CALIFORNIA SCHOOL CODES AND REGULATIONS

E-mail: Sandrajo.Hammer@CDPH.CA.GOV Sandra Jo Hammer, RN, MSN, MPH Nurse Consultant III Immunization Branch California Department of Public Health (510) 620-3735 E-mail: Sandrajo.Hammer@CDPH.CA.GOV

Polio vaccine was delivered in schools The concept and execution of school vaccination goes back to the 1950’s when there was an urgent need to administer polio vaccine to stop ongoing polio disease.Schools were accepting of mass vaccination efforts as polio was so feared and concern was so high that children would contract the disease. Since the 1950’s, all state have enacted regulated school entry vaccine requirements. Most vaccines are delivered during routine care but on occasion, such as the recent H1N1 influenza pandemic, schools were again used as sites for rapid immunization of vulnerable children.

History of CA School Law Smallpox 1961 Polio 1967 Measles 1972 Diphtheria, Tetanus, Pertussis 1980 Mumps, Rubella Broad regulatory authority to DHS Hib Hep B, 7th Gr Pertussis 1991 1994 2011 1999 Smallpox (1889-1921) Polio (1961) Measles, DTP (1971) Late 1970’s (current structure of laws) 1989-1991 (measles resurgence) 1990’s – Hib, Hep B, Varicella requirements. 1990’s were a decade of support, new requirements, huge financial support for vaccines (VFC) 2000’s – No new mandates or regulations until Tdap (2010) . Some challenges to expanded mandates; HPV mandate controversies. 2010’s – Any expansion of mandates will be influenced by disease, vaccines available, and support . Regulations will be rewritten to modernize. 1977 1992-6 1997 2001 Enforcement, implementation strengthened; Day care added Family Childcare Hep B at K Varicella

Vaccines: Required vs. Recommended Required is by state law and/or regulations Recommended is by a recognized group or advising agency (CDC, ACIP, AAP) and is practice standard Very important: Do not to use the two words as the same Recognize the difference. Sometimes, when we talk about vaccines and refer to required and recommended and imply hey are the same. This is not true and a very important difference. Required vaccines are usually by law (in CA , school law, ATD standard) or instituional policy (like hospital pre emplyment). Recommended vaccines are carefully considered policy or guidelines of recognized subject matter experts. So, ACIP is a carefully appointed panel of vaccine experts who consider vaccine recommendations for children and adults. As a coordinator, it is important that you are aware of the differences and avoid using required and recommended interchangably.

Vaccines Required Vaccines required are specific or can be determined by the department California H&S Code, Section 120325-120380 Authority to department (CDPH) to implement vaccine and dose requirements via regulations (rules) California Code of Regulations (CCR), Title 17 § 6000-6075) In CA, vaccines required for childcare and school entry are described in regulations. CDPH has the authority to write regulations and require a specific number of vaccine doses for entry. Regulations are complicated and do not often change. If the law has particular restrictions, these must be demonstrated in the regulations (Varicella restriction for example).

Vaccines Required Code restrictions must be accommodated in regulations Varicella Age restriction Example: 7th grade Hepatitis B In CA, vaccines required for childcare and school entry are described in regulations. CDPH has the authority to write regulations and require a specific number of vaccine doses for entry. Regulations are complicated and do not often change. If the law has particular restrictions, these must be demonstrated in the regulations (Varicella restriction for example).

HEALTH AND SAFETY CODE SECTION 120325-120380 …it is the intent of the Legislature to provide: (a) A means for the eventual achievement of total immunization of appropriate age groups against the following childhood diseases: (1) Diphtheria. (2) Hepatitis B. (3) Haemophilus influenzae type b. (4) Measles. (5) Mumps. (6) Pertussis (whooping cough). (7) Poliomyelitis. (8) Rubella. (9) Tetanus. Example of Heath and Safety Code. Any other disease that is consistent with the most current recommendations of the United States Public Health Services' Centers for Disease Control Immunization Practices Advisory Committee and the American Academy of Pediatrics Committee of Infectious Diseases, and deemed appropriate by the department.

Regulations 120330. The department, in consultation with the Department of Education, shall adopt and enforce all regulations necessary to carry out Chapter 1….

