with human immunodeficiency virus(HIV)infection and CD4+ Special populations
• Notes:Live attenuated influenza vaccine(LAIV)should not be used T-lymphocytecount a200 cells/NI for at least 6 months who do not have
during the 2016-2017 influenza season.A list of currently available evidence of measles,mumps,or rubella immunity should receive 2 Adults aged 60 years they
hav a m chronic medical conditions may
doses of MMR at least 28 days apart.Adults with HIV infection and CD4+ receive HZV unless they have a medical contraindication,e.g.,pregnancy
influenza vaccines is available at www.cdc.gov/flu/protect/vaccine/ n P or severe immunodeficiency.
vaccines.htm. T-lymphocytecount<200 cells/NI should not receive MMR ry
Adults who work in healthcare facilities should receive 2 doses of MMR Adults with malignant conditions,including those that affect
Special populations at least 28 days apart;healthcare personnel born before 1957 who are the bone marrow or lymphatic system or who receive systemic
Adults with a history of egg allergy who have only hives after unvaccinated or lack laboratory evidence of measles,mumps,or rubella immunosuppressive therapy,should not receive HZV.
exposure to egg should receive age-appropriate IIV or RIV. immunity,or laboratory confirmation of disease should be considered Adults with human immunodeficiency virus(HIV)infection and CD4+
• Adults with a history of egg allergy other than hives,e.g., for vaccination with 2 doses of MMR at least 28 days apartfor measles or T-lymphocyte count<200 cells/NI should not receive HZV.
angioedema,respiratory distress,Iightheadedness,or recurrent mumps,or 1 dose of MMR for rubella. 6. Human papillomavirus vaccination
emesis,or who required epinephrine or another emergency medical Adults who are students in postsecondary educational institutions or
intervention,may receive age-appropriate IIV or RIV.The selected plan to travel internationally should receive 2 doses of MMR at least 28 General information
vaccine should be administered in an inpatient or outpatient days apart. • Adultfemales through age 26 years and adult males through age 21
medical setting and under the supervision of a healthcare provider Adults who received inactivated(killed)measles vaccine or measles years who have not received any human papillomavirus(HPV)vaccine
who is able to recognize and manage severe allergic conditions. vaccine of unknown type during years 1963-1967 should be should receive a 3-dose series of HPV vaccine at 0,1-2,and 6 months.
Pregnant women and women who might become pregnant in the revaccinated with 1 or 2 doses of MMR. Males aged 22 through 26 years may be vaccinated with a 3-dose series
upcoming influenza season should receive IIV. Adults who were vaccinated before 1979 with either inactivated mumps of HPV vaccine at 0,1-2,and 6 months.
vaccine or mumps vaccine of unknown type who are at high risk for Adult females through age 26 years and adult males through age
2. Tetanus,diphtheria,and aeellular pertussis vaccination mumps infection,e.g.,work in a healthcare facility,should be considered 21 years(and males aged 22 through 26 years who may receive HPV
General information for revaccination with 2 doses of MMR at least 28 days apart vaccination)who initiated the HPV vaccination series before age 15 years
Adults who have not received tetanus and diphtheria toxoids and 4. Varieella vaccination and received 2 doses at least 5 months apart are considered adequately
aeellular pertussis vaccine(Tdap)or for whom pertussis vaccination General information vaccinated and do not need an additional dose of HPV vaccine.
status is unknown should receive 1 dose of Tdap followed by a Adult females through age 26 years and adult males through age
tetanus and diphtheria toxoids(Td)booster every 10 years.Tdap • Adults without evidence of immunity to varicella(defined below)should 21 years(and males aged 22 through 26 years who may receive HPV
receive 2 doses of single-antigen varicella vaccine(VAR)4-8 weeks apart, vaccination)who initiated the HPV vaccination series before age 15 years
should be administered regardless of when a tetanus or diphtheria or a second dose ifthey have received only 1 dose. and received only 1 dose,or 2 doses less than 5 months apart,are not
toxoid-containing vaccine was last received. • Persons without evidence of immunityfor whom VAR should be considered adequately vaccinated and should receive 1 additional dose
Adults with an unknown or incomplete history of a 3-dose primary emphasized are:adults who have close rontart with persons at high of HPV vaccine.
series with tetanus and diphtheria toxoid-containing vaccines risk for serious complications,e.g.,healthcare personnel and household Notes:HPV vaccination is routinely recommended forchildren at age 11
should complete the primary series that includes 1 dose of Tdap. contacts of immunocompromssed persons;adults who live or work in or 12 years.For adults who had initiated but did not complete the HPV
Unvaccinated adults should receive the first 2 doses at least 4 weeks an environment in which transmission of varicella zoster virus is likely, vaccination series,consider their age atfirst HPV vaccination(described
apart and the third dose 6-12 months after the second dose. e.g.,teachers,childcare workers,and residents and staff in institutional above)and other factors(described below)to determine if they have
Notes:Information on the use ofTd orTdap as tetanus prophylaxis in settings;adults who live or work in environments in which varicella been adequately vaccinated.
wound management is available at www.cdc.gov/mmwr/preview/ transmission has been reported,e.g.,college students,residents and
mmwrhtml/rr5517a1.htm. staff members ofcorrectional institutions,and military personnel;non- Special populations
Special populations pregnant women of childbearing age;adolescents and adults living in Men who have sex with men through age 26 years who have not
Pregnant women should receive 1 dose ofTdap during each households with children;and international travelers. received any HPV vaccine should receive 3-dose series of HPV vaccine
Notes:Evidence of immunity to varicella in adults is:U.S.-born before at0,1-2,and 6 months.
pregnancy,preferably during the early part of gestational weeks 1980(for pregnant women and healthcare personnel,U.S:bom before Adultfemalesand males through age 26 years with
27-36,regardless of prior history of receiving Tdap. 1980 is not considered evidence of immunity);documentation of 2 immunocom promising conditions(described below),including those
3. Measles,mumps,and rubella vaccination doses of VAR at least 4 weeks apart;history of varicella or herpes zoster with human immunodeficiency virus(HIV)infection,should receivea
diagnosis or verification of varicella or herpes zoster disease by a 3-dose series of HPV vaccine at 0,1-2,and 6 months.
General information healthcare provider;or laboratory evidence of immunity or disease. Pregnant women are not recommended to receive HPV vaccine,
Adults born in 1957 or later without acceptable evidence of Special populations although there is no evidence that the vaccine poses harm.lfa woman
immunity to measles,mumps,or rubella(defined below)should Pregnant women should beassessed for evidence ofvaricella immunity. isfound to be pregnant after initiating the HPVvaccination series,delay
receive 1 dose of measles,mumps,and rubella vaccine(MMR)unless Pregnant women who do not have evidence of immunityshould receive the remaining doses until afterthe pregnancy.No other intervention
they have a medical contraindication to the vaccine,e.g.,pregnancy the first dose of VAR upon completion or termination of pregnancy and is needed.Pregnancy testing is not needed before administering HPV
or severe immunodeficiency. before dischargefrom the healthcare facility,and the seconddose4-8 vaccine.
Notes:Acceptable evidence of immunity to measles,mumps,or weeks after the first dose Notes:Immunocompromising conditions for which a3-doseseriesof
rubella in adults is:born before 1957,documentation of receipt of Healthcare institutions should assess and ensurethatall healthcare HPVvaccine is indicated are primary or secondary immunocompromising
MMR,or laboratory evidence of immunity or disease.Documentation personnel haveevidence of immunity to varicella. conditions that might reduce cell-mediated or humoral immunity,e.g.,
of healthcare provider-diagnosed disease without laboratory Adults with malignant conditions,including those thataffect B-lymphocyte antibody deficiencies,complete or partial T-lymphocyte
confirmation is not acceptable evidence of immunity. the bone marrow or lymphatic system or who receive systemic defects,HIV infection,malignant neoplasm,transplantation,autoimmune
immunosuppressive therapy,should not receive VAR. disease,and immunosuppressive therapy.
7. PneumoL�Ccal vaccination Special populations 9 . 10.Meningococcal vaccination •
General information Adults with any of the following indications should receive a HepA Special populations
Adults whoareimmunocom etentanda ed65 ears or older should series:have chronic liver disease,receive clotting factor concentrates,
p 9 y men who have sex with men,use injection or non-injection drugs Adults with anatomical orfunctional asplenia or persistent complement
,
receive 13-valent pneumococcal conjugate vaccine(PCV13)followed by component deficiencies should receive a 2-dose primary series of
23-valent pneumococcal polysaccharide vaccine(PPSV23)at least 1 year or work with hepatitis A virus-infected primates or in a hepatitis A serogroups A,C,W,and Y meningococcal conjugate vaccine(MenACWY)
research laboratory setting.
after PCV13. at least 2 months apart and revaccinate every 5 years.They should also
• Notes:Adults are recommended to receive 1 dose of PCV13 and 1,2, Adults who travel in countries with high or intermediate levels of receive a series of serogroup B meningococcal vaccine(MenB)with either
or 3 doses of PPSV23 depending on indication.When both PCV13 and endemic hepatitis A infection or anticipate close personal contact
p g with an international adoptee,e.g.,reside in the same household or series
series of Men6-4C ro)at least 1 month apart or a 3-dose
PPSV23 are indicated,PCV13 should be administered first;PCV13 and seriries of MenB-FHbp(Trumenbaenba)at 0,1-2,and 6 months.
PPSV23 should not be administered during the same visit If PPSV23 has regularly babysit,from a country with high or intermediate level of Adults with human immunodeficiency virus(HIV)infection who have
previously been administered,PCV13 should be administered at least 1 endemic hepatitis A infection within the first 60 days of arrival in the not been previously vaccinated should receivea 2-dose primary series of
year after PPSV23.When two or more doses of PPSV23 are indicated,the United States should receive a HepA series. MenACWY at least 2 months apartand revaccinate every 5 years.Those
interval between PPSV23 doses should be at least 5 years.Supplemental g• Hepatitis B vaccination who previously received 1 dose of MenACWY should receive a second
information on pneumococcal vaccinetiming for adults aged 65 years dose at least 2 months after thefirst dose Adults with HIV infection are
or older and adults aged 19 years or older at high risk for pneumococcal General information not routinely recommended to receive Men B because meningococcal
disease(described below)is available at www.cdc.gov/vaccines/vpd-vac/ Adults who seek protection from hepatitis B virus infection may disease in this population is caused primarily by serogroups C,W,and Y.
pneumo/downloads/adult-vax-clinician-aid.pdf.No additional doses of receive a 3-dose series of single-antigen hepatitis B vaccine(HepB) Microbiologists who are routinely exposed to isolates ofNeisseria
PPSV23 are indicated for adults who received PPSV23 at age 65 years (Engerix-B,Recombivax HB)at 0,1,and 6 months.Adults may also meningitidis should receive 1 dose of MenACWY and revaccinate every 5
or older.When indicated,PCV13and PPSV23 should be administered receive a combined hepatitis A and hepatitis B vaccine(HepA-HepB) years if the riskfor infection remains,and eithera 2-doseseries of MenB-
to adults whose pneumococcal vaccination history is incomplete or (Twinrix)at 0,1,and 6 months.Acknowledgment of a specific risk. 4C at least 1 month apart or a 3-dose series of MenB-FHbp at0,1-2,and
unknown. factor by those who seek protection is not needed. 6 months.
