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Chapter 10 - Preventive Health

Part 3 - Professional Services

Title Section
Purpose 3-10.1
Immunization Information and Clinics 3-10.2
Reference 3-10.3
Interrupted and Completed Immunization Series 3-10.4
Routine Immunization Procedures and Tuberculin Testing 3-10.5
    Schedule 3-10.5A
    BCG Vaccine 3-10.5B
    Influenza Vaccine 3-10.5C
    Measles 3-10.5D
    Pertussis Vaccine 3-10.5E
    Other Routine Vaccines 3-10.5F
    Dosage 3-10.5G
    Parent's Consent 3-10.5H
    Immunizations for Pregnant Women 3-10.5I
Vaccines, Serums & Gloubulins for the Prevention of Specific Diseases 3-10.6
Precautions 3-10.7
    Needles and Syringes 3-10.7A
    Allergic Reactions 3-10.7B
    Children Six Years of Age and Under 3-10.7C
    Well Infants and Children 3-10.7D
    Second Injections of Infants 3-10.7E
    Use of Aspirin 3-10.7F
Contraindications to Immunizations 3-10.8
    Respiratory or Other Acute Infections 3-10.8A
    Neurologic Disorder's, Convulsions, or Cerebral Damage 3-10.8B
    Children with Eczema or Other Forms of Dermatitis 3-10.8C
Tuberculin Test 3-10.9

3-10.1  PURPOSE

This chapter brings together-policy statements, standards and guidelines regarding preventive health matters.  Each Area and Service Unit will develop manual supplements of local procedures and policies for the control of communicable diseases, especially tuberculosis and venereal diseases.


The Indian Health Area Directors are encouraged to publicize their vaccination program in ways best calculated to reach Indian health beneficiaries and, in addition to immunization at established clinics, consideration should be given to establishing special clinics for this purpose.  Immunization is considered a part of general health supervision, especially of infants and children.  Such protection is a vital part of hospital and field medical services, and each child should be fully immunized and immunization maintained at all times.


Each facility should have for reference current copies of "Report of the Committee on the Control of Infectious Diseases" American Academy of Pediatrics, P.O. Box 1034, Evanston, Illinois 60204; "Control of Communicable Diseases in Man" published by the American Public Health Association, 1790 Broadway, New York, New York 10019; and the current reports of the Public Health Service Advisory Committee on Immunization Practice.


Interrupted Immunization Schedule.  If the original series for immunization is interrupted, it is not necessary to start the series over again, provided the past history is known as to which immunizations were given.  Although the child is not as well protected during the interval, there is evidence that he gets better antibody response by spacing the immunizations over a longer period of time than the normal six to eight weeks.  If the series is interrupted, complete it as soon as possible and continue on with the booster doses as originally scheduled.

Completed Immunization Series.  Refer to the latest Reports of the Committee on the Control of Infectious Diseases of the American Academy of Pediatrics, the Public Health Service Advisory Committee on Immunization Practice and/or the package insert of the immunizing agent, for information as to the number of immunizations that constitutes a completed series for each specific immunization procedure.

For statistical purposes the following will be considered completed immunizations:  DPT, 3 injections; DT when used for primary immunization, 3 injections; polio oral vaccine (monovalent or trivalent) 3 doses; measles live virus vaccine, one injection; influenza, 2 injections; typhoid, 2 injections, smallpox, one vaccination.


  1. Schedule.  In general, immunization schedules will be those of the State in which the reservation is located.  If the State has no specific schedule, the following schedule should be used: 1/

    2 - 3 months -------- DTP2/ - Type 1 OPV or Trivalent OPV3/
    3 - 4 months -------- DTP - Type 3 OPV or Trivalent OPV
    4-5 months -------- DTP - Type 2 OPV or Trivalent OPV
    9 - 11 months -------- Tuberculin Test
    12 months -------- Measles Vaccine
    15 - 18 months -------- DTP - Trivalent OPV - Smallpox Vaccine 4/
    2 years -------- Tuberculin Test
    3 years -------- DTP - Tuberculin Test
    4 years -------- Tuberculin Test
    6 years -------- TD - Smallpox Vaccine - Tuberculin Rest 5/
    -------- Trivalent OPV
    8 years -------- Tuberculin Test 5/
    10 years -------- Tuberculin Test 5/
    12 years -------- TD - Smallpox Vaccine - Tuberculin Test 4/, 6/
    14 years -------- Tuberculin test 5/
    16 years -------- Tuberculin Test 5/

