Meningococcal Vaccine (Menactra) Consent Form

[Pages:1]Meningococcal Vaccine (Menactra) Consent Form

MENINGITIS: Meningococcal Meningitis is a serious bacterial infection caused by Neisseria meningitides that infects the blood, spinal cord and brain. The usual signs and symptoms of meningitis are high fever, headache, and stiff neck. Meningococcal disease can spread from one person to another through droplets of saliva that are expelled into the air when an infected person coughs or sneezes, or by sharing utensils, drinking glass or kissing an infected person. There are five strains or serogroups of N. meningitides that cause meningococcal disease, serogroups A, B, C, Y and W-135. This vaccine (Menactra) will provide protection against all strains except serogroup B, which is responsible for approximately 30%-40% of invasive meningococcal disease in the U.S.

Menactra (MCV-4) is a quadrivalent meningococcal vaccine that was approved in the United States in 2005 for use in adolescents and adults 11-55 years of age. Menactra is given intramuscularly (IM) as a single 0.5ml dose in the deltoid muscle and is 85% - 96% effective in preventing meningitis in adult against serotypes A, C,Y and W-135. Protective levels of antibody are usually achieved within 7-10 days of vaccination. Employees who are at increased risk of exposure to meningitis (age 55 or younger) should receive a booster dose of Menactra 5 years after the first dose.

PLEASE ANSWER THE FOLLOWING QUESTIONS:

Date of last meningococcal vaccine: _______________ > 5 years, give booster

1. yes no 2. yes no 3. yes no 4. yes no 5. yes no n/a

Are you 56 years of age or older (If yes, give Menamune) Do you currently have an acute illness, fever or infection? Have you ever had a serious allergic reaction to a previous meningococcal or diptheria vaccine? Do you have a history of Guillain-Barre' syndrome? Are you pregnant or breast-feeding?

If you answered YES to any of the above questions, you should NOT receive Menactra at this time.

6. yes no 7. yes no

Do you have any condition or are you under any treatment (steroids, chemotherapy) that may alter your immune system? If yes, the expected immune response may not be obtained. Do you have a history of a bleeding disorder or are you on anticoagulant therapy? (If yes, consult with ARNP/RN)

Possible Vaccine Side Effects:

Adverse reactions to the meningococcal vaccine are generally mild and include:

1. The most frequent reaction is pain, headache and redness at the injection site. 2. Less common reactions include fever, malaise, joint pain, diarrhea and vomiting 3. Severe reactions are rare and include anaphylaxis and neurological reactions such as paresthesias, seizures, and

Guillain-Barr?.

I have read the above information and have had an opportunity to ask questions regarding the Menactra meningococcal vaccine. I have received the latest release of the CDC Vaccine Information Statement . I request that the vaccine be given to me.

__________________________

Print Name

_______________________________

Signature

_________________________

Department

______________

Job Title

____________

Date

Lot #/Manufacturer: _________________________ Immunization Exp. Date __________________

Employee Health Services

________________

Badge #

___________________

EHS Staff

Site: RA LA

Revised 2/1/2011

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