Special populations Special populations Adults at risk because of a meningococcal disease outbreak should
Adults aged 19 through 64 years with chronic heart disease including Adults at risk for hepatitis B virus infection by sexual exposure should receive 1 dose of MenACWY if the outbreak is attributable to serogroup
congestive heartfailureand cardiomyopathies(excluding hypertension); receive a HepB series,including sex partners of hepatitis B surface A,C,W,orY,or either a 2-dose series of MenB-4C at least 1 month apart or
chronic lung disease including chronic obstructive lung disease, antigen(HBsAg)-positive persons,sexually active persons who a 3-dose series of MenB-FHbp at 0,1-2,and 6 months if the outbreak is
emphysema,and asthma;chronic liver disease including cirrhosis; attributable to serogroup B.
are not in a mutually monogamous relationship,persons seeking Adults who travel to or live in countries with h erendemic or epidemic
alcoholism;ordiabetesmellitus;orwhosmokecigarettesshouldreceive yp
evaluation or treatment for a sexually transmitted infection,and men meningococcal disease should receive 1 dose of MenACWY and
PPSV23.At age 65 years or older,they should receive PCV13 and another g
who have sex with men(MSM). revaccinate eve 5 ears if the risk for infection remains.MenB is not
dose of PPSV23 at least 1 year after PCV13 and at least 5 years after the y
most recent dose of PPSV23. Adults at risk for hepatitis B virus infection by percutaneous or routinely indicated because meningococcal disease in these countries is
most
centdosged 19 years PPSVderwith immunocompromising conditions or mucosal exposure to blood should receive a HepB series,including generally not caused by serogroup B.
anatomical orfunctional asplenia(described below)should receive s or adults who are recent or current users of injection drugs,household Military recruits should receive 1 dose of MenACWY and revaccinate
contacts of HBsAg-positive persons,residents and staff of facilities eve 5 ears if the increased risk for infection remains.
and adoseofPPSV23at least 8weeks after PCVl3,followedbyasecond for develo mental) disabled persons, ry y
dose of PPSV23 at least 5 years after the first dose of PPSV23.If the most developmentally p First-yea r college students aged 21 years or younger who live e
recent dose of PPSV23 was administered before age65 years,at age 65 and public safety workers at risk for exposure to blood or blood- residence halls should receive 1 dose of MenACWY if they have not
years or older,administer another dose of PPSV23 a least 8 weeks after contaminated body fluids,younger than age 60 years with diabetes received MenACWY at age 16 years or older.
mellitus,and age 60 years or older with diabetes mellitus at the Young adults aged 16 through 23 ears referred age range is 16
PCV13 and at least 5 years after the most recent dose of PPSV23. 9 g g y (p g g
serogroup
Adults aged l9yearsorolder with cerebrospinal fluid leakorcochlear Adult with chronic the liverng
Bmeningococthrough 18 rs)whose(hecribe above)
eceiveased either
implant should receive PCV13 followed by PPSV23 at least 8 weeks after Adults with chronic liver disease including,but not limited to, B meningococcal disease(described above)may receive either a 2-dose
PCV13.if the most recent doseofPPSV23 was administered before age hepatitis C virus infection,cirrhosis,fatty liver disease,alcoholic liver series of MenB-4Cat least 1 month apartor a 2-closeseriesof MenB-
65 years,atage65 years or older,administer another dose of PPSV23 at disease,autolmmune hepatitis,and at)alanineaminotransferase FHbp atO and 6 monthsfor short-term protection against moststrains of
least 8 weeks after PCV13 and at least 5 years after the most recent dose (ALT)or aspartate aminotransferase(AST)level greater than twice serogroup B meningococcal disease.
of PPSV23. the upper limit of normal should receive a HepB series. For adults aged 56 years orolder who have not previously received
Notes:Immunocompromising conditions that are indications for Adults with end-stage renal disease including those on pre-dialysis serogroups A,C,W,andY meningococcal vaccine and need only 1
pneumococcal vaccination arecongenital oracquired immunodeficiency care,hemodialysis,peritoneal dialysis,and home dialysis should dose,meningococcal polysaccharide serogroups A,C,W,andY vaccine
including B-orT-lymphocyte deficiency,complement deficiencies, receive a HepB series.Adults on hemodialysis should receive a (MPSV4)is preferred.For adults who previously received MenACWY
and phagocytic disorders excluding chronic granulomatous disease; 3-dose series of 40 µg Recombivax H B at 0,1,and 6 months or a or anticipate receiving multiple doses of serogroups A,C,W,and Y
human immunodeficiency virus(HIV)infection;chronic renal failure 4-dose series of 40 µg Engerix-B at 0,1,2,and 6 months. meningococcal vaccine,MenACWY is preferred.
and nephrotic syndrome,leukemia,lymphoma,Hodgkin disease, Adults with human immunodeficiency virus(HIV)infection should Notes:MenB-4C and MenB-FHbp are not interchangeable,i.e.,the same
generalized malignancy,and multiple myeloma;solid organ transplant; receive a HepB series. vaccine should be used for all doses to complete the series.There is no
and iatrogenic immunosuppression including long-term systemic Pregnant women who are at risk for hepatitis B virus infection recommendation for MenB revaccination atthis time.MenB may be
corticosteroid and radiation therapy.Anatomical orfunctional asplenia during pregnancy,e.g.,having more than one sex partner during administered at the same time as MenACWY butata different anatomic
that are indications for pneumococcal vaccination are sickle cell disease the previous six months,been evaluated or treated for a sexually site,if feasible.
and other hemoglobinopathies,congenital or acquired asplenia,splenic transmitted infection,recent or current injection drug use,or had an 11.Haemophilus influenzae type b vaccination
dysfunction,and splenectomy.Pneumococcal vaccines should begiven HBsAg-positive sex partner,should receive a HepB series.
at least 2 weeks before immunosuppressive therapy or an elective International travelers to regions with high or intermediate levels of Special populations
splenectomy,and as soon as possibleto adults whoarediagnosed with endemic hepatitis B virus infection should receive a HepB series. Adults who have anatomical orfunctional asplenia or sickle cell disease,
HIV infection. Adults in the following settings are assumed to be at risk for or are undergoing elective splenectomy should receive 1 dose of
8. Hepatitis A vaccination hepatitis B virus infection and should receive a HepB series:sexually Haemophilusinffuenzae type b conjugate vaccine(Hib)ifthey have not
transmitted disease treatment facilities,HIV testing and treatment previously received Hib.Hib should be administered at least 14 days
General information facilities,facilities providing drug-abuse treatment and prevention before splenectomy.
Adults who seek protection from hepatitis A virus infection may receive services,healthcare settings targeting services to persons who Adults with a hematopoietic stem cell transplant(HSCT)should receive
a2-dose series of single antigen hepatitis A vaccine(HepA)at either 0 inject drugs,correctional facilities,healthcare settings targeting 3 doses of Hib in at least 4 week intervals 6-12 months after transplant
and 6-12 months(Havrix)or0 and6-18 months(Vagta).Adults may services to MSM,hemodialysis facilities and end-stage renal disease regardless of their Hibhistory.
also receivea combined hepatitis Aand hepatitis Bvaccine(HepA-HepB) programs,and institutions and nonresidential day care facilities for Notes:Hib is not routinely recommended foradults with human
(Twinrix)asa3-doseseriesat0,1,and 6 months.Acknowledgment ofa developmentally disabled persons. immunodeficiency virus infection becausetheirriskforHoemophilus
specific riskfactor by those who seek protection is not needed. influenzae type b infection is low.
Table.Arainclications and precautions for vaccines recommended for adults aged 19 years or older*
The Advisory Committee on Immunization Practices(ACIP)recommendations and package inserts for vaccines provide information on contraindications and precautions related to vaccines.Contraindications are conditions
that increase chances of a serious adverse reaction in vaccine recipients and the vaccine should not be administered when a contraindication is present Precautions should be reviewed for potential risks and benefits for vaccine
recipient.For a person with a severe allergy to latex,e.g.,anaphylaxis,vaccines supplied in vials or syringes that contain natural rubber latex should not be administered unless the benefit of vaccination clearly outweighs the risk for
a potential allergic reaction.For latex allergies other than anaphylaxis,vaccines supplied in vials or syringes that contain dry,natural rubber or natural rubber latex may be administered.
Contraindications and Drecautions for vaccines routineiv recommended for adults
Vaccine Contrainclications Precautions
All vaccines routinely recommended for adults • Severe reaction,e.g.,anaphylaxis,after a previous dose or to a vaccine component Moderate or severe acute illness with or without fever
Additional contraindications and Drecautions for vaccines routinelv recommended for adults
vaccine Additional Contrainclications Additional Precautions
IIV' History of Guillain-Barre Syndrome within 6 weeks after previous influenza vaccination
Egg allergy other than hives,e.g.,angioedema,respiratory distress,lightheadedness,or recurrent emesis;
or required epinephrine or another emergency medical intervention(IIV may be administered in an
inpatient or outpatient medical setting and under the supervision of a healthcare provider who is able to
recognize and manage severe allergic conditions)
RIV' History of Guillain-Barre Syndrome within 6 weeks after previous influenza vaccination
LAIV LAIV should not be used during 2016-2017 influenza season LAIV should not be used during 2016-2017 influenza season
Tdap/Td For pertussis-containing vaccines:encephalopathy,e.g.,coma,decreased level of consciousness,or Guillain-Barre Syndrome within 6 weeks after a previous dose of tetanus toxoid-contain ing vaccine
prolonged seizures,not attributable to another identifiable cause within 7 days of administration of a History of Arthus-type hypersensitivity reactions after a previous dose of tetanus or diphtheria toxoid-
previous dose ofa vaccine containing tetanus or diphtheria toxoid oracellular pertussis containing vaccine.Defer vaccination until at least 10 years have elapsed since the last tetanus toxoid-
containing vaccine
For pertussis-containing vaccine,progressive or unstable neurologic disorder,uncontrolled seizures,
or progressive encephalopathy(until a treatment regimen has been established and the condition has
stabilized)
MMR' Severe immunodeficiency,e.g.,hematologic and solid tumors,chemotherapy,congenital Recent(within 11 months)receiptof antibody-containing blood product(specific interval depends on
immunodeficiency or long-term immunosuppressive therapy',human immunodeficiency virus(HIV) product)'
infection with severe immunocompromise History of thrombocytopenia or thrombocytopenic purpura
Pregnancy Need for tuberculin skin testing'
VAR' Severe immunodeficiency,e.g.,hematologic and solid tumors,chemotherapy,congenital Recent(within 11 months)receipt of antibody-containing blood product(specific interval depends on
immunodeficiency or long-term immunosuppressive therapy',HIV infection with severe product)'
immunocompromise Receiptof specific antiviral drugs(acyclovir,famciclovir,or valacyclovir)24 hours before vaccination
Pregnancy (avoid use ofthese antiviral drugs for 14 days after vaccination)
HZV' Severe immunodeficiency,e.g.,hematologic and solid tumors,chemotherapy,congenital Receiptof specific antiviral drugs(acyclovir,famciclovir,or valacyclovir)24 hours before vaccination
immunodeficiency or long-term immunosuppressive therapy',HIV infection with severe (avoid use of these antiviral drugs for 14 days after vaccination)
immunocompromise
Pregnancy
HPV vaccine Pregnancy
PCV13 Severe allergic reaction to any vaccine containing diphtheria toxoid
1. For additional information on use of influenza vaccines among persons with egg allergy,see:CDC.Prevention and control of seasonal influenza with vaccines:recommendations of the Advisory Committee on Immunization
Practices—United States,2016-17 influenza season.MMWR 2016;65(RR-5):1-54.Available at www.cdc.gov/mmwr/volumes/65/rr/rr6505a1.htm.
