2. Childhood Immunization Update Presented by: Deanna Brown, IPC, State Immunization Program Patty Portwood, IC, South Central Health District Date: April 22, 2015

3. Conflicts of Interest and Disclosures Neither the planners or presenters indicated that they have any real or perceived vested interest that relate to this presentation nor any relationships with pharmaceutical companies, biomedical device manufacturers, and/or other corporations whose products and services are related to the vaccines we discuss. There is no sponsorship or commercial support being received for this activity. The mention of specific brands of vaccines in this presentation is for the purpose of providing education and does not constitute endorsement by the provider or ANCC of any commercial products. For certain vaccines this may represent a slight departure from or off-label use of the vaccine package insert guidelines.

4. Objectives Explain vaccine preventable diseases and morbidity rates for preventable diseases in GA Discuss GA immunization law and DPH rules and regulations for GA immunization certificates; including the new seventh grade school requirements Review the provider, school and parent responsibility to enforce the law Describe standards for issuing and filing certificates of immunizations Review the public health assessment process Identify common errors seen on GA Immunization certificates

5. The Impact of Vaccines N/A = Data not available * MMWR 48(12);243-248 April 2, 1999 ** MMWR 63(32);702-715 August 15, 2014

6. Herd Immunity Immunized individuals block infection from reaching those who are unimmunized INFECTED UNIMMUNIZED INFECTED = immunized

7. Advisory Committee on Immunization Practices (ACIP) 15 voting members with expertise in one or more of the following:  Vaccinology  Immunology  Infectious diseases  Pediatrics  Internal Medicine  Preventive medicine  Public health  Consumer perspectives and/or social and community aspects of immunization programs ACIP develops recommendations and schedules for the use of licensed vaccines

8. Indications Recommendations Requirements Indication - Information about the appropriate use of the vaccine Recommendation - ACIP statement that broadens and further delineates the Indication found in the package insert -Basis for standards for best practice Requirement - Mandate by a state that a particular vaccine must be administered and documented before entrance to child care and/or school

9. Immunization Schedules All staff must use the same immunization schedule Four Schedules:  Children & Adolescents 0 through 18 years  Catch-up schedule for ages 4 months -18 years  Adult 19 years and older  Adult based on medical and other indications READ THE FOOTNOTES http://www.cdc.gov/vaccines/schedules/hcp/child-adolescent.html http://www.cdc.gov/vaccines/schedules/hcp/adult.html

10. IT’s The Law!

11. Observe the Guidelines Route of administration Number of doses required 4-day grace period Minimal age for immunization Minimal interval between doses

12. General Recommendations Simultaneous Administration Non-Simultaneous Administration Two live-vaccines Violation of minimal time interval for live vaccines Minimum time and age intervals Violation of minimum time and age intervals/grace period Administration of vaccines later than recommended schedule Vaccine Administration principles Administering combination vaccines Contraindications and Precautions

13. Diphtheria Pertussis Tetanus Required for school and child care attendance

17. Hepatitis B

19. Hepatitis A Required for school or child care attendance for children born on or after 1-1-06

21. Haemophilus influenzae Type b (Hib) Required only for child care and pre-K attendance

24. Polio Ref. MMWR 2009; 58 (30);829-830 (August 7, 2009) Source: World Health Organization Required for school and childcare attendance

26. Measles (M) Mumps (M) Rubella (R) Congenital Rubella (R) Measles, Mumps, Rubella Source: Creative Commons Source: American Academy of Pediatrics Red Book On Line Visual Library

28. Varicella (Chickenpox) © Copyright American Academy of Pediatrics

31. Spacing of Live Virus Vaccines and Other Products PPD and live virus vaccine – Apply PPD at same visit as MMR – If MMR given first, delay PPD 4 weeks or longer – Apply PPD first, then give MMR when skin test read Spacing with antibody-containing products such as immune globulin (IG)

32. Pneumococcal Disease Required for child care and pre-K attendance

36. Influenza Vaccine Not required for school or child care attendance

39. Flucelvax (Novartis) – Approved for persons 18 yrs and older – Vaccine viruses are not propagated in eggs; however, initial reference strains have been passaged in eggs – Cannot be considered egg-free, though expected to contain less egg protein than other IIVs – Abbreviated ccIIV FluBlok (Protein Sciences) – Approved for persons 18 and older – Vaccine contains recombinant influenza virus hemagglutinin Protein is produced in insect cell line No eggs or influenza viruses used in production – Egg-free – Abbreviated (RIV) Influenza Vaccines Produced via Non-Egg-Based Technologies

40. Influenza Vaccine and Egg Allergy Recommendations regarding influenza vaccination of persons who report allergy to eggs — ACIP 2014–15 influenza season

41. Meningococcal Disease New 7 th Grade School Requirement

45. Types of Human Papilloma Virus (HPV) Mucosal/Genital ~40 types Cutaneous ~60 types Cervical cancer Anogenital cancer Oropharyngeal Cancer Cancer precursors Low grade cervical disease Genital Warts Laryngeal Papillomas Low grade cervical disease Skin warts Hands and Feet High risk types 16, 18, 31, 33, 45, 52, 58 (and others) Low risk types 6, 11 and others Ref: 1.Epidemiology and Prevention of Vaccine Preventable Diseases 12 th Edition, May 2012 2. Red Book – AAP 2012 Report of the Committee on Infectious Diseases

49. Just as a reminder…… Regardless of: – the availability of vaccine – the funding of the vaccine (VFC, state- supplied, or private stock) – whether the vaccine is required for school or child care or not………. FOLLOW ACIP Recommendations !!!

