SCRIPT. Childhood Immunizations

SCRIPT Childhood Immunizations Slide #1 Introduction Welcome to Childhood Immunizations. This 1- hour course is designed to help you gain a better understanding of childhood vaccinations, including the benefits, requirements, and the diseases they prevent. This course was developed and produced by the Texas AgriLife Extension Service of the Texas A&M University System. Funding support was provided by Office of Title V and Family Health, Texas Department of State Health Services using Title V Maternal and Child Block Grant Funds. Slide #2 Learning Objectives Before we move into the course content, let us take a few minutes to review the learning objectives of this course. After completing the course, you should be able to: Define Immunizations. Understand the benefits of vaccinations. Identify 2-3 common childhood diseases that are prevented with vaccines. Identify what vaccinations are required in all childcare facilities. Take practical steps to reduce vaccine preventable diseases in your childcare facility. Slide #3 Advancing to Next Section Please click on the Next Section button at the bottom of this page to continue with this course. You will follow this procedure after each section. 1

Slide #4 Defining Immunizations Immunizations are also called vaccinations, inoculations, or shots. Immunizations help protect children and adults from disease that otherwise would cause serious illness and even death. They help prevent the spread of disease to others that could have easily been affected with complications of this disease. Immunity is either natural or acquired through previous infection or by vaccinations. Vaccines help develop immunity without a person getting sick first. According to the Department of State Health Services, A fully immunized society is necessary to eliminate vaccine-preventable disease. The Centers for Disease Control and Prevention states that vaccines are the Most important public health intervention in history by saving millions from death and preventing hundreds of millions from once crippling and deadly diseases. Slide #5 How do vaccines work? Vaccines work by introducing the body to foreign germs in the form of antigens. Your body develops antibodies to fight the foreign germs, but will become sick during this time with symptoms of the disease that the germs represent. When the germs are gone and the body has won the battle, the body keeps the antibodies to remember the germs for future battles. Then when the body is introduced to similar germs, it does not become sick. The antibodies are stronger and are able to resist this new invasion therefore, you are considered immune. Slide #6 How are vaccines given? Vaccines are commonly given in four different ways. There are different routes depending on the type of vaccine to be given and the purpose of that vaccine. Dosages and the route are determined for the best effectiveness based on clinical trials and experience. One is a spray that is sprayed into the nose. It is then inhaled and it coats the respiratory system. The second way is in the muscle. Commonly known as a shot, it is mainly given in the arm or upper thigh of children less than a year old. Some vaccines are given under the skin in the fatty tissue above the muscle. Lastly, they can be given by mouth and then swallowed. 2

Slide #7 Importance and benefits of immunizations Vaccines are the greatest public health achievements in the past 100 years. Vaccines reduce the effects of disease, death, and disabilities. Over the years, many diseases have become less common and others have been eliminated from the United States. The effects of childhood diseases are now minimized due to vaccines. This has increased children s quality of life and ensures that they have a chance of living a long and healthy life. Vaccines enhance the immune system. Vaccines control many diseases and their impact on society and the population as a whole. Even children and adults that are not vaccinated have some minute amount of protection from others around them who have been vaccinated. This is known as Community immunity. Slide # 8 Risks of not vaccinating There are many risks associated with not vaccinating, including the possibility of a deadly disease reoccurring. The social and economic costs associated with not vaccinating are also very high. This includes the strain and stress on family members who must care for those with a disease that would otherwise have been prevented if they were vaccinated against it. In addition, there is the added burden that comes with doctor visits, doctor bills, loss of workdays, and reduced quality of life. If families do not have the financial resources to pay for vaccines, the state has programs to assist. We will talk more about these programs later in the presentation. The diseases in which vaccines prevent have not disappeared. Other countries still have diseases that many in the United States have been vaccinated against. People can bring and spread diseases from other countries by either visiting that country or when people immigrate to the United States. Therefore, if we stop vaccinating here the diseases will come back. Slide #9 Side Effects of Vaccines Overall, vaccines are very safe. In fact, the Food and Drug Administration (FDA) must approve them before they can be administered. All new precautions, alerts and sideeffects are reported to doctors as they are discovered. (AAP) Side-effects known from vaccinations tend to be very mild (e.g., sore muscles of the arm or leg where the shot was given). Moderate reactions include a low-grade fever that can last a day or so. 3