What are regulations? (CCR, Title 17, §6020) “The rules” Definitions, like what is a pupil, what is school entry Number of vaccine doses by age and grade (table on page D-78 of blue book) Unconditional and conditional admission

Nothing is Easy! California Immunization Childcare and School Laws and Regulations are complicated Based on number of doses received Requires

Why was Varicella Different? (10) Varicella (chickenpox), effective July 1, 2001. Persons already admitted into California public or private schools at the kindergarten level or above before July 1, 2001, shall be exempt from the varicella immunization requirement for school entry.

Physician signature here Varicella Physician signature here

CALIFORNIA SCHOOL CODES AND REGULATIONS While this publication appears out of date, it is still technically accurate except for Tdap.

The “Blue Card” is the official California school immunization record..

ShotsforSchool.org Website

We will be referring to the new blue book and the Grades K-12 fact sheet (page B-41 & B-42) throughout much of the presentation. This Fact Sheet will come in very handy when you are trying to decide what immunizations a child needs before starting school.

Footnote regarding 4-day “grace period” In some situations, local or state requirements may mandate that doses of certain vaccines be administered on or after specific ages. For example, a school entry requirement may not accept a dose of MMR or varicella vaccine given prior to the first birthday. California will accept any dose administered up to 4 days before a specific birthday except Tdap.

Pertussis 7th Grade Requirement On and after July 1, 2012, the governing authority shall not unconditionally admit any pupil to the 7th grade level, nor unconditionally advance any pupil to the 7th grade level, of any of the institutions listed in subdivision (b) unless the pupil has been fully immunized against Pertussis. Perussis 7th grade goes into effect July 1, 2012 and is on going. The requirement is a dose of pertussis vaccine on or after the 7th birthday.

Materials for Schools – Tdap Sticker To accommodate current blue cards and not require schools recopy information, a sticker is attached to current blue card for documentation of 7th grade pertussis immunization 20

Vaccine Exemptions

Medical Exemption’s (PME’s) Allowed by statute and regulation in California Can be temporary or permanent Must have signed physician statement describing circumstance and length of exemption

Personal Belief Exemptions (PBE’s) Allowed by statute and regulation in California Should not be used a “convenience” but reflect parent’s beliefs

PBE Parent or guardian must submit letter or affidavit “Blue card” provides an affidavit for parents For 7th grade, a separate PBE form provided or submit letter or affidavit

Parents may request a Personal Beliefs Exemption (PBE) Parents may request a Personal Beliefs Exemption (PBE). This is their right by law. A PBE is not intended to be used because of failure to obtain the vaccine in a timely manner. This new form is provided because it gives parents more detail about the pertussis disease and school exclusion. The parent should request a PBE and sign and date the form. The exemption is then noted on the sticker.

PBE Education Two tools about vaccine safety: “What if” brochure – school closures, outbreaks – very applicable to parents, available for download at ShotsForSchool.org Vaccine Safety Sheet – developed by CIC, available for download on CIC website, immunizeca.org OR can be ordered through CDPH (IZ Coordinators/Mario)

Schools’ Responsibilities Complete a CA Student Immunization Record for each child (CSIR – “blue cards”) Unconditionally admit all students who have completed required number of doses Conditionally admit students who are “up-to-date”. Follow-up with these students when doses become due Admit children with signed PBE affidavit (back of blue card, 7th grade sheet) or medical exemptions Exclude students not up-to-date, conditional admissions who have not complied with series continuation or completion Complete and submit California School Assessment Forms on-line Schools must also… Conditionally admit students who are “up-to-date”, but are missing additional doses Follow-up with conditionally admitted students Exclude students not up-to-date Update and maintain accurate CA Student Immunization Records (CSIR – blue cards) Complete and submit CA School Assessment Forms Kindergarten and 7th Grade

‘New’ 7th Grade Reporting Page We’re in the process of creating a new 7th grade reporting page.

Additions to School Law Bills can always be introduced that might affect school immunization law Nothing is law until it is signed by the governor CDPH can not comment on any bill in process Process issues New bill (law) – maybe swift Regulations – often take years but “overhaul” package is in process Budget can be a barrier All bills and regulations require fiscal analysis Additions to School Law