Ordering Vaccine

All VFC and 317 vaccine requests must be placed through ShowMeVax. Training videos may be found on how to place an order in the Reports menu in ShowMeVax (under Reports, Missouri Forms and Documents, ShowMeVax Training videos). Routine vaccine orders are accepted from the 1st through the 14th of each month; however, orders will be accepted at any time as long as there are no more than 14 days between reconciliations. All questions for VFC orders are handled by the Vaccine Support Team.

• Determine vaccine needs based on data
  • Review the provider profile, doses on hand, review usage amounts from the previous year
  • Maintain inventory for a four to six week (4 -6) supply
• Providers may choose the vaccine brand (but it is not guaranteed that they will get that brand)
• Order from the manufacturer you are familiar with to prevent vaccine administration errors (same box and same manufacturer).
• When placing an order for 317 vaccine(s), the order must be separate from a VFC order. Add a comment in the ‘Clinic Comments’ section indicating you are ordering 317 vaccine(s) for adults.
• If VFC providers need to place an order more than 14 days after the last count date, you must submit a new reconciliation and temperature logs.

VFC providers placing an initial order upon enrollment may contact the Vaccine Support Team for assistance. All other orders must be placed in ShowMeVax.

Note: When ordering more vaccine than normal due to upcoming clinics or during back-to-school, explain the reason for the order increase in the ‘Clinic Comments’ of the vaccine order screen in ShowMeVax to avoid rejection or processing delays.

Vaccine Reconciliation

VFC providers must offer all ACIP-recommended vaccines for the population they serve and are responsible for proper maintenance of VFC vaccine inventory. VFC providers must count and reconcile the VFC vaccine inventory and complete the reconciliation in ShowMeVax between the 1st and the 14th of each month. Reconciliation is required by the CDC and is an accounting of VFC vaccine doses administered, wasted, expired, lost (or unaccounted for), and doses currently in inventory from the first through the last day of the previous month. The VFC Program recommends VFC providers maintain a four-to-six-week supply of the VFC and private vaccine inventories based on the provider profile information.

• VFC Providers must have separate inventories for publicly purchased vaccines and private vaccines. Vaccines do not have to be stored in separate storage units.
• Provider must reconcile VFC inventory even if a VFC order is not placed.
• Any provider who repeatedly fails to reconcile the VFC inventory in a timely and accurate manner will be suspended from ordering.

ShowMeVax has tutorials in the Reports section to assist with VFC vaccine reconciliation. If VFC providers need additional assistance, please call the Vaccine Support Team at 866-256-3166 or email at VFC-SMVsupport@health.mo.gov.

Receiving VFC or 317 Vaccine

VFC providers must have steps and procedures in place for immediate receipt and storage of vaccine. All clinic staff must be trained to recognize a VFC vaccine shipment and follow steps to ensure vaccine is stored in the appropriate storage unit. The following steps must occur upon receipt:

1. Open vaccine packages immediately.
2. Inspect the vaccine and package for damage.
3. Compare the vaccine received to the vaccines on the packing slip.
4. Check the temperature monitor readings in the shipping package (if available).
5. Immediately store the VFC vaccine in the appropriate storage unit at the appropriate temperature.
6. If there is a problem with shipping temperatures contact McKesson at 1-800-877-7123.
7. If there are other problems with the order, contact the VFC program immediately at 866- 256-3166.
8. You must electronically indicate receipt of the order in ShowMeVax under ‘Inventory’, ‘On Hand’ and click the blue link to accept the shipment. Verify the quantity and lot number.
9. Never refuse a VFC vaccine delivery. Providers should post signage directing delivery personnel to not leave deliveries unattended.
10. Do not place unpacked or unopened shipment box in a vaccine storage unit.
11. Failure to appropriately store vaccine upon delivery could result in vaccine loss that requires replacement dose-for-dose with private stock.

Check Vaccine Deliveries Received

When 317 or VFC vaccine arrives, review the following at a minimum:

• Review the packing slip and verify that this matches contents received (Reminder: maintain packing slips for three years). Discrepancies between the packing slip and contents received is the provider’s responsibility if not reported to the VFC Program within one hour of delivery.
• Review any temperature indicators associated with the order and verify appropriate temperatures were maintained. Follow guidance below to report problems.
• Expiration dates match and should be at least six months from date of receipt.
• Presentation of vaccine (vials vs syringe) matches.
• The package and the vaccine boxes should not be damaged.
• Remove vaccines from the box and bags and store according to VFC guidelines.
• Compare packing slip and contents to the ShowMeVax order. If you find any discrepancies, contact the help desk immediately.
• If problems are identified, follow the guidance below within one hour of receipt.