Severe allergic reactions are possible, but tend to be very rare (i.e., one in a million). Some examples of severe allergic reactions include hives, breathing difficulties, paleness, wheezing, dizziness, and weakness. A doctor needs to be notified right away if you think you or a child is having an allergic reaction to a vaccine. There are some vaccine specific side effects that need to be noted. The doctor s office will provide you with a vaccine information statement so that you know what to look for. Slide #10 Misconceptions of not vaccinating Not everyone recognizes the benefits of vaccinations. Some object to vaccines due to religious or other reasons. Some people are concerned about safety issues. Others are unsure if the diseases for which the vaccines are given are still a threat today. One common myth is Vaccines did not reduce disease; it was due to having a civilized society. Yes, we do live in a society full of technological gizmos and gadgets and our society is much more civilized as compared to years past. Sanitation systems have improved tremendously, as well as nutrition and hygiene practices. Yet, with all these advancements in society, there has been no other greater direct impact on disease than that of vaccines. Since the licensure and wide-spread use of the Measles vaccine in 1963, there has been a significant drop in measles cases. Similar drops in disease rates have been discovered with other diseases after the introduction and wide-spread use of a particular vaccine in a population. (CDC) Slide #11 Myths: Vaccine leads to disease Another myth is that vaccines lead to disease. This has not been proven and it is known that vaccines are not 100 percent effective. Due to issues related to the individual person, some people just do not develop immunity, even if they are vaccinated. Other reasons for lack of full immunity are: not completing all doses in a vaccine series not getting vaccinated at an age appropriate time, or not getting booster vaccinations for diseases whose virus changes, such as the seasonal flu. Therefore, vaccines help prevent disease only if the individual responds and all booster vaccinations are administered. 4

Slide #12 Benefits vs. Risk of harm As compared to the benefits, the risk of harm is minimal. Vaccines have greatly increased the quality of life for children and adults alike. Here are some statistics from the Centers for Disease Control and Prevention (CDC) comparing the effects of Measles, Mumps and Rubella to those of being vaccinated. With the Measles: 6 out of 100 people would get pneumonia, 1 out of 1,000 would end up with encephalitis; and 2 in 1,000 will die from the disease. 1 out of 4 pregnant women infected with Rubella will pass on the disease as congenital Rubella Syndrome to their child. Comparing the statistics for Measles, Mumps and Rubella to the possibility of having a severe allergic reaction, which is 1 in one million, the benefits of the vaccine definitely outweigh the risk of harm. Similar comparisons have been done with other vaccines and the results are the same. Slide # 13 Immunization Schedule The CDC has outlined an immunization schedule for both children and adults. This schedule is based on age and recommended vaccine guidelines. All vaccines are safely given to the youngest age group at risk for the disease. According to the CDC, approximately 2-5% of people vaccinated for Measles develop immunity from the first dose alone (CDC, 2004). Immunization can be ineffective if the immune system of the person does not respond. Some vaccines last a lifetime, while others do not. (USHHS) The effectiveness of protection wears off over time or the germ that causes the disease might change. Multiple doses or booster vaccinations are necessary for vaccines whose effects do not last a lifetime. Immunity develops over time with exposure; therefore, the needs for multiple doses of certain vaccines are necessary to ensure proper immunity is developed. The seasonal flu is an example of a disease whose virus changes and requires a booster vaccination every year. A catch-up schedule is set by the CDC for those whose vaccinations have been delayed. A vaccine series do not need to be started over, despite the time that has passed since the last dose. 5