    ABBREVIATIONS - DTP (Diphtheria and Tetanus Toxoids and Pertussis Vaccine combined); OPV (Oral Polio vaccine - if trivalent OPV used - interval should be 6 weeks or longer); TD (Tetanus and Diphtheria Toxoids, Adult Type)

  2. BCG Vaccine.  BCG vaccine is to be used as determined by the Indian Health Area Director according to the needs in each locality and the recommendations of the Public Health Service Advisory Committee on Immunization Practice dated July 21-22, 1966.  Parent's consent must be obtained if an infant is immunized with BCG.
  3. Influenza Vaccine.  Influenza vaccine (polyvalent) should be given each fall to boarding school students.  Influenza vaccine should also be considered under the following circumstances:
    1. Patients with organic heart disease
    2. Patients with chronic broncho pulmonary disease
    3. Patients with chronic diseases of the kidneys, central nervous system or endocrine glands
    4. Hospital employees
    5. Law and order enforcing officers
  4. Measles.  Measles vaccine is indicated primarily for children who have not had measles.  For maximum efficacy, live attenuated measles virus vaccine should be administered to those at lease 12 months of age or as soon thereafter as possible.  However, it may be given to infants 9-12 months of age with the realization that there may be a slight reduction in efficacy.  Immunization against measles is particularly important for children with chronic illnesses such as heart disease, cystic fibrosis and chronic pulmonary diseases and, indeed, for any individual prone to serious complications following natural measles.  Vaccination of adults at the present time is rarely necessary because most individuals are serologically immune by age 15.  Live attenuated (Edmonston Strain) measles vaccine with or without Measles Immune Globulin or further attenuated vaccine (Schwartz Strain) without Measles Immune Globulin at the discretion of the physician is recommended.
  5. Pertussis Vaccine.  Pertussis vaccine not combined with diphtheria and tetanus toxoids is indicated chiefly for attempted rapid primary protection of young infants in the presence of a local epidemic of whooping cough and for primary immunization of infants and older children who already have been inoculated against diphtheria and tetanus.  The single antigen also is used for recall injections against pertussis, particularly following exposure.
  6. Other Routine Vaccines.1/  (See references under 3-10.3 and Area Service Unit supplements.)
  7. Dosage.  The dosage should be in accordance with the manufacturer's instructions.
  8. Parent's Consent.  Consent of the parents for the immunization of each child should be secured annually before immunizations are begun.
  9. Immunizations for Pregnant Women.  Except for polio, immunizations will not be given to pregnant women unless specifically ordered by the responsible physician.


Vaccines and serums for use in specific diseases should be used when medically indicated.

  1. Infectious Hepatitis1/  (See references under 3-10.3 and Area Service Unit supplements.)
  2. Diphtheria1/  (See references under 3-10.3 and Area Service Unit supplements.)
  3. Tetanus1/  (See references under 3-10.3 and Area Service Unit supplements.)
  4. Pertussis1/  (See references under 3-10.3 and Area Service Unit supplements.)
  5. Measles1/  (See references under 3-10.3 and Area Service Unit supplements.)
  6. Rabies1/  (See references under 3-10.3 and Area Service Unit supplements.)
  7. Other1/  (See references under 3-10.3 and Area Service Unit supplements.)


  1. Needles and Syringes.  Both needle and syringe must be sterile between each injection.   The use of one syringe with change of needle only between injection is not considered a safe procedure.  Disposable syringes and needles may be used for each injection.
  2. Allergic Reactions.  Steps to prevent allergic reaction should be followed.
  3. Children Six Years of Age and Under.  In children 6 years of age and under, triple antigens (diphtheria and tetanus toxoids combined with pertussis vaccine) should be employed.  In children over 6 years of age, many physicians prefer to use, single antigensor a combination of diphtheria and tetanus toxoids without pertussis vaccine because of the greater frequency of more severe febrile reactions following use of the triple antigens in the older group.
  4. Well Infants and Children.  Only well infants and children should receive immunization injections.
  5. Infant Second Injection.  When an infant is brought in for his second injection the parent should be questioned in regard to the occurrence of fever, somnolence, and local reaction following the previous injection.
  6. Use of Aspirin.   Aspirin, 65 mg per each year of age, may be given within an hour to two of injection and repeated four hours thereafter to alleviate pain or fever.


