Vaccination Technical Instructions for Civil Surgeons Joanna Regan, MD, MPH, FAAP Medical Assessment and Policy (MAP) Team Immigrant, Refugee, and Migrant Health Branch November 14, 2018 National Center for Emerging and Zoonotic Infectious Diseases Division of Global Migration and Quarantine Vaccinations in Immigration Law Immigration and Nationality Act (INA) amended in 1997 Immigrants not admissible if They fail to present documentation of having received vaccination against vaccine-preventable diseases including o Mumps, measles, rubella, polio, tetanus, diphtheria, pertussis, influenza B *, hepatitis B o Vaccines recommended by the Advisory Committee on Immunization Practices (ACIP) * Interpreted to mean Haemophilus influenzae type B
Clarifying ACIP Recommendations in the Context of Immigration ACIP recommends many vaccinations for various circumstances INA does not specify which ACIP recommendations to follow for applicants General public Travelers Special circumstances Immigrant vaccine requirements needed clarification with the new criteria Criteria for Required Vaccinations for Immigration 2009 Federal Register Notice (FRN) Criteria: The vaccine must Be age-appropriate for the immigrant applicant Protect against a disease that has the potential to cause an outbreak in the US Protect against a disease that has been eliminated or is in the process of being eliminated in the United States
Vaccination Technical Instructions (TIs) The 2009 Vaccination TIs were developed by the CDC MAP team based on INA amendment and FRN criteria and updated in 2017 Goal Interpret the US immigration vaccine requirements into usable instructions for civil surgeons 2017 Changes to Vaccination Technical Instructions Varicella verbal history clarification DTaP/Tdap clarification and vaccine decision tool
Overview Section Designed to give a quick overview Provides brief background and links to more in-depth explanation of the Vaccination TIs Lists diseases for which applicants must have evidence of vaccination Provides quick link to the table Provides quick links to the most commonly used resources, for example, CDC Pink Book*, vaccine storage and handling guidance, Vaccine Information Statements *Epidemiology and Prevention of Vaccine-Preventable Diseases Review of Vaccination Records Applicant should provide all written records of vaccination history to the civil surgeon Must be in the form of a written personal vaccination record or copy of a medical chart Must include the date of each dose (month, day, and year) Civil Surgeon must document all acceptable vaccination history and relevant immunity on the I-693
Laboratory Confirmation of Immunity Acceptable for the following diseases: Measles Mumps Rubella Hepatitis A Hepatitis B Polio Varicella Laboratory Confirmation of Immunity Laboratory confirmation not required for varicella if a reliable written or oral history of disease is provided New TIs further define what is considered an acceptable history: To verify a history of varicella, health care providers should inquire about: an epidemiologic link to another typical varicella case or to a laboratory confirmed case, or evidence of laboratory confirmation, if testing was performed at the time of acute disease Persons who have neither an epidemiologic link nor laboratory confirmation of varicella should not be considered as having a valid history of disease. CDC definition of typical varicella case The rash is generalized and pruritic (itchy). It progresses rapidly from macules to papules to vesicular lesions before crusting. The rash usually appears first on the head, chest, and back then spreads to the rest of the body. The lesions are usually most concentrated on the chest and back. In healthy children, varicella is generally mild, with an itchy rash, malaise, and temperature up to 102 F for 2 to 3 days. Infants, adults, and immunocompromised people are at risk for more severe disease and have a higher incidence of complications.
Determining the Vaccines the Applicant Needs The applicant must show proof of having age-appropriate vaccination or immunity to the following diseases Diphtheria Tetanus Pertussis Polio Measles Mumps Rubella Rotavirus Haemophilus influenzae type b (Hib) Hepatitis A Hepatitis B Meningococcal disease Varicella Pneumococcal disease Influenza The New Table
Sample of the CDC DTaP/Tdap decision tool Determining the Vaccines the Applicant Needs (cont d) If the applicant received one or more doses of a required vaccine and is due for the next dose in the series, it should be given at the medical examination If the applicant has not received any of the doses of a vaccine required for their age, the first dose should be given In order to determine the number of doses and spacing for each vaccine, use the standard ACIP recommendations; the TIs contain a link In addition to the standard ACIP recommendations, there are recommended doses for medical conditions and other situations such as pregnancy or travel; these additional vaccines are not required for status adjustment
ACIP-recommended Immunization Schedule for Persons Ages 0 Through 18 Years United States, 2018 http://www.cdc.gov/vaccines/schedules/downloads/child/0-18yrs-child-combined-schedule.pdf ACIP-recommended Adult Immunization Schedule United States, 2018 https://www.cdc.gov/vaccines/schedules/downloads/adult/adult-schedule.pdf
Identifying Potential Contraindications and Precautions to Vaccination A contraindication is a condition that is likely to result in a life-threatening problem if the vaccine is given A precaution is a condition that might increase the chance of a serious adverse reaction if the vaccine is administered or a condition that might compromise the immune response to the vaccine In general, civil surgeons should not give a vaccine when a precaution or contraindication is present Identifying Potential Contraindications and Precautions to Vaccination Resources ACIP immunization schedules footnotes The Pink Book s chapter on General Recommendations on Immunization gives a helpful summary of ACIP s contraindications, precautions, misconceptions about contraindications, and a list of screening questions that civil surgeons can use Contraindications and precautions to specific vaccines are available at https://www.cdc.gov/vaccines/hcp/aciprecs/general-recs/contraindications.html For pregnant women, contraindications and precautions available at http://www.cdc.gov/vaccines/pubs/pregguide.htm
Waivers and Documenting Reasons for Not Giving a Vaccine Blanket Waiver Categories Not age-appropriate Insufficient time interval between doses Contraindication Not routinely available Influenza vaccine not available Known chronic hepatitis B virus infection Applicants may request a waiver based on religious or moral convictions If applicants refuse vaccines and don t have a waiver, they are inadmissible Vaccine Resources for Civil Surgeons Handling, Storage, and Administration: Pink Book chapter on Vaccine Storage and Handling, CDC s Vaccine Storage and Handling website, and http://www.immunize.org/packageinserts/ Counseling and Resources: Vaccine Information Statements Advisory Committee on Immunization Practices (ACIP) Schedules and Updates: links included to both Epidemiology and Prevention of Vaccine-Preventable Diseases Pink Book
Printable PDFs Thank you qapcivilsurgeons@cdc.gov For more information please contact Centers for Disease Control and Prevention 1600 Clifton Road NE, Atlanta, GA 30333 Telephone: 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348 Visit: www.cdc.gov Contact CDC at: 1-800-CDC-INFO or www.cdc.gov/info The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. National Center for Emerging and Zoonotic Infectious Diseases Division of Global Migration and Quarantine