Georgia Requirements for School and Childcare Attendance

1. Georgia Requirements for School and Childcare Attendance Presentation to: Presented by: Date:

2. Conflicts of Interest and Disclosures • Neither the planners or presenters indicated that they have any real or perceived vested interest that relate to this presentation nor any relationships with pharmaceutical companies, biomedical device manufacturers, and/or other corporations whose products and services are related to the vaccines we discuss. • There is no sponsorship or commercial support being received for this activity. • The mention of specific brands of vaccines in this presentation is for the purpose of providing education and does not constitute endorsement by the provider or ANCC of any commercial products. • Off Label Use- For certain vaccines a slight departure from or off-label use of the vaccine package insert guidelines may be discussed during presentation.

3. Notice of Requirements for successful completion • To obtain nursing contact hours for this session, you must be present for the entire presentation and complete and submit an evaluation. • Contact hours for this session will be available from 02/1/2012 until 02/01/2014 only for those who successfully complete this educational activity.

4. Objectives • Identify vaccine preventable diseases and how vaccines impact morbidity rates for these preventable diseases in GA • Recall GA immunization law, DPH rules and regulations for GA immunization certificates and provider, school facilities and parent responsibility to enforce the law • Describe standards for issuing and filing certificates of immunizations • Identify valid and invalid GA immunization certificates and how to use filing tickler system

5. Objectives continued…. • Describe the public health audit process and the responsibilities of school and child care facilities • Identify common errors seen on GA Immunization certificates

6. Topics • Review of childhood vaccine preventable diseases • Georgia immunization requirements for preschool, child care, and school attendance • Review policy guide for completing form 3231 • How to monitor, follow up and enforce the requirements for the certificates of attendance • Resources

7. Diphtheria • Spread by direct contact • Incidence in United States has decreased • Still occurs in other countries • Disease can be prevented by vaccine • Vaccine given in combination with tetanus and pertussis (DTaP, DT, Tdap,or Td) • Required for school and child care attendance

8. Tetanus • Tetanus germ lives in dirt