Microsoft word - aug18_evss_consent form_en_[final].doc

This page to be retained by client Elderly Vaccination Subsidy Scheme (EVSS) 2011/12
Information about Seasonal Influenza Vaccination and Pneumococcal
Vaccination

Benefits of Getting Seasonal Influenza Vaccination and Pneumococcal Vaccination
Infection of the airway such as those caused by seasonal influenza virus and pneumococcus is common. Once
elders are infected, they are at higher risk of developing serious complications, including infection of the
airway, lungs, blood stream and membranes of the brain, and even death in the most serious cases.
Vaccination can effectively prevent these infections and the related hospitalisation and death.
Part A: Information about Influenza Vaccination
1. Influenza
Influenza is an infectious disease caused by various types of influenza virus. In Hong Kong, the two
subtypes of influenza A virus, H1N1 and H3N2, are most commonly seen. Influenza occurs in Hong Kong
throughout the year, but is usually more common in periods from January to March and from July to August.
The virus mainly spreads by respiratory droplets through coughing and sneezing. The disease is
characterised by fever, sore throat, cough, headache, muscle aches, runny nose and general tiredness. It is
usually self-limiting with recovery in 2 - 7 days. However, it can be a serious illness to the weak and frail,
such as elderly persons, and may be complicated by infection of the airway or lung, or even death in the most
serious cases. Serious influenza infection can occur even in healthy individuals.
2. Influenza Vaccination
Recommended composition
The vaccine recommended by the Scientific Committee on Vaccine Preventable Diseases of the Centre for Health Protection in 2011/2012 contains the following: Type and recommended dose
Elders are recommended to receive 1 dose in the 2011/12 season. The influenza vaccines that are licensed in Hong Kong and indicated for elders aged 65 or above are inactivated trivalent influenza vaccine given by intramuscular or intradermal injection. Note: Nasal spray live attenuated influenza vaccine is not suitable for persons above 49 years old. Contraindications
People who are allergic to a previous dose of inactivated influenza vaccine or other vaccine components (e.g. neomycin or polymyxin) are not suitable to have inactivated influenza vaccination. Individuals with diagnosed or suspected egg allergy who are considering an influenza vaccination should be evaluated by a specialist (allergist or immunologist) for egg allergy and have inactivated influenza vaccine administered by these specialists if clinically indicated. Those with bleeding disorders or on warfarin may receive the vaccine by deep subcutaneous injection. If an individual has fever on the day of vaccination, the vaccination should be deferred till recovery. Side effects
This page to be retained by client Inactivated influenza vaccine is very safe and usually well tolerated apart from occasional soreness, redness or
swelling at the injection site. Some recipients may experience fever, muscle and joint pains, and tiredness
beginning 6 - 12 hours after vaccination and lasting up to 2 days. If fever or symptoms persist, please consult
your doctor. Immediate severe allergic reactions like hives, swelling of the lips or tongue, and difficulties in
breathing are rare and require emergency consultation.
Influenza vaccination may be rarely followed by serious adverse events such as Guillain-Barré syndrome* (1
to 2 case per million vaccinees), inflammation of brain membranes or brain disease (1 in 3 million doses
distributed) and severe allergic reaction (anaphylaxis) (9 in 10 million doses distributed). However, influenza
vaccination may not necessarily have causal relations with these adverse events.
*Guillain-Barré Syndrome (GBS)
GBS is a rare neurological disorder causing paralysis and even respiratory difficulties. While most people
recover completely, some may have chronic weakness. While GBS has been suspected to be related with
influenza vaccination, the disease can also develop following a variety of infections, including seasonal
influenza. So far, no clear association has been found between GBS and seasonal influenza vaccine.
Therefore, the benefits of receiving seasonal influenza vaccine far outweigh the risks.
As it is unknown whether influenza vaccination is causally associated with increased risk of recurrent GBS,
precaution should be made to ascertain the temporal relationship if there is a history of GBS. People with a
history of GBS developed within 6 weeks after receiving influenza vaccine should consult their doctors before
receiving either live attenuated or inactivated influenza vaccine.
Part B: Information about Pneumococcal Vaccination
1. Pneumococcal Infection
Pneumococcal infection represents a wide range of diseases caused by the bacterium Streptococcus
pneumoniae (or more commonly referred as pneumococcus). While pneumococcus is a common cause of mild
illnesses such as paranasal sinus or middle ear infections, it may also cause severe or even life-threatening
invasive pneumococcal diseases such as infection of lung, bloodstream and membrane of the brain etc. The
case fatality rate for invasive pneumococcal diseases is substantially higher among elderly patients.
2. Pneumococcal Vaccination
Type and recommended dose
One dose of 23vPPV is recommended for elders aged 65 or above who have never received 23vPPV before
(or have received 1 dose before age 65 but was more than 5 years earlier). The Scientific Committee on
Vaccine Preventable Diseases does not recommend any person to receive more than 2 doses of 23vPPV.
Contraindications
Severe allergic reaction following a previous dose of 23vPPV or to the vaccine component is a
contraindication to further doses of the vaccine.
Side effects
23vPPV has been demonstrated to be safe. Slight swelling and tenderness at the injection site may occur shortly following injection. Local reactions are more severe following a second dose but nearly all reactions resolve within a few days without treatment. For prevention against influenza and pneumococcal infection, vaccinated individuals should continue to maintain good personal and environmental hygiene practices; keep a balanced diet, exercise regularly, take adequate rest and not to smoke. Consent to Use Vaccination Subsidy
Elderly Vaccination Subsidy Schemes
Department of Health
(For person aged 65 or above)
Transaction No.: _______________
Void Transaction No.: _______________
Note 1: This Form must be legibly completed to be valid. Note 2: Please fill in according to the format shown on the identity document * Delete as appropriate *********************************************************************************
I confirm that I am / the recipient indicated below is* a Hong Kong resident aged 65 or above this year. I
consent to use the following Government subsidy to receive/ for the recipient indicated below to receive*
vaccination(s) provided by (name of doctor) on (date of vaccination)
( Put a " " where appropriate):
Subsidy for seasonal influenza vaccination The personal details of recipient:
Sex: *Male / Female (* delete as appropriate) Identity document (Please tick the box and fill in the document number as appropriate):
Date of Issue: _____/_____/_____ (dd/mm/yyyy) Serial No. of the Certificate of Exemption: Date of Issue: ____________________________________ Signature of recipient (or finger print if illiterate):
Contact Telephone No.:
Complete only if the recipient has mental capacity but is illiterate
This document has been read and explained to the recipient in my presence.
Complete only if recipient is mentally incapacitated