Note: VFC Providers may order a single dose of Td, PPSV23, or DT. These are shipped in 6” x 8” Amber UV bags. Since these come directly from the distributor, they are considered original packaging and offer protection for light-sensitive vaccines. The single doses should remain in these bags until they are ready to be administered.

Temperature/Viability Issues/Spoiled in Shipment

If you receive a VFC vaccine delivery that is damaged/compromised, shows a temperature indicator issue, etc., store the vaccine in the appropriate storage unit, label it DO NOT USE, and immediately contact McKesson or Merck:

• McKesson’s Vaccine Viability Line: 1-877-836-7123
  • Call McKesson at the phone line above and notify the VFC Program. Once McKesson has been contacted, the provider must work with the VFC Program for guidance and follow-up. If replacement vaccine is needed, the distributor will work with the provider to email a return label directly to the provider (rather than ShowMeVax return/wastage report), as well as send a replacement order. This may require ShowMeVax inventory be adjusted to remove the spoiled shipment and re-enter the new shipment with correct inventory information.
• Merck Call Center: 1-800-637-2579
  • Call Merck at the phone line above and notify the VFC Program. Once Merck has been contacted, the provider must work with the VFC Program for guidance and follow-up. If replacement vaccine is needed, the distributor will work with the provider to email a return label directly to the provider (rather than ShowMeVax return/wastage report), as well as send a replacement order. This may require ShowMeVax inventory be adjusted to remove the spoiled shipment and re-enter the new shipment with correct inventory information.

VFC/317 Vaccine Returns/Wastage

Acceptable Returns 

1. Expired vaccine
2. Natural disaster/power failure
3. Failure to store vaccine properly upon receipt
4. Refrigerator temperature too cold
5. Refrigerator/freezer temperature too warm
6. Vaccine spoiled in transit (freeze/warm monitor activated)
7. Mechanical/Unit failure
8. Recall

Wastage (Do not return)

1. Broken vial/syringe
2. Lost or unaccounted for vaccine
3. Open vial but not all doses administered
4. Vaccine drawn into the syringe but not administered

All vaccines that fall under the Acceptable Returns column above must be reported in ShowMeVax so that the vaccines may be returned to the supplier. The return process must be completed in ShowMeVax in order to generate a shipping label. Shipping labels are emailed to the Primary VFC Contact as noted in ShowMeVax. Vaccines that fall under the acceptable returns column must be returned within six months. The VFC provider packages the vaccine for return and places the return label on the package (no cool or freezer packs are needed). The package is returned via UPS at no cost if it is part of a regular pick-up. To review the steps for this process, please refer to the Reports Section of ShowMeVax and find the ‘Inventory Adjustments and Wastage’ User guide. If you need further assistance with returns, please contact the Vaccine Support Team at 866-256-3166 or VFCSMVsupport@health.mo.gov.

Vaccines that fall under the wastage column are not returned and should be discarded as the incidence occurs. Wastage doses must be deducted by completing a wastage adjustment to the onhand inventory in ShowMeVax. VFC providers will utilize the appropriate method of discarding vaccine per individual clinic policy.

Vaccine Borrowing

VFC providers are expected to maintain a four-to-six-week supply of private stock vaccines and public (VFC, 317, CHIP) vaccines. Borrowing of vaccine between public and private vaccine should be a rare and unplanned occurrence. Private stock vaccines may be borrowed for Section 317/VFC eligible patients; however, the repayment is done at the clinic risk as the public funded vaccine stock may not be available for repayment. In situations where borrowing is needed, the borrowing must be documented on a “dose-by-dose” basis on the Vaccine Borrowing Report [NEEDS LINK] [BROKEN LINK]. All columns of the form must be complete, including the reason for the borrowing. The borrowing form must remain onsite at the clinic and be made available for review by the VFC Consultant ShowMeVax has a Vaccine Borrowing form tutorial in the Reports Section for additional information regarding how to complete the inventory adjustments when borrowing is necessary.

