Changes to the Georgia DHR Immunization Rules & Regulations for Childcare and School

1. Changes to the Georgia DHR Immunization Rules & Regulations for Childcare and School March 1, 2007 Video Interactive Conference System (VICS) Georgia CTAE Resource Network Instructional Resources Office

2. Disclosure Statements • Neither the planners of this session nor I have any financial relationship with pharmaceutical companies, biomedical device manufacturers, or corporations whose products and services are related to the vaccines we discuss. • There is no commercial support being received for this event. • The mention of specific brands of vaccines in this presentation is for the purpose of providing education and does not constitute endorsement. • The GA Immunization Program utilizes ACIP recommendations as the basis for this presentation and for our guidelines, policies, and recommendations

3. Discussion Topics • Background and processes • Basis for changing the rules and regulations • Changes to the rules and regulations • Documentation on the revised Certificate of Immunization (Form 3231) • Resources

4. Background & Process • Summer and Fall 2006 • Drafted new rules, gained stakeholder input, briefed Division of Public Health • November 2006 • Submitted proposed changes and justification to DHR Public Health Sub-committee for review • December 2006 • PH Committee proposed rules changes to DHR Board • January 2007 • Period of public comment opened for 1 month • Notices sent to stakeholders

5. Process continued………. • February 2007 • February 2---Public hearing • February 5---Close of public comment period • February 9---Summary of Public Comments sent to PH Committee and DHR Board for review • February 21---DHR Board approved Immunization Rules Changes • February 22---began notification to stakeholders

6. Before presentation to PH Committee Had discussions with stakeholders before proposed changes Received 17 letters of support before Nov. from organizations including: GA AAP, DHR Family Health, GA DOE, GA HMHB, GA DECAL, CHOA, School Nurse Association and private practice physicians During the Public Comment period Received letter of support from Every Child by Two, GA AFP, National HMHB Coalition At the Public Hearing, Georgia Academy of Family Physicians read letter of support and Dr. Keyserling, Emory University (AAP ID Committee) presented supporting evidence for changes Stakeholder Input

7. Getting the word out !!! • News Release • Blast faxes • Providers • Letters and/or Emails: • Over 600 public health and private providers • Approximately 200 school superintendents and 2500 principals of public and private schools • Home School Association • Approximately 10,,00 directors of licensed and family child care facilities, including 4 year old Pre K and Head start programs • School Nurse Association • Articles in professional and parent newsletters • Georgia Immunization Program Web site

8. Basis for Change: ACIP Recommendations • What is the ACIP? • ACIP Recommendations documents • Published statements http://www.cdc.gov/nip/publications/ACIP-list.htm • Provisional statements http://www.cdc.gov/nip/recs/provisional_recs/default.htm • Recommended Childhood and Adolescent Immunization Schedule

9. 2007 Recommended Childhood and Adolescent Immunization Schedules Ages 0-6 years Ages 7-18 years

12. 20th Century Annual and Current Morbidity of Vaccine-Preventable Diseases Percent Decrease 20th Century Annual Morbidity† 2005† Disease Diphtheria Measles Mumps Pertussis Polio (paralytic) Rubella Congenital Rubella Syndrome Tetanus H. influenzae, type b and unknown (<5 yrs) 175,885 503,282 152,209 147,271 16,316 47,745 823 1,314 20,000‡ 0 66 314 25,616 1 11 1 27 226** 100% >99% >99% 83% >99% >99% >99% 98% 99% †Sources: CDC. MMWR 1999; 48:242-264 and MMWR2006;55:883-893. ‡ Data are estimated. Values in YELLOW= at or near record lows in 2005. ** Includes serotype b (9) and unknown serotype (217)

13. Low Rates of Childhood Vaccine Preventable Diseases • Vaccines work • Immunization Laws work • Partnerships work

14. Georgia Law All children attending a facility or school must be immunized according to the rules and regulations established by the Georgia Department of Human Resources (DHR).

15. DHR Rules and Regulations • Provide definition of terms • Determine the specific requirements for immunization based on an immunization regimen equivalent to the current immunization schedule developed by the ACIP and adopted by DHR. • Stipulate which immunizations are required • Provide acceptable means for documentation of immunity and for medical and religious exemptions • Provide directions for issuing, maintaining, and inspecting certificates

16. Changes to DHR Rules & Regulations: New Definition Added • “New entrant” means any child entering any school or facility in GA for the 1st time or entering after having been absent from a GA school or facility for >12 months or 1 school year.

17. Changes to DHR Rules & Regulations: Immunization against 2 additional diseases: • Pneumococcal:Pneumococcal Conjugate Vaccine (PCV) • Hepatitis A: Hepatitis A Vaccine Additional dose requirements to 2 existing required vaccines: • Mumps: 2nd dose • Varicella: 2nd dose

18. Vaccine Requirements • Consistent with the Recommended Childhood and Adolescent Immunization Schedule • Children are required to be age appropriately immunized against each of these diseases: Hepatitis B Polio Diphtheria Measles Tetanus Mumps* Pertussis Rubella Haemophilus Influenzae type b Hepatitis A Varicella (chicken pox)*Pneumococcal disease * 2 doses required

19. Changes to DHR Rules & Regulations: New Certificate

22. Pneumococcal Disease • Pneumococcal Conjugate Vaccine (PCV) is recommended for all children <24 mos. of age and those 24-59 mos. with certain risk factors. • PCV is now required for all children under 5 years of age who attend child care facilities. • The number of doses needed depends on the child’s age at the time the series was started and on their current age.

