ARKANSAS DEPARTMENT OF HEALTH Immunizations: Overview and Changes to the Rules & Regs Jennifer Dillaha, MD Medical Director, Immunizations Medical Advisor,

ARKANSAS DEPARTMENT OF HEALTH

ARKANSAS DEPARTMENT OF HEALTHARKANSAS DEPARTMENT OF HEALTH

Immunizations: Overview and Changes to the Rules & Regs

Jennifer Dillaha, MDMedical Director, Immunizations

Medical Advisor, Health Literacy and CommunicationsArkansas Department of Health

School-based Health Alliance of ArkansasSchool Health Spring SymposiumCamp Aldersgate, Little Rock, AR

April 22, 2015


Objectives

1. Review the ACIP recommendations for Immunizations and the current Arkansas Rules & Regulations Pertaining to Immunization Requirements for school attendance

2. Describe the major risks associated vaccine administration

3. Identify the major myths associated with childhood immunizations


Arkansas Has the Lowest Immunization Rates in U.S.

• 2013 National Immunization Survey for children aged 19-25 months

• AR ranked 51st in combine vaccine series (57.1% vs 70.4% US)

• Additional information about the 2013 NIS data is available on the CDC website at http://www.cdc.gov/vaccines/imz-managers/coverage/nis/child/index.html

http://www.cdc.gov/vaccines/imz-managers/coverage/nis/child/index.html

http://www.cdc.gov/vaccines/imz-managers/coverage/nis/child/index.html


Arkansas Kindergartners

• CDC reported for 2013-2014 school year, AR had 3rd lowest rates for

– 2 doses of MMR (86.5% vs 94.7%)

– 4 doses of DTaP (83.3% vs 95.0%)

– 2 doses of Varicella (85.4% vs 93.3%)

• A full report on vaccination rates among children in kindergarten in the U.S. during the 2013–14 School Year can be found at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6341a1.htm

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6341a1.htm

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6341a1.htm


2013 NIS-Teen Survey

• For adolescents ages 13-17 years

• For routinely recommended vaccinations:– 1 dose of Tdap (77.7% vs 86.0%) (45th) – 1 dose of MCV4 (40.4% vs 77.8%) (51st) – 1 dose of HPV for females (44.3% vs 57.3%) (tied for 50th)– 1 does of HPV for males (17.7% vs 34.6%) (48th)

• For “catch up” vaccinations:– 2 doses of MMR (89.5% vs 91.8%) (41st)– 2 doses of varicella (59.6% vs 78.5%) (45th)

• More information about the 2013 NIS-Teen data is available on the CDC website at http://www.cdc.gov/vaccines/imz-managers/coverage/nis/teen/index.html

http://www.cdc.gov/vaccines/imz-managers/coverage/nis/teen/index.html

http://www.cdc.gov/vaccines/imz-managers/coverage/nis/teen/index.html


Arkansas Immunization Registry

• Web IZ

• Operated by the Arkansas Dept. of Health

• Mandatory reporting of all vaccine doses given to children under the age of 22

• Optional reporting of vaccine doses given to adults age 22 and older


ACIP Recommended Vaccines for Children

• Advisory Committee for Immunization Practices

• Advisory to the Centers for Disease Control and Prevention (CDC)

• Birth-18 Years & “Catch-up” Immunization Schedules: http://www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html

• Easy-to-Read Schedules for All Ages: http://www.cdc.gov/vaccines/schedules/


Changes to the Arkansas Rules & Regulations

• Effective September 1, 2014

• Students immunized according to the ACIP recommended schedule will meet the school requirements

• http://www.healthy.arkansas.gov/aboutADH/RulesRegs/ImmunizationRequirements.pdf


Preschool/Childcare Requirements

• Age appropriate• Diphtheria, tetanus, acellular pertussis (DTaP)• Polio (IPV)• Haemophilus influenzae Type B (Hib)• Hepatitis B• Measles, mumps, rubella (MMR)• Varicella• Pneumococcal (PCV13)• Hepatitis A


