Vaccinating Adults: A Step-by-Step Guide - Step 3 Vaccine Storage and Handling

Vaccinating Adults: A Step-by-Step Guide Immunization Action Coalition

•

www.immunize.org

•

www.vaccineinformation.org

his chapter will help you prepare for your

ﬁrst vaccine shipment. Vaccines only work

when they are viable, that is, when they are intact –

undamaged and uncontaminated. To ensure vac-

cines are viable or potent or “good,” you must main-

tain them between the manufacturer-recommended

temperature ranges that are not too cold or too

warm. This information is available in the package

insert. Although most vaccines should not be frozen,

certain vaccines containing varicella vaccine virus

(VAR, MMRV, and Zostavax) require frozen storage.

In addition, several vaccines including MMR, MMRV,

VAR, Zostavax, IPV, HPV (Gardasil 9), meningo -

coccal ACWY (Menveo), meningococcal B (Bexsero),

and certain formulations of inﬂuenza vaccine (Aﬂu -

ria, Fluad, Fluarix, Flublok, FluLaval, FluMist, Flu virin,

and Flucelvax) should be protected from light.

Before we get started on this important topic, be

sure to review the three resources shown below.

The ﬁrst two provide some basic information to help

as you are setting up your vaccine operations, while

the third is a guide that offers a wealth of infor -

mation to help with almost any vaccine storage and

handling issue you are likely to encounter.

•

Checklist for Safe Vaccine Storage and Handling

www.immunize.org/catg.d/p3035.pdf

•

Don't Be Guilty of These Preventable Errors

in Vaccine Storage and Handling!

www.immunize.org/catg.d/p3036.pdf

•

Vaccine Storage and Handling Toolkit

www.cdc.gov/vaccines/hcp/admin/storage/toolkit/

storage-handling-toolkit.pdf

step

₃

Vaccine Storage and Handling

Step-by-Step: Vaccine Storage

and Handling Tasks

• Receive vaccine shipments

– Open package immediately

– Assess for proper storage conditions of

the vaccine shipment upon arrival

– Store vaccines immediately at the recom-

mended storage temperature

– Know where to place vaccines within the

refrigerator or freezer

• Monitor and record temperatures at least

twice each day

– Choosing thermometers

• If there’s a problem, take appropriate action

right away; report power failures or other

storage issues immediately!

• Transport vaccines properly (and only when

absolutely necessary)

– Transporting frozen varicella-containing

vaccines to an offsite clinic location

To ensure vaccines are viable or potent or

“good,” you must maintain them between the

manufacturer-recommended temperature

ranges that are not too cold or too warm.

Vaccinating Adults: A Step-by-Step Guide Immunization Action Coalition

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www.immunize.org

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www.vaccineinformation.org

Receive vaccine shipments

Open package immediately

Vaccine deliveries should be made only when your

vaccine coordinator or backup person is present.

But it is important for everyone in your clinic –

especially your front desk staff or any individuals

who receive deliveries – to know how important it

is to store these fragile vaccines promptly when

they arrive. Don’t let a vaccine package sit at the

front desk or outside your front or back door!

Assess for proper storage conditions

of the vaccine shipment upon arrival

Packages should be opened and inspected imme-

diately for any damage and to determine if the

packages seem too warm or too cold to the touch.

Examine temperature indicators if they are included

in the box. Check the vaccine quantities, lot num-

bers, and expiration dates against the packing slip.

If there are discrepancies, contact the source of

the shipment (e.g., manufacturer, distributor, state

health department) immediately.

When your shipments arrive, check to see that the

inactivated vaccines are cold but not frozen, and

that the varicella and Zostavax vaccines are frozen.

MMR vaccine may be refrigerated or frozen. Nasal

spray inﬂuenza vaccine is refrigerated. If a tempera-

ture indicator (often, this is a temperature-sensitive

strip that changes colors) is included in the ship-

ment, check it to see if appropriate temperatures

have been maintained. Not all shipments will con-

tain a temperature indicator. That’s acceptable if

the shipments have been packed according to cer-

tain FDA-approved packing standards. But make

30 step

: Vaccine Storage and Handling

A Little Background:

Types of Vaccines and Diluents

Inactivated vaccines can be composed of either

killed whole viruses, or fractions of either viruses or

bacteria. Inactivated vaccines are damaged by freez-

ing. The inactivated vaccines needed by many

adults include:

• tetanus, diphtheria, and pertussis (Tdap/Td);

• injectable inﬂuenza;

• pneumococcal polysaccharide and conjugate;

• human papillomavirus;

• hepatitis A and B;

• meningococcal ACWY and B vaccines; and

• zoster (shingles; Shingrix).

Live attenuated vaccines consist of a weakened

form of the live virus. They are easily damaged or

destroyed by heat and light. This makes it even more

important that they be stored and handled with

extreme care. Live attenuated vaccines available for

many adults include:

• measles, mumps and rubella (MMR);

• varicella (chickenpox);

• zoster (shingles; Zostavax); and

• nasal spray inﬂuenza vaccine

(when recommended).

Diluents are liquids used with some vaccines.

Most vaccines are provided as a liquid that is already

packaged in a syringe, or in a vial, ready to be

drawn into a syringe and injected. However, some

vaccines are provided as a lyophilized (freeze-dried)

powder. A separate liquid (the diluent) is provided

for lyophilized vaccines. The diluent must be

added to the lyophilized powder before injection, a

process called “reconstitution.” A lyophilized vaccine

must only be reconstituted with the speciﬁc diluent

provided for that vaccine; diluents are not inter-

changeable. Most vaccine diluents may be stored

either in the refrigerator or maintained at room

temperature. Check the package insert to determine

appropriate storage guidance for the speciﬁc dilu-

ent you are using. Summary information may be

found in the Immunization Action Coalition’s (IAC)

Vaccines with Diluents: How to Use Them, available

at www.immunize.org/catg.d/p3040.pdf.

It is important for everyone in your

clinic .. . to know how important it is to

store these fragile vaccines promptly

when they arrive.

Vaccinating Adults: A Step-by-Step Guide Immunization Action Coalition

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step 3: Vaccine Storage and Handling 31

sure the container included appropriate insulation

and gel packs or ice packs and that any ice packs

have not completely thawed. If the product seems

to have been exposed to too-high or too-low (i.e.,

frozen) temperatures or something seems amiss,

put the vaccine in a specially marked, segregated

area or tray in the refrigerator or freezer (whichever

is indicated according to the type of vaccine deliv-

ered). Call the source of your shipment (e.g., man-

ufacturer, distributor, state health department) for

advice about what to do next.