Slide #14 Immunization Schedule Here is an example of the Immunization Schedule set by the CDC, for children from birth to six years of age. This schedule is located on the Centers for Disease Control and Prevention, Vaccines and Immunizations website. Each vaccine is labeled to indicate the time to administer in either months or years. Individual doses are in white, age ranges are illustrated in yellow and those of certain high-risk groups are in purple. For example, in this schedule there are three recommended doses of the Hepatitis A vaccine; given at birth, between 1-2 months of age, and again between 6 and 18 months. Slide #15 Immunization Schedule Here is an example of the Immunization Schedule from seven years to eighteen years of age. This is located on the Centers for Disease Control and Prevention, Vaccines and Immunizations website. Age ranges are illustrated in yellow, the catch-up schedule is illustrated in light blue, and high-risk groups are in purple. There is also an adult immunization schedule that addresses immunizations that adults need in order to live a long, disease-free, and healthy life. But, for the focus of this course we will limit our discussion to the childhood schedules. Slide # 16 Common Childhood Immunizations Listed here are the common childhood immunizations that are recommended for every child as per the Immunization Schedule. All these diseases were once a serious threat to children and youth in the United States. Today, they are controlled with the aid of routine required immunizations. (CDC) We will now go into detail about these vaccines and the diseases they prevent. Slide # 17 Hepatitis A Hepatitis A is a liver disease caused by a virus. Some of Hepatitis A s symptoms are fever, extreme tiredness, jaundice (which is the yellowing of the skin and eyes), stomach pains, vomiting and diarrhea. Hepatitis A can lead to liver failure and even death. Hepatitis A is spread through the fecal-oral route when non-suspecting people accidently ingest feces or poop of an infected person. This often happens when hands are not washed properly after using the toilet or changing a diaper. Food and water can be contaminated with Hepatitis A by improper septic systems and the lack of hand 6

hygiene of the food handler. Approximately 100 people die every year from liver failure that is caused by Hepatitis A. (CDC). The hepatitis A vaccine is a shot given in the muscle. It is given in a series of two doses that are at least six months apart. The Hepatitis A vaccine is 94-100 percent effective in preventing the disease after both doses are given. People with allergic reactions to alum should not get the Hepatitis A vaccine. This vaccine can be administered to children 1 year old and older. Slide # 18 Hepatitis B Hepatitis B is another liver disease that is caused by a virus. Some of Hepatitis B symptoms are extreme tiredness, muscle pains, diarrhea, vomiting, stomach pains, and jaundice. Hepatitis B is spread through contact with blood and other body fluids. Pregnant women are known to infect their newborn babies if they have Hepatitis B. Hepatitis B can be a chronic or long-term disease, but some people have completely recovered from Hepatitis B. Others carry the virus around with them and can infect others easily. Approximately 4 to 5 thousand people die every year from cirrhosis and cancer of the liver caused by Hepatitis B. The Hepatitis B vaccine is a shot that is given in the muscle in a series of 3 to 4 doses. After the completed series, it gives long-term immunity against Hepatitis B. The first dose is currently given at birth and the complete series can be completed by 6 to 18 months of age. (CDC) The Hepatitis B vaccine has significantly reduced the amount of Hepatitis B in the United States. There has been approximately 95% fewer children and youth who have become infected. Slide #19 Diphtheria, Tetanus, and Pertussis Diphtheria is a respiratory disease caused by bacteria. Symptoms include coating of the back of the throat, chills, painful swallowing, and an extreme barking-like cough. It can lead to paralysis, heart failure, breathing problems, and even death. Diphtheria is spread through aerosolized germ filled droplets from a cough or a sneeze. Diphtheria is highly contagious. The tetanus bacteria are found in dirt and enter the body through a sore, cut or scrape where it produces a toxin that attacks the nervous system. Tetanus is also known as lockjaw due to the jaw muscles tighten up so tight that a person is unable to open their mouth or even swallow. It can lead to very painful muscle spasms of the entire body and even death. 7

Pertussis is a highly contagious disease caused by bacteria. Pertussis is also known as Whooping Cough due to violent coughing. The cough from Pertussis can be so severe that the ribs can break. Other symptoms include vomiting, disturbed sleep, diarrhea, and fever. The vaccine for Diphtheria, Tetanus and Pertussis are all combined into one shot that is given into the muscle. There are five childhood doses, but immunity wears off over time; therefore, booster vaccines are necessary retain immunity throughout adulthood. Slide #20 Haemophilus influenzae Type b Meningitis is the swelling and inflammation of the area surrounding the brain and spinal cord. Meningitis is commonly caused by bacterial or viral infections. It is highly contagious and is spread through breathing the air contaminated by others with the disease. Symptoms include a stiff neck, severe headache, fever, and sensitivity to light. Meningitis can lead to pneumonia, severe swelling of the throat, brain damage, and even death. Haemophilus influenzae Type b (Hib) is only one of many infections that may lead to meningitis. It was the leading cause of bacterial meningitis prior to the development of the vaccine. The Hib vaccine has been proven to be 95 to 100 percent effective in preventing Hib meningitis after a complete series of 3 to 4 doses that is given in the muscle. (CDC, VIS, Google Health) Slide #21 Meningococcal Meningococcal is a bacterial infection that may also lead to meningitis. Up to 2,600 people are infected with meningococcal meningitis every year and one out of ten will die from it. Meningococcal meningitis is common in infants who are younger than one year old. The Meningococcal vaccine is 90 percent effective at protecting against four types of meningococcal disease. It is given either in the muscle or in the fatty tissue under the skin. (CDC, VIS) Slide #22 Pneumococcal Pneumococcal is a bacterial infection that may also lead to meningitis and pneumonia. This form of meningitis kills 3 out of 10 people who get it. 8