2. MMR may be administered together with VAR or HZV on the same day.If not administered on the same day,separate live vaccines by at least 28 days.
3. 1 mmunosu ppressive steroid dose is considered to be daily receipt of 20 mg or more prednisone or equivalent for two or more weeks.Vaccination should be deferred for at least 1 month after discontinuation of
immunosuppressive steroid 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.
4.Vaccine should be deferred for the appropriate interval if replacement immune globulin products are being administered.See:CDC.General recommendations on immunization:recommendations of the Advisory Committee
on Immunization Practices(ACIP).MMWR 201 1;60(No.RR-2).Available at www.cdc.gov/mmwr/preview/mmwrhtml/rr6002al.htm.
5. Measles vaccination may temporarily suppress tuberculin reactivity.Measles-containing vaccine may be administered on the same day as tuberculin skin testing,or should be postponed for at least 4 weeks after vaccination.
* Adapted from:CDC.Table 6.Contraindications and precautions to commonly used vaccines.General recommendations on immunization:recommendations ofthe Advisory Committee on Immunization Practices.MMWR
2011;60(No.RR-2):40-41 and from:HamborskyJ,Kroger A,Wolfe S,eds.Appendix A.Epidemiology and prevention of vaccine preventable diseases.1 3th ed.Washington,DC:Public Health Foundation,2015.Available at www.cdc.
gov/vaccines/pubs/pinkbook/index.html.
Acronyms of vaccines recommended for adults
HepA hepatitis A vaccine LAIV live attenuated influenza vaccine PCV13 13-valent pneumococcal conjugate vaccine
HepA-HepB hepatitis A and hepatitis B vaccines MenACWY serogroups A,C,W,and Y meningococcal conjugate PPSV23 23-valent pneumococcal polysaccharide vaccine
HepB hepatitis B vaccine vaccine RIV recombinant influenza vaccine
Hib Haemophilus influenzae type b conjugate vaccine MenB serogroup B meningococcal vaccine Td tetanus and diphtheria toxoids
HPV vaccine human papillomavirus vaccine MMR measles,mumps,and rubella vaccine Tdap tetanus toxoid,reduced diphtheria toxoid,and
HZV herpes zoster vaccine MPSV4 serogroups A,C,W,and Y meningococcal acellular pertussis vaccine
IIV inactivated influenza vaccine polysaccharide vaccine VAR varicella vaccine
C5270457-A
Suzanne Doty RN BSN
Salem Board of Health
Public Health Nurse
Public Health Nurse Report
Reporting on March 10, 2017 through April 6, 2017
Disease Prevention and Health Promotion
• Investigated reportable diseases and reported case information to MDPH.
• Coordinating follow up with North Shore Pulmonary Clinic on tuberculosis cases.
• Continually inputting flu doses and clinic information into the Massachusetts
Immunization Information System(MIIS) for up to date vaccine records and better
continuity of care between clinics and providers.
• Added posts to the Board of Health Facebook page including information from the
Salem Overdose and Substance Use Prevention page on the"Parent Dinner Club"at the
Boys and Girl Club and the Free screening of"If Only", shared flyer and link for the
Town of Beverly's household hazardous waste day for Salem residents, shared CDC
grand round video"Emerging Tickborne Disease"and a link the Attorney General
Consumer Advisor regarding out-of-state Addiction treatment facilities scams.
Meetings/Trainings
• Continued modules, conference calls and Working on Wellness webinars. Submitting on
going assignments as plans become more finalized. First round of seed funding of$2,000
awarded on December 15`h and arrived mid-January. Second round of seed funding for
$7,000 has also been awarded and arrived mid-February. Held a committee meeting on
March 21". Currently completing the task of creating encouraging signage to increase use
of the stairs in our buildings instead of the elevators and will be launching the program
before May I"including a welcome bag for each department and exercise challenge.
• On March 8th, attended a Life Skills training by the Bureau of Substance Abuse Services.
This class taught us about the program, what is available to our communities and the
value of life skills training for children and adolescents.
• Attended the North Shore Emergency Preparedness meeting on March 22"d, the
collaboration of 15 cities and towns for emergency planning and preparedness, completed
and submitted a purchase request for sidewalk signage for emergency dispensing sites.
• On March 23`a, attended the Salem local elder collaboration meeting at the Salem police
station with North Shore elder services, the Salem Community Impact Unit and Salem
Council on Aging. The Board of Health is providing sharps containers and disposal
information for the police department and Council on Aging for residents and police
cruisers (while supply lasts as funded by the North Shore Shared Public Health services
grant from DPH).
• Attended a meeting with the North Shore public health nurses on March 28`h to
collaborate on issues we are seeing within our communities such as food borne illnesses
reported and Tuberculosis education, treatment and other ongoing updates.
• On March 30th, held the training/presentation for the public health nurses and all
recreational camp directors with the Department of Public Health regarding camp
regulations. It was attended by camp directors from several camps in Salem, including 2
new camps this year planning to run this year. All camp packets have been sent to camp
directors and I will be continuing to meet and communicate with camp directors in
preparation for licensing this summer.
Monthly Report of Communicable Diseases: March 2017
Disease New Carry Over Discharged/ Total# Of Running Total for Total for
g
Reported Cases this Total for 2016 2015
Closed Month 2017
Tuberculosis 0 0 0 0 0 4 4
(Active)
Latent 0 0 0 0 3 31 47
berculosis*
Arbovirus* 0 0 0 0 0 0 0
Babesiosis 0 0 0 0 0 0 1
Calicivirus/No 0 0 0 0 0 0 1
rovirus
Campylobacte 0 0 0 0 0 15 11
riosis
Chikungunya 0 0 0 0 0 0 0
Dengue* 0 0 0 0 0 0 0
Ehrlichiosis 0 0 0 0 0 0 0
Enterovirus 0 0 0 0 0 0 1
Giardiasis 1 0 1 1 2 6 2
Group A 0 0 0 0 1 0 4
Streptococcus
Group B* 0 0 0 0 3 2 7
reptococcus
Human 0 0 0 0 0 1 1
Granulocytic
Anaplasmosis
Haemophilus 0 1 1 1 1 2 1
Influenzae
Hansen's 0 0 0 0 0 0 0
Disease
Hepatitis A 0 0 0 0 0 0 0
Hepatitis B* 0 0 0 0 1 8 0
Hepatitis C* 5 0 5 5 15 30 29
Influenza* 21 0 21 21 49 19 29
Legionellosis 0 0 0 0 0 2 1
Lyme 0 0 0 0 0 0 2
IsDisease*
(27**)
(Probable)
Malaria 0 0 0 0 0 2 0
Measles 0 0 0 0 0 1 0
Meningitis 0 0 0 0 0 0 0
Mumps 0 0 0 0 0 1 0
Pertussis 0 0 0 0 0 1 1
Rocky 0 0 0 0 0 0 0
Mountain
Spotted Fever
Salmonellosis 0 0 0 0 1 11 6
Shigatoxin 0 0 0 0 0 0 0
Producing
Organism
Shigellosis 0 0 0 0 0 3 0
Streptococcus 2 0 2 2 2 8 3
10eumomae*
Varicella* 0 0 0 0 0 1 0
Vibrio 0 0 0 0 0 1 0
West Nile 0 0 0 0 0 0 0
Yersomosis 0 0 0 0 0 0 1
Zika Virus 0 0 0 0 0 1 0
Infection
Total 29 1 30 29 78 204 140
March 2017
*Notifications only, LBOH not required to follow up or investigation per DPH.
**Total reflects cases that have also been reported as suspect cases.
All Communicable disease totals above are subject to change in the event that the follow-up investigation
results in the revocation of the diagnosis.
Yearly totals for 2016 have been updated,for year end with the number of CONFIRMED cases.
Summary of Current Communicable Diseases
Giardia:
Case 1: This case was treated by their primary care physician after developing minor symptoms after
returning from a trip out of the country. They are not a food handler nor work in a direct care setting.
They have recovered, no contacts are ill and no further cases have been reported. No further follow up
necessary, this case is closed.
Zika Virus Infection:
32 cases of Zika Virus Infection previously listed as cases have been revoked after lab tests. In
the month of March, there were no new cases of testing and 1 revoked cases.
Confirmed Case(June 2016): Case not pregnant at time of diagnosis. Case traveled to
Dominican Republic and reported symptoms of fever and rash.
a
Health Agent report February 2017
. Announcements/Updates
• Paul Kirby, Chair, Board of Health was reappointed to the Board term ending 3/1/2020
• Janet Greene, Board member has submitted her resignation to the mayor effective March
1 , 2017
Community Outreach
• Met with Students form SSU Expect program to develop a marketing program to address
ongoing Opiate problem in Salem
• Met with Harvard Students to discuss Salem problem properties and access to the City
Nexus data portal
• Attended Parent SAPC marketing Focus group
Meetings and Trainings
• Larry Ramdin and Suzanne Doty attended Personal Protective Equipment train the trainer
seminar hosted by the Delvalle Institute. The training trained us in use of PPE and
prepared us to become trainers.
• • Larry Ramdin attended the MEHA seminar"Onsite waste water for Local Officials"
• Larry Ramdin attended one stop meetings where for FW Webb Building construction and
Northshore CDC proposals on 2 Buildings in the Point Neighborhood
• Larry Ramdin participated in a Fats oils and Grease meeting with the City Engineer to
discuss upcoming FOG survey and outcomes of previous surveys.
Environmental Health Activities
• Met with Julie Rose, Sharon Kishida(MA DEP) and Dominick Pangallo to discuss
Mandatory recycling for private waste generators
• Met with David Bowie of Salem Spice to discuss planned shared kitchen in Pickering
Wharf
• Meetings with Salem Hotel to discuss Food service at proposed Hotel on Essex Street
• Met with owner of proposed restaurant on Essex Street to discuss requirements and
processes for licensure and conducted a site visit at the proposed site to advise owner on
same.