Store vaccines immediately at the

recommended storage temperature

Most vaccines (all inactivated vaccines and live nasal

spray inﬂuenza vaccine) must be stored between

2° to 8°C (36° to 46°F), which is the recommended

refrigerator temperature. Live varicella (chickenpox)

and Zostavax (shingles) vaccines must be stored

frozen between -50° to -15°C (-58° to +5°F). These

vaccines may be temporarily stored in a refrigerator

(between 2° to 8°C [36° to 46°F]) for up to 72 hours

before use, if they

have not been

recon stituted and

will be used within

that time period.

If they are not used within 72 hours, they must be

discarded. Once these vaccines have been stored

in the refrigerator, they must not be refrozen; once

they have been reconstituted, you have only 30

minutes in which to administer these sensitive vac-

cines before they lose potency and cannot be used.

Bottom line – don’t remove these vaccines from

the freezer or reconstitute them until you have your

patient sitting in front of you! (More information

on this subject is located in Step 5: Administering

Vaccines.)

The live MMR vaccine can be stored in either the

freezer or the refrigerator. However, once the vac-

cine has been drawn into the syringe, it must be

used within 8 hours or discarded.

It is critical to

keep each vaccine

at its proper stor-

age temperature.

A simple sign on

the refrigerator

and freezer can

remind you where

each vaccine goes.

For example, the

Immunization

Action Coalition’s

(IAC) handy

Vaccine Handling

Tips, available at

www.immunize.org/catg.d/p3048.pdf

, can be posted

on your refrigerator and freezer doors to remind

staff of the appropriate storage temperatures and

other basics of good vaccine management.

Remember, when vaccines get too warm or too cold,

you can’t tell by looking or feeling if they have been

damaged. That’s why it’s so critical to monitor

and record the temperatures inside your refrigerator

and freezer at least twice each day to make sure they

are within the proper range. If the temperature

goes out of range, you must take immediate steps

to respond to the situation. IAC’s Vaccine Storage

Troubleshooting Record, available at

www.immunize.

org/catg.d/p3041.pdf

, offers guidance to help you

determine what should be done in this situation.

If the product seems to have been exposed to

too-high or too-low (i.e., frozen) temperatures

or something seems amiss, put the vaccine

in a specially marked, segregated area or tray

in the refrigerator or freezer.

It is critical to keep each

vaccine at its proper

storage temperature.

cdc

Vaccinating Adults: A Step-by-Step Guide Immunization Action Coalition

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32 step

: Vaccine Storage and Handling

Know where to place vaccines

within the refrigerator or freezer

Vaccines should always be stored in the middle of

the refrigerator or freezer – never in the doors.

Why? Because items stored in

the door are frequently exposed

to warm temperatures when the

unit is opened. CDC's “best

storage practice” is to place the

vaccines in the center refrigera-

tor space, contained in the

original packaging, inside desig-

nated storage trays positioned 2 to 3 inches from

refrigerator walls. Also, be sure to keep older vac-

cines toward the front of the shelf. When new prod-

uct arrives, “rotate your stock” by placing the newer

vaccines behind the older ones. This will help

ensure that vaccines with the earliest (soonest)

expiration dates are used ﬁrst. CDC has developed

informative labels you can print and use to help

organize vaccine placement in your refrigerator or

freezer. These labels are found at

www.cdc.gov/

vaccines/hcp/admin/storage/guide/vaccine-storage-

labels.pdf

Monitor and record temperatures at least

twice each day

As you set up your refrigerator and freezer, you

should take steps to help stabilize and maintain

the proper temperatures in both units. You should

place at least two or three containers (for example,

plastic liter or gallon bottles) of water in areas

of the refrigerator where vaccine cannot be stored,

such as in the doors. Similarly, you should keep

several frozen water bottles in the freezer to help

maintain the cold temperature in the event of a

power outage. Get in the habit of periodically check-

ing the gasket seals of your refrigerator and freezer

units. These seals must be intact to ensure that

the door always closes completely.

You also should post the appropriate temperature

log sheets (both Celsius and Fahrenheit versions

are available through the links shown below) on

your refrigerator and freezer.

Celsius

refrigerator

www.immunize.org/catg.d/p3037C.pdf

freezer

www.immunize.org/catg.d/p3038C.pdf

Fahrenheit

refrigerator

www.immunize.org/catg.d/p3037F.pdf

freezer

www.immunize.org/catg.d/p3038F.pdf

Checking Expiration Dates

Be aware that if the expiration date on the vial consists

of just a month and a year (e.g., “12/18”), the vaccine

may be used until the last day of December 2018.

In this case, the expiration month includes the whole

month. If a full date is included (e.g., 9/15/18), then

the vaccine should not be used after the printed date.

The Centers for Disease Control and Prevention’s

(CDC) Vaccine Storage and Handling Toolkit, available

www.cdc.gov/vaccines/hcp/admin/storage/toolkit/

storage-handling-toolkit.pdf

, provides additional infor-

mation about reading vaccine labels and determining

expiration dates. Never use a vaccine that has been

contaminated or has expired! If an expired vaccine –

even 1 day expired – is administered to a patient, the

dose must be repeated.

Vaccine should

always be stored

in the middle of

the refrigerator

or freezer – never

in the doors.

cdc

Vaccinating Adults: A Step-by-Step Guide Immunization Action Coalition

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www.immunize.org

•

www.vaccineinformation.org

Use the appropriate logs to document your twice-

each-day checks (ﬁrst thing in the morning and

late afternoon before closing) of the temperatures

in your vaccine storage units.

And remember to pay attention

to the temperatures you’re

recording on these logs. It’s

easy to get in the habit of writ-

ing without noticing, even

when the temperature you have

just written down is out of range and requires

action. If you note an out-of-range temperature,

consult the Vaccine Storage Troubleshooting Record

www.immunize.org/catg.d/p3041.pdf

for guid-

ance on appropriate actions to take.

Loss of power to a refrigerator or freezer can hap-

pen in a number of ways. The one that is easiest to

avoid is loss of power at the plug. For example,

maintenance workers or others might pull the plug

from the socket to free it for a “temporary” use,

such as using electrical equipment to clean the

ﬂoors. Make sure this doesn’t happen in your facility!

One of the simplest ways to prevent this problem

is to apply a bright and easily understood “Do Not

Unplug” sign (

www.immunize.org/catg.d/p2090.pdf

)

right above the electrical outlet.