The Vaccine protects against seven strains of the pneumococcal bacteria. It is given in four doses to children from two to 15 months of age. Before the vaccine, there were about 700 cases of meningitis and 200 deaths every year in children less than five years old in the United States. The three main bacterial infections that cause Meningitis are vaccine preventable. Slide #23 Poliovirus Polio is a disease caused by a virus that affects the nervous system. Symptoms start out feeling like the common cold, but then worsen to include stiffness and pain in the neck, back and even legs. It can progress to paralysis of the legs, and even, though rarely, the lungs. Currently, polio is not present in the United States, but other countries are still trying to eliminate this virus. The vaccine is given in four doses into the muscle. It is known to be 99 percent effective in preventing the disease after a series is completed. Slide #24 Rotavirus Rotavirus disease causes severe diarrhea, fever, and vomiting. Rotavirus is the leading cause of diarrhea in children younger than 5 years of age and almost all children in the U.S. will be infected. It is easily spread among family members, schools, and childcare facilities through the fecal-oral route. Up to 600,000 children worldwide die every year from the Rotavirus. Adults can be infected, but the effects of the disease are more severe in young children. Clean water and good hygiene have reduced the likelihood of this disease. However, this alone has not been able to eliminate the Rotavirus. (CDC) The vaccine decreases the likelihood of a child needing to be hospitalized. The Rotavirus vaccine is given orally in three doses. Please note that this vaccine does not affect diarrhea caused by any other germ or disease. Slide #25 Varicella Varicella, which is commonly known as Chicken Pox, was one of the most common childhood illnesses in years past. It is a serious disease in infants and adults. It causes a blistery rash, fever, itchiness, and tiredness. In severe cases it leads to skin infections, scars, brain damage, pneumonia, and even death. The Varicella vaccine has been 95% effective in preventing the severe effects of Chicken Pox. It provides lifelong immunity after two doses that are given in the muscle. People who have had chicken pox do not need to be vaccinated. Prior to the vaccine, there were 4 million people infected every year in the United States. (CDC) 9

Slide #26 Measles, Mumps, and Rubella Measles is a disease caused by a virus. Its symptoms are a whole body rash, fever, cough, and runny nose. It spreads by breathing germ contaminated air from others coughs and sneezes. It can lead to ear infections, seizures, brain damage, and even death. Mumps causes swollen glands, headache and fevers. On the serious side, it can lead to deafness, genital swelling, meningitis, and even death. Rubella is also known as German Measles, some symptoms are a body rash, arthritis, and fever. Rubella can affect the unborn child of pregnant women and leads to severe birth defects or miscarriage. The Measles, Mumps, and Rubella Vaccine is a combination vaccine given in three doses. It has decreased cases of these diseases significantly since the vaccination was licensed. Slide #27 Seasonal Flu Seasonal influenza, commonly known as the Flu, is a contagious disease that is caused by a virus. It affects the upper respiratory system, which consists of the nose, mouth, sinuses, and throat. Influenza is spread through aerosolized droplets when a person coughs or sneezes. Some symptoms of the flu include coughing, sneezing, sore throat, body aches, and high fever. Children may also have nausea, vomiting and diarrhea. According to the CDC, Seasonal Flu affects up to 20% of the U.S. population every year. On average there are greater than 200,000 hospitalizations and 36,000 deaths annually. The very young, pregnant women, elderly, and people with chronic health conditions are more at risk of catching and having complications from the flu. The Flu vaccine is produced and given every year due to the fact that the Flu virus is constantly changing. The best time to get the flu vaccine is in the fall to protect throughout the entire flu season which is from October to May. There are two types of Flu vaccines. One is shot given into the muscle, and the other is an aerosol sprayed into the nose. They both are very effective, but the aerosol spray version is not for everyone because it can take up to 2 weeks after vaccination for full immunity against the flu. Slide # 28 Childcare: Required Immunizations The State of Texas requires that all children in childcare facilities be immunized against the following illnesses while they are under the care of a childcare facility: 10