• Plans submitted for Salem Tipico
i
Inspections
Item Monthly Total YTD 2016 Total
Certificate of Fitness 25 60 506
Inspection
Certificate of Fitness 7 12 42
re-inspection
Food Inspection 12 21 241
Food Re-inspections 7 11 31
Retail Food 3 4 17
Inspections
Retail Food 0 0 12
• re-inspection
Temporary Food 1 1 Not tracked
separetely
General Nuisance 0 1 26
Inspections
Food— 0 2
Administrative
Hearings
Housing Inspections 6 17 94
Housing re- 7 20 25
inspections
Rodent Complaints 0 0 24
Court 0 0 3
Hearings/filings
•
Item Monthly Total YTD 2016
Trash Inspections 41 96 114
Orders served by 0 0 3
Constable
Tanning Inspections 0 0 0
Body Art 0 0 0
Swimming pools 0 0 9
Bathing Beach 0 0 108
Inspection/testing
Recreational Camps 0 0 6
• Lead Determination 0 0 2
Septic Abandonment 0 0 0
Septic System Plan 0 0 0
Review
Soil Evaluation 0 0 0
Percolation tests 0 0 0
Total 109 243 1699
•
• Health Agent report March 2017
Announcements/Updates
• The Mayor has nominated Kerry Murphy to serve on the Board of Health. The
nomination has its first hearing before the City Council and will be heard a second time at
which time her nomination will be confirmed. After confirmation she will be seated as a
member of the Board,bringing the Board back to its full complement of 5.
• Elizabeth Gagakis graduated from the Local Public Health Institute's Managing
Effectively in Today's Public Health Environment program. The program addressed
among other things Topics covered include:Leading Organizational Change, Managing
People, Managing Budgets and Fiscal Resources, Managing Projects &Teams,
Managing Operations and Office Performance, and Moving Forward
• The Local Health Institute is offering an online Local Public Health Core Certificate
program. It is a series of courses designed to enhance the skills of local health
practitioners and Board's of Health in key issues in Local Public health. The institute has
provided information on the program online at
http://sites.bu.edu/masslocalinstitute/training/certificates/
Community Outreach
• Elizabeth Gagakis and Janice Orta participated in the Pathways Health Fair the focus of
our table was on lead paint in the home and understanding risks
Meetings and Trainings
• The entire technical team attended Chemical Biological, Radiological Nuclear and Explosives
(CBRNE) response training that was held at the Topsfield fairgrounds. The training was
introductory.
• Environmental Health staff attended MA DEP Annual Updates seminar on March 21
• A regional meeting with Camp Directors was held on March 30, the Camp Directors were
provided with information managing camps and regulatory requirements related to camp
licensing
Environmental Health Activities
• We continue to deal with indiscriminate dumping and hope to have cameras installed at
identified hotspots and when we identify the offenders they will be fined .
• The Environmental Health Unit supported the Engineering Department by assisting with
18 Grease trap inspections as part of the ongoing Fats Oils and Grease survey.
•
• Inspections
Item Monthly Total YTD 2016 Total
Certificate of Fitness 46 106 506
Inspection
Certificate of Fitness 7 19 42
re-inspection
Food Inspection 22 43 241
Food Re-inspections 9 20 31
Retail Food 0 4 17
Inspections
Retail Food 0 0 12
re-inspection
• Temporary Food 18 19 48
General Nuisance 4 5 26
Inspections
Food— 0 0 2
Administrative
Hearings
Housing Inspections 9 26 94
Housing re- 0 20 25
inspections
Rodent Complaints 0 0 24
Court 0 0 3
Hearings/filings
is
• Item Monthly Total YTD 2016
Trash Inspections 103 199 574
Orders served by 0 0 3
Constable
Tanning Inspections 0 0 0
Body Art 0 0 0
Swimming pools 0 0 9
Bathing Beach 0 0 108
Inspection/testing
Recreational Camps 0 0 6
•
Lead Determination 0 0 2
Septic Abandonment 0 0 0
Septic System Plan 0 0 0
Review
Soil Evaluation 0 0 0
Percolation tests 0 0 0
Total 211 454 1699
•
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MASSACHUSETTS ENVIRONMENTAL PUBLIC HEALTH TRACKING
COMMUNITY PROFILE FOR:
Salem
Click here for a PDF version for printing Select a different community
Promoting environmental public health for the protection of health and wellness and the reduction of risks in our air, food,
water, soil, and housing for all residents of the Commonwealth.
Click a topic to skip to that page
Geography Population Health Environment Climate Change
Salem's Geography
r
Percent of Land Use
. r Agriculture-0.2%
y
•�. Forest-26A%
Total Area Total Population Open space-10.6%
Recreation-6.1%
82 square miles 41,340 people Urban-54.6"/0
Office of Geographic Information(MassGIS),2005 U.S.Census,2010
Water-1.6%
Office of Geographic Information(MassGIS),2005
Salem's Population back to top
Some people are more vulnerable to the negative effects of different environmental hazards than others. For example, the
effects of lead poisoning are worse in young children. This is why it is important to not only collect data about the
environmental health of an area, but also understand the sociodemographic makeup of a community. Population
characteristics are important to know because they can help a community learn about the needs of its residents, and better
target public health messages and programs.
Demographics
Age
Think about all the different
health needs of older and
0-19 � z2 younger populations. Older
adults are more likely to
20-34 have many different
preexisting health conditions
35-64 that may be complicated by
11 environmental hazards,
65+ 4 while young children have
2ffib growing bodies that are
1 more sensitive to
environmental pollutants.
Population breakdown by age
U.S.Census American Community Survey(ACS),5-year estimates,2015
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Income Median household income
51% is the total amount of
money made by people who
<$40K live together, who may or
may not be related to each
$40-60K other.
$60K+
14%
3fi%
Distribution of household income
U.S.Census American Community Survey(ACS),5-year estimates,2015
Poverty
Poverty status for a
household is determined by
Below the income and makeup of
that household.
Above A household is "below the
poverty line" if the total
household income falls
below a value set by the
14% federal government.This
value changes according to
household size and ages of
household members, and is
Percent of households below the poverty line updated every year.
U.S.Census American Community Survey(ACS),5-rear estimates,2015
Race Ethnicity Race refers to sets of physical
characteristics like skin color,
while ethnicity refers to sets of
ter, 17% shared cultural, social, or
linguistic characteristics. Race
2% and ethnic categories are not
5% mutually exclusive. For
�'� example, someone can be of
14% Hispanic ethnicity, but of white
or black race.
I Asian Black Other white Not Hispanic Hispan�
Population breakdown by racial groups Population breakdown by ethnic groups
U.S.Census American Community Survey(ACS), U.S.Census American Community Survey(ACS),
5-year estimates,2015 5-year estimates,2015
Environmental Justice (EJ)
People who are members of minority racial and ethnic groups, and
people who are poor, may face more environmental burdens in their Salem: 31.4 %
neighborhoods.According to the U.S. Centers for Disease Control,
members of these populations are more likely to live near toxic waste Statewide: 12.1 %
sites, in areas with high air pollution, and in substandard housing.
Furthermore, these populations might have difficulty accessing health Percentage of population residing in a Mock group where one or
more of the EJ criteria is met,compared to the average
resources. percentage for all MA communities,calculated using data from
the 2010 U.S.Census and the EOEEA.
The principle of environmental justice was developed to address this inequality. This principle states that all people,
regardless of income or race, have the right to fair treatment and equal involvement in environmental issues, and the right to
live in environmentally healthy neighborhoods.
The Massachusetts Executive Office of Energy and Environmental Affairs (EOEEA)defines environmental justice
neighborhoods as census block groups where at least one of the following is true:
• Median annual household income is at or below 650/6 of the statewide median income;
• 25%or more of the residents are a minority; or
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• 250/6 or more of the residents are not fluent in the English language.
EJ neighborhoods where more than one criteria are met may be the most vulnerable to environmental and health hazards.
To find out more about environmental justice populations and your community, visit the Executive Office of Energy and
Environmental Affairs EJ webpage at: htto://www.mass.00v/eea/agencies/massdep/servicetjustice/.
For more detailed information about how EJ neighborhoods are defined, visit the glossary.
Click the link! Click on the blue underlined text within the next few sections to find more information about a topic.
Salem's Health backtotop
The environment can contribute to the development of chronic disease. Chronic illnesses are some of the most common,
expensive, and avoidable health problems.
Some links between chronic disease and the environment are well understood—it is common knowledge that smoking
cigarettes can cause lung cancer. However, many links between chronic disease and the environment are not well
understood. It is very difficult to determine the true cause of an illness. Individual genetics, the natural and built
environment, and lifestyle can all play a role in determining whether or not a person develops a chronic disease.
Childhood Lead Poisoning
Lead paint in older homes is the most common source of lead poisoning. Chipping and peeling paint, and paint disturbed
during home remodeling, can release lead dust which is then inhaled or consumed. Lead can cause damage to the brain,
kidneys, and nervous system; slow growth and development; and create behavioral problems and learning disabilities in
children. The use of lead in household paint was banned in 1978, but lead paint applied before the ban is still present in
many older homes across the Commonwealth.
Lead Screening Confirmed Blood Lead Levels(BLL) Lead in Homes
76.9% 79%
Rate is below the state
Statewide: 76% Statewide: 3.6 Statewide: 71%
Percentage of children 9 to c48 months 5-year average annual rate per 1,000 Percentage of housing units built before
screened for lead children 9 to c48 months with confirmed 1978
MDPH BEH Childhood Lead Poisoning Prevention BLL X 10 pg/dL U.S.Census American Community Survey(ACS),5-
Program(CLPPP),2015 MDPH BEH Childhood Lead Poisoning Prevention year estimates,2015
Program(CLPPP),2011-2015
State and federal regulations are in CLPPP considers a child with a The Massachusetts Lead Law
place to monitor children's lead confirmed blood lead level of requires that homeowners delead
levels,which are detected with a 10 micrograms per deciliter(pg/dL) homes built before 1978 that have
blood test. Massachusetts requires all or more as elevated and requiring a lead paint where any children under
children to be tested 3 times by the public health intervention. the age of six live. Deleading means
age of 3(and again at age 4 if they that lead hazards in the home such
live in a high-risk community). as peeling lead paint are covered or
removed. If you have questions about
having your home inspected for lead,
Do you live in a high risk lead community?A community is considered locating a licensed deleader, or
high risk for childhood lead poisoning based on the number of old houses it understanding the Lead Law, contact
has in stock, the percent of low to moderate income families and the the CLPPP at 14800)532-9571.
number of first time elevated blood lead levels over the past five years.All
cities and towns are reassessed for lead risk annually.
Based on these factors, Salem was not considered a
high risk lead community for 2014.
Heart Attack
While risk factors for having a heart attack include Heart Attack Hospitalizations
obesity, smoking, and high cholesterol, exposure to air
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pollution, specifically ozone or particulate matter, can 45
also increase risk. 40 38.5 39.2
Heart attack hospitalizations are tracked for adults 35 30.7
over age 35. Hospitalization data are presented 30
in age-adjusted rates per 10,000 people. 25 22.9 23.6
20
4 15 19.1
410
5 ■
0
Male Female. Total
Salem Statewide
Age-adjusted rate per 10,000 people
Massachusetts Center for Health Information and Analysis(CHIA),2012
Asthma
Asthma attacks can be triggered by environmental Asthma Emergency Department Visits
pollutants and asthmagens like cigarette smoke. This 120
illness is more common in children than adults and is 102.4
increasing in prevalence. 100 871 95.1
Asthma hospitalization is tracked for people of all 80 70.9 76.8 73.9
ages who visit the emergency department of a 60
hospital for an asthma-related reason. Hospitalization W
data are presented in age-adjusted rates per 10,000 �' 40
people. 20
Asthma prevalence in Massachusetts is also tracked 0
among children from the time they enter kindergarten Male Female Total
(K)through the 8th grade. Prevalence is expressed as Salem Statewide
a percentage of all children enrolled in these grades.