It also helps to put a “Do Not

Turn Off Circuit Breaker” sign

(

www.immunize.org/catg.d/

p2091.pdf

) by the breaker

box so that someone doesn’t

inadvertently cut off the power

supply to the vaccine storage

units.

Choosing thermometers

Thermometers are a critical part of good storage and

handling practice. A storage unit is only as effec-

tive as the temperature monitoring system inside.

An accurate temperature history that reﬂects the

actual vaccine temperatures is imperative to effec-

tive vaccine management.

Every freezer and refrigerator unit used to store

vaccine should have a calibrated thermometer. CDC

recommends using only calibrated thermometers

with a Certiﬁcate of Traceability and Calibration

Testing (“Report of Calibration”). This certiﬁcate

informs the user about a thermometer’s level of

accuracy compared to a recognized standard.

Before purchasing thermometers for your refriger -

ator and freezer units, you should review the exten-

sive information about thermometers found in

CDC’s Vaccine Storage and Handling Toolkit (Toolkit),

available at

www.cdc.gov/vaccines/hcp/admin/

storage/toolkit/storage-handling-toolkit.pdf

In general, CDC recom-

mends thermometers that

measure temperatures

constantly (e.g., a continu-

ous monitoring and recording digital data logger or

“DDL”) and use a probe inserted into a glycol-ﬁlled

bottle. This arrangement more closely approximates

the vaccine vial temperature than measuring the

more variable temperature of the air in the storage

unit. CDC also recommends the thermometer

have an alarm for out-of-range temperature and be

capable of showing the current temperature as

well as the minimum and maximum temperatures

reached during a designated period of time. CDC

step 3: Vaccine Storage and Handling 33

www.immunize.org/catg.d/p2091.pdf  Item #P2091 (10/15)

Immunization Action Coalition

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WARN I NG!

EXPENSIVE VACCINE

IN STORAGE!

AVISO!

Contiene vacunas caras.

DO NOT TURN OFF

CIRCUIT BREAKER #

nnn

No apague el interruptor

de circuito #

nnn

In the event of an electrical problem,

immediately contact

Si hay un problema con la electircidad,

comuniquese inmediatamente con

Remember to

pay attention to

the temperatures

you’re recording

on these logs.

www.immunize.org/catg.d/p2090.pdf  Item #P2090 (10/15)

Immunization Action Coalition

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DO NOT UN PLUG

RE FRIGERATOR

OR FREEZER!

¡No d esconec te

el refrigerador o congelador!

EXPE NS IVE VACC IN E I N STO RAG E!

AVIS O!

CO NTI EN E VAC UN AS C ARAS .

In the event of a problem, immediately contact

Si hay un problema, comuniquese inmediatamente con

www.immunize.org/catg.d/p2090.pdf

www.immunize.org/catg.d/p2091.pdf

www.cdc.gov/vaccines/hcp/

admin/storage/toolkit/storage-

handling-toolkit.pdf

Vaccinating Adults: A Step-by-Step Guide Immunization Action Coalition

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www.vaccineinformation.org

34 step

: Vaccine Storage and Handling

does not recommend using: ﬂuid-ﬁlled biosafe liquid

thermometers, bi-metal stem thermometers, food

thermometers, household thermometers, chart

recorders, infrared thermom eters, or thermometers

that are not calibrated.

Be sure to check the CDC Toolkit for answers to your

questions about choosing thermometers. State and

local health department immunization programs

also are excellent resources for information about

thermometers. Providers who receive Vaccines

for Children (VFC) vaccines or other vaccines pur-

chased with public funds should consult their immu-

nization program regarding thermometer recom-

mendations and requirements.

If there’s a problem, take appropriate

action right away; report power failures

or other storage issues immediately!

Power failures happen. It’s crucial that your clinic

fosters a culture of openness about reporting

interruptions in the power supply or other vaccine

mishaps. First, it’s a matter of ethics. You don’t

want to administer vaccine of questionable viability

to anyone. And you certainly don’t want to be

placed in the position of having to recall patients

and re-administer vaccines. Finally, if problems are

reported promptly, actions may be taken and you

may be able to salvage the affected vaccines.

If you suspect that vaccines have been exposed to

out-of-range temperatures or have been left out of

the refrigerator or freezer, mark those vaccine vials

with “Do Not Use” and transfer them to a func-

tioning refrigerator or freezer at the proper storage

temperature as soon as possible, while you are

determining if the vaccine is still viable. If the prob-

lem is a faulty refrigerator or freezer, immediately

record the temperature inside the affected unit to

help determine the timeframe of the exposure.

This is when using the recommended type of ther-

mometer really pays off! If you have been using a

continuously recording thermometer, you can

review information from the thermometer to deter-

mine when the temperature problem began. A

thermometer that records minimum and maximum

temperatures will indicate the lowest and highest

temperatures recorded since you last reset it. This

information can be invaluable in helping determine

if the vaccine may still be viable. If the vaccines

were inadvertently left out at room temperature or

were left in some other improper storage condition

(e.g., temperatures that are too warm or too cold),

record the length of time that may have elapsed.

Be sure to immediately notify the clinic supervisor

and vaccine coordinator about what has happened.

Then your vaccine coordinator will contact your

state or local health department and/or the manu-

facturer to discuss the situation and determine an

appropriate course of action.

Be sure to check the CDC Toolkit for answers

to your questions about choosing thermometers.

State and local health department immunization

programs also are excellent resources for

information about thermometers.

cdc

Vaccinating Adults: A Step-by-Step Guide Immunization Action Coalition

•

www.immunize.org

•

www.vaccineinformation.org

Be sure to check out IAC’s Vaccine Storage Trouble -

shooting Record at

www.immunize.org/catg.d/

p3041.pdf

and Emergency Response Worksheet at

www.immunize.org/catg.d/p3051.pdf

for quick

guidance on what to do

when you discover vaccine

storage outside the recom-

mended temperature range.

If you are told that the vac-

cines should not be used,

use a permanent black

marker to write “nonviable” on the glass or label

and remove them from the refrigerator or freezer so

that they aren’t administered by mistake. Ask your

state health department or manufacturer(s) how you

should dispose of the nonviable vaccine.

Transport vaccines properly

(and only when absolutely necessary)

Vaccine manufacturers generally do not recommend

or provide guidance for transport of vaccines. But

during an emergency, or if you host an offsite vacci-

nation clinic, you may need to transport vaccines

from one place to another. It is critical that you main-

tain and monitor the vaccine cold chain during

hese activities. (See special information for frozen

varicella-containing vaccines in the next paragraph.)