Diphtheria, Tetanus, and Pertussis (DTaP) Poliovirus (IPV) Haemophilus influenzae type b (Hib) Measles, Mumps, Rubella (MMR) Hepatitis B (Hep B) Hepatitis A (Hep A) Varicella (Chicken Pox) Pneumococcal (PCV) These guidelines are given by the state to ensure the safety of all children in your childcare facility. There are a set doses required per vaccination that have to be met by each child prior to admittance and ongoing attendance in the childcare facility. The guidelines are located on the Texas Department of State Health Services, Immunization Branch s website. Post these guidelines in a location where children are admitted into the facility to help determine if the child complies with Texas immunization requirements. Slide # 29 K- 12: Required Immunizations Students are also required by the State of Texas to be immunized against the following illnesses while they are in attendance at both Elementary and Secondary Schools: Diphtheria, Tetanus, and Pertussis (DTaP/Tdap) Measles, Mumps, Rubella (MMR) Poliovirus (IPV) Hepatitis B (Hep B) Varicella (chicken pox) Meningococcal (MCV) Hepatitis A (Hep A) The state has set guidelines on when these vaccinations should take place and the required amount of doses each student needs to be accepted into school. 11

The guidelines are located on the Texas Department of State Health Services, Immunization Branch s website. Slide # 30 Exclusions from Compliance There are two methods that allow a child to be exempt from getting the required immunizations and still be admitted into a childcare facility. These methods are Medical exemptions and Conscience exemptions. A parent may request a Medical exemption by filing with the facility a statement signed by the child s doctor after examination that states the vaccine is medically contraindicated or poses a risk to the health and well-being of the child or other household members. Unless the written statement states a lifelong condition exists, the exemption is valid for only one year from the time it has been signed by the doctor. A parent may claim exemption for the reason of conscience, which includes religious beliefs, by presenting a signed affidavit. An affidavit is valid for a two-year period. The affidavit is administered after written consent from the parent or guardian is submitted to the Texas Department of State Health Services. The affidavit can be requested via mail or through the website at www.immunizetexas.org. When a parent signs an affidavit form they accept that their child may be excluded from school in times of emergency or epidemic that is declared by the Texas Commissioner of Health. An exempt child who is not immunized for the above reasons, will, interestingly, be less vulnerable to vaccine preventable diseases because of community immunity. Community immunity plays a role in protecting the child if the other people in the child s life are immunized. Since others have been immunized it reduces the likelihood the exempt child will become ill from being exposed to a variety of diseases. Slide #31 Get Vaccinated! You might be wondering how you can help prevent the spread of vaccine preventable diseases in your childcare facility. Here are some words of advice: Follow the State of Texas guidelines for required vaccinations located at the immunization branch of the Texas Department of State Health Services website. These guidelines are set by the state to protect children Ensure that all children admitted into your childcare facility are current on all required vaccinations before they enter the program. 12

Have a file for each child admitted into the childcare facility and keep a running log of vaccinations matched to that of the state s requirements and the immunization schedule. Keep each child s records up to date by reviewing them periodically (at least every six months). Children less than two years of age, especially, need to keep their records current. Use the ImmTrac Texas Immunization Registry to aide in keeping immunization records up to date. The ImmTrac is an electronic database of vaccine records of all children who are registered. It is located on the Texas Department of State Health Services Website. Encourage parents to vaccinate their children on time. You can provide reminders to parents when the child is getting close to the next vaccine requirement milestone. A short friendly reminder would encourage parents to meet these requirements. Policies in your facility need to be enforced to ensure the health and safety of children, staff and their families. Encourage all staff to be current on their vaccinations since they are in constant contact with children who may have a contagious illness. According to the American Academy of Pediatrics (AAP), this is especially important for the staff of childbearing age. Women in this age group have an increased likelihood of acquiring an infection that could affect their unborn child. Two vaccination recommendations that are often overlooked are the Hepatitis A vaccine series and the annual seasonal flu vaccination. The American Academy of Pediatrics recommends the staff of childcare centers get their Hepatitis A vaccines because adults are more likely to be severely affected by the symptoms of this disease than are children. Review your vaccination records, compare it to the adult immunization schedule, consult your doctor and get vaccinated! If you have any questions, please contact your doctor. Slide # 32 Vaccine Locations Children are encouraged to get their vaccinations at their Pediatrician or Family Doctor s office. This is a great opportunity for children to receive their vaccinations as well as their regular health check-up. Other locations that give vaccinations to children are local health clinics and health departments. To find out where these places are located, dial 2-1-1. 2-1-1 is a toll-free number that provides health and social services information in your area. You may also contact the Texas Department of State Health Services at 1-800-252-9152 to find the locations of places administering vaccinations. 13

