2. Immunization waivers for school - age children NURSING 310 ASHLEY GOSS ERIK MORELL RANDI SNIEGOWSKI SUSAN TRUDEAU www.images.google.com

3. Introduction: The purpose of this presentation is to address immunization waivers and how they affect school – age children and the community as a whole. The following topics will be addressed in this presentation: Exemptions and non-medical waivers Description of the vulnerable population Literature review Health risk factors including cultural, environmental and community Statistics related to the population at risk Health promotion theory Goals related to Healthy People 2020 Design of a health promotion tool to target the population

4. History: In 1850, the first school vaccination requirement was enacted in Massachusetts to prevent smallpox transmission in schools (Malone & Hinman, 2007). By 1980, all states required children to be vaccinated against certain communicable diseases as a condition for school attendance. The purpose is protect school children from vaccine preventable diseases. (Malone, & Hinman, 2007). There are exemptions to the state requirements.

5. Exemptions: The exemptions to the legislative requirement for school aged children vary state to state (National Conference of State Legislatures, 2016). All states allow medical exemptions (medical contraindications) Almost all allow religious exemptions (non-medical waiver) 20 states allow philosophical exemptions (non-medical waivers) The approach to obtaining the exemptions vary state to state. The requirements to report vary state by state California and Vermont passed recent legislation that will not allow philosophical exemptions beginning July 2016. Several other states are considering legislation to address exemptions (National Conference of State Legislatures, 2016).

6. Non-Medical Waivers in Michigan: In 2014, the state of Michigan had the 6 th highest immunization waiver rate in the country with more than 5% of Kindergarten students not vaccinated with all of the required vaccines. High waiver rates result in more children susceptible to serious vaccine preventable diseases. To address the higher waiver rates, a new rule went into effect in January of 2015 that required parents that wanted a non-medical waiver to meet with health department staff to obtain the waiver. Prior to the new rule, parents could get a waiver from the school at the time of enrollment. The purpose of the rule change was to allow parents an opportunity to discuss their concerns and provide parents with evidence based knowledge when making the decision to immunize or not. (Michigan Department of Health & Human Services, 2016).

7. Vulnerable population: ● Vaccines have minimized or eliminated outbreaks, but the viruses are still circulating. ● Choosing an immunization waiver poses a health risk to: Those with severe allergic reactions to an ingredient in the vaccine and unable to be vaccinated Children that are too young to receive the vaccine or are not old enough to have received the full series (example: newborn immunizations start at 2 month maybe longer if prematurely born, MMR and varicella 1 year old, Meningitis 11 years old) Unvaccinated people based on religious or philosophical reasons Under vaccinated based on an alternate schedule or not up to date with their immunizations Elderly - decreased immune response (Center for Disease Control, 2016).

8. Demographics & Social Determinants: Under vaccinated children: Mothers are young Mothers have low educational level Household in poverty Live in central area’s of a city Tend to be male More likely to be African American Unvaccinated children: Mothers are middle age Mothers have high level of education Household yearly income > $75,000 Tend to be male More likely to be Caucasian Concerned about vaccine safety www.images.google.com (Smith, Chu, & Barker, 2004).

9. Cultural descriptors: Religious: Constitutional right due to religious beliefs Ethical dilemma associated with using human tissue cells to create a vaccine The body is sacred and should not receive chemicals Belief that GOD and nature should heal the body Philosophical & Personal: Attitude and personal and ethical beliefs Vaccines are not important for children's health Concerns that vaccines are given for diseases that are not serious Believe their child is unlikely to contract vaccine preventable diseases Lack of confidence in the safety of vaccines Children get too many vaccines that are not good for them Exposure to painful situation Household income and lack of access to health care systems (Kennedy, Brown, & Gust, 2005).

10. Health risk factors in the population: Vaccine-preventable diseases can be deadly. Polio and diphtheria are common in other parts of the world and can be brought to the United States placing unvaccinated children at risk. Michigan reports an increase in pertussis disease in 2014 (1,301 cases). Michigan reports over 600 cases of measles in 2014, the greatest number since 1996. Children too young or those unable to be vaccinated are at risk when disease is introduced to the community. (Center for Disease Control and Prevention, 2016).

11. Environmental & Community risk factors: Vaccine refusals increases risk to individuals and the entire community. High vaccine rates in the community create a herd immunity which benefits the community overall as well as the individual. Children in the community with medical conditions and those that are too young to be vaccinated are more susceptible to disease than the general public. Outbreaks in the community tend to start among those not vaccinated and spread rapidly placing children at serious risk. One case is enough to cause concern in a community. Any vaccine-preventable disease can strike at any time because the diseases are still present in other parts of the world. Measles and pertussis outbreaks are on the rise and can quickly lead to thousands of cases in the community. (Center for Disease Control and Prevention, 2016). (Omer, Salmon, Orenstein, deHart, & Halsey, 2009).

12. Statistics: (Smith et al., 2015). The National Healthy People 2020 target for vaccine coverage for kindergarten children is ≥ 95%. (Smith et al., 2015).

13. Statistics: According to the Michigan Department of Health and Human Services, the change in the waiver process, based on preliminary numbers from the school reporting in November, showed almost 8,000 less waivers for school aged children. (Michigan Department of Health & Human Services, 2016). The improvement in the vaccination coverage rates means that more children are protected from vaccine preventable diseases.