VFC and Section 317 vaccines have specific funding sources. VFC vaccines may not be borrowed for Section 317 eligible patients and vice versa.

Note: At the beginning of each influenza vaccine season there are differences in the arrival times of influenza vaccines for VFC and non-VFC patients. Borrowing VFC influenza vaccines is not permitted unless specified by the VFC Program.

Vaccine Transfers

VFC providers may need to transfer VFC or 317 stock to another VFC provider. All transfers must be approved prior to the transfer process by the VFC Support Team or your VFC Consultant. Receiving providers must indicate in the ‘Vaccine Return Clinic Comments’ the vaccine was received in a transfer from “provider name” and “VFC PIN”. If you accept a transfer of VFC stock from another VFC provider and the vaccine expires, the clinic will not be required to attempt to transfer the vaccine, nor will the clinic be held accountable for replacement. Transfers are completed in ShowMeVax under ‘Vaccines’, ‘On-Hand’ under the ‘Inventory Section’. The Vaccine Support Team can assist with transfers at 866-256-3166 or by email at VFC-SMVsupport@health.mo.gov.

Vaccine Replacement

The Vaccine Replacement Policy was developed in accordance with the Center for Disease Control and Prevention (CDC) and Missouri’s Vaccines for Children (VFC) program for the purpose of replacing vaccine wasted or spoiled due to non-compliance or negligence and/or failure to properly store, handle, or rotate vaccine inventory.

Situations Requiring Vaccine Replacement

The following situations are examples of non-compliance or negligence that require vaccine replacement. This list is not all inclusive:

• Failing to contact at least three VFC providers to attempt to transfer vaccine at least ninety (90) days prior to the expiration of the VFC vaccine.
• Ordering habits resulting in overstocking that leads to expiration of vaccines (i.e., maintaining an inventory of more than a 90-day supply).
• Drawing vaccine prior to patient screening.
• Improper storage and handling of vaccine.
• Failing to provide proof of equipment repair or equipment replacement to the VFC program within 30 days from the date a unit problem is identified.
• Failing to act according to the provider/practice’s Emergency Response Plan during any power outages.
• Discarding multi-dose vials thirty (30) days after opening rather than the actual expiration date.
• Administering vaccine that was expired or stored improperly.
• Administering vaccines in error (not due to timing and spacing).

Situations Not Requiring Vaccine Replacement

The following situations are examples considered to be out of the providers’ control, and generally do not require vaccine replacement. This list is not all inclusive:

• Receiving a delivery of vaccine from UPS, FedEx or other delivery service in an untimely manner resulting in lost and/or spoiled vaccine in which the manufacturer has determined the vaccine to be non-viable.
• Moving vaccine to a location with a secure power source due to anticipated inclement weather and power is lost at that location, resulting in spoiled vaccine in which the manufacturer has determined the vaccine to be non-viable.
• Partially used multi-dose vials that have expired.
• Accidentally dropping or breaking a vaccine vial.
• Providing proof of equipment repair or equipment replacement to the VFC program within 30 days from the date a unit problem is identified.
• Unsuccessfully attempting to transfer vaccine 90 days or more prior to expiration. (Written documentation is required noting medical provider’s attempt to transfer vaccine to three or more VFC providers. Attempts must be noted in ‘Vaccine Return Clinic Comments’ with the name and PIN of the provider who declined the transfer).
• Preparing vaccine in which a parent later refuses.
• Vaccine which was received in a transfer and expired before it could be used.

Vaccine Replacement Procedure

If the provider/practice is found to have wasted vaccine due to non-compliance or negligence, the following conditions will apply:

• The provider/practice will purchase, or transfer from private stock, vaccine to replace the negligently wasted vaccine on a dose-for-dose basis. The provider/practice has ninety (90) days to submit a vaccine invoice and/or a Vaccine Replacement form to the VFC program as proof of the vaccine purchase or transfer.
  • Vaccine invoice(s) must be submitted when purchasing vaccine for replacement.
  • A Vaccine Replacement form must be submitted when transferring from private stock already on hand. The Replacement Form can be found here [NEEDS LINK].
  • The doses replaced must be used only for VFC eligible children.
  • The doses replaced must be tracked; noting the date it was replaced, identifier of patient receiving the vaccine, patient insurance status and patient date of birth.
• The provider/practice will be suspended from ordering vaccine until the vaccine invoice or Vaccine Replacement form is received.
• If the provider/practice has failed to keep vaccine viable (temperatures out of the acceptable range) or improperly administered vaccine that results in the re-vaccination of children, the provider/practice will be responsible for the cost of the vaccine for re-vaccination. The provider must prepare and submit to the VFC program a listing of all children needing re-vaccination within 10 days of notification from the VFC program. Within 90 days of notification, the provider/practice shall submit to the VFC program a re-vaccination report confirming the date each child was re-vaccinated or the results of contact made to re-vaccinate each child.
• If necessary, a VFC Consultant will conduct a follow-up visit within six months of the incident to monitor storage and handling practices.

