Welcome to the California Immunization Coalition Education ... · PDF fileWebinar Objectives...

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Welcome to the California Immunization Coalition

Education Hour

Webinar Objectives Understand the impact of Senate Bill 277 on medical

practices and schools

Understand medical exemption from immunization

Locate resources to educate parents and providers

about SB 277

.

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New School Rules: What Providers and Parents Need to Know

New School Rules: What

Providers and Parents

Need to Know

Scott Clark

Associate Director, Medical & Regulatory Policy

California Medical Association

CIC Education Hour, October 28, 2015

Senate Bill 277

Senators Richard Pan, MD & Ben Allen

Challenges to the new law

Referendum to repeal SB 277 needed

365,880 verified signatures

• 233,758 total submitted

• Declared failed October 9

Parental Rights and Responsibilities

Act filed September 23

• Withdrawn October 16

Removes the personal belief

exemption (PBE) from school

vaccination requirements

Allows exemptions only for medical

reasons

SB 277

Applies to:

Public and private elementary or

secondary schools

Child care centers, day nurseries,

nursery schools, family day care

homes and development centers

SB 277

Applies to children entering the California school

system for the first time…

Or when a child advances to the next grade span:

• Birth – preschool

• Transitional K – 6th grade

• 7th – 12th grade

Any child who has a PBE form on file with their

school prior to January 1, 2016 will continue to be

exempted for the remainder of that grade span

SB 277

Clarifies that “family medical history” may be

considered in making the determination, but

the law does not require a medical exemption

based on family medical history

The determination of medical exemptions

remains at the discretion of the licensed

physician

SB 277

SB 277 does not alter current law regarding

physician liability for medical exemptions

from vaccine requirements

Physicians must continue to exercise their

professional judgment in providing or not

providing medical exemptions from the

vaccination requirements to ensure that it

falls within the standard of care

SB 277

Scott Clark

[email protected]

916-551-2887

FAQ available at

www.cmanet.org

mailto:[email protected]

mailto:[email protected]

http://www.cmanet.org/

New School Rules: What Providers Need to Know About Medical Contraindications to Immunization Under SB 277 Randy Bergen, MD, Pediatric Infectious Disease Kaiser Permanente, Northern California

14 | © Kaiser Permanente 2010-2011. All Rights Reserved. October 29, 2015

Randy Bergen, MD Pediatric Infectious Disease

Kaiser Permanente, Walnut Creek

15 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only. October 29, 2015

Objective

Understand the process for determining

medical exemption from immunization

Third Agenda

Fourth Agenda

Fifth Agenda


Be Clear About Your Role

Clinicians provide health care.

Schools enforce the law.

Exemptions Permitted by California Law

Requirements for Medical Exemptions

A parent or guardian must submit a written statement from a licensed physician (M.D. or D.O.) which states:

• That the physical condition or medical circumstances of the child are such that the required immunization(s) is not indicated.

• Which vaccines are being exempted.

• Whether the medical exemption is permanent or temporary.

• The expiration date, if the exemption is temporary. .


Exemptions Permitted by California Law

Temporary Medical Exemption

If a child has a temporary medical condition which rules out one or more immunizations, or the physician wishes to delay an immunization, the child can be temporarily exempted from the requirement. A written statement from the physician must be presented at registration. This statement must indicate that there is a medical condition which rules out immunization(s) temporarily, how long it will last, and which immunization(s) must be postponed. It must be signed by the physician.


Intent of the Law

Whether a child should get a medical exemption is a case-by-case decision made by the licensed physician.

No different from other clinical decisions based on evidence, standard of care and best judgment.