Age-adjusted rate per 10,000 people
Massachusetts Center for Health Information and Analysis(CHIA),2012
The Indoor Air Quality (IAQ) Program Pediatric Asthma Prevalence in K-8 Students
evaluates indoor environmental quality in public 96 14.4
schools at the request of the public. For more 14 13.2
information about school assessments or to — 12.4
find out if an assessment has been conducted e.12 1o.s 10.6
at a school in your community, visit 11
10 8.9
www.mass.gov/dah/iaq. dt e
6
a 4
2
0
Male Female Total
Salem Statewide
Rate per 100 K-8 students
MA Department of Public Health(MDPH)Bureau of Environmental Health(BEH),
2013-2014 school year
Salem's Environment back to top
The air we breathe and the water we drink can sometimes be impacted by pollutants, which may come from historical
sources, accidental releases, manufacturing processes or even regular activities like driving a car. The state and federal
governments are responsible for setting standards and guidelines for environmental pollutants; ensuring that monitoring of
those pollutants takes place; and taking action if there is a violation.The degree to which a person might be impacted by an
environmental hazard is extremely variable and depends on many factors.Age and individual health status might play a
role, as well as the length of time of exposure to the hazard and the amount of the hazard present.
Air Quality
Exposure to air pollution can contribute to heart or lung illnesses,
particularly for people at-risk because of preexisting heart or lung In 2015, Essex County had
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disease.Air pollution can aggravate asthma or other respiratory 1 day with ozone levels above the 8-
ailments, or trigger heart attacks. The U.S. EPA establishes limits on air hour NAAQS of 0.075 ppm and
pollution levels to protect public health, including the health of at-risk
populations. These limits, called National Ambient Air Quality 0% of monitoring days of PM2.5
Standards(NAAQS), apply to widespread pollutants including ozone levels above the 24-hour NAAQS of
and fine particles. Currently, EPHT air quality measures are available for 35 Ng/m3.
counties with monitoring stations, which are maintained by the
Massachusetts Department of Environmental Protection(MassDEP).
Fine Particles(PM2.5) Ozone(ppm)
Percent of days where the 24-tour PM2.5 daily Number of days where the 8-hour ozone level exceeded
concentration exceeded the NAAQS of 35 pg/m3 the NAAQS of 0.075 ppm
a 4
0.0
=2.a
B g 2
c 5
a 1
13 �
x o.a
0 0
2011 2012 2013 2014 2015 2011 2012 2013 2014 2015
Year Nbur
f Essex County f Essex County
MassDEP Air Assessment Branch(AAB),2011-2015 MassDEP Air Assessment Branch(AAB),2011-2015
Fine particulate matter or PM2.5 refers to a mixture of Ozone is a colorless gas. This measure reflects the number
extremely small airborne particles. PM2.5 is displayed here of days in a year that ozone concentrations exceeded the
as the percent of monitored days when concentrations were NAAQS over an 8-hour period.
above the NAAQS over a 24-hour period.
"No Data"is displayed when the monitoring station did not capture a minimum amount of days of data.
Drinking Water Quality
The U.S. EPA sets limits for acceptable and safe levels of contaminants in
drinking water, and the MassDEP Drinking Water Program is responsible for Contaminants tracked by EPHT:
monitoring and enforcing those limits. The EPHT program has information
Arsenic
available for nine contaminants. Atrazine
Most people in Massachusetts drink water from a public community water DEHP
system. Providers are responsible for testing water and reporting test results to Disinfection Byproducts
the MassDEP. Contact your town water department or water provider to obtain Lead
a copy of current test results. Nitrates
Some people have private wells on their properties that provide drinking water. PCE
Those individuals are responsible for testing their own well water to ensure it is TCE
safe for drinking. Uranium
It is important to track the water quality of community water systems. Health Have a private well?
effects from potential contaminants will depend on the pollutant, the amount
ingested, how it was ingested(for example, if the polluted water was Visit MA DEP for
introduced into the body by drinking or skin absorption)and the sensitivity of drinking water testing
the individual. recommendations
Of the nine contaminants tracked by EPHT there have been no violations reported for water
systems that service Salem.
MassDEP Drinking Water Program,2M-2013
Climate Change back to top
Massachusetts is already experiencing the effects of climate change, from hotter summers to rising sea levels.These
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effects will have consequences for the health of many people across Massachusetts. With evidence suggesting that effects
of climate change will be most directly felt at the local level, MDPH is working with local health partners to prepare for the
health threats and challenges posed by a changing climate in their community.
MDPH is implementing CDC's Building Resilience Against Climate Effects (BRACE)framework to help communities better
prepare and respond to potential climate related impacts. EPHT data can inform strategies to: 1)better understand links
between climate and health; 2)identify vulnerable populations or areas; 3)identify interventions to reduce potential health
impacts; and 4)support local planning efforts.
The information provided below gives an example of how data from the MA EPHT program website can help communities in
preparing for extreme heat4elated events. You can read more about BRACE on our website's .climate change page
Understanding the Climate and Health Link: Extreme Heat-Related Events
Tracking Links between Climate and Health Heat Stress Emergency Department Visits
One predicted impact of climate change is an 18 16.4 15.4
increase in the number of days over 90 degrees. 111 14 13.1
More days of extreme heat increase the number 12 9.9
of residents at risk for experiencing heat stress, 9 1g
the effects of which include fatigue, cramps, 4
dehydration and heat stroke. EPHT tracks the 2 N5 NS
number of emergency room visits for heat stress 0
in each community in Massachusetts. Male Female Total
Salem Statewide
Age-adjusted rate per 100,000 people
Massachusetts Center for Health Information and Analysis(CH[A),2012
Tracking Vulnerable Populations Percent of Population over 65 Living Alone
Studies of deaths during extreme heat events s
0 Salem
found that older adults, especially those living 4'6 4.3 ■Statewide
alone, are more vulnerable. EPHT provides ;, 4
a vulnerability mapping tool that displays this a
measure and other demographic data for each d 2
community.
0
U.S.Census American Community Survey(ACS),5-year estimates,
Identifying Possible Interventions Percent Green Space
Green space decreases overall outdoor 00 74.8
temperature because trees and shrubs can TO ■Salem
B0 Statewide
provide shade. Green space is measured as the 0 43.3
percent of land in the town devoted to agriculture, 40
forest, open space, and recreation. EPHT a 20
provides percent of green space in each 10
community in the vulnerability mapping tool. 0
Calculated using data from the Office of Geographic Information(MassGIS),2W5
Supporting Intervention Planning Efforts
In this example, interventions can be implemented to monitor and communicate risk to the elderly who are living alone
during times of extreme heat, improve access to cooling centers, and support longer-term efforts to reduce the impact of
increasing temperature by creating more green space, especially where vulnerable populations are located.
What You Can Do
There are many ways to minimize the impacts of environmental hazards to your health and the health of your family.
- Get tested: Have your home tested for radon(1-800-RADON95)and for the presence of lead paint, especially if
you live in a house or apartment built before 1978(1-800-532-9571); if you drink pnvate well water, regularly have
your water tested for contaminants.
- Read labels and follow instructions when using household chemicals.
- Wash fruits and vegetables before consuming, and follow fish consumption advisories.
- Monitorair,iollution levels and avoid strenuous activity when pollution levels are bad, especially if you have
asthma.
- Maintain your car so it bums fuel oil efficiently, and take public transportation if possible.
Ll - Avoid cigarette smoke and quit if you are a reguiarsmoker (1-800-QUITNOW).
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-Maintain overall good health by staying active and eating healthy foods.
Learning about environmental public health in your community is the best place to start.
Together,we can work toward healthier communities.
About the Data
Data presented on this profile are collected by many different partners of the MA EPHT Program and are the most up-to-
date data available for each topic. For more information about the data visit http://www.mass.gov/dph/matracking.
Demographics: US Census Bureau,American Community Survey (ACS), 5-year
estimates, 2010 https://www.census.ciov/proorams-surveys/acs
Geography: Office of Geographic Information, Commonwealth of Massachusetts,
MasslT, 2005 http://www.mass.00v/anf/research-and-terlVit-serv-and-support/application-serv/office-of-geographic-
information-massgis/
Environmental Justice:Office of Geographic Information, Commonwealth of Massachusetts, MasslT, 2010
http://www.mass.gov/anf/research-and tectVit-serv-and-support/application-serv/office-of-geooraphicAnformation-
massgis/datalavers/cen20l Oei.htmI
Asthma prevalence: MDPH BEH, 2013-2014 school year http://www.mass.gov/dph/asthma
Hospitalization: Massachusetts Center for Health Information and Analysis (CHIA), 2012 http://www.chiamass.gov/
Childhood lead poisoning: MDPH BEH Childhood Lead Poisoning Prevention Program
(CLPPP), 2015 http://www.mass.gov/doh/clppp and United States Census Bureau, 2015 http://www.census.gov/
Air quality. MassDEP Air Assessment Branch, 2011 -2015 httl2://www.mass.gov/eea/auencies/massdep/air
Drinking water quality: MassDEP Drinking Water Program, 2009-2013
http•//www mass gov/eea/agencies/massdep/water/drinking
Climate change: MDPH BEH and U.S. Centers for Disease Control
(CDC)http://www.cdc.ggv/climateandhealttVbrace.htm
Contact Us
We appreciate your comments, suggestions, and questions. Did you know?The MA EPHT program is part of a
You may send an email to the MA EPHT program at MA- national network of state and local health
EPHT@State.MA.US.We can also be reached at 1-800-319- departments committed to tracking environmental
3042. Please leave a voicemail if calling after office hours. public health. Click here to see a list of other
tracking programs.
Acknowledgements
This program was made possible thanks to the U.S. Centers for Disease Control and Prevention grant for the Maintenance
and Enhancement of the State and National Environmental Public Health Tracking Network.
Glossary
Age-adjusted rate-A statistical method applied to the rates of a disease in a population that allows comparison among
populations with different age distributions; also known as age-standardized rate.
Census block group-A geographic area used by the U.S. Census. Block groups are smaller than census tracts and
usually hold between 600 to 3,000 people.
Chronic disease-A chronic disease is an illness that is persistent over time.According to the U.S. Centers for Disease
Control and Prevention, chronic diseases are among the most prevalent, expensive and preventable diseases.
Community Water System (CWS)-Any water system that provides water for human consumption through pipes or other
constructed conveyances to at least 15 service connections or serves an average of at least 25 people for at least 60 days
a year.
Confirmed Blood Lead Level -A confirmed blood lead specimen is either a single venous blood lead specimen of any
value, or the highest confirmed value of two or more capillary blood lead specimens >=10 pg/dL drawn within 12 weeks of
each other.
Deciliter(dL) -A metric measure of capacity that is 1/10th of a liter.