Slide #33 Vaccine Programs The Vaccines for Children Program is a vaccine administration service that is provided through Pediatricians and Family Doctors. The State of Texas provides vaccines to doctor s offices, so they can administer vaccines to eligible children free of charge. There are over 6,000 doctor s offices across the state that are enrolled in this program to remove the barriers to children getting immunized. All children from birth to eighteen years of age are eligible for this service through their doctor s office if they are underinsured due to financial hardship. Children with insurance that pays for immunization services and children whose parents are able to pay the co-pay or deductibles for immunization services DO NOT qualify. Children on Children s Health Insurance Program (CHIP), Children of Native American or Native Alaskan heritage and children who are on Medicaid are eligible for this immunization service. Children s Health Insurance Program (CHIP) and Children s Medicaid offer many benefits, including regular check-ups and vaccinations. Children eighteen years and younger may qualify for this program if they are a Texas resident and a U.S. citizen or are a legal permanent resident. Citizenship status of the child s parents does not affect a child s eligibility. CHIP and Children s Medicaid are income based programs. Children s Medicaid is health coverage that is free to eligible children. CHIP is for those that may earn too much money to qualify for Medicaid but do not have other medical insurance. The guidelines are illustrated on this slide and more information can be found at http://www.chipmedicaid.org/. Slide #34 Conclusion Thank you for taking the Childhood Immunizations online course through the Texas AgriLife Extension Service online course system. By taking this course you are now familiar with immunizations, their benefits, and some practical steps you can take to reduce vaccine preventable diseases in your child care facility. This concludes the informational portion of this course. Please click on the Next Section button at the bottom of this page to proceed to the post-test. If you would like to review any of the previous sections, click on the desired title in the left menu bar. 14

Resources http://www.dshs.state.tx.us/immunize/default.shtm http://www.dshs.state.tx.us/immunize/school/default.shtm#childcare http://www.chipmedicaid.org/ http://www.cdc.gov/vaccines/default.htm http://www.cdc.gov/vaccines/recs/schedules/default.htm http://www.cdc.gov/vaccines/pubs/vis/default.htm Bibliography American Academy of Pediatrics. (2008, March). Facts for Parents About Vaccine Safety. Retrieved August 2009, from American Academy of Pediatrics: http://www.aap.org/advocacy/releases/autismparentfacts.htm American Academy of Pediatrics. (2008, June). Vaccine Safety: The Facts. Retrieved August 2009, from http://www.cispimmunize.org/pro/pdf/vaccinesafety_parenthandout.pdf Centers for Disease Control and Prevention. (2007, July 18). Hepatitis B Vaccine. Vaccine Information Statements. Centers for Disease Control and Prevention. (2009, August 11). Inactivated Influenza Vaccine 2009-2010. Vaccine Information Statements. Centers for Disease Control and Prevention. (2008, March 13). Measles, Mumps, and Rubella Vaccines. Vaccine Information Statements. Centers for Disease Control and Prevention. (2008, December 9). Pneumococcal Conjugate Vaccine. Vaccine Information Statements. Centers for Disease Control and Prevention. (2008, August 28). Rotovirus Vaccine. Vaccine Information Statements. Centers for Disease Control and Prevention. (2009, June 24). Vaccine-Preventable Childhood Diseases. Retrieved August 2009, from Vaccines and Immunizations: http://www.cdc.gov/vaccines/vpd-vac/child-vpd.htm Centers for Disease Control and Prevention. (2008, March 13). Chickenpox Vaccine. Vaccine Information Statements. 15