50. Requirements for School and Childcare Attendance

51. Vaccines Required for School and Childcare Attendance: Consistent with the Recommended Childhood and Adolescent Immunization Schedule Require children to be age appropriately immunized against each of the specified vaccine preventable diseases

52. Goal Vaccines work Goal 100 % compliance rate Immunization Laws work Partnerships work

53. DPH Rules and Regulations Provide definition of terms Stipulate the specific requirements – List required vaccines or – Acceptable proof of immunity – Define medical and religious exemptions Provide directions for issuing, maintaining, and inspecting certificates GA Rules and Regulations updated for the 2014-2015 school year to reflect the new school requirements. (511-2-2)

54. 3231 REQ

55. 3231 INS

56. Form 3231

57. Certificate of Immunization (Form 3231) A child must have a certificate on file at each facility or school he attends Photocopies of appropriately completed and signed certificates are acceptable If a certificate is not on file for each child attending, the facility is held legally responsible A licensed Georgia physician, APRN, PA or public health official is responsible for the interpretation of and compliance with the requirements for vaccines and completing the certificate Only physician offices and health clinics can obtain blank certificates

58. “X” Marks the Spot If child is under four years of age, a certificate: – Must be marked with a “Date of Expiration” – Must have vaccine administration dates, year of disease diagnosis, positive serology, disease history, or medical exemption If child is over four years of age, a certificate must be completed with: – Vaccine administration dates, year of disease diagnosis, positive serology, disease history, or medical exemption; and – An “x” in the “Complete for K-6 th Grade“ box along with a “Date of Expiration”; or – An “x” in the “Complete for 7 th Grade or higher” box and “K-6 th Grade” box if all required vaccines for school attendance have been documented

59. Certificate Expiration Date Expires on the date entered as “Expiration Date” Must be replaced with a current certificate within 30 days after the expiration date, or child is excluded from attending Allows for a child who does not meet all the immunization requirements to attend child care or school while he is catching up Required for all children four years and older who have not completed vaccine requirement for 7 th grade Required if a medical exemption for a vaccine(s) is marked Should not be completed if “Complete for 7 th Grade or higher” is marked

60. “Complete for School Attendance” Do not expire May be issued only to children who: – Are four years of age or older; and – Have met all the requirements for school attendance as outlined in the Policy Guide 3231REQ; and – Have all the required vaccine administration dates or natural immunity dates filled in; and – Do not have a “Date of Expiration” completed

61. Immunity and Medical Exemptions Diagnosed Serology History Medical Exemption

62. Exemptions Medical: – Should be used only when there is a physical disability or condition that contraindicates immunization for that specific vaccine – Should be documented in the medical exemption box indicated for each vaccine – Should be reviewed annually

63. Exemptions Religious: – Not documented on the certificate – No special certificate available or needed – Documented by a notarized affidavit stating that immunization conflicts with the parent/guardian’s religious belief – Notarized statement should be kept on file by the school or facility in lieu of a Certificate of Immunization – Do not expire

64. Child Care Vaccine Requirements The number of doses for each required vaccine depends on the child’s age at the time of child care attendance. – If under 4 years of age, child will always need more doses and Certificate of Immunization should have a current “Expiration Date” indicated. – If 4 years or older, and has met all requirements for school entry, the Certificate of Immunization is marked as “Complete for K through 6 th Grade,” with a “Date of Expiration” indicated for 7 th Grade vaccination requirements.

65. School Vaccine Requirements A “new entrant” enrolling in a Georgia school at any grade or level, must be age appropriately immunized with all the required vaccines. The number of doses for each vaccine depends on the child’s age at the time of school entry Once enrolled and a “Complete for 7 th Grade or higher ” certificate is on file further immunizations may be recommended but are not required. – Reminder: Check for one dose of Tdap and one dose of MCV4 at entry into 7 th grade for those students born on or after 1-1-2002 and all “new entrants” 8 th through 12 th grades – Also double check for 2 doses of measles, mumps, and varicella or immunity status

66. Immunization Assessments The following information is recorded during the immunization assessment:  Number of children enrolled  Number of children who have valid current certificates  Number of children with expired certificates  Number of children with current 30-day waivers  Number of children with religious exemptions  Number of children with medical exemptions  Number of children with certificates marked “complete” but missing required doses  Number of children with no documentation on file

67. School Immunization Assessments – Children entering kindergarten, 7th grade and all “new entrants”, must adhere to new school requirements based on the revised rules and regulations. – Students K-6 that have a Form 3231 that is marked as “Complete for School Attendance” must obtain a new 3231 prior to 7 th grade reflecting all new required vaccines. – Children who have certificates that will expire after 7-1-14 are considered to be current until the “Date of Expiration”. They should obtain a new 3231. – Children in 7th grade or higher born prior to January 1, 2002 and have a “Complete for School” certificate on file, do not need to obtain a revised certificate.