Environmental hazard A substance or situation in the environment that might adversely affect human health. People can
be exposed to physical, chemical, or biological toxins from various environmental sources through air, water, soil, and food.
https!/cognosl0.hhsstate.main/cvl0pub/cgi-t n/cogrmsisapi.dil 7/8
3/29/2017 community-profile-IBM Cognos Viewer
Environmental Justice(EJ) -The fair treatment and meaningful involvement of all people regardless of race, national
origin, color, or income when developing, implementing, and enforcing environmental laws, regulations, and policies. Fair
treatment means that no group of people, including a racial, ethnic, or socioeconomic group, should bear more than its share
of negative environmental impacts.
Median-The median is the number in a data set that separates the upper half of the data in the data set from the lower
half.
Micrograms(Ng) -Unit of measure for weight/mass equal to one-millionth of a gram used to measure the concentration of
pollutants in the air.
National Ambient Air Quality Standards(NAAQS) -Standards established by U.S. EPA that apply to outdoor air
throughout the country.
Ozone-There are two types of ozone=good"ozone and"bad", ground-level ozone. Good ozone occurs high in the
atmosphere and forms a layer that deflects harmful ultraviolet (UV)rays, preventing them from reaching the Earth. Bad
ozone is an odorless, colorless gas that is created by a chemical reaction and can affect health.
Particulate matter-"Particles"or"particulate matter"are terms used to describe the mixture of solid particles and liquid
droplets in the atmosphere. The microscopic solid and liquid particles are of human and natural origin and can vary greatly in
size and composition.
Poverty-Poverty status for a household is determined by the income and makeup of that household. A household is "below
the poverty line" if the total household income falls below a value set by the federal government. For more information about
how the government defines poverty, including tables of poverty thresholds, visit the U.S. Census Bureau's Poverty
webpage(httos://www.census.gov/hhes/www/povertyLindex.htmo.
PPM -Parts per million; denotes 1 part per 1,000,000 parts. Used to measure the concentration of ozone in the air.
Prevalence-The proportion of individuals in a population having a disease or condition. Prevalence is a statistic that refers
to the number of cases of a disease that are present in a particular population at a given time.
Sociodemographic-A term describing data relating to sociologic and demographic factors.
Massachusetts Department of Public Health-Bureau of Environmental Health
Report created on Mar 29,2017
•
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Log in
Search HealthyPeople.gov
2020 Go
Topics&Objectives Leading Health Indicators Data Search Healthy People in Action Tools&Resources Webinars&Events About
I
Home))2020 Tonics&Obiectives»Social Determinants of Health Print Share
Social Determinants of Health New
Overview 1 Objectives „ Interventions&Resources ' National Snapshots '
Goal
Create social and physical environments that promote good health for all.
Overview
Health starts in our homes,schools,workplaces,neighborhoods,and communities.We know that l_
taking care of ourselves by eating well and staying active,not smoking,getting the recommended
immunizations and screening tests,and seeing a doctor when we are sick all influence our health.
Our health is also determined in part by access to social and economic opportunities;the
resources and supports available in our homes,neighborhoods,and communities;the quality of ,
our schooling;the safety of our workplaces;the cleanliness of our water,food,and air;and the
nature of our social interactions and relationships.The conditions in which we live explain in part View HP2020 Data for:
why some Americans are healthier than others and why Americans more generally are not as Social Determinants of
healthy as they could be. Health
Healthy People 2020 highlights the importance of addressing the social determinants of health by Midcourse Review Data Is In[
including"Create social and physical environments that promote good health for air as one of the Check out our interactive
four overarching goals for the decade?This emphasis is shared by the World Health infograahic to see progress
Organization,whose Commission on Social Determinants of Health in 2008 published the report, toward the Social Determinants of
Closing the gap in a generation:Health equity through action on the social determinants of Health objectives and other
health?The emphasis is also shared by other U.S.health initiatives such as the National Healthy People topic areas.
Partnership for Action to End Health Disparities a and the National Prevention and Health
Promotion Strategy.!
The Social Determinants of Health topic area within Healthy People 2020 is designed to identify ways to create social and physical
environments that promote good health for all.All Americans deserve an equal opportunity to make the choices that lead to good health.
But to ensure that all Americans have that opportunity,advances are needed not only in health care but also in fields such as education,
childcare,housing,business,law,media,community planning,transportation,and agriculture.Making these advances involves working
together to:
• Explore how programs,practices,and policies in these areas affect the health of individuals,families,and communities.
• Establish common goals,complementary roles,and ongoing constructive relationships between the health sector and these areas.
• Maximize opportunities for collaboration among Federal-,state-,and local-level partners related to social determinants of health.
Back to Top
Understanding Social Determinants of Health
Social determinants of health are conditions in the environments in which people are born,live,learn,work,play,worship,and age that
affect a wide range of health,functioning,and quality-of-life outcomes and risks.Conditions(e.g.,social,economic,and physical)in these
various environments and settings(e.g.,school,church,workplace,and neighborhood)have been referred to as"place"5 In addition to the
hit M,ww.healthypeople.gov/202OAopics-objectives/topic/social-determinants-of-health 1/5
3/22/2017 Social Determinants of Health I Healthy People 2020
more material attributes of"place,"the patterns of social engagement and sense of security and well-being are also affected by where
people live.Resources that enhance quality of life can have a significant influence on population health outcomes.Examples of these
resources include safe and affordable housing,access to education,public safety,availability of healthy foods,local emergency/health
services,and environments free of life-threatening toxins.
Understanding the relationship between how population groups experience"place"and the
impact of"place"on health is fundamental to the social determinants of heafth--4ncluding Learn More
both social and physical determinants. CDC Social Determinants of
Health
Examples of social determinants include: Secretary's Advisory Committee
Social Determinants of Health
• Availability of resources to meet daily needs(e.g.,safe housing and local food Report
MAP-IT Toolkit
markets) MAP-IT SDOH 0
• Access to educational,economic,and job opportunities
• Access to health care services
• Quality of education and job training
• Availability of community-based resources in support of community Irving and opportunities for recreational and leisure-time activities
• Transportation options
• Public safety
• Social support
• Social norms and attitudes(e.g.,discrimination,racism,and distrust of government)
• Exposure to crime,violence,and social disorder(e.g.,presence of trash and lack of cooperation in a community)
• Socioeconomic conditions(e.g.,concentrated poverty and the stressful conditions that accompany it)
• Residential segregation
• Language/Literacy
• Access to mass media and emerging technologies(e.g.,cell phones,the Internet,and social media)
• Culture
• Examples of physical determinants include:
• Natural environment,such as green space(e.g„trees and grass)or weather(e.g.,climate change)
• Built environment,such as buildings,sidewalks,bike lanes,and roads
• Worksites,schools,and recreational settings
• Housing and community design
• Exposure to toxic substances and other physical hazards
• Physical barriers,especially for people with disabilities
• Aesthetic elements(e.g.,good lighting,trees,and benches)
By working to establish policies that positively influence social and economic conditions and those that support changes in individual
behavior,we can improve health for large numbers of people in ways that can be sustained over time.Improving the conditions in which we
live,learn,work,and play and the quality of our relationships will create a healthier population,society,and workforce.
Back to Top
Healthy People 2020 Approach to Social Determinants of Health
A"place-based"organizing framework,reflecting five(5)key areas of social determinants of health(SDOH),was developed by Healthy
People 2020.
These five key areas(determinants)include:
• Economic Stability
• Education
• Social and Community Context
• Health and Health Care
• Neighborhood and Built Environment
httpsJM,ww.healthypeople.gav/202D/topics-objectives/topiGsocial-determinants-of-health 215
3/22/2017 Social Determinants of Health Healthy People 2020
• u
Suctal and
Community
Context "I."
Each of these five determinant areas reflects a number of critical components/key issues that make up the underlying factors in the arena of
SDOH.
• Economic Stability
. Poverty
. • Employment
. Food Security
• Housing Stability
• Education
• High School Graduation
• Enrollment in Higher Education
• Language and Literacy
• Early Childhood Education and Development
• Social and Community Context
• Social Cohesion
• Civic Participation
• Discrimination
• Incarceration
• Health and Health Care
• Access to Health Care
• Access to Primary Care
. Health Literacy
• Neighborhood and Built Environment
• Access to Healthy Foods
• Quality of Housing
• Crime and Violence
• Environmental Conditions
This organizing framework has been used to establish an initial set of objectives for the topic area as well as to identify existing Healthy
People objectives(i.e.,in other topic areas)that are complementary and highly relevant to social determinants.It is anticipated that
additional objectives will continue to be developed throughout the decade.
hitpsJ/www.healthypeople.gov/202DAopics-objecbves/topic/social-determinants-0f-health 315
3122/2017 Social Determinants of Health I Healthy People 2020
In addition,the organizing framework has been used to identify an initial set of evidence-based resources and other key tools/examples of
how a social determinants approach is or may be implemented at a state and local level.
Back to Too
• Emerging Strategies To Address Social Determinants of Health
A number of tools and strategies are emerging to address the social determinants of health,including:
• Use of Health Impact Assessments to review needed,proposed,and existing social policies for their likely impact on healthy
• Application of a"health in all policies"strategy,which introduces improved health for all and the closing of health gaps as goals to be
shared across all areas of government 7
References
'Secretary's Advisory Committee on Health Promotion and Disease Prevention Objectives for 2020.Healthy People 2020:An Opportunity to
Address the Societal Determinants of Health in the United States.July 26,2010.Available from:
http:itwww.healthypeop le.gov/2010/hp2O2C/advisory/SocietalDeterminantsHealth.htm
ZWorld Health Organization,Commission on Social Determinants of Health.Closing the Gap in a Generation:Health equity through action
on the social determinants of health.Available from:.httD:11www.who.int/sociaI determinants/en If
3National Partnership for Action:HHS Action Plan to Reduce Racial and Ethnic Health Disparities,2011;and The National Stakeholder
Strategy for Achieving Health Equity,2011.Available from:http://minoritvhealth.hhs.gov/noa
4The National Prevention and Health Promotion Strategy.The National Prevention Strategy:America's Plan for Better Health and Wellness,
June 2011.Available from:http://www.suraeonueneral.aov/initiatives/preventionistrateav/
rlThe Institute of Medicine.Disparities in Health Care:Methods for Studying the Effects of Race,Ethnicity,and SES on Access,Use,and
• Quality of health care,2002.Available
from:http://www.iom.edu►—/medialFiles/Activity%2OFiles/Quality/NHDRGuidance/DisparitiesGomick.pdf rPDF-108 KBl L
611ealth Impact Assessment:A Tool to Help Policy Makers Understand Health Beyond Health Care.Annual Review of Public Health
2007;28:393-412.Retrieved October 26,2010.Available from:
http:l/www.annualreviews.omldoilabs/10.1146/annumv.pubihealth.28,083006,131942 0.
7European Observatory on Health Systems and Policies.Health in All Policies:Prospects and potentials,2006.Accessed on June 16,2011.