You will need at least one insulated container (see

Step 2: Setting Up for Vaccination Services) with a

thermom eter to place near the vaccine. Think of this

container as your clinic’s vaccine storage area in

miniature: you’ll need to monitor it with a temper-

ature log as well, just like you do when in the oﬃce.

CDC’s Vaccine Storage and Handling Toolkit, avail-

able at

www.cdc.gov/vaccines/hcp/admin/storage/

toolkit/storage-handling-toolkit.pdf

, devotes several

pages to the topic of transporting vaccines.

Transporting frozen varicella-containing

vaccines to an offsite clinic location

Neither CDC nor the vaccine manufacturer recom-

mends transporting frozen varicella-containing

vaccines. But if these vaccines must be moved (for

example, during an emergency), they should be

transported in a portable freezer unit that maintains

the temperature range of -50° to -15°C (-58° to +5°F).

Port able freezer units may be available for rent

in some locations. But if frozen varicella-containing

vaccines must be transported and a portable freezer

unit is not available, do NOT use dry ice, as this

actually could allow the vaccines to become too cold.

This in turn could affect the vial seal and possibly

allow outside air to enter the vial. If frozen varicella-

containing vaccines are transported at refrigerated

temperatures (2° to 8°C [36° to 46°F]), they must be

discarded if they have not been used within 72 hours.

This chapter has covered the basic steps involved in

vaccine storage and handling for adult vaccines. Be

sure you print up the forms, establish policies, and

select someone in your oﬃce to be in charge of

vaccines. Now, let’s vaccinate!

step

: Vaccine Storage and Handling 35

Neither CDC nor the vaccine manufacturer

recommends transporting frozen varicella-

containing vaccines.

Health Departments

ocal Health Department phone State Health Department phone

Follow these procedures:

. Close the door tightly.

En s u re t h e v a c c i n e is k e p t a t a p p ro p r i a t e t e m p er a t u r e s . M a ke s u r e t h e r e f ri g -

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ines into proper storage conditions as quickly as possible.

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Emergency Response Worksheet

What to do in case of a power failure or other event that results in vaccine storage outside of the recommended

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Adapted by the Immunization Action Coalition, courtesy of the Michigan Department of Community Health

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eqirus

$IOXULD  



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Valn eva

ō

www.immunize.org/

catg.d/p3051.pdf

cdc

Vaccinating Adults: A Step-by-Step Guide Immunization Action Coalition

•

www.immunize.org

•

www.vaccineinformation.org

36 step

: Vaccine Storage and Handling

▸

Tools for Providers

Checklist for Safe Vaccine Storage and Handling

(IAC) – www.immunize.org/catg.d/p3035.pdf

Do Not Turn Off Circuit Breaker – sign (IAC)

www.immunize.org/catg.d/p2091.pdf

Do Not Unplug – sign (IAC)

www.immunize.org/catg.d/p2090.pdf

Don’t Be Guilty of These Preventable Errors

in Vaccine Storage and Handling! (IAC)

www.immunize.org/catg.d/p3036.pdf

Emergency Response Worksheet (IAC)

www.immunize.org/catg.d/p3051.pdf

Temperature Log for Freezer – Celsius (IAC)

www.immunize.org/catg.d/p3038C.pdf

Temperature Log for Freezer – Fahrenheit (IAC)

www.immunize.org/catg.d/p3038F.pdf

Temperature Log for Refrigerator – Celsius (IAC)

www.immunize.org/catg.d/p3037C.pdf

Temperature Log for Refrigerator – Fahrenheit (IAC)

www.immunize.org/catg.d/p3037F.pdf

Vaccine Handling Tips (IAC)

www.immunize.org/catg.d/p3048.pdf

Vaccine Storage Troubleshooting Record (IAC)

www.immunize.org/catg.d/p3041.pdf

Vaccines with Diluents: How to Use Them (IAC)

www.immunize.org/catg.d/p3040.pdf

▸

Additional Provider Resources

Vaccine Storage and Handling Toolkit (CDC)

www.cdc.gov/vaccines/hcp/admin/storage/toolkit/

storage-handling-toolkit.pdf

Vaccine Storage and Handling Web Section (CDC)

www.cdc.gov/vaccines/recs/storage/default.htm

Vaccine Storage and Handling Web Section (IAC)

www.immunize.org/handouts/vaccine-storage-

handling.asp

▸

General Information

Immunization Action Coalition (IAC)

www.immunize.org

note: The publisher of each resource is shown as an acronym

in the parentheses following the title. A key to these acronyms

is included in Appendix A: Acronyms and Abbreviations.

step

₃

: vaccine storage and handling

Materials and Resources for You to Use

To access the current, ready-to-copy version of this toolkit, visit

www.cdc.gov/vaccines/hcp/admin/storage/toolkit/

storage-handling-toolkit.pdf

Vaccinating Adults: A Step-by-Step Guide Immunization Action Coalition

•

www.immunize.org

•

www.vaccineinformation.org

step

: Vaccine Storage and Handling 37

The

CDC Toolkit

is 82 pages in

length.

To access the current, ready-to-copy versions of these temperature logs, visit

www.immunize.org/handouts/temperature-logs.asp

Vaccinating Adults: A Step-by-Step Guide Immunization Action Coalition

•

www.immunize.org

•

www.vaccineinformation.org

38 step

: Vaccine Storage and Handling

Temperature Log for Refrigerator – Celsius

age 1 of 3

DAYS 1

–

onitor temperatures closely!



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

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ake action if temp is out of range – too warm (above 8ºC) or too cold (below 2ºC).

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PDQXIDFWXUHUV

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Month

Year VFC PIN or other ID #

Facility Name

If you have a vaccine storage issue, also complete “Vaccine Storage Troubleshooting Record” found on page 3.

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anger! Temperatures above 8

C are too warm! Write any out-of-range temps and room temp on the lines below and call your state or local health department immediately!

anger! Temperatures below 2

C are too cold! Write any out-of-range temps and room temp on the lines below and call your state or local health department immediately!

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temperatures

action

Aim for 5

dapted with appreciation from California Department of Public Health

distributed by the

Immunization Action Coalition

Sa int Pau l, Min neso ta



651

647

9009



www.immunize.org



www.vaccineinformation.org

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If you have a vaccine storage issue, also complete “Vaccine Storage Troubleshooting Record” found on page 3.

