welcome to the california immunization coalition education ... · pdf filewebinar objectives...
TRANSCRIPT
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1
Welcome to the California Immunization Coalition
Education Hour
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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
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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
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Senate Bill 277
Senators Richard Pan, MD & Ben Allen
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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• Withdrawn October 16
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Removes the personal belief
exemption (PBE) from school
vaccination requirements
Allows exemptions only for medical
reasons
SB 277
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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
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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
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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
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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
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Scott Clark
916-551-2887
FAQ available at
www.cmanet.org
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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
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14 | © Kaiser Permanente 2010-2011. All Rights Reserved. October 29, 2015
Randy Bergen, MD Pediatric Infectious Disease
Kaiser Permanente, Walnut Creek
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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
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16 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only. October 29, 2015
Be Clear About Your Role
Clinicians provide health care.
Schools enforce the law.
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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 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only. October 29, 2015
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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 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only. October 29, 2015
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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
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Vaccines Required for Childcare / Preschool
20 | © 2015 Regional Health Education, The Permanente Medical Group, Inc. October 29, 2015
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/
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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
21 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only. October 29, 2015
www.shotsforschool.org/k-12/
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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)
22 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only. October 29, 2015
www.shotsforschool.org/k-12/
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School requirements are only a subset of all routinely recommended vaccines - Number and timing of doses may vary
23 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only. October 29, 2015
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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.
24 | © 2014 Regional Health Education, The Permanente Medical Group, Inc. October 29, 2015
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The Providers Role
Clinicians need to
– Be clear on what constitutes a medical contraindication
– Communicate his or her assessment to parents
25 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only. October 29, 2015
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What Qualifies as a Medical Exemption?
26 | © 2014 Regional Health Education, The Permanente Medical Group, Inc. October 29, 2015
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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 | © 2014 Regional Health Education, The Permanente Medical Group, Inc. October 29, 2015
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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 | © 2015 Regional Health Education, The Permanente Medical Group, Inc. October 29, 2015
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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
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Example 1: Mild or Moderate Local Reaction
CDC and ACIP– No
AAP– No
Vaccine Package Inserts – No
30 | © 2014 Regional Health Education, The Permanente Medical Group, Inc. October 29, 2015
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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 | © 2014 Regional Health Education, The Permanente Medical Group, Inc. October 29, 2015
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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 | © 2014 Regional Health Education, The Permanente Medical Group, Inc. October 29, 2015
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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 | © 2014 Regional Health Education, The Permanente Medical Group, Inc. October 29, 2015
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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
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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
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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
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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 | © 2015 Regional Health Education, The Permanente Medical Group, Inc. October 29, 2015
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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
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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 | © 2015 Regional Health Education, The Permanente Medical Group, Inc. October 29, 2015
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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.
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Resources
41
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Centers for Disease Control and Prevention
www.cdc.gov/vaccines/recs/vac-admin/contraindications.htm
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Centers for Disease Control and Prevention
www.cdc.gov/vaccines/recs/vac-admin/contraindications-vacc.htm
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Shots for School
www.shotsforschool.org/laws/exemptions/
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www.EZIZ.org
A one stop shop
for immunization
training and
resources –
including the
updated
California
Immunization
Handbook!
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Immunization Action Coalition
www.immunize.org/catg.d/p4065.pdf
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Vaccine Adverse Events Reporting System VAERS
www.cdc.gov/vaccinesafety/ensuringsafety/monitoring/vaers/index.html
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Twitter @ImmunizeCA
Facebook ImmunizeCA
Tweet and Follow
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Question and Answer Session
49
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Please Complete
Online Evaluation!
50
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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