Available from:htta://www.euro.who.inU data/assets►pdf file/0003►109146/E89260.pdf rPDF-1.23 MBI 0
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OMB No.0990-0379 Up.Date 08/31/2017
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htlpsJlwww.healthypeople.gov/202MWics-objectives/topic/social-determiriants-of-health 4/5
Health Dept. Clerical Report FY JW7 •
Burial Permits Permits Plan Reviews Certificate of Copies / Fines Revenue Permit Fees
Jul -16 $475.00 $2,210.00 $1,950.00 $4,635.00 Food Service Est. <25seats $140
August $700.00 $985.00 $1,500.00 $3,185.00 25-99 seats $28o >99 seats $420
September $1,475.00 $2,165.00 $4,300.00 $300.00 $8,240.00 Retail Food <l000sq' $70
October $475.00 $3,415.00 $2,150.00 $6,040.00 loon-lo,000 $280 >lo,000 $420
November $500.00 $7,785.00 $2,150.00 $150.00 $10,585.00 Temp.Food 1-3 days s35
December $700.00 $36,265.00 $700.00 $37,665.00 4-7 days s7o >7days s
January-1 7 Example of>7 day temp food permit.
$750.00 $12,220.00 $90.00 $600.00 $13,660.00 14(days)divided bY7=2 x$70=$140
February $1,075.00 $1,495.00 $1,400.00 $3,970.00 Frozen Desserts $25
March $0.00 Mobile Food $210
April $0.00 Plan Reviews New s18o
May $0.00 Remodel sgo
June Catering s25 per event l$20o
$0.00 catering kitchen
Body Art Est. $315
Total $6,150.00 $66,540.00 $90.00 $14,750.00 $450.00 $87,980.00 Body Art Practitioner 135
Review Plans s18o
Fiscal Year Budget 2017 Suntan Est. $140
Rec.Day Camp $10
Salary Starting Kafing Expenses Ext.Paint Removal s35
Full Time $362,039.00 $128,525.75 Starting Ending Transport Off.Subst. s1o5
Part Time $28,306.00 $10,991.61 $16,500.00 $7,112.09 Tobacco Vendors $135
Overtime $2,000.00 $264.57 Swimming Pools Seasonal $140
Balance $392,345.00 $139,781.93 Health Clinic Revolving Account Annual$210 Nonprofit$40
S10,726.38 Title V Review s18o
Well Application $180
Disposal works $225118o
Health Dept. Clerical Report FY%7
Burial Permits Permits Plan Reviews Certificate of Copies / Fines Revenue Permit Fees
Jul -16 $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 25-99 seats s28o >99 seats $420
September $1,475.00 $2,165.00 $4,300.00 $300.00 $8,240.00 Retail Food <l000sq' $70
October $475.00 $3,415.00 $2,150.00 $6,040.00 .1000-1o,000 $28o >1o,000 $420
November $500.00 $7,785.00 $2,150.00 $150.00111 $10,585.00 Tema Food 1-3 days s35
December $700.00 $36,265.00 $700.00 $37,665.00 4-7days s7o I>7days s
January-17 i
Example of>7 day temp food permit:
$750.00 $12,220.00 $90.00 $600.00 $13,660.00 14(days)divided bY7=2x$35=$490
February $1,075.00 $1,495.00 $1,400.00 $3,970.00 Frozen Desserts $25
March $1,525.00 $2,660.00 $1,080.00 $2,100.00 $500.00 $7,865.00 Mobile Food $210
April $0.00 Plan Reviews New s28o
May _ �, $0.00
!Remodel sgo
June Catering $25pereventl$200
$0.00 catering kitchen
Body Art Est. $315
Total $7,675.00 $69,200.00 $1,170.00 $16,850.00 $950.00I 1 $95,845.00 1 ody Art Practitioner 135
Review Plans s28o
Fiscal Year Budget 2017 Suntan Est. $140
Rec. Day Camp $10
SalaU Startinq Ending Expenses Ext.Paint Removal s35
Full Time $362,039.00 $107,251.04 Startinq Ending Transport Off.Subst. s1o5
Part Time $28,306.00 $9,193.59 $19,000.00 $8,816.34 Tobacco Vendors $135
Overtime 1 $2,000.00 $16.50 'Swimming Pools Seasonal $140
Balance $392,345.00 $116,461.13 Health Clinic Revolving Account Annual$210 Nonprofit$40
$12,415.74 Title V Review s18o
Annual Food Temp-Pop Up Retail Frozen Dessert Other-Pain ell Tobacco Viol. Late Fee I Well Application $28o
10 6 1 1 2 3 2 1 Disposal works $22SI180
r.
CITY OF SALEM,
MA SS AC H U SETTS
Wim ov 1-f m I"ti Pub1 Cat
120 WASHINGTON.SnW-L7',41/1 FLOOR Pre�eM1.rr�mau..yroier,.
KIMBERIXYDRISCOLL Tii-L- (97�)741-1800 FA1(978)745-0343
Inindin @ salem.-ozm I' un, Iuvw)IN,ItS/itla is,(,:I IO,cr-i-'S
MAYOR HiC.U:I'i I ACiI?N'1'
February 16,2017
Vapor Outlet
103 Lafayette St.
Salem, MA 01970
Dear Owner:
Vapor Outlet is in violation of the Salem Board of Health Regulation Affecting sales to a minor. According to this
section,the sale of cigarettes,chewing tobacco,snuff,or any tobacco in any of its forms to any person under the
age of twenty-one shall be punished by a fine of$200.00 Hundred Dollars for the second offense plus a 7-day
suspension. You will be advised of the dates of the suspension by the Health Agent.
On Thursday,January 19,2017 at 4:12pm personnel from the Tobacco Control Program conducted a compliance
check.During that compliance check,a 17-year-old female,a minor,was sold a 3mg large bottle of Simply
Pineapple liquid nicotine from a clerk In your store. Documentation is now on file at the Board of Health
regarding that sale.
FOLLOVWNG THE THIRD(3RD)OFFENSE, THE BOARD MAY CONSIDER POSSIBLE REVOCATION OR
SUSPENSION OF THE PERMIT. I
,
Therefore,you are ordered to pay a fine of$200.00 for the violations.A check or money order payable to
the City of Salem must be at the Board of Health office,120 Washington Street,41h floor,within ten days of
receipt of this notice.
Should you be aggrieved by this Order,you have the right to request a hearing before the Board of Health. A
request for such a hearing must be received in writing in this office of the Board of Health within seven(7)days of
receipt of this Order. At said hearing,you will be given the opportunity to be heard and to present witness and
documentary evidence as to why this Order should be modified or withdrawn. You may be represented by an
attorney. Please also be informed that you have the right to inspect and obtain copies of all relevant inspection or
Investigation reports,orders,and other documentary information in the possession of this Board,and that any
adverse party has the right to be present at the hearing.
If you have any questions regarding this notification,please call me at 978-741-1800.
Sincerely yours,
e_1, vv�
Larry Ram-Min
Health Agent
LRmip
CERTIFIED MAIL:70121640 0002 33131369
cc:North Shore/Cape Ann Tobacco and Alcohol Policy Program
Paul Kirby.Board of Health Chair and Members
y
Violation Notice
City own Board of Health
Hirt
revent. Promote. Protect.
D
This notice is to inform you that your.establishment,violated the Board of Health Sale of Tobacco Products
&Nicotine Delivery Products and/or Environmental Tobacco Smoke(ETS)Regulation.
VC-i
Name of est blishment
.:
Address JJ
V X �
tclo viola ort Time of violation Minor's age/gender Minor's ID#
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, .
( ct' onstltuting Vio ation)
M JAA r,
Narrative information:
YV0,
�ff r the pe ptury,that the above report is true to the best of my knowledge
d belief.
KA`., r
Inspector;( i ) (Print name)
I acknowledge I received This Violation Notice on , 20-1.:]
at M d I am being. -'ven a,carbon copy of this notice.I also know.dge that I
have been in orm_ed., a e Peabo y Bay d of Health.will provide additional,follow-up information to
thj atic�Iati,"-"--CC
b er Sgture) (Print name)
N vendor refuses this Notice or if the-inspector.feels unsafe in delivering it,an explanation must be
written on a note attached hereto.Mailing of this Notice is thus required.
• Contact the North ShoWCape Ann Tobacco Alcohol Policy Program at 781-586-6821 with questions
Establishment-white NSTCF-yellow Board of Health-pink
t '
' CITY OF SALEM,
MASSACHUSETTS
BOARD OF HEALTH PublicEleaft
120 WASHINGTON STREET,4T"FLOOR Prevent.Promote.Protect.
KIMBERLEY DRISCOLL TEL. (978) 741-1800 FAx(978) 745-0343
lramdin@salem.com L;\RRY RAMDIN,RS/RIiI IS,CI-Iq,Cl 1 S
MAYOR HI:\L,I"I I AGENT
0,
August 10,2015
Vapor Outlet
103 Lafayette Street
Salem, MA 01970
Dear Owner:
On Tuesday July 27,2015 1:19pm personnel from the Tobacco Control Program conducted a compliance check
to determine if your permitted establishment would sell a tobacco product to a minor. A 17 year-old female
purchased tobacco from a clerk in your store. Documentation is now on file at the Board of Health regarding
that sale.
Vapor Outlet is in violation of Section III (A)of the Salem Board of Health Regulation Affecting the Sales of
tobacco to a minor. According to this section,the sale of cigarettes,chewing tobacco, snuff, or any tobacco in any
of its forms to any person under the age of eighteen shall be punished by a fine of$100.00 Hundred Dollars for
• the first offense.
FOLLOWING THE THIRD(3")OFFENSE,THE BOARD MAY CONSIDER POSSIBLE REVOCATION OR
SUSPENSION OF THE PERMIT.
The North Shore/Cape Ann Tobacco Alcohol Policy Program and the Salem Board of Health have worked with you
and your employees to demonstrate methods to ensure compliance with this regulation.
Therefore,you are ordered to pay a fine of$100.00 for the violations stated above. A check or money order
payable to the City of Salem must be at the Board of Health office, 120 Washington Street,4th floor,within
ten days of receipt of this notice.
Should you be aggrieved by this Order, you have the right to request a hearing before the Board of Health. A
request for such a hearing must be received in writing in this office of the Board of Health within seven(7)days of
receipt of this Order. At said hearing,you will be given the opportunity to be heard and to present witness and
documentary evidence as to why this Order should be modified or withdrawn. You may be represented by an
attorney. Please also be informed that you have the right to inspect and obtain copies of all relevant inspection or
investigation reports,orders, and other documentary information in the possession of this Board, and that any
adverse party has the right to be present at the hearing.
If you have any questions regarding this notification please call me at 978-741-1800.
Sincerely yours,
Larry Ram 2n
Health Agent
LR/hlp
CERTIFIED MAIL: 7012 1640 0002 3313 1260
cc: North Shore Tobacco Control Program
Dr. Shama Alam, Board of Health Chairperson and Members
v,
Violation Notice;.
F Cit wn . �`�''� - Board of Health,
lic Health y
ent. Promote. Protect. 1
This notice is to inform you that.your establishment violated the Board_of Health Sale of Tobacco Products
&:Nicotine Delivery Products-and/or Environmental Tobacco Smoke(ETS)Regulation.
Name of a ablishmen 1
Address ,
..