Preschool/Childcare Requirements

• 1 or 2 doses of Hepatitis A vaccine, depending on their age

• 1 to 4 doses of Polio vaccine with at least 6 months between the third and fourth doses

• Children age 13 months and older are to have 1 dose of varicella vaccine

– Medical history of varicella disease will be accepted


Kindergarten

• 4 doses of DTaP

• 3 or 4 doses of IPV with one dose after 4th birthday and minimum of 6 month between next to last and last dose

• 2 doses of MMR with one dose after 1st birthday and at least 28 days between doses

• 3 doses Hep B

• 2 doses of Varicella or a history by a medical professional

• 1 dose Hep A after 1st birthday


Grades 1-12

• Grade 1 only: 1 dose of Hep A

• 4 doses TDaP and 1 dose of Tdap for age 11 as of September 1 each year

• 3 doses of IPV

• 2 doses of MMR

• 2 or 3 doses of Hep B

• 1 dose of MCV4 in 7th grade and second dose at age 16 as of September 1 each year

• 2 doses of varicella


College/University Requirements

• For freshmen and foreign-born students who are full-time students or part-time students living on campus:

– 2 doses of MMR with 1 dose on or after the 1st birthday

and 28 days between the 2 doses

• For all other full-time students and part-time students living on campus:

– 1 dose of MMR on or after the 1st birthday

• No recent changes for the college/university immunization requirements


Tdap Vaccine

• One dose of tetanus, diphtheria, and acellular pertussis (Tdap) vaccine required for children aged 11 years or older on or before September 1 of each school year

• Previously, the requirement was for students entering Grade 7

• Students entering Grades 1-12 must have had 4 doses of DTaP vaccine (or 3 doses if none were given before age 7 years).


Meningococcal Vaccine

• MCV4

• Students entering Grade 7 need 1 dose of the meningococcal (MCV4) vaccine regardless of age.

• Students turning age 16 years on or before September 1– If a student has had 1 dose of MCV4, a second dose

is required, if it has been 8 weeks since the first dose.– If no previous dose was received and is student 16 by

September 1, the student needs 1 dose and no second dose is required.


Meningococcal Vaccine

• To meet thes requirement for 16-year olds, a student must receive a MCV4 dose on or after their 16th birthday. A dose given at age 15 years will not meet this requirement.


Polio Vaccine

• Students entering K-12: a series of at least 3 doses of polio vaccine.

• The new requirement is that one of the doses must be given on or after the child’s 4th birthday and there must be a minimum of 6 months between the second and third dose

• Students who receive 4 doses of the polio vaccine with one dose on or after their 4th birthday and a minimum interval of 6 months between the third and fourth doses will meet the requirement


Hepatitis A Vaccine

• For Kindergarten and Grade 1

• Students need 1 dose Hepatitis A vaccine given on or after their first birthday

• ACIP recommends 2 doses, although only 1 is required


Varicella Vaccine

• Kindergarten through Grade 12

• 2 doses of varicella vaccine are required

• History of disease meets this requirement if reported by a medical professional– Medical doctor– Doctor of osteopathy– Advanced practice nurse– Physician assistant

• Parental history of disease is no longer accepted


MMR and Hep B Vaccines

• Measles, Mumps, and Rubella (MMR) vaccine requirements are 2 doses

– 1 dose on or after the first birthday

– 28 days between the 2 doses

• Hepatitis B vaccine

– Kindergarten: 3 doses required

– Grades 1-12: 2 or 3 depending on whether or not a 2-

dose schedule was used


Contraindications & Precautions

• Contraindication: a condition in a recipient that increases the chance of a serious adverse reaction

• Precaution: a condition in a recipient that might:

– Increase the chance or severity of an adverse

reaction, or

– Compromise the ability of the vaccine to produce

immunity


Invalid Contraindications to Vaccination

• Minor illness • Mild/moderate local reaction or fever following a

prior dose • Antimicrobial therapy • Disease exposure or convalescence • Pregnancy or immunosuppression in the household • Premature birth • Breastfeeding • Allergies to products not in vaccine • Family history (unrelated to immunosuppression)