19 | © 2014 Regional Health Education, The Permanente Medical Group, Inc. October 29, 2015

Vaccines Required for Childcare / Preschool


Age When Entering Immunizations (shots) Required

2–3 Months 1 each of Polio, DTaP, Hib, Hep B

4–5 Months 2 each of Polio, DTaP, Hib, Hep B

6–14 Months 3 each of DTaP

2 each of Polio, Hib, Hep B

15–17 Months 3 each of Polio, DTaP

2 Hep B

1 MMR

1 Hib

18 months–5 years 3 Polio

4 DTaP

3 Hep B

1 MMR

1 Hib

1 Varicella

www.shotsforschool.org/child-care/

Students Admitted at 4-6 Years Need:

Diphtheria, Tetanus, and Pertussis (DTaP, DTP, or DT) - 5 doses (4 doses OK if one was given on or after 4th birthday)

Polio (OPV or IPV) - 4 doses (3 doses OK if one was given on or after 4th birthday)

Hepatitis B - 3 doses

Measles, Mumps, and Rubella (MMR) - 2 doses (Both given on or after 1st birthday)

Varicella (Chickenpox) - 1 dose


www.shotsforschool.org/k-12/

http://www.cdc.gov/vaccines/vpd-vac/diphtheria/default.htm

http://www.cdc.gov/vaccines/vpd-vac/tetanus/default.htm

http://www.cdc.gov/vaccines/vpd-vac/pertussis/default.htm

http://www.cdc.gov/vaccines/vpd-vac/polio/default.htm

http://www.cdc.gov/vaccines/vpd-vac/hepb/default.htm

http://www.cdc.gov/vaccines/vpd-vac/measles/default.htm

http://www.cdc.gov/vaccines/vpd-vac/mumps/default.htm

http://www.cdc.gov/vaccines/vpd-vac/rubella/default.htm

http://www.cdc.gov/vaccines/vpd-vac/varicella/default.htm

Students admitted at 7-17 Years Need: Diphtheria,Tetanus, and Pertussis (DTaP, DTP, DT, Tdap, or Td) - 4

doses

(3 doses OK if last dose was given on or after 2nd birthday)

Polio (OPV or IPV) - 4 doses

(3 doses OK if one was given on or after 2nd birthday)

Measles, Mumps, and Rubella (MMR) - 1 dose

(2 doses required at 7th grade)

Varicella (chickenpox)

(Admission at ages 7-12 years need 1 dose; ages 13-17 years need

2 doses)

Tetanus, Diphtheria, and Pertussis (Tdap) - 1 dose at 7th grade or

out-of-state transfer admission at 8th - 12th grades

(1 dose on or after the 7th birthday)


www.shotsforschool.org/k-12/




http://www.cdc.gov/vaccines/vpd-vac/polio/default.htm

http://www.cdc.gov/vaccines/vpd-vac/measles/default.htm

http://www.cdc.gov/vaccines/vpd-vac/mumps/default.htm

http://www.cdc.gov/vaccines/vpd-vac/rubella/default.htm

http://www.shotsforschool.org/7th-grade/




http://www.cdc.gov/vaccines/vpd-vac/varicella/default.htm







School requirements are only a subset of all routinely recommended vaccines - Number and timing of doses may vary


Why are we discussing what constitutes a medical contraindication?

Before 2014: Personal belief exemptions (PBEs) were easier to obtain.

2014-15: Under AB 2109, a parent’s request for a PBE required documentation from providers about sharing information on the benefits and risks of

vaccination.

2016- : Under SB 277, PBEs may no longer be filed.

Medical exemptions might be requested by vaccine-hesitant parents as a substitute for PBEs.


The Providers Role

Clinicians need to

– Be clear on what constitutes a medical contraindication

– Communicate his or her assessment to parents


What Qualifies as a Medical Exemption?


Types of Medical Exemptions

Permanent

– Anaphylaxis to vaccine component

– Permanent immune suppressed condition (SCIDS) – Live vaccines only:

MMR, VZV, FluMist, Yellow Fever, Oral Typhoid

Temporary

– Temporarily immunosuppressed (e.g., during cancer chemotherapy) – Live vaccines only


Reasons for Medical Exemptions Typically Rare

History of anaphylaxis

Severely Immunocompromised

Encephalopathy

Guillian-Barré Syndrome

Sources:

Centers for Disease Control and Prevention

Advisory Committee on Immunization Practices

Vaccine Package Inserts


Medical Exemptions and family history

Not mentioned by CDC or ACIP

Not mentioned by AAP

Package Insert MMR, VZV – ‘individuals with a family history of congenital or hereditary immunodeficiency should be evaluated.’