Date o violation Time`of violation Minor's age/gender Minor's ID#
1t
rdinance,Sec eg lation.
f ( c Constituting Violation)
r . r
F Narrative information: _ , ,,,,
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: I n$er the pains d p n ties of erjury,that the above report is true to the best of my knowledge
and i
t ~4+
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Inspec r( nature), -,Z4 (Print name)
STATEMENTiel
I acknowledge I received this"Violation Notice on " . ,`20 '
at. AM M- I am being given a carbon copy of this notice.I also cknowledge that I
" have been informed tha. eabody Board of Health will provide additional,follow-up information to
this violation notice.
1 < y 4
ner/Manager//C (Signature). (Print name)
If vendor refuses this Notice or if the inspector feels unsafe in delivering it,an explanation must be
• written_on"a note attached'hereto.Mailing of this Notice is thus required. <'
Contact the North Shore/Cape Anufiobacco Alcohol Pohcy,Program"at 781-586-6821 with questions
Establishment white NSTGP-yellow Board of Health,pink
,
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MTCP User Administration Page l of 1
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From Date: 01-01-2014
To Date: 03-22-2017
Establishment: APOROUTLET-103LAFAYETTEST =v
Output Formats: Q CSV @ HTML O PDF
Osnarate Report
Independent
Establishment Name: VAPOR OUTLET
Establishment Address: 103 LAFAYETTE ST
Town: SALEM
• Establishment Style: Otter
Establishment Type:
DOR License:
BOH Permit:
Tobacco Was We. WWI;Type Brand of The cost
Survey Was the µ,se Was purchase Gender the
Age on
Supervisor Purchaser survey purchaser tobacco tobacco of the Compliance
Date marketed askedhis/her ofdvksale
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01-19• ecvyec�re 2�5r�37�22��04 00 RJedrord (15825332) Yes oY cou�nlee No No Male Ecigarette Other Yes 20.00 17
®Commonwealth of Massachusetts Site Policy Contact Us Help Site Map
http://www.masstcp.com/desktop.php?module=reporting&page=report&report id=11 3/22/2017
MTCP User Administration Page 1 of 1
Welcome Joyce Red(nrd — — - — ' — Change My Password I Edit my Profile i Lagout
MTCP
Massachusetts Tobacco Control Program
Home I CorhjhiiaocaChecks I'Inspections Pricing ( Enforcement I Estapiisl~' is I Adminlstrative -Users
,-Compliance SurV4 Tool
i- DateRlme purchaser exited the establishment:(Qt) 01-19.2017 04:12 PM
2- Town:(02) Salem
3- Establishment(03) VAPOR OUTLET 103 LAFAYETTE ST
a. Supervisor.(04) Joyce Redford
5- Purchaser(Q5) 253720(15825332)
6- WAS the survey completed?(Q6) Yes
7- Tobacco was marketed via:(09) Over the Counter
a- Was purchaser asked forlD?(Q1a) No
9- Was the purchaser asked hisMer age?(Q111 No
10- Was this an I04based chock?(012) No
11- Gender of clerk:(Q13) Male
12- Approximate age of cleric(Q14) Adult
13- Type of tobacco purchased:(Q16) Ecigere to
14. Brand of tobacco purchased:(Q17) Other
IS- Was the product requested flavored(NOTTobacco or Menthol)?? Yes
(Q22o)
16- Was the sale made?(Q1s) Yes
IT- The cost of the produtt.(019) 20.00
1e- Method of paywient µ 20) $20 bill
19- Purchaser received araceipt?(021) No
20- Other purchases made?(022) No
21- comments:(057) 20�o apes�3 lager,ski oid the product was XOD asked another clerk about price as youth only had
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Massachusetts Tobacco Coritebl'Prografn.
Home I ComplianceChocka 1 tnapeegons j_fAnng Frdarcoment Establishments Administrative J, users
Coinpllaetce'sU vey,Too€
i- Oatertime purchaser exited the establishment:(Q1) 07-27-2015 01:14 PM
2- Town:(Q2) Salem
3- Establiahnwnt:(03) VAPOR OUTLET 103 tAFAYETTE ST
4. Supervisor.(Q4) Joyoe Redford
s- Purchaser(05) 920322(14333004)
6- Was the survey completed?(06) Yes
7- Tobacco was marketed via:(Q9) Over the Counter
8- Was purchaser asked for ID?(Qie) No
9- Was the purchaser asked his/her age?1011) No
10- Was this an ID-based check?(Q12) NO
ill- Gentler of clerk:(013) Mate
12- AppMxlmate age of clerk:(Q14) Adult
13- Type oftobaeco purchased;(016) E-ewrette
14- Brand of tobacco purchased:(017) Other
16. Wea the product requested flavored(NOTTobacco or Menthol)?? Yes
(Q220)
is- Was the sale made?(Q18) Yes
I?- The cost of the product:(019) 10.61
18- Method of payment;(Q20) $10 Mll(a)
19- Purchaserreceived a receipt?(021) No
20- Other purchases made?(Q22) No
21- Comments:(057) liquid nicotine
TCance(and Ratu.Ho Return to the Enforceiment Case
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Violation Notice
Dtyown C
k e �`'Y'1 Board of Health
✓Health
Promote. Protect.
This notice is to inform you that your establishment violated the Board of Health Sale of Tobacco Products
&Nicotine Delivery Products and/or Environmental Tobacco Smoke(ETS)Regulation.
v� J_
Name of establishment {
•.
Address '
1
Date of violas on Time of violation Minor's age/gender Minor's ID#
- 1CL>� rd
(O ante,Section;lieg atC65
4 ) ; A� \ Y
(Ac Constituting Violation)
Ss M12VA 0,0 r, of)U MC,— tO.A04 Y)tAt
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Narrative information:
air
� . )Dc)0-_Q O x C Y1 6 cup - f
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U n t � -0. 0 n� ice,�
aaffirm, the p ' s 8 pen 'it • perjury,that the above report is true to the best of my knowledge
nd belief.
r r
Inspector(Sag Lure) (Print name)
VE R STATE acknowledge I received this Violation Notice on , 20
at ems- Pd I am being€'ven a carbon copy of this notice.I also actknowlbdge that I
have been informed.th�a�e Peab y Boaid of Health will provide additional,follow-up information to
thisyaalat%�p.notace.
i
-�"' .9 of .,� "'•-,.,. � ,t� .�� Ir'�U',�J,i�-a
Owner ter-fC§lerk(Signature) - (Print'name)
If vendor refuses this Notice or if the inspector feels unsafe in delivering it,an explanation must be
• written on a note attached hereto.Mailing of this Notice is thus required.
Contact the North Shore/Cape Ann Tobacco Alcohol Policy Program at 781-586-6821 with questions
Establishment-white NSTCP-yellow Board of Health-pink
;v r
2/22/2017 FES 2 7 '011
_. ..._. `� C11-Y OF SALEM
Vapor Outlet, 103 Lafayette St, Salem, Ma 01970 aoARo of HEALTH
To: Board of Health Salem, Ma
i would like to request a hearing as to the the compliant of
selling a tobacco product to a minor on January 19, 2017.
Sincere _
ric Stone
Owner-978-594-5623
4r,
s CITY OF SA
MASSACHUSETTS
BOARD OF HEALTH PublicHealth
Prevent.Promote.Protect.
120 WASHINGTON STREET,4"'FLOOR.
T-F-L:(978) 741-1800 F<�z-(978):745-0343
KIMBERLEY DRISCOLL lra1-180� alem.com LARRY RAMI)IN,RS/RI?I IS,C110,CI'-IDS
MAYOR o HI?r1I:I'[-I r1GE?N'I'
February 16, 2017
Vapor Outlet
103 Lafayette St.
Salem, MA 01970
Dear Owner:
Vapor Outlet is in violation of the Salem Board of Health Regulation Affecting sales to a minor. According to this
section,the sale of cigarettes, chewing tobacco, snuff,or any tobacco in any of its forms to any person under the
age of twenty-one shall be punished by a fine of$200.00 Hundred Dollars for the second offense plus a 7-day
suspension.You will be advised of the dates of the suspension by the Health Agent.
On Thursday,January 19, 2017 at 4:12pm personnel from the Tobacco Control Program conducted a compliance
• check. During that compliance check,a 17-year-old female, a minor,was sold a 3mg large bottle of Simply
Pineapple liquid nicotine from a clerk ' your store. Documentation is now on file at the Board of Health
regarding that sale.
FOLLOWING THE THIRD(3RD)OFFENSE,THE BOARD MAY CONSIDER POSSIBLE REVOCATION OR
SUSPENSION OF THE PERMIT.
Therefore,you are ordered to pay a fine of$200.00 for the violations. A check or money order payable to
the City of Salem must be at the Board of Health office, 120 Washington Street, 4t''floor,within ten days of
receipt of this notice.
Should you be aggrieved by this Order, you have the right to request a hearing before the Board of Health. A
request for such a hearing must be received in writing in this office of the Board of Health within seven(7)days of
receipt of this Order. At said hearing, you will be given the opportunity to be heard and to present witness and
documentary evidence as to why this Order should be modified or withdrawn. You may be represented by an
attorney. Please also be informed--that.you have the right to inspect and obtain copies of all relevant inspection or
investigation reports, orders, and other documentary information in the possession of this Board, and that any
adverse party has the right to be present at the hearing.
If you have any questions regarding fhis notification, please call me at 978-741-1800.
Sincerely yours,
�..
Larry Ram m
Health Agent -
LR/hlp
• CERTIFIED MAIL: 7012 1640 0002 3313 1369
cc: North Shore/Cape Ann Tobacco and Alcohol Policy Program
Paul Kirby, Board of Health Chair and Members
J �
FARRELL WALEER & SMITH LLP
• ATTORNEYS AT LAW&PROCTORS IN ADMIRALTY
admiraltylawo ffice.com
David C.Farrell
Direct Dial: 978-744-8918 e-mail: dcfarrell@fmsfirm.com
Respond to Salem Office RECEIVED
MAR 0 2 2017
February 27,2017
CITY OF SALEM
Attn: Larry Ramdin, RS/REHS, CHO, CP-FS BOARD OF HEALTH
Health Agent
Salem Board of Health via First Class Mail
120 Washington Street, 4m door
Salem, MA 01970
Re: Vapor Outlet Notice Dated 01/1912017
Alleged Sale of Liquid Nicotine to Minor
Alleged Second Offense
Dear Mr. Ramdin,
• Please be advised that I represent Eric Stone, owner of the Salem Vapor Outlet, with
respect to the alleged violation referenced above.
Pursuant to your letter dated February 16, 2017, I hereby request a copy of all relevant
inspection and/or investigation reports, orders, and other documentary information howsoever
relating to the above-referenced incident in the possession of the Board of Health.
Since my office is directly across the street from Salem City Hall, kindly notify me when
these documents are available and I will gladly pick them up in person. Thank you for your
assistance with this matter.
Very truly yours, W ) -b Ar
David C. Fat
• 2355 MAIN STREET,P.O.BOX 186 60 WASHINGTON STREET, STE 303
S. CHATHAM,MASSACHUSETTS 02659 SALEM, MASSACHUSETTS 01970
(P)508.432.2121 (F)978.666.0383 (P)978.744.8918(F)978.666.0383