69. 3: Completing both boxes: When all requirements have not been met 10: “Complete for School” checked for child under age 4 9: No dose DTaP after 4th birthday 2: Doses Hep B spaced incorrectly 7: 1st dose MMR given before age 1 yr. 6: 1st dose varicella given before age 1 yr. 8: No 2nd dose varicella documented 5: Varicella Immunity not documented by vaccine or hx/dx/serology date 4: Address and/or contact information not completed 1: No physician, APRN or PA signature 11. No dose of Tdap or MCV4 for students born on or after 1-1-2002 entering 7 th grade or “new entrants”

70. Maintenance of Certificates To be valid, certificates must be current – Certificate becomes invalid on the “Date of Expiration” – Child must submit a current certificate within 30 days after the expiration date or be excluded from attendance – Facility or school is responsible for notifying parent/guardian of an upcoming expiration date and requesting a current certificate be submitted – Any school/facility official who does not enforce the requirements shall be guilty of a misdemeanor

71. Filing of Certificates All children enrolled must have a valid Certificate of Immunization on file Certificates must be available for inspection by health officials If child attends more than one facility, a photocopy to the second facility is acceptable If child leaves or transfers to another school or facility, the certificate should be given to a parent/guardian or sent to the new school/facility In the case of religious exemption, a dated notarized statement must be on file

72. Tickler Filing System Immunization Guidelines for Child Care Facility Operators & School Personnel (Form 3258) provides “how to” instructions Tickler system is method for filing and maintaining current certificates (set up by month and year) Remind parents or care givers Give parents information sheet about requirements Document follow-up Enforce requirements

73. Georgia Registry of Immunization Transactions and Services (GRITS)

74. Responsibilities Physicians and Public Health Clinics: – Know current legal requirements for attendance and accurately completing the certificate – Administering immunizations according to the current Recommended Childhood and Adolescent Immunization Schedule – Report the occurrence of any disease listed on the “Notifiable Disease List” – Report any adverse event following the administration of a vaccine to VAERS Child Care and School : – Review the certificates for validity prior to accepting – Develop a system for immunization certificate management/Tickler system – Have certificates available for inspection and audit by health officials – Report the occurrence of any disease listed on the “Notifiable Disease List” Parent/Caregiver: - Stay on immunization schedule – Obtain immunization certificate – Provide copy of certificate to each facility

75. Critical Elements for Immunization Services

76. Every Office and Clinic Needs A Vaccine Champion! Lead your immunization team. Educate all staff about new vaccines and recommendations. Teach new staff about vaccine storage, handling, & administration. Initiate processes to improve immunization rates in your practice/facility. Assure immunizations of all staff are up-to-date.

77. Standards for Child, Adolescent, and Adult Immunization Practices Availability of vaccines Assessment of client’s vaccination status Effective communication with client or parent Proper storage and handling of vaccines Accurate documentation of vaccinations Implementation of strategies to improve rates Developing partnerships and community-based approaches to vaccine delivery

78. VAERS

79. Vaccine Injury Compensation Program (VICP) National Vaccine Injury Compensation Program provides compensation to individuals found to be injured by or have died from certain childhood vaccines. – Established in 1988 by NCVIA – Federal “no fault” system to compensate those injured – Claim must be filed by individual, parent or guardian – Must show that injury is on “Vaccine Injury Table”

80. Notifiable Disease Reporting

81. IT STARTS WITH YOU!

82. Healthcare Personnel (HCP) Need These Immunizations: Annual influenza vaccine Tdap or Td Hepatitis B (exposure risk) Check immunity Validate immune status of: Varicella Measles, Mumps & Rubella(MMR) Are YOU up to date?

83. Resources for Factual & Responsible Vaccine Information www.immunize.org

84. Stay Current! Sign up for listserv sites which provide timely information pertinent to your practice www.immunize.org/resources/emailnews.asp www.immunize.org/resources/emailnews.asp – AAP Newsletter – CDC immunization websites (32 in all) – CHOP Parents Pack Newsletter – IAC Express – Websites specific to particular vaccines

85. Internet Resources Georgia Department of Public Health http://dph.georgia.gov/immunization-section CDC Immunization information http://www.cdc.gov/vaccines/ CDC Flu information http://www.cdc.gov/flu/ Immunization Action Coalition www.immunize.org

86. Resources Local health department District Immunization Coordinator GA Immunization Program Office – On call Help line: 404-657-3158 – GRITS Help Line:1-866-483-2958 – VFC Help Line:1-800-848-3868 – Website http://dph.georgia.gov/immunization-section – Your local Immunization Program Consultant (IPC) – Epidemiology: 1-866-782-4584 GA Chapter of the AAP GA Academy of Family Physicians

87. http://dph.georgia.gov/immunization-section

88. It’s a Team Effort! High Immunization rates begin with a team designed plan! What can your team do to improve rates?