Temperature Log for Refrigerator – Fahrenheit

age 1 of 3

DAYS 1

–

Monitor temperatures closely!

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Take action if temp is out of range – too warm (above 46ºF) or too cold (below 36ºF).

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Month

Year VFC PIN or other ID #

Facility Name

ay of Month 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Staﬀ Initials

Exact Time

in/Max Temp

(since previous reading)

anger! T

mperatures above 46ºF are too warm! Write any out-of-range temps and room temp on the lines below and call your state or local health department immediately!

anger! T

mperatures below 36ºF are too cold! Write any out-of-range temps and room temp on the lines below and call your state or local health department immediately!

Write any out-of-range

emps (above 46ºF

or below 36ºF) here:

Room Temperature

am pm am pm am pm am pm am pm am pm am pm am pm am pm am pm am pm am pm am pm am pm am pm

acceptable temperatures

action

Ai m f or 40

Adapted with appreciation from California Department of Public Health

Immunization Action Coalition

Saint Paul, Minnesota



651

647

9009



www.immunize.org



www.vaccineinformation.org

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acceptable

temperatures

Temperature Log for Freezer – Celsius

3DJHRI

DAYS 1

–

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onth

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Immunization Action Coalition

Sa int Pau l, Min neso ta



651

647

9009



www.immunize.org



www.vaccineinformation.org

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Temperature Log for Freezer – Fahrenheit

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–

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HSDUWPHQWIRUJXLGDQFH

 'RFXPHQWWKHDFWLRQWDNHQRQWKHö9DFFLQH6WRUDJH7URXEOHVKRRWLQJ5HFRUG÷RQSDJH

Month

Year VFC PIN or other ID #

Facility Name

If you have a vaccine storage issue, also complete “Vaccine Storage Troubleshooting Record” found on page 3.

am pm am pm am pm am pm am pm am pm am pm am pm am pm am pm am pm am pm am pm am pm am pm

acceptable

temperatures

Adapted with appreciation from California Department of Public Health

distributed by the

Immunization Action Coalition

Sa int Pau l, Min neso ta



651

647

9009



www.immunize.org



www.vaccineinformation.org

7HFKQLFDOFRQWHQWUHYLHZHGE\WKH&HQWHUVIRU'LVHDVH&RQWURODQG3UHYHQWLRQ

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

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Celsius

Fahrenheit

Refrigerator

www.immunize.org/catg.d/p3037C.pdf

Freezer

www.immunize.org/catg.d/p3038C.pdf

Refrigerator

www.immunize.org/catg.d/p3037F.pdf

Freezer

www.immunize.org/catg.d/p3038F.pdf

To access the current, ready-to-copy version of this piece, visit

www.immunize.org/catg.d/p3035.pdf

nsure Optimal Operation of Storage Units

11. We have a “Do Not Unplug” sign (e.g., ZZZLPPXQL]HRUJFDWJGS209 0.pdf) next to the electrical outlets

IRUWKHUHIULJHUDWRUDQGIUHH]HUDQGDö'R1RW6WRS3RZHU÷ZDUQLQJODEHOHJZZZLPPXQL]HRUJFDWJG

p2091.pdf) by the circuit breaker for the electrical outlets. Both signs include emergency contact information.

12.

We perform regular maintenance on our vaccine storage units to assure optimal functioning. For example, we

keep the units clean, dusting the coils and cleaning beneath the units as recommended by the manufacturer.

Maintain Correct Temperatures

13. We always keep at least one accurate calibrated thermometer (+/-0.5ºC [+/-1ºF]) with the vaccines in the

UHIULJHUDWRUDQGDVHSDUDWHFDOLEUDWHGWKHUPRPHWHUZLWKWKHYDFFLQHVLQWKHIUHH]HU

14. We use a thermometer that

a. uses an active display to provide continuous monitoring information.

ELVGLJLWDODQGKDVDGHWDFKDEOHSUREHWKDWKDVEHHQEXƪHUHGDJDLQVWVXGGHQWHPSHUDWXUHFKDQJHV

E\EHLQJLPPHUVHGLQDYLDOƫOOHGZLWKOLTXLGHJJO\FROHWKDQROJO\FHULQORRVHPHGLDHJVDQG

ODVVEHDGVRUDVROLGEORFNRIPDWHULDOHJDOXPLQXP7HƬRQ

. includes an alarm for out-of-range temperatures.

d. has a digital data logger that indicates current, minimum, and maximum tempreratures.

. can measure temperatures within +/-0.5ºC (+/-1ºF).

f. has a low-battery indicator.

15. We maintain the refrigerator temperature at 2

–

8ºC (36

–

46ºF), and we aim for 5ºC (40ºF).

16. :HPDLQWDLQWKHIUHH]HUWHPSHUDWXUHEHWZHHQr&DQGr&r)DQGr)

 :HVHWWKHWKHUPRVWDWIRUWKHUHIULJHUDWRUDQGWKHIUHH]HUDWWKHIDFWRU\VHWRUPLGSRLQWWHPSHUDWXUHV

1 :HNHHSH[WUDFRQWDLQHUVRIZDWHULQWKHUHIULJHUDWRUHJLQWKHGRRUDQGRURQWKHƬRRURIWKHXQLW

where the YHJHWDEOHELQVZHUHORFDWHGWRKHOSPDLQWDLQFRROWHPSHUDWXUHV:HNHHSLFHSDFNVLFHƫOOHG

FRQWDLQHUVRUIUR]HQZDWHUERWWOHVLQWKHIUHH]HUWRKHOSPDLQWDLQFROGWHPSHUDWXUHVDQGWRKDYHIUR]HQ

water bottles available for conditioning in the event of an emergency.

Maintain Daily Temperature Logs

2QGD\VZKHQRXUSUDFWLFHLVRSHQZHYLVXDOO\LQVSHFWWKHYDFFLQHVWRUDJHXQLWWZLFHDGD\ƫUVWWKLQJLQ

KHPRUQLQJDQGULJKWEHIRUHRXUIDFLOLW\FORVHVDQGGRFXPHQWUHIULJHUDWRUDQGIUHH]HUWHPSHUDWXUHVRQ

he appropriate log. (See selections at ZZZLPPXQL]HRUJFOLQLFVWRUDJHKDQGOLQJDVS.)

:HGRFXPHQWWKHPLQLPXPDQGPD[LPXPWHPSHUDWXUHUHDGLQJVLQWKHUHIULJHUDWRUDQGIUHH]HURQFH

each day, preferably in the morning.