Possible Side-effects from Vaccines

• Side effects vary with vaccine type

• Generally mild, including: – Pain, redness, tenderness or swelling at injection site– Fatigue– Headache– Itching at injection site– Nausea– Mild rash– Fever– Dizziness or fainting (most common in adolescents)

• List for each specific vaccine: http://www.cdc.gov/vaccines/vac-gen/side-effects.htm


Vaccine Adverse Event Reporting System

• Severe adverse events after administration of any vaccine are rare

• Reports may be made online, by fax, or by mail

• National reporting system administered by CDC and FDA

• Passive (depends on healthcare providers and others to report)

• Receives about 28,000 reports per year

• More information: http://vaers.hhs.gov


Vaccine Safety Monitoring

The Vaccine Adverse Event Reporting System (VAERS)– An early warning public health system where people can report

adverse health events following vaccination, that helps CDC and FDA detect possible new, unexpected, or increased trends in reported adverse events

The Vaccine Safety Datalink (VSD) – Collaboration between CDC and several healthcare

organizations which uses de-identified health records to monitor and evaluate adverse events following vaccination

The Clinical Immunization Safety Assessment (CISA) – Collaboration between CDC and several medical research

centers in the United States to conduct research to understand how adverse events might be caused by vaccines

http://www.cdc.gov/vaccinesafety/vaccines/HPV/Index.html#monitor


References

• The Pink Book. Epidemiology and Prevention of Vaccine-Preventable Disease, 12th Edition, May 2012. CDC. http://www.cdc.gov/vaccines/pubs/pinkbook/index.html

• Red Book, 29th Edition. 2012 Report of the Committee on Infectious Diseases. American Academy of Pediatrics. http://aapredbook.aappublications.org/


Vaccine Hesitancy Defined

“Vaccine-hesitant individuals are a heterogeneous group who hold varying degrees of indecision about specific vaccines or vaccination in general.”

Strategic Advisory Group of Experts (SAGE)


Modern Vaccine Hesitancy

A Historical Progression




Vaccines and Autism

• MMR vaccine

• Thimerosal

• Too many vaccines

Gerber JS and Offit PA. Vaccines and Autism: A Tale of Shifting Hypotheses. CID 2009: 48, 456-461.


MMR Vaccine

• Ecological studies

• Retrospective, observational studies

• Prospective, observational studies


Thimerosal

• Ecological studies

• Cohort studies


Too Many Vaccines

• Vaccines do not overwhelm the immune system

• Multiple vaccinations do not weaken the immune system

• Autism is not an immune-mediated disease

• No studies have compared the incidence of autism in vaccinated, unvaccinated, or alternatively vaccinated children


Internet Myths/Urban Legends

• Myth: HPV Vaccine has been proved to have cause the deaths of 32 women.

• Myth: Dr. Diane Harper (misidentified as the lead researcher in development of Gardasil) gave a talk and admitted that “Gardisil and Cervarix don’t work, are dangerous and weren’t tested”.

• Snopes.com

http://www.snopes.com/medical/drugs/gardasil.asp


What You May Hear from Parents

• Questions about whether vaccines cause autism

• Questions about the number of vaccines

• Questions about vaccine ingredients

• Questions about known side effects

• Questions about unknown serious adverse events

www.cdc.gov/vaccines/conversations


Communication Strategies

• Take time to listen.

• Solicit and welcome questions.

• Keep the conversation going.

• Science versus anecdote?

• Acknowledge benefits and risks.

• Respect parents’ authority.

• Reduce the stress of shots.



Jennifer Dillaha, MDMedical Director for Immunizations

Medical Advisor for Health Literacy and Communication

Arkansas Department of Health4815 W. Markham Street, Slot 48

Little Rock, AR 72205Office: 501-661-2864

Email: [email protected]

Documents

ARKANSAS DEPARTMENT OF HEALTH Immunizations: Overview and Changes to the Rules & Regs Jennifer Dillaha, MD Medical Director, Immunizations Medical Advisor,