– Immune competence should be demonstrated prior to live virus vaccines

Only applies to live vaccines

No clear guidance on what an ‘evaluation’ should be


Example 1: Mild or Moderate Local Reaction

CDC and ACIP– No

AAP– No

Vaccine Package Inserts – No


Example 2: Anaphylaxis to Tetanus Toxoid

Yes. But only those vaccines that contain tetanus toxoid

All tetanus vaccines – including DTaP, Tdap, Td

Some HiB Vaccines- Including HibeRix, ActHiB, and MenHibRix (contain Tetanus toxoid carrier protein)


Example 3: Personal or Family History of Seizures

Family History – No

Personal history – Maybe

– Depends on type of seizure

– Depends of temporal relationship with vaccination

– In general febrile seizures that might be triggered by vaccine-associated fever is not a contraindication

May wish to consult Pediatric Neurologist


Example 4: Family History of an Autoimmune Disease

CDC / ACIP – No

AAP – No

Vaccine package inserts – No

No recommendations that HLA typing should be done


Example 5: Child on Chemotherapy for Acute Lymphocytic Leukemia (ALL)

Yes

Live vaccines (e.g., MMR, VZV) contraindicated until child is once again immunocompetent

Inactivated vaccines can be administered


Example 6: Breastfeeding, pregnancy or immunocompromised condition in a household contact

Breastfeeding, pregnancy or immunocompromised condition in a household contact – Not contraindicated

But if patient is pregnant

– No live vaccines

– Inactivated vaccines are OK


Conditional Exemptions

Child has not received all required vaccines, but parents are following the catch-up schedule specified in state regulations

o Schedule varies slightly from CDC/AAP/AAFP minimum intervals, but those minimum intervals will also suffice

Schools are required to follow-up on students until they are caught up.

Parents may share with you school communications about compliance with catch-up schedule

All vaccines may and should be given concurrently


Communication Tips for Physicians

Empathy – don’t be adversarial

Cognitive Ease – make getting the vaccine the natural choice

Identity Strategy – you and the family are on the same side. Both want the best for the child.

Advantageous terms – don’t use negative terms – focus on protection


Communication Tips

Be mindful of consistency

Don’t let conflict pull you into signing forms if you wouldn’t sign otherwise

Reach out to subspecialty colleagues to discuss difficult cases


Communication Tips

Emphasize the unique nature of each encounter

“In this room, it’s just you and me and your child. And I still care for him ( or her), and will work with you, just like I always have.”


SUMMARY

There are justifiable reasons for Medical Exemptions to vaccines, but they are limited.

The final decision about a medical exemption to a vaccine has to be an individual decision a physician makes for each patient.


Resources

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www.cdc.gov/vaccines/recs/vac-admin/contraindications.htm


www.cdc.gov/vaccines/recs/vac-admin/contraindications-vacc.htm

Shots for School

www.shotsforschool.org/laws/exemptions/

http://www.shotsforschool.org/laws/exemptions/

www.EZIZ.org

A one stop shop

for immunization

training and

resources –

including the

updated

California

Immunization

Handbook!

Immunization Action Coalition

www.immunize.org/catg.d/p4065.pdf

http://www.immunize.org/catg.d/p4065.pdf

Vaccine Adverse Events Reporting System VAERS

www.cdc.gov/vaccinesafety/ensuringsafety/monitoring/vaers/index.html

http://www.cdc.gov/vaccinesafety/ensuringsafety/monitoring/vaers/index.html

Twitter @ImmunizeCA

Facebook ImmunizeCA

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Question and Answer Session

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Online Evaluation!

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Thank you

Health Net of California, Inc.

Kaiser Permanente, Northern California

California Medical Association

California Department of Public Health Immunization Branch

Welcome to the California Immunization Coalition Education ... · PDF fileWebinar Objectives...

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