21. We consistently record temperatures on the log either in Fahrenheit or Celsius. We never mix temperature

scales when we record our temperatures.

2 ,IWKHWHPSHUDWXUHORJSURPSWVXVWRLQVHUWDQö[÷E\WKHWHPSHUDWXUHWKDWôVSUHSULQWHGRQWKHIRUPZH

do not attempt to write in the actual temperature.

23. We follow the directions on the temperature log to call appropriate personnel if the temperature in a

storage unit goes out of range.

,IRXWRIUDQJHWHPSHUDWXUHVRFFXULQWKHXQLWZHFRPSOHWHWKHVaccine Storage Troubleshooting Record

(ZZZLPPXQL]HRUJFDWJGS3041.pdf) to document actions taken when the problem was discovered

and what was done to prevent a recurrence of the problem.

yes no

Checklist for Safe Vaccine Storage and Handling (continued) page 2 of 3

Immunization Action Coalition



Sa int Paul, Minn esota



651

647

9009



www.immunize.org



www.vaccineinformation.org

ZZZLPPXQL]HRUJFDWJGS3035.pdf



,WHP33035 (11/16)

ontinued on the next page



Vaccinating Adults: A Step-by-Step Guide Immunization Action Coalition

•

www.immunize.org

•

www.vaccineinformation.org

step

: Vaccine Storage and Handling 39

25. TUDLQHGVWDƪRWKHUWKDQVWDƪGHVLJQDWHGWRUHFRUGWKHWHPSHUDWXUHVUHYLHZWKHWHPSHUDWXUHORJVZHHNO\



 :HNHHSWKHWHPSHUDWXUHORJVRQƫOHIRUDWOHDVW\HDUV

Store Vaccines Correctly

27. We post signs (e.g., ZZZLPPXQL]HRUJFDWJGS3048.pdfRQWKHGRRUVRIWKHUHIULJHUDWRUDQGIUHH]HU

WKDWLQGLFDWHZKLFKYDFFLQHVVKRXOGEHVWRUHGLQWKHUHIULJHUDWRUDQGZKLFKLQWKHIUHH]HU

28. We do not store any food or drink in any vaccine storage unit.

2 :HVWRUHYDFFLQHVLQWKHPLGGOHRIWKHUHIULJHUDWRURUIUHH]HUDZD\IURPZDOOVDQGYHQWVOHDYLQJURRP

for air to circulate around the vaccine. We never store vaccine in the doors.

30. We have removed all vegetable and deli bins from the storage unit, and we do not store vaccines in these

mpty areas.

31. ,IZHPXVWXVHDFRPELQDWLRQUHIULJHUDWRUIUHH]HUXQLWZHVWRUHYDFFLQHVRQO\LQWKHUHIULJHUDWRUVHFWLRQ

RIWKHXQLW:HGRQRWSODFHYDFFLQHVLQIURQWRIWKHFROGDLURXWOHWWKDWOHDGVIURPWKHIUHH]HUWRWKH

UHIULJHUDWRURIWHQQHDUWKHWRSVKHOI,QJHQHUDOZHWU\WRDYRLGVWRULQJYDFFLQHVRQWKHWRSVKHOIDQGZH

place water bottles in this location.

32. We check vaccine expiration dates and rotate our supply of each type of vaccine so that vaccines with the

earliest expiration dates are located close to the front of the storage unit, facilitating easy access.

33. We store vaccines in their original packaging in clearly labeled uncovered containers.

Take Emergency Action As Needed

,QWKHHYHQWWKDWYDFFLQHVDUHH[SRVHGWRLPSURSHUVWRUDJHFRQGLWLRQVZHWDNHWKHIROORZLQJVWHSV

D :HUHVWRUHSURSHUVWRUDJHFRQGLWLRQVDVTXLFNO\DVSRVVLEOH,IQHFHVVDU\ZHODEHOWKHYDFFLQHö'R

Not Use” and move it to a unit where it can be stored under proper conditions. We do not discard the

vaccine before discussing the circumstances with our state/ local health department and/or the

appropriate vaccine manufacturers.

b. We follow the Vaccine Storage Troubleshooting Record’s (ZZZLPPXQL]HRUJFDWJGS3041.pdf)

instructions for taking appropriate action and documenting the event. This includes recording details

such as the length of time the vaccine was out of appropriate storage temperatures and the current

URRPWHPSHUDWXUHDVZHOODVWDNLQJDQLQYHQWRU\RIDƪHFWHGYDFFLQHV

F :HFRQWDFWRXUFOLQLFVXSHUYLVRURURWKHUDSSURSULDWHFOLQLFVWDƪWRUHSRUWWKHLQFLGHQW:HFRQWDFWRXU

state/ local health department and/ or the appropriate vaccine manufacturers for consultation about

whether the exposed vaccine can still be used.

d. We address the storage unit’s mechanical or electrical problems according to guidance from the

XQLWôVPDQXIDFWXUHURUDTXDOLƫHGUHSDLUVHUYLFH

H ,QUHVSRQGLQJWRLPSURSHUVWRUDJHFRQGLWLRQVZHGRQRWPDNHIUHTXHQWRUODUJHFKDQJHVLQWKHUPRVWDW

VHWWLQJV$IWHUFKDQJLQJWKHVHWWLQJZHJLYHWKHXQLWDWOHDVWDGD\WRVWDELOL]HLWVWHPSHUDWXUH

I :HGRQRWXVHH[SRVHGYDFFLQHVXQWLORXUVWDWHORFDOKHDOWKGHSDUWPHQWôVLPPXQL]DWLRQSURJUDPRU the

YDFFLQHPDQXIDFWXUHUKDVFRQƫUPHGWKDWWKHYDFFLQHLVDFFHSWDEOHIRUXVH:HUHYLHZWKLVLQIRUPDWLRQ

ZLWKRXUFOLQLFPHGLFDOGLUHFWRUEHIRUHUHWXUQLQJWKHYDFFLQHWRRXUVXSSO\,IWKHYDFFLQHLVQRWDFFHSW-

able for use, we follow our state/local health department instructions for vaccine disposition.