  1. Respiratory or Other Acute Infections.  A respiratory or other acute infection or a fever Of 99.5 by mouth or 100.5 by rectum is reason for delaying injections.  Prolonging the intervals between injections interfere rarely if ever with the final immunity.
  2. Neurologic Disorders, Convulsions, or Cerebral Damage.  The presence of a Neurologic disorder, a history of convulsions or cerebral damage is an indication for delaying immunization procedures until one year of age, Such children should be immunized only by a medical officer or on his specific order.  Single antigens rather than the usual mixed antigens are recommended and fractional doses should be employed.
  3. Children with Eczema or other Forms of Dermatitis.  Children with eczema or other forms of dermatitis should not be vaccinated against smallpox because of the danger of producing general vaccinia.  Except in an epidemic, the child should not be vaccinated against smallpox, if anyone in the family or household has eczema, dermatitis, chickenpox, conjunctivitis, ulcerated eyelids, or conjuctiva because of the danger of cross infection.  If the child can be completely separated from contact with household members with the above mentioned conditions for a period of 10 days, then the small pox vaccine may be given.  For further information refer to the use of vaccinia immune globulin (human) in the Report of the Committee on the Control of Infectious Diseases of the American Academy of Pediatrics.


Tuberculin Test.  If BCG 1/ has been administered to newborns, test infants at two and twelve months of age.  If BCG has not been administered, infants should receive a tuberculin test between three and twelve months of age.  In the preschool age group the frequency of retesting depends on the prevalence of tuberculosis in the community; tuberculin testing of preschool children every two years or every year until conversion occurs may be recommended in communities with high prevalence of tuberculosis.  All children entering school, not known to be positive reactors, will be tested.  If tuberculin positive rate of children in a school is higher than 5 percent, children should be tested annually until conversion occurs.  If tuberculin positive rate is less than 5 percent, tuberculin test will be repeated - except in those children known to be positive reactors - in the 6th, 9th and 12th grades.  The above schedules may vary depending on local situation.  All admissions to pediatric wards will be tuberculin tested.  Converters should be placed on INH prophylaxis and their family contacts investigated.  PPD intermediate strength - 5 TU, equivalent to 0.0001 mg PPD - is recommended.  All reactions 6mm or more of induration should be read as positive.  Record the size of all positive reactions.  In reporting tuberculin surveys report positive reactors in two groups:  a) positive with induration 6 to 9 mm; b) positive with induration 10 mm and over.  Skin reactions to be read 3 days later, although it could be read 48 to 72 hours after it is given.  If the Tine test is used, it will be read in 48 to 72 hours; a positive reaction will show an induration of 2mm and over.  If the Tine test is used and an equivocal reaction is obtained, repeat the test with intradermal PPD, intermediate strength.



1/ From Table 1, Page 5, "Report of the Committee on the Control of Infectious Diseases," 1996, American Academy of Pediatrics.

2/ Immunization may be started at any age.  The immune response is limited in a proportion of young infants and the recommended booster doses are designed to insure or maintain immunity.  Protection of infants against pertussis should start early.  The best protection of newborn infants against pertussis is avoidance of household contacts by adequate immunization of older siblings.  This schedule is intended as a flexible guide which may be modified within certain limits to fit individual situations.

3/ An alternative for polio immunization using trivalent oral polio vaccine is the one recommended by the Public Health Service Advisory Committee on Immunization Practices which follows (See Morbidity and Mortality Weekly Report, August 19, 1967, page 278):  "The three-dose immunization series should be started at 6 to 12 weeks of age, simultaneously with the first DPT inoculation.  The second dose should be given no less than 6 and preferably 8 weeks later.  The third dose is an integral part of primary immunization and should be administered 8 to 12 months after the second dose."

4/ Initial smallpox vaccine may be given at any time between 12 and 24 months of age.

5/ Frequency of repeated tuberculin tests dependent on risk of exposure of children under care and the prevalance of tuberculosis in the population group.

6/ After age 12 followup procedures recommended for adults; i.e., smallpox vaccine every five years and tetnus toxoid booster every ten years as TD.

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