1. School Immunization Compliance www.ImmunizeTexas.com Department of State Health Services

2. 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

3. 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

4. Recommended or Required? Recommendations are for everyone Requirements are for children attending child-care facilities or school

5. 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)

6. 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

7. 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

8. Requirement-DTP/DTaP/Td Upon entry into Kindergarten: Five doses of any combination DTaP/DTP with one dose on or after 4 th birthday Or, if the 4 th dose was administered on or after the fourth birthday, only four doses are required.

9. DTaP/Polio Calendar Month of 4 th Birthday Students who received the 4 th dose in the calendar month of or prior to the 4 th birthday are in compliance IF: –The 4 th dose was administered prior to August 1, 2004 –Enrolled in a grade (K-12) prior to August 1, 2004

10. 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.

11. 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 4 th dose in the calendar month of or prior to the 4 th birthday prior to 8/1/04 be in compliance.

12. 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 (3 rd and 4 th dose only)

13. Requirement - Polio Grades K-12: –Upon entry into Kg, 4 doses of IPV, one of which has to be on/after 4 th birthday; –3 doses okay if the third dose was given on/after 4 th birthday

14. Frequently Asked Question Q: “On or after the 4 th birthday”– is there any flexibility? A: Yes. A dose of DTP or polio vaccine required “on or after the 4 th birthday” may have been received up to four days before the 4 th birthday. And, if the dose was received prior to 8/1/04, the student is in compliance.

15. 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

16. 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

17. Hepatitis A Requirement 2 doses on or after 2 nd birthday Required for students attending Kindergarten (K) through third grade in designated counties Pre-K –Statewide requirement (HB 1316 79 th session) –Verification of 2 nd dose not required for kindergarten entry unless the school is located in one of the 40 designated counties

18. 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

19. 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

20. 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

21. Requirement - Varicella One dose on or after 1 st birthday for students in grades 1-12 Two doses if first dose of vaccine given at 13 years of age or older.

22. Recommendation - Hepatitis B At birth, 1-2 months, and 6-18 months OR 1-2 months, 4 months, and 6-18 months

23. Requirement - Hepatitis B Three doses are required for students in grades K-12

24. 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

25. Recommendation - MMR MMR at 12-15 months and 4-6 years First MMR should not be administered before 12 months of age

26. 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.

27. Frequently Asked Question 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.

28. 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

29. Frequently Asked Question 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.

30. Frequently Asked Question 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.

31. Frequently Asked Question 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

32. 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

33. 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

34. Frequently Asked Question 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.

35. Frequently Asked Question Q: “Can a student have two exemption forms filed simultaneously”? A: Yes. Both forms are valid.

36. 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:

37. 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

38. On the Horizon… Vaccine requirements to be proposed - (earliest adoption for SY 08-09): –2 doses of MMR at kindergarten entry –2 nd varicella dose at kindergarten entry –Tdap for a certain grade level (7 th ) replacing Td 10 years since last dose

39. 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

40. 2007 Legislative Session

41. 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

42. Summary of Legislation 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

43. Summary of Legislation Other Bills Passed HB 1098 –No HPV requirement for 6 th grade girls HB 1379 –HPV awareness

44. Summary of Legislation Please contact DSHS Immunization Branch, Austin for further information on the implementation of adopted bills Contact Information: Monica Gamez 800.252.9152

45. 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 Ivette.Nunez@dshs.state.tx.us

46. QUESTIONS? www.ImmunizeTexas.com