If we answer to all of the above, we give ourselves a pat on the back! If not, we assign someone

to implement needed changes!

yes no

Checklist for Safe Vaccine Storage and Handling (continued) page 3 of 3

Immunization Action Coalition



Sa int Paul, Minn esota



651

647

9009



www.immunize.org



www.vaccineinformation.org

ZZZLPPXQL]HRUJFDWJGS3035.pdf



,WHP33035 (11/16)

yes

stablish Storage and Handling Policies

1. We have designated a primary vaccine coordinator and at least one alternate coordinator to be in charge

of vaccine storage and handling at our facility.

2. Both the primary and alternate vaccine coordinator(s) have completely reviewed either CDC’s Vaccine

Storage & Handling Toolkit (www.cdc.gov/vaccines/hcp/admin/storage/toolkit/storage-handling-toolkit.

pdfRUHTXLYDOHQWWUDLQLQJPDWHULDOVRƪHUHGE\RXUVWDWHRUORFDOKHDOWKGHSDUWPHQWôVLPPXQL]DWLRQSURJUDP

3. We have detailed, up-to-date, written standard operating procedures for general vaccine management,

including procedures for routine activities and an emergency vaccine retrieval and storage plan for power

utages and other problems. Our procedures are based on CDC’s Vaccine Storage & Handling Toolkit

QGRURQLQVWUXFWLRQIURPRXUVWDWHRUORFDOKHDOWKGHSDUWPHQWôVLPPXQL]DWLRQSURJUDP

:HUHYLHZWKHVHSROLFLHVZLWKDOOVWDƪDQQXDOO\DQGZLWKQHZVWDƪLQFOXGLQJWHPSRUDU\VWDƪZKHQWKH\

are hired.

og In New Vaccine Shipments

5. We maintain a vaccine inventory log that we use to document the following:

a. Vaccine name and number of doses received

. Date we received the vaccine

c. Condition of vaccine when we received it

d. Vaccine manufacturer and lot number

e. Vaccine expiration date

Use Proper Storage Equipment

6. :HVWRUHYDFFLQHVLQVHSDUDWHVHOIFRQWDLQHGXQLWVWKDWUHIULJHUDWHRUIUHH]HRQO\,IZHPXVWXVHDKRXVH-

ROGVW\OHFRPELQDWLRQXQLWZHXVHLWRQO\IRUVWRUDJHRIRXUUHIULJHUDWHGYDFFLQHVPDLQWDLQLQJIUR]HQ

accinesLQDVHSDUDWHVWDQGDORQHIUHH]HU

7. We store vaccines in units with enough room to maintain the year’s largest inventory without crowding.



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WKHIUHH]HUFRPSDUWPHQWLQVLGHWKHUHIULJHUDWRU

9. :HXVHRQO\FDOLEUDWHGWKHUPRPHWHUVWKDWKDYHD&HUWLƫFDWHRI&DOLEUDWLRQTesting* (“Report of Calibra-

ion”) and are calibrated every 1 to 2 years from the last calibration testing date or according to the

manufacturer’s suggested timeline.

10. We have planned back-up storage unit(s) in the event of a power failure or other unforeseen event.

yes no

Checklist for Safe Vaccine Storage and Handling

Are you doing everything you should to safeguard your vaccine supply?

eview this list to see where you might make improvements in your vaccine

management practices. Check each listed item with either or .

yes no

&HUWLƫFDWHRI&DOLEUDWLRQ7HVWLQJö5HSRUWRI&DOLEUDWLRQ÷ZLWKFDOLEUDWLRQPHDVXUHPHQWVWUDFHDEOH

WRDODERUDWRU\ZLWKDFFUHGLWDWLRQIURPWKH,QWHUQDWLRQDO/DERUDWRU\Accreditation Cooperations

,/$&0XWXDO5HFRJQLWLRQ$UUDQJHPHQW05$VLJQDWRU\ERG\

Technical content reviewed by the Centers for Disease Control and Prevention

Sa int Paul, Minn esota



651

647

9009



www.immunize.org



www.vaccineinformation.org

ZZZLPPXQL]HRUJFDWJGS3035.pdf



,WHP33035 (11/16)

ontinued on the next page



To access the current, ready-to-copy version of this piece, visit

www.immunize.org/catg.d/p3036.pdf

error: Inadvertently cutting the power supply to the

storage units

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error: Recording temperatures only once per day

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immunization

immunize.org

action

coalition

Vaccinating Adults: A Step-by-Step Guide Immunization Action Coalition

•

www.immunize.org

•

www.vaccineinformation.org

40 step

: Vaccine Storage and Handling

Do you see your clinic or practice making any of these

requently reported errors in vaccine storage and handling?

Although some of these errors are much more serious than

thers, none of them should occur. Be sure your healthcare

setting is not making any of these preventable errors.

error: Designating only one person, rather than at least

two, to be responsible for storage and handling of vaccines

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continued on the next page

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immunization

immunize.org

action

coalition

'RQôW%H*XLOW\RI7KHVHPreventable ErrorV

in VDFFLQH6WRrDJHDQG+DQGOLQJ

To access the current, ready-to-copy version of this piece, visit

www.immunize.org/catg.d/p3048.pdf

Vaccine Handling Tips

remember: Improperly stored or outdated vaccines won’t protect your patients!

Maintain refrigerator

temperature between

2° and 8°C (36° and 46°F).

Aim for 5°C (40°F).

DTaP, Tdap, Td, DT

epatitis A

Hepatitis B

QƬXHQ]DH

type b

(Hib)

Human papilloma-

irus

,QƬXHQ]D

olio (IPV)

MMR*

Meningococcal

Pneumococcal

Rotavirus

MMR*

MRV

Varicella

oster

Maintain freezer

temperature between

-50° and -15°C

(-58° and 5°F).

Freezer Refrigerator

Manage vaccine inventories.

Inventory your vaccine supplies at least monthly and before

placing an order. Expired vaccine must never be used and

it becomes “cash in the trash!”

Always use the vaccine with the soonest expiration

GDWHƫUVW

Move vaccine with the soonest expiration date to the front

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vaccine from the unit.

Store vaccine appropriately.

†

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receiving shipment. Keep vaccine vials in their original packag-

ing. Place vaccine in clearly labeled wire baskets or other open

containers with a 2–3" separation between baskets and 4"

from wall of unit. Separate or clearly mark vaccines to distin-

guish those that were supplied from your state’s Vaccines for

Children program (or other state-funded source) from those

that were privately purchased. Do not store vaccines in the

GRRURURQWKHƬRRURIWKHXQLW

Stabilize temperatures.

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refrigerator along with the vaccines. This will help maintain

a stable, cold temperature in case of a power failure or if the

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ately place the vaccine in recommended storage, mark it “do not use,” and then

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gency Response Worksheet” (ZZZLPPXQL]HRUJFDWJGSSGI).