Vaccine Schedules

VFC providers are required to comply with the immunization schedules, dosages, and contraindications recommended by the ACIP, unless:

1. In the provider’s medical judgment, and in accordance with accepted medical practice, such compliance is medically inappropriate for the child.
2. State law, including laws pertaining to religious and other exemptions, applies.

Contraindications - Contraindications (conditions in a patient that increases the risk for a serious adverse reaction) to vaccination are conditions under which vaccines should not be administered. The Immunization Action Coalition has a one-page Summary of Contraindications that may be used as a tool or guide. Patients may be screened for contraindications with a Screening Checklist. For detailed guidance on contraindications providers may refer to the General Best Practices [BROKEN LINK] by ACIP.

Immunization schedules can be found on the CDC website. The CDC Vaccine Schedule app is also available for both iOS and Android devices. Child Care/Preschool Requirements [NEEDS LINK] and School Requirements [NEEDS LINK] for Missouri can be found on the Department of Health and Senior Services website.

Standards for Pediatric Vaccination Practices

The National Vaccine Advisory Committee published the following standards to define appropriate vaccination practices. The standards focus on priorities such as ensuring vaccine availability, providing effective communication, proper storage and handling, and improving coverage rates.

1. Immunization services are readily available.
2. There are no barriers or unnecessary prerequisites to the receipt of vaccines.
3. Immunization services are available free or for a minimal fee.
4. Providers utilize all clinical encounters to screen and, when indicated, vaccinate children.
5. Providers educate parents and guardians about immunization in general terms.
6. Providers question parents or guardians about contraindications and, before vaccinating a child, inform them in specific terms about the risks and benefits of the vaccinations their child is to receive.
7. Providers follow only true contraindications.
8. Providers administer simultaneously all vaccine doses for which a child is eligible at the time of each visit.
9. Providers use accurate and complete recording procedures.
10. Providers co-schedule immunization appointments in conjunction with appointments for other child health services.
11. Providers report adverse events following vaccination promptly, accurately, and completely.
12. Providers operate a tracking system.
13. Providers adhere to appropriate procedures for vaccine management.
14. Providers conduct semi-annual audits to assess immunization coverage levels and to review immunization records in the patient populations they serve.
15. Providers maintain up-to-date, easily retrievable medical protocols at all locations where vaccines are administered.
16. Providers practice patient-oriented and community-based approaches.
17. Vaccines are administered by properly trained persons.
18. Providers receive ongoing education and training regarding current immunization recommendations.

Refusal to Consent to Vaccination

Providers should document vaccine refusals in the Electronic Health Record/Electronic Medical Record and in ShowMeVax (Patient Menu on the navigational panel and create a note or complete under Exemptions). Immunization Action Coalition has a form that parents may sign to decline vaccination.

Vaccine Preparation and Administration

VFC vaccines must be prepared immediately prior to administration. Do not pre-draw doses. Prepare vaccine in a designated, clean medication area, away from where potentially contaminated items are placed.

Additional preparation and administration practices:

• Follow ACIP recommendations, contraindications and precautions, Standards of Pediatric Immunization Practices, and vaccine package inserts.
• Never administer expired vaccines or diluent. Always check expiration dates for vaccines and diluent prior to preparation.
• Discard any un-used prepared doses no later than the end of the workday or per the manufacturer package insert, which may be sooner (reconstitution time limits).
  • For guidance on time allowed between reconstitution and use, see this resource (Vaccines with Diluents: How to Use Them).
• Only use the diluent provided by the manufacturer for that vaccine.
• Provide or offer up-to-date VIS prior to the administration of vaccines.
• A single-dose vial contains one dose and should only be used for one patient.