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환자 이름: ______________________ 생년월일: ____/____/_____
계절성 독감 및 H1N1 독감 백신 주사 접종 대상자
선별 질문
백신 접종 대상 성인 환자 및 어린이의 부모님께, 다음 질문은 귀하 또는 귀하의 자녀가 오늘 독감 백신
주사 접종을 피해야 할 이유가 있는지 확인하기 위한 질문입니다. 질문에 “예”라고 대답한다고 해서
귀하 또는 귀하의 자녀에게 백신을 접종할 수 없다는 의미는 아닙니다. 이는 추가적인 확인을 위한
질문이 더 필요하다는 의미입니다. 질문이 분명하게 이해되지 않으면 의료인에게 설명을 요청하십시오.
예 아니요 모름
1. 백신 접종 대상자가 오늘 아픕니까?
2. 백신 접종 대상자에게 달걀이나 백신 성분에
대한 알러지가 있습니까?
3. 백신 접종 대상자가 과거에 독감 백신에 대해
심각한 반응을 보인 적이 있습니까?
4. 백신 접종 대상자에게 길랑 바레 증후군(일시적으로 나타나는 심각한 근육 약화 현상)이 나타난 적이
있습니까?
작성자:___________________________________________ 날짜:_______________
검토자:____________________________________________날짜:_______________
.
Technical content reviewed by the Centers for Disease Control and Prevention. September 2009.
Adapted by MDPH from Screening Questionnaire for Injectable Vaccination from the Immunization Action Coalition (9-
09)--www.immunize.org
Screening Questionnaire for Seasonal and H1N1 Influenza Injectable Vaccination September 2009 (Korean)
Information for Health Professionals about the Screening Questionnaire
for Seasonal and H1N1 Influenza Injectable Vaccination
Are you interested in knowing why we included a certain question on the Screening
Questionnaire? If so, read the information below. If you want to find out even more, consult the
sources listed at the bottom of this page.
1. Is the person to be vaccinated sick today? 3. Has the person to be vaccinated ever had a
There is no evidence that acute illness reduces serious reaction to influenza vaccine in the
vaccine efficacy or increases vaccine adverse past?
events. Persons with an acute febrile illness usually Patients reporting a serious reaction to a previous
should not be vaccinated until their symptoms have dose of inactivated influenza vaccine should be
improved. Minor illnesses with or without fever do asked to describe their symptoms. Immediate—
not contraindicate use of influenza vaccine. Do not presumably allergic—reactions are usually a
withhold vaccination if a person is taking antibiotics. contraindication to further vaccination against
influenza.
2. Does the person to be vaccinated have an
allergy to eggs or to a component of the Fever, malaise, myalgia, and other systemic
vaccine? symptoms most often affect persons who are first-
Allergic reactions to any vaccine component can time vaccinees. These mild-to-moderate local
occur. The majority of reactions probably are reactions are not a contraindication to future
caused by residual egg protein. Although current vaccination. Also, red eyes or mild upper facial
influenza vaccines contain only a limited quantity of swelling following vaccination with inactivated
egg protein, this protein can induce immediate injectable influenza vaccine is most likely a
allergic reactions among persons who have severe coincidental event and not related to the vaccine;
egg allergy. If a person can eat eggs, they can these persons can receive injectable vaccine
receive inactivated influenza vaccine. However, without further evaluation.
persons who have experienced an anaphylactic
reaction (e.g., hives, swelling of the lips or tongue, 4. Has the person to be vaccinated ever had
acute respiratory distress, or collapse) after eating Guillain-Barré syndrome?
eggs should consult a physician for appropriate It is prudent to avoid vaccinating persons who are
evaluation to help determine if vaccine should be not at high risk for severe influenza complications
administered. Persons who have documented but who are known to have developed Guillain-
immunoglobulin E (IgE)-mediated hypersensitivity Barré syndrome (GBS) within 6 weeks after
to eggs, including those who have had occupational receiving a previous influenza vaccination. As an
asthma or other allergic responses to egg protein, alternative, physicians might consider using
might also be at increased risk for allergic reactions influenza antiviral chemoprophylaxis for these
to influenza vaccine. Consultation with a physician persons. Although data are limited, the established
should be considered. Protocols have been benefits of influenza vaccination for the majority of
published for safely administering influenza vaccine persons who have a history of GBS, and who are at
to persons with egg allergies (see source 3). high risk for severe complications from influenza,
justify yearly vaccination.
FluZone (sanofi pasteur) contains gelatin as a
stabilizer; therefore a history of anaphylactic ______________________
reaction to gelatin is a contraindication. Some Sources:
inactivated influenza vaccines contain thimerosal as
1. CDC. Epidemiology & Prevention of Vaccine-Preventable Diseases,
a preservative. Most persons with sensitivity to WL Atkinson et al., editors, at www.cdc.gov/vaccines/ pubs/pinkbook.
thimerosal, such as that found in contact lens 2. CDC. “General Recommendations on Immunization:
solution, do not experience reactions to thimerosal Recommendations of the Advisory Committee on Immunization
administered as a component of vaccines. Check Practices (ACIP)” at www.cdc.gov/vaccines/pubs/acip-list.htm.
3. CDC. “Prevention and Control of Influenza—Recommendations of
the package insert at www.immunize.org/ ACIP” at www.cdc.gov/flu/professionals/ vaccination.
packageinserts for a list of the vaccine components 4. CDC. “Use of Influenza A (H1N1) 2009 Monovalent Vaccine” at
(i.e., excipients and culture media) used in the http://www.cdc.gov/mmwr/PDF/rr/rr5810.pdf.
production of the vaccine, or go to www.cdc.gov/
vaccines/pubs/pinkbook/downloads/appendices/B/e
xcipient-table-2.pdf.
Adapted by MDPH from Screening Questionnaire for Injectable Vaccination from the Immunization Action Coalition (9-
09)--www.immunize.org
Screening Questionnaire for Seasonal and H1N1 Influenza Injectable Vaccination September 2009 (Korean)
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