Centers for Disease Control and Prevention. (2009, August). Common Questions Parents ask about Infant Immunizations. Retrieved August 2009, from http://www.cdc.gov/vaccines/events/niiw/2009/downloads/f_provider-qa-color-508.pdf Centers for Disease Control and Prevention. (2007, May 17). Diphtheria, Tetanus, and Pertussis Vaccines. Vaccine Information Statement. Centers for Disease Control and Prevention. (2008, May 12). Frequently Asked Question about Multiple Vaccinations and the Immune Syetem. Retrieved August 2009, from Vaccine Safety: http://www.cdc.gov/vaccinesafety/updates/multiplevaccines.htm Centers for Disease Control and Prevention. (1998, December 16). Haemophilus Influenzae Type b Vaccine. Vaccine Informaiton Statements. Centers for Disease Control and Prevention. (2006, March 21). Hepatitis A Vaccine. Vaccine Information Statements. Centers for Disease Control and Prevention. (2009, August). How Vaccines Prevent Disease. Retrieved August 2009, from http://www.cdc.gov/vaccines/vac-gen/howvpd.htm Centers for Disease Control and Prevention. (2009, July). Immunization Update 2009: Slides. Retrieved August 2009, from Education & Training: http://www.cdc.gov/vaccines/ed/imzupdate09/imzupdate-slides.htm Centers for Disease Control and Prevention. (2009, August 11). Live, Intranasal Influenza Vaccine 2009-2010. Vaccine Information Statements. Centers for Disease Control and Prevention. (2008, January 28). Meningococcal Vaccines. Vaccine Information Statements. Centers for Disease Control and Prevention. (2004, May 3). MMR Vaccine Questions and Answers. Retrieved August 2009, from Vaccines and Preventable Diseases. Centers for Disease Control and Prevention. (2006, December 1). Morbidity and Mortality Weekly Report. Retrieved August 2009, from General Recommendations on Immunization: http://www.cdc.gov/mmwr/pdf/rr/rr5515.pdf Centers for Disease Control and Prevention. (2007). Parent's Guide to Childhood Immunizations. : United States Government Printing Office. Centers for Disease Control and Prevention. (2007, May 29). Some Common Misconceptions about vaccination and how to respond to them. Retrieved August 2009, from Basic and Common Questions: http://www.cdc.gov/vaccines/vacgen/6mishome.htm#diseaseshadalready 16

Centers for Disease Control and Prevention. (2007, June 12). What would Happen if We Stopped Vaccinations? Retrieved August 2009, from Vaccines and Immunizations: http://www.cdc.gov/vaccines/vac-gen/whatifstop.htm Every Child By Two. (2008). Vaccinate your Baby. Retrieved August 2009, from http://www.vaccinateyourbaby.org/ Texas Administrative Code. (2007). IMMUNIZATION REQUIREMENTS IN TEXAS ELEMENTARY AND SECONDARY SCHOOLS AND INSTITUTIONS OF HIGHER EDUCATION. Texas Department of State Health Services. (2009). Retrieved August 2009, from Immunize Texas: http://www.immunizetexas.com/ Texas Department of State Health Services. (2009, June 25). Immunization Branch. Retrieved August 2009, from Texas Vaccines for Children: http://www.dshs.state.tx.us/immunize/tvfc/tvfc_about.shtm Texas Department of State Health Services. (2008, January). Questions and Answers. Retrieved August 2009, from Texas Vaccine for Children Progam. The Children's Hospital of Philadelphia. (2006). Thimerosal: What you should know. Retrieved August 2009, from Vaccine Education Center: http://www.chop.edu/vaccine/images/vec_thimerosal.pdf United States Department of Health and Human Services. (n.d.). The Effectiveness of Immunizations. Retrieved August 2009, from Immunization: http://www.hhs.gov/nvpo/concepts/intro6.htm * This course was developed and produced by the Texas AgriLife Extension Service of the Texas A&M University System through funding support was provided by Office of Title V and Family Health, Texas Department of State Health Services using Title V Maternal and Child Block Grant Funds. Educational programs of the Texas AgriLife Extension Service are open to all people without regard to race, color, sex, disability, religion, age, or national origin. The Texas A&M University System, U.S. Department of Agriculture, and the County Commissioners Courts of Texas Cooperating 17