23. Hepatitis A • Hepatitis A Vaccine is recommended for all children 12-23 mos. of age with catch-up vaccination of older children as indicated. • Immunity will be requiredfor children attending school and child care and who were born on or after 1-1-06. • 2 doses of vaccine administered on or after the first birthday and at least 6 months apart • Date of positive serology

24. Mumps • 2 doses of mumps vaccine are recommended for school aged children and adults at high risk • 2 doses of vaccine or serologic proof of immunity is nowrequired for: • Entry to Kindergarten • Entry to 6th grade • A “New Entrant” at any grade • Vaccine doses must be administered on or after the first birthday and at least 28 days apart

25. Varicella/Chickenpox • Vaccine is recommended for all persons over one year of age who have not had the disease • 2 doses of vaccine or proof of immunity is nowrequired for: • Entry to Kindergarten • Entry to 6th grade • A “New Entrant” at any grade

26. Evidence of Varicella Immunity • Documentation of age-appropriate vaccination: • Preschool-aged children > 12 months: 1 dose • School-aged children, adolescents and adults: 2 doses • If under 13 years of age, a minimum of 3 months apart • If 13 years of age or older, a minimum of 1 month apart • Laboratory evidence of immunity or laboratory confirmation of disease • History of herpes zoster or shingles • A healthcare provider diagnosis of varicella or healthcare provider verification of history of varicella disease. For mild or atypical case: • Assessment by physician is recommended to determine: • Epidemiological link to typical case • Laboratory evidence of immunity if titer done at time of disease

27. New School/ Child Care Requirements Effective 7-1-07 For children attending child care facilities • Hepatitis A vaccination if born 1-1-2006 or later or proof of immunity • Pneumococcal vaccination (If under 5 years of age) For children entering kindergarten, sixth grade and new entrants into Georgia schools • Vaccination with 2nd dose of mumps and varicella vaccines or proof of immunity

28. Form 3231 as of 7-1-07 REQUIRED RECOMMENDED Revised 03/07

29. Age of Child “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 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, and /or year of disease diagnosis, positive serology,disease history, or medical exemption; and • A “Date of Expiration”;or • A mark in the “Complete for School Attendance” box

30. 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 attendance • Each vaccine dose or immunity status must be documented on the certificate.

31. Documentation of Additional Requirements Additional Required Vaccines: • Pneumococcal conjugatevaccine (PCV) (If under age 5 years) • Hepatitis A (Born on or after 1/1/06) Additional Dose Requirements : • Mumps: 2nd dose • Varicella: 2nd dose

32. Immunity and Medical Exemptions Medical Exemption Diagnosed Serology History

33. DELETED

34. Prior to 07/01/2007: Base on current rules and regulations Educate operators and parents of new requirements On or After 07-01-2007: Base on the revised rules and regulations and documentation should be on Form 3231 (Revised 3/2007) with following exceptions: Children who have certificates that will expire after 7/1/07 are considered to be current until the “Date of Expiration”. Children who are enrolled in both school and child care or “after school” programs and andhave “Complete for School” certificates on file at both facilities, do not need to obtain a revised certificate. Immunization InventoriesChildcare Facilities

35. On or after 7-1-07: For children entering kindergarten, 6th grade and all “new entrants”, base on the revised rules and regulations. Documentation should be on Form 3231 (Revised 3/2007) with following exception: If student has a Form 3231 (revised 10/2003) that is marked as “Complete for School Attendance” and the new requirements for 2 doses of varicella and mumps vaccines or proof of immunity are appropriately documented. Immunization InventoriesSchools

36. Children currently enrolled in schools, who have a valid certificate on file, will not be required to meet the new rules and regulations and will not be required to obtain the revised Certificate of Immunization dated 3/2007. Exceptions are: Students entering 6th grade Students who do not have a certificate on file Students who leave and return as “New Entrants”. Immunization InventoriesSchools

37. 2006 Top Ten Certificate “Bloopers” Top Ten 1: Completing both boxes: Should be one or the other 8:Missing information 2: No dose DTaP after 4th birthday 3: Doses Hep B given too early 4: 1st dose MMR given before age 1 yr. 5: No 2nd dose MMR documented 7: Immunity not documented by vaccine or hx/dx/serology date 6: 1st dose varicella given before age 1 yr. 9: Not completed 10: No signature

38. Availability of Vaccines from VFC Program for VFC Eligible Children • PCV: • All children 6 weeks through 23 months of age • Children 24-59 months of age with moderate and high risk conditions (This includes children who attend child care) • Hepatitis A: • All children 12 months through 18 years of age • Mumps vaccine: • All children 12 months through 18 years of age

39. Availability of Vaccines from VFC Program for VFC Eligible Children • Varicella Vaccine: • Two doses for all children 12 months through 18 years of age, including: • 2nd dose for children age 4-6 receiving boosters for kindergarten • 2nd dose for children entering 6th grade • 2nd dose for “new entrants” • Two doses for adolescents ≤18 years of age entering college if not already received

40. Possible Vaccine Supply Issues • MMRV: • Anticipate short supply in 3rd and 4th quarter of 2007 • Varicella: • Do not anticipate supply issues with single antigen varicella vaccine

41. Revised Certificates of Immunization(Form 3231) • Are available from the GA Immunization Program Office • Can be printed from the GA Registry of Immunization Transactions and Services (GRITS) • Can be printed from office software systems • If a provider requests permission and receives approval for the certificate from the Georgia Immunization Program • If provider is active participant in GRITS • Certificate must include exact information and have same appearance as DHR Certificate to be approved.

42. Resources • Local health department • District Immunization Coordinator • GA Immunization Program Office • On call Help line: 404-657-3158 • GRITS Help Line:1-888-223-8644 • VFC Help Line:1-800-848-3868 • Website www.health.state.ga.us/programs/immunization • Your local Immunization Program Consultant (IPC) • GA Chapter of the AAP • GA Academy of Family Physicians