Technical content reviewed by the Centers for Disease Control and Prevention

Saint Paul, Minnesota



651

647

9009



www.immunize.org



www.vaccineinformation.org

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Vaccinating Adults: A Step-by-Step Guide Immunization Action Coalition

•

www.immunize.org

•

www.vaccineinformation.org

step

: Vaccine Storage and Handling 41

To access the current, ready-to-copy version of this piece, visit

www.immunize.org/catg.d/p3041.pdf

Vaccinating Adults: A Step-by-Step Guide Immunization Action Coalition

•

www.immunize.org

•

www.vaccineinformation.org

42 step

: Vaccine Storage and Handling

Date & Time of Event

If multiple, related events occurred,

see Description of Event below.

Storage Unit Temperature

at the time the problem was discovered

Room Temperature

at the time the problem was discovered

Person Completing Report

When recording temperatures, indicate F (Fahrenheit) or C (Celsius).

Date: Temp when discovered: Temp when discovered: Name:

Time: Minimum temp: Maximum temp:

Comment (optional):

Title: Date:

Description of Event (If multiple, related events occurred, list each date, time, and length of time out of storage.)

 General description (i.e., what happened?)

 Estimated length of time between event and last documented reading of storage temperature in acceptable range (36

to 46

F [2° to 8°C] for refrigerator; -58º to 5ºF [-50° to -15°C] for freezer)

 Inventory of aected vaccines, including (1) lot #s and (2) whether purchased with public (for example, VFC) or private funds (Use separate sheet if needed, but maintain the inventory with this troubleshooting record)

 At the time of the event, what else was in the storage unit? For example, were there water bottles in the refrigerator and/or frozen coolant packs in the freezer?

 Prior to this event, have there been any storage problems with this unit and/or with the aected vaccine?

 Include any other information you feel might be relevant to understanding the event.

Action Taken (Document thoroughly. This information is critical to determining whether the vaccine might still be viable!)

 When were the aected vaccines placed in proper storage conditions? (Note: Do not discard the vaccine. Store exposed vaccine in proper conditions and label it “do not use” until after you can discuss with your state/

local health department and/or the manufacturer[s].)

 Who was contacted regarding the incident? (For example, supervisor, state/local health department, manufacturer—list all.)

 IMPORTANT: What did you do to prevent a similar problem from occurring in the future?

Results

 What happened to the vaccine? Was it able to be used? If not, was it returned to the distributor? (Note: For public-purchase vaccine, follow your state/local health department instructions for vaccine disposition.)

Vaccine Storage Troubleshooting Record (check one) □Refrigerator □Freezer

Use this form to document any unacceptable vaccine storage event, such as exposure of refrigerated or frozen vaccines to temperatures that are outside the manufacturers' recommended storage ranges.

istributed b

the

Immunization Action Coalition

Saint Paul, Minnesota



651

647

9009



www.immunize.org



www.vaccineinformation.org

echnical content reviewed by the Centers for Disease Control and Prevention

www.immunize.org/catg.d/p3041.pdf

 Item #P3041 (8

16)

Date & Time of Event

f multiple, related events occurred,

see Description of Event below.

Storage Unit Temperature

t the time the problem was discovered

Room Temperature

t the time the problem was discovered

Person Completing Report

Date: ȿȭɏȩɰOʝɦ Temp when discovered: 45ºF Temp when discovered: ʳºF Name: 1ʋQʎɨ1ʦUȿɏ

Time: ȿȭɏȩɰOʝɦ Minimum temp: 38ºF

Maximum temp: 53ºF

Comment (optional):

ɀʑʛɞLɡʋSʠUʝɧ

Title: 9)&&RʝUʏʖQDWʝɠ Date: 6/24/13

Results

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DFȪʑSWɪɬȵɏIʝɠXȿɏ+ɏWɼOɍȷɏʃKDɢYDFʎʖȸɏFʝʅOɍʃȱʑȾHIʝȾɏȩɏȾʑPʝɃHɍʓUʝəʡXʋUʋQʤʖȸɏ,ʏLVʎXʽHɍʃȱɏʑQʤʖȾɏʣLʤXDʤLʝɚʨLʃɓ6XʣȲɏ6ʦȼʑʢʧLVʝɠʋQɍ

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Vaccine Storage Troubleshooting Record (check one) □Refrigerator □Freezer

Use this form to document any unacceptable vaccine storage event, such as exposure of refrigerated vaccines to temperatures that are outside the manufacturers' recommended storage ranges.

A llable troubleshooting record (i.e., editable pdf) can also be found at www.immunize.org/clinic/storage-handling.asp

Example

Description of Event (If multiple, related events occurred, list each date, time, and length of time out of storage.)

 General description (i.e., what happened?)

 Estimated length of time between event & last documented reading of storage temperature in acceptable range (36

to 46

F [2

to 8

C] for refrigerator; -58º to 5ºF [-50

to -15

C] for freezer)

 At the time of the event, what else was in the storage unit? For example, were there water bottles in the refrigerator and/or frozen coolant packs in the freezer?

 Prior to this event, have there been any storage problems with this unit and/or with the aected vaccine?

 Include any other information you feel might be relevant to understanding the event.

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3OʋɚWɛIɼɸOʝɦʦɞʨLʃɓ,Pʛʦʜɔ]DʤLʝɚ3URʔUʋəʝɚGDWɈORJȰʑUɡʨLʃɓɪOʋʢPɡʃKDɢFʝʅOɍȩɏȿʑQɢWɛFRʝUʏʖQDWʝɠʋQɍEDɭɖʦɞɿKʝȸHɡ

Action Taken (Document thoroughly. This information is critical to determining whether the vaccine might still be viable!)

state/local health department and/or the manufacturer[s].)

 Who was contacted regarding the incident? (For example, supervisor, state/local health department, manufacturer—list all.)

 IMPORTANT: What did you do to prevent a similar problem from occurring in the future?

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ɄȭɰȴʑQɍPʋɨKʋɃɏɈՔHFɀHɍSʝɄʑɠ

distributed by the

Immunization Action Coalition

Saint Paul, Minnesota



651

647

9009



www.immunize.org



www.vaccineinformation.org

Technical content reviewed by the Centers for Disease Control and Prevention

www.immunize.org/catg.d/p3041.pdf

 Item #P3041 (8

16)

The form includes

6 ﬁlled-in

example pages.