Welcome to the California Immunization Coalition Education Hour

Welcome to the California Immunization Coalition Education Hour 1

. New School Rules: What Providers and Parents Need to Know 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 2

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233,758 total submitted Declared failed October 9 Parental Rights and Responsibilities Act filed September 23 Withdrawn October 16

SB 277 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 6 th grade 7 th 12 th 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

FAQ available at www.cmanet.org Scott Clark sclark@cmanet.org 916-551-2887

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

Randy Bergen, MD Pediatric Infectious Disease Kaiser Permanente, Walnut Creek 14 October 29, 2015 Kaiser Permanente 2010-2011. All Rights Reserved.

Objective Understand the process for determining medical exemption from immunization Third Agenda Fourth Agenda Fifth Agenda 15 October 29, 2015 2011 Kaiser Foundation Health Plan, Inc. For internal use only.

Be Clear About Your Role Clinicians provide health care. Schools enforce the law. 16 October 29, 2015 2011 Kaiser Foundation Health Plan, Inc. For internal use only.

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.. 17 October 29, 2015 2011 Kaiser Foundation Health Plan, Inc. For internal use only.

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. 18 October 29, 2015 2011 Kaiser Foundation Health Plan, Inc. For internal use only.

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

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/ 20 October 29, 2015 2015 Regional Health Education, The Permanente Medical Group, Inc.

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/ 21 October 29, 2015 2011 Kaiser Foundation Health Plan, Inc. For internal use only.

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 2 nd birthday) Polio (OPV or IPV) - 4 doses (3 doses OK if one was given on or after 2 nd birthday) Measles, Mumps, and Rubella (MMR) - 1 dose (2 doses required at 7 th 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 7 th grade or out-of-state transfer admission at 8 th - 12 th grades (1 dose on or after the 7th birthday) www.shotsforschool.org/k-12/ 22 October 29, 2015 2011 Kaiser Foundation Health Plan, Inc. For internal use only.

School requirements are only a subset of all routinely recommended vaccines - Number and timing of doses may vary 23 October 29, 2015 2011 Kaiser Foundation Health Plan, Inc. For internal use only.

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 vaccinehesitant parents as a substitute for PBEs. 24 October 29, 2015 2014 Regional Health Education, The Permanente Medical Group, Inc.

The Providers Role Clinicians need to Be clear on what constitutes a medical contraindication Communicate his or her assessment to parents 25 October 29, 2015 2011 Kaiser Foundation Health Plan, Inc. For internal use only.

What Qualifies as a Medical Exemption? 26 October 29, 2015 2014 Regional Health Education, The Permanente Medical Group, Inc.

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 27 October 29, 2015 2014 Regional Health Education, The Permanente Medical Group, Inc.

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 28 October 29, 2015 2015 Regional Health Education, The Permanente Medical Group, Inc.

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 29 October 29, 2015 2015 Regional Health Education, The Permanente Medical Group, Inc.

Example 1: Mild or Moderate Local Reaction CDC and ACIP No AAP No Vaccine Package Inserts No 30 October 29, 2015 2014 Regional Health Education, The Permanente Medical Group, Inc.

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) 31 October 29, 2015 2014 Regional Health Education, The Permanente Medical Group, Inc.

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 32 October 29, 2015 2014 Regional Health Education, The Permanente Medical Group, Inc.

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 33 October 29, 2015 2014 Regional Health Education, The Permanente Medical Group, Inc.

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 34 October 29, 2015 2014 Regional Health Education, The Permanente Medical Group, Inc.

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 35 October 29, 2015 2014 Regional Health Education, The Permanente Medical Group, Inc.

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 36 2014 Regional Health Education, The Permanente Medical Group, Inc. October 29, 2015

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 37 October 29, 2015 2015 Regional Health Education, The Permanente Medical Group, Inc.

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 38 October 29, 2015 2015 Regional Health Education, The Permanente Medical Group, Inc.

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. 39 October 29, 2015 2015 Regional Health Education, The Permanente Medical Group, Inc.

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. 40 October 29, 2015 2014 Regional Health Education, The Permanente Medical Group, Inc.

Resources 41

Centers for Disease Control and Prevention www.cdc.gov/vaccines/recs/vac-admin/contraindications.htm

Centers for Disease Control and Prevention www.cdc.gov/vaccines/recs/vac-admin/contraindications-vacc.htm

Shots for School www.shotsforschool.org/laws/exemptions/

A one stop shop for immunization training and resources including the updated California Immunization Handbook! www.eziz.org

Immunization Action Coalition www.immunize.org/catg.d/p4065.pdf

Vaccine Adverse Events Reporting System VAERS www.cdc.gov/vaccinesafety/ensuringsafety/monitoring/vaers/index.html

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Question and Answer Session 49

Please Complete Online Evaluation! 50

Thank you Health Net of California, Inc. Kaiser Permanente, Northern California California Medical Association California Department of Public Health Immunization Branch