14. Health Promotion Model Nola Pender’s Health Promotion Model targets the emphasis of healthy lifestyle behaviors to improve life. Vaccines have been shown to reduce and eliminate contagious diseases, therefore allowing them to have the chance to make healthy choices. Focuses upon education of promoting healthy behaviors. Supports vaccination through local, state, and global perspectives. Vaccination refusals put the health of children and the community at risk. www.images.google.com

15. Plan of action: In order to reach both the under vaccinated and unvaccinated parent demographic, a campaign on educating the public about the benefits of vaccines will be implemented: Television and radio commercials Billboards Magazine advertisements Advertisements on social media Provide evidence based statistics such as : “A greater than 92% decline in cases and a 99% or greater decline in deaths due to diseases prevented by vaccines recommended before 1980 were shown for diphtheria, mumps, pertussis, and tetanus” (Roush & Murphy, 2007). Roush, S. W., & Murphy, T. V. (2007, November 14). Historical Comparisons of Morbidity and Mortality for Vaccine-Preventable Diseases in the United States. The Journal of the American Medical Association, 298(18). doi:10.1001/jama.298.18.2155 www.images.google.com

16. Plan implementation: Petition schools and hospitals to put up pro-vaccination posters. Utilize online platforms such as Facebook, Twitter, Pinterest, and Instagram. Petition state and federal representatives to make vaccine education a priority. Create local pro-vaccine support groups to spread the benefits of vaccination. www.images.google.com

17. Setting for health promotion activity: Who: *Parents of school-aged children. *Designed to be a short, simple, powerful message that makes the population think of the possible repercussions of non-vaccination. When: *From birth to adulthood. How: *Powerful message poster. Where: *Hospitals (OB & Pediatric units), Pediatric offices, schools, daycares, health departments, online social media.

18. Healthy People 2020: Goal in Healthy People 2020 (healthypeople.gov): “Increase immunization rates and reduce preventable infectious diseases.” As cited from Healthypeople.gov, Vaccines saves 33,000 lives Prevents 14 million cases of diseases Reduces health care cost by $9.9 billion More specific goals Maintain vaccination coverage levels for children in kindergarten Increase routine vaccination of adolescents Achieve and maintain effective vaccination coverage levels for universally recommended vaccines among young children (Office of Disease Prevention and Health Promotion, 2016).

19. Healthy People 2020: Presentation The importance of vaccination in school-aged children will directly effect the healthy people 2020 goals Use of immunization waivers contribute to lack of vaccination, negatively impacting the goals of healthy people 2020 (Office of Disease Prevention and Health Promotion, 2016). www.images.google.com

20. Referenceseferences: Centers for Disease Control and Prevention (CDC). (2016). Vaccines and Immunizations. Retrieved from http://www.cdc.gov/vaccines/ Center for Disease Control and Prevention (CDC). (2016). If you choose not to vaccinate your child, understand the risks and responsibilities. Retrieved from http://cdc.gov/vaccines/hcp/patient-ed/converstations/downloads/not-vacc-risk-bw-office.pdf Google Images (2016). Retrieved from www.images.google.com Kennedy, A.M., Brown, C.J., & Gust, D.A. (2005). Vaccine beliefs of parents who oppose compulsory vaccination. Public Health Reports 120(3), 252-258. Retrieved from www.ncbi.nlm.gov.libvat.ferris.edu/pcm/articles/PMC1497722 Malone, K., Hinman, A. (2007). Vaccination mandates: The public imperative and individual rights. Goodman, R. (Ed.), Law in public health practice (pp. 262-284). doi:10.10931/acprof:oso19780195301489.003.0014 Michigan Department of Health & Human Services. (2016, January 28). Preliminary data shows a statewide decrease in school-aged vaccine waiver rates. Retrieved from: http://www.michigan.gov/mdhhs/0,5885,7-339-73970_71692_71696-374966--,00.html National Conference of State Legislatures. (2016, January 21). States with religious and philosophical exemptions from school immunization requirements. Retrieved from :http://www.ncsl.org/research/health/school-immunization-exemption-state-laws.aspx Office of Disease Prevention and Health Promotion. (2016). Healthy People 2020: Immunization and Infection Diseases. Retrieved from healthypeople.gov.

21. Omer, S.B., Salmon, D.A., Orenstein, W.A., deHart, P., & Halsey, N. (2009). Vaccine refusal, mandatory immunization, and the risks of vaccine- preventable diseases. The New England Journal of Medicine, 360, 1981-1988. doi: 10.1056/NEJMsa0806477 Pender, N. J., Murdaugh, C. L. & Parsons, M. A. (2015). Health promotion in nursing practice (7th ed., pp. 34-35). Upper Saddle River, NJ: Pearson. Roush, S. W., & Murphy, T. V. (2007, November 14). Historical Comparisons of Morbidity and Mortality for Vaccine-Preventable Diseases in the United States. The Journal of the American Medical Association, 298(18). doi:10.1001/jama.298.18.2155 Seither, R., Calhoun, K., Knighton, C.L., Mellerson, J., Meador, S., Tippins, A.,…Dietz, V. (2015). Vaccination coverage among children in kindergarten- United States, 2014-15 school year. Morbidity and Mortality Weekly Report 64(33), 897-904. Retrieved from www.cdc.gov/mmwr/preview/mmwrhtml/mm6433a2.htm Smith, P.J., Chu, S.Y., & Barker, L.E. (2004). Children who received no vaccines: who are they and where do they live? Pediatrics, 114(1), 187-195. Retrieved from http://pediatrics.aappublications.org/content/114/1/187

22. Appendix A Health Promotion Tool Picture retrieved from http://www.kidspot.com.au/Kidspot-Best-of-Awards-2013-Kidspot-Best-of-Awards-5-toys-for-preschoolers- mumslove+7272+763+article.htm

23. Appendix B Health Promotion Tool Picture retrieved from http://www.handinhandparenting.org/article/scrapes-cuts-and-dustups-helping-your-child-heal/