Vaccination Case Study Session Joanna Regan, MD, MPH Medical Assessment and Policy Team Immigrant, Refugee, and Migrant Health Branch Panel Physicians Training Summit March 2017 National Center for Emerging and Zoonotic Infectious Diseases Division of Global Migration and Quarantine

After this workshop, you should be able to Learning Objectives After this workshop, you should be able to Use the Vaccine TI table and ACIP tables to determine which vaccines are needed and how to give them Complete the DS 3025 CO: I left this as is to be formatted according to the template you’ve developed as we discussed With the removal of the other STDs, I condensed the bullet points here to apply to just syphilis and Hansen’s disease

How to Use Vaccine Technical Instructions Table and ACIP Recommendations

Vaccination Table in Vaccination Technical Instructions http://www.cdc.gov/immigrantrefugeehealth/exams/ti/panel/vaccination-panel-technical-instructions.html

ACIP-recommended Immunization Schedule for Persons Ages 0 Through 18 Years – United States, 2016 http://www.cdc.gov/vaccines/schedules/downloads/child/0-18yrs-child-combined-schedule.pdf

ACIP-recommended Adult Immunization Schedule – United States, 2016 https://www.cdc.gov/vaccines/schedules/downloads/adult/adult-schedule.pdf

ACIP routine immunization schedule for adults Question 1 A 45-year-old applicant brings you his/her vaccination records, which include college and employer records. What table should you follow to determine what vaccines are needed for U.S. immigration? Vaccine TI table ACIP routine immunization schedule for adults World Health Organization (WHO) Expanded Programme for Immunization Dorland’s guidelines for adult immunizations Answer=A

Process Determine applicant’s age Review his/her vaccination records and medical history Determine the vaccines the applicant needs by referring to Vaccine TI table Current age-appropriate ACIP schedule Assess contraindications and precautions Determine if testing for laboratory evidence of immunity is indicated Provide needed vaccines Complete DS 3025

Vaccine TI Table and ACIP Tables Vaccine TI table provides structure for meeting US immigration immunization requirements Where differences exist between vaccine TI table and ACIP tables: Follow vaccine TI table ACIP tables are comprehensive for that vaccine, including for contraindications Use as detailed resource once you commit to giving a specific vaccine based on the TI table

Vaccine TI Table Strengths Quick way to determine diseases an applicant must be vaccinated against All age groups are on one table Weaknesses Does not provide number of doses Does not explain spacing of doses Does not provide detailed information about contraindications

ACIP Tables Strengths Provides number of vaccine doses, spacing and catch up schedules Comprehensive information for specific vaccines including contraindications Weaknesses Multiple documents, lots of detail U.S. domestic recommendations for individual patient health, not immigration requirements Some differences from TIs (e.g., HPV, zoster)

How to Complete the DS Forms

So the parents have duplicate copies Question 2 You examine a family immigrating to the United States. After giving the family their DS 3025, they ask why you are giving copies of the DS 3025 for the adults, not just the children who need the record for school. Why are you giving the adults a DS 3025 as well? So the parents have duplicate copies For the family to take to their interview CDC Vaccine TI requirement To provide a comprehensive vaccination record Answer=D

DS 3025 Officially: Documents whether or not applicant is inadmissible Documents that applicant has received required vaccinations In addition: Comprehensive vaccination record Resource for applicant after arrival to the United States Captures vaccine doses given as part of special program for U.S.-bound refugees

For All Applicants Obtain vaccine history Document vaccine history Provide a copy of the DS 3025 to the applicant

DS 3025 Page 1 Vertical orientation All diseases must have a vaccine disposition Panel physician must sign and date the form

Immunization Record Record vaccines previously given to applicant in the first four columns Immigrants will only receive one dose of a specific required vaccine by the panel physician before travel Thus, only one column for vaccines you give

Blanket Waiver To our knowledge, no applicant has completed every required vaccine series at the time of the panel physician examination Therefore, “Blanket Waiver” is needed to allow immigration process to continue Blanket waivers for the specific reasons defined are given by the panel physician

Mark Blanket Waiver “A” not age appropriate Question 3 A 45-year-old applicant should receive a dose of varicella vaccine. However, varicella vaccine is not licensed for use in your country. What should you do? Mark Blanket Waiver “A” not age appropriate Mark Blanket Waiver “B” insufficient time interval Mark Blanket Waiver “D” not routinely available Perform laboratory testing for immunity Answer=C.

Mark Blanket waiver “A” not age appropriate Question 4 A family is immigrating to the United States and has a 3-month-old infant who is breastfed. The infant received Haemophilus influenza type b (Hib) vaccine at 2 months of age. What should you do? Mark Blanket waiver “A” not age appropriate Mark Blanket waiver “B” insufficient time interval Finish the medical when Hib vaccine can be given Perform laboratory testing for immunity on infant Perform laboratory testing for immunity on mother Answer=B

Blanket Waiver Category Examples A – Age not appropriate If applicant does not need specific vaccine B – Insufficient time interval to complete series Child receives dose in series but will travel before next dose is due C – Contraindicated D – Not routinely available In country or region Specific vaccine not licensed for age of applicant F – Not flu season Flu season is fall-winter in either hemisphere Tropics: give if product available in your country Not responsible for stocking both hemisphere vaccines H – Known chronic hepatitis B virus infection Document if known, but do not test

Summary for Immigrant Visa Applicants Complete, but requests a Blanket Waiver Applicant is admissible U.S. vaccination requirements not complete Individual waiver Must be opposed to all vaccinations Applicant should discuss the waiver process with the Consular Section Adoptee exemption Applicant refuses vaccinations – inadmissible

Refugee Vaccine Initiative CDC partnering with the International Organization for Migration (IOM) and Department of State to vaccinate refugees Doses provided in that program are documented in these columns Initiative uses different guidance provided by CDC than what is in the Vaccine TI

DS 3025 Page 2

Cases

Thank you cdcQAP@cdc.gov http://www.cdc.gov/panelphysicians http://www.cdc.gov/vaccines/schedules/hcp For more information please contact Centers for Disease Control and Prevention 1600 Clifton Road NE, Atlanta, GA 30333 Telephone: 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348 Visit: www.cdc.gov | Contact CDC at: 1-800-CDC-INFO or www.cdc.gov/info The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. National Center for Emerging and Zoonotic Infectious Diseases Division of Global Migration and Quarantine

Answers A D C B