Undertaking and Declaration
1. I declare the information provided in this consent form is correct. 2. I agree to provide my / the recipient's* personal data in this consent form and any information related to this consultation for the use by the Government for the purposes as set out in the "Statement of Purpose". I hereby give consent to the doctor to transfer and release such personal data and any information related to this consultation to the Government, its agents, or other persons authorised by the Government. I note that I may be contacted to verify the information and vaccination given to me / the recipient*. 3. For Smart Identity Card holder: I agree to authorise the doctor to read my / the recipient's* personal data [limited to Hong Kong Identity Card No., Name (in English and Chinese), date of birth and date of issue of Hong Kong Identity Card] stored in the chip embodied in my / the recipient's* Smart Identity Card for the use by Government for the purposes as set out in the "Statement of Purpose". 4. This consent shall be governed by and construed in accordance with the laws of Hong Kong Special Administrative Region and I and the Government shall irrevocably submit to the exclusive jurisdiction of the Courts of Hong Kong Special Administrative Region. 5. I have read this consent carefully and fully understood my obligations and liability under this consent. (name)____________________ and I fully understood my obligations and liability under this consent.) Statement of Purpose

Purposes of Collection
1.
The personal data provided will be used by the Government for one or more of the following for creation, processing and maintenance of an eHealth account, payment of subsidy, and the administration and monitoring of the Vaccination Subsidy Schemes, including but not limiting to a verification procedure by electronic means with the data kept by the Immigration Department; (b) for statistical and research purposes; and (c) any other legitimate purposes as may be required, authorised or permitted by law. 2. The vaccination record made for the purpose of this consultation will be accessible by health care personnel in the public and private sectors for the purpose of determining and providing necessary health care service to the recipient. 3. The provision of personal data is voluntary. If you do not provide sufficient information, you may not be able to use the subsidy.
Classes of Transferees
4.
The personal data you provide are mainly for use within the Government but they may also be disclosed by the Government to other organisations, and third parties for the purposes stated in
paragraphs 1 and 2 above, if required.
Access to Personal Data
5.
You have a right to request access to and to request the correction of your personal data under sections 18 and 22 and principle 6, schedule 1 of the Personal Data (Privacy) Ordinance. A fee may be
imposed for complying with a data access request.
Enquiries
6.
Enquiries concerning the personal data provided, including the making of access and correction, Executive Officer, Vaccination Office, Centre for Health Protection, 2/F 147C Argyle Street, Kowloon Telephone No.: 2125 2125

Source: http://www.ucn.org.hk/images_e/or4.pdf