school immunization compliance department of state health services

SchoolImmunization Compliance

www.ImmunizeTexas.com

Department of State Health Services

Learning Objectives

At the end of this presentation, each participant will be able to:

• Identify the source & authority for immunization rules

• Interpret the differences between immunization recommendations and immunization requirements

• Differentiate between the two allowable exclusions from compliance

Learning Objectives, Con’t.At the end of this presentation, each

participant will be able to:

• List possible items that will be considered for upcoming agency rule review

• Identify recent legislation relating to immunization requirements and immunization awareness

Recommended or Required?

• Recommendations are for everyone

• Requirements are for children attending child-care facilities or school

Source and Authority• Recommendations are made by the CDC’s

Advisory Committee on Immunization Practices (ACIP), which has representatives of the American Academy of Pediatrics (AAP), and the American Academy of Family Practitioners (AAFP)

• Requirements are authorized by the Texas Education Code and Human Resources Code and are specified in 25 TAC §§97.61-72 (Texas Administrative Code)

Recommendation - DTaP

• DTaP – at 2 months, 4 months, 6 months, 15-18 months, and a booster at 4-6 years

• Final dose in series should be given on/after 4 years of age

Tdap Recommendation• Adolescents 11-12 years of age should

receive a single dose of Tdap instead of Td*

• Adolescents 13-18 years who have not have not received Tdap should receive a single dose of Tdap as their catch-up booster instead of Td*

*If the person has completed the recommended childhood DTaP/DTP vaccination series AND has not yet received a Td booster

Requirement-DTP/DTaP/Td

Upon entry into Kindergarten:

• Five doses of any combination DTaP/DTP with one dose on or after 4th birthday

• Or, if the 4th dose was administered on or after the fourth birthday, only four doses are required.

DTaP/Polio Calendar Month of 4th Birthday

• Students who received the 4th dose in the calendar month of or prior to the 4th birthday are in compliance IF:– The 4th dose was administered prior to

August 1, 2004– Enrolled in a grade (K-12) prior to August

1, 2004

7 years or older

• Students 7 years or older

– Three doses of any combination Td/DT/DTP/DTaP vaccine (pertussis vaccine is not required)

– One dose of tetanus-diphtheria containing vaccine is required within last ten years.

Frequently Asked Question

• Q: “Are children who received their 4 year immunizations in the month of or prior to 4th birthday grandfathered under the new law”?

• A: Yes. The rules now contain language stating that students who received the 4th dose in the calendar month of or prior to the 4th birthday prior to 8/1/04 be in compliance.

Recommendation - Polio

• All IPV schedule – at 2 months, 4 months, 6-18 months, and a booster at 4-6 years

• OPV acceptable only in special circumstances

– Unvaccinated child traveling to polio-endemic area in < 4 weeks

– Parents refuse additional injections (3rd and 4th dose only)

Requirement - Polio

• Grades K-12:

– Upon entry into Kg, 4 doses of IPV, one of which has to be on/after 4th birthday;

–3 doses okay if the third dose was given on/after 4th birthday


• Q: “On or after the 4th birthday”– is there any flexibility?

• A: Yes. A dose of DTP or polio vaccine required “on or after the 4th birthday” may have been received up to four days before the 4th birthday. And, if the dose was received prior to 8/1/04, the student is in compliance.

Recommendation-Hepatitis A

• Statewide routine recommendation for children 1 – 18 years of age

• Special recommendation for areas where hepatitis A incidence has exceeded 10 cases per 100,000 on average over a 10 year period

Hepatitis A Requirement

• Required for K-3 grade in areas where hepatitis A incidence has exceeded 10 cases per 100,000 on average over a 10 year period

• Notification will be made by August 1 of each year

• Effective by August 1 of the next year• No counties added since 2005

Hepatitis A Requirement

• 2 doses on or after 2nd birthday

• Required for students attending Kindergarten (K) through third grade in designated counties

• Pre-K– Statewide requirement (HB 1316 79th session)– Verification of 2nd dose not required for

kindergarten entry unless the school is located in one of the 40 designated counties

Counties Requiring Hepatitis A for Kg Entry

Counties that require hepatitis A vaccine for entry into school or child-care:

Newly added counties as of December 2003**Requirement effective August 1, 2005

Recommendation - Varicella

• All children <13 years of age should be administered routinely two doses of varicella-containing vaccine, with the first dose administered at 12-15 months of age and the second dose at 4-6 years of age (i.e., before a child enters kindergarten or first grade)

• A second dose catch-up varicella vaccination is recommended for children, adolescents, and adults who previously had received one dose, to improve individual protection against varicella and for more rapid impact on school outbreaks

• The ACIP recommends that all people ≥13 years of age without evidence of immunity be vaccinated with two doses of varicella vaccine at an interval of 4-8 weeks

Reliable Varicella History

• Written statement from a parent or guardian

• Written statement from a physician

• Written statement from a school nurse

• Serologic test result

*The acceptable evidence of immunity has not changed per the 2006 ACIP recommendation

Requirement - Varicella

• One dose on or after 1st birthday for students in grades 1-12

• Two doses if first dose of vaccine given at 13 years of age or older.

Recommendation - Hepatitis B

• At birth, 1-2 months, and 6-18 months OR 1-2 months, 4 months, and 6-18 months

Requirement - Hepatitis B

• Three doses are required for students in grades K-12

Two-Dose Hepatitis B Vaccine

• Approved only for 11-15 year olds• 2 (1.0 ml) doses given 4-6 months apart• 1.0 ml Merck dose must be documented• Children and adolescents who have begun

vaccination with the three-dose series should complete the three-dose series

• If it is not clear which dose an adolescent was administered at the start of a series, the series should be completed with the three-dose schedule

Recommendation - MMR

• MMR at 12-15 months and 4-6 years

• First MMR should not be administered before 12 months of age

Requirement – MMR/Measles

• Two doses of a measles-containing vaccine with the first dose on or after the first birthday; second dose by age 5 or entry into kindergarten.


• Q: “On or after the first birthday” is there any flexibility?

• A: Yes. Up to four days prior to first birthday. Doses administered prior to September 1, 1990 may have been administered in the calendar month of the first birthday.

Provisional Enrollment Opinion Rendered by Attorney General

(GA-0178)

• DSHS correctly interprets statutes• DSHS provisional rules are enforceable• A child may be denied school admission if the child is

not immunized, does not qualify for one of the statutory exemptions, or does not qualify for provisional admission

• DSHS, and not TEA, has statutory authority to adopt rules on provisional school admission based upon immunization status


• Q: “Are there any exceptions to compliance?”

• A: Yes. Children and students may be excluded from compliance if a medical contraindication to vaccination exists, for reasons of conscience, including a religious belief, or if they are on active duty status in the United States Military.


• Q: “How are Medical Contraindications documented?”

• A: Medical contraindications must be signed by an MD or DO licensed to practice in the U.S. The statement should indicate that it is the physician’s opinion that the required immunization would be injurious to the health and well being of the child/student or a family household member.


• Q: “What needs to be included in the Medical exemption?”

– Must specify the specific vaccination contraindicated

– Unless a lifelong condition is specified, it is valid for one year from date signed and must be renewed annually

– Does not have to be notarized

Conscientious Exemption• Allows exemption for reasons of

conscience, including a religious belief

• Applies to child-care facilities, elementary or secondary schools and institutions of higher education

• Student may be excluded in times of emergency or epidemic

• Requires affidavit

Conscientious Exemption

– Requires written requests for affidavit, including facsimiles

– Requires full name and date of birth of child

– Allows request for up to five forms per child

– Allows exemption for one or more vaccines

– Affidavit form is valid for two years


• Q: “Can an existing exemption form be modified to include newly added vaccine requirements ?”

• A: No. Children and students wishing to claim an exemption for reasons of conscience, including a religious belief must submit another exemption form to the school.


• Q: “Can a student have two exemption forms filed simultaneously”?

• A: Yes. Both forms are valid.

Conscientious Exemption Requests

Current Data on Affidavit Requests (as of dd/mm/yyyy):

• Number of forms sent out:

• Number of requests received:

• Number of children:

On the Horizon…

• Required 4-year review of current rules will begin Summer 2007

• Workgroups will be formed to review proposals for new requirements– July to August

• Proposed Rule timeline – Initial Proposal to DSHS Council, Fall 2007– Final Adoption sometime in 2008

On the Horizon…• Vaccine requirements to be proposed -

(earliest adoption for SY 08-09):– 2 doses of MMR at kindergarten entry– 2nd varicella dose at kindergarten entry– Tdap for a certain grade level (7th)

replacing Td 10 years since last dose

On the Horizon…• Nothing is FINAL—still in the early

phases– The department will follow standard rule

procedure at the time of the official proposal

– All stakeholders will be given opportunity to provide input on all proposed rules via the Texas Register commenting period

2007 Legislative Session

Summary of Legislation

Bills Signed into Law

• HB 1059– Requires each ISD with internet access to

post DSHS immunization requirements/recommendations, flu information, flu clinic locations, and information on how to request a conscientious exemption


Bills Signed into Law• HB 3184 (Relates to child-care facilities)

– Requires DSHS to publish flu awareness information on its website

– Requires DSHS to work with Family & Protective Services to ensure flu awareness information is distributed to parents in August & September of each year


Other Bills Passed

• HB 1098 – No HPV requirement for 6th grade girls

• HB 1379– HPV awareness


Please contact DSHS Immunization Branch, Austin for further information on

the implementation of adopted bills

Contact Information:

Monica Gamez

800.252.9152

Who Do I Contact For More Information on

Immunization Requirements?

Ana Ivette Nunez

Department of State Health Services

Region (11) Immunization Branch

(956) 423-0130

[email protected]

QUESTIONS?

www.ImmunizeTexas.com

school immunization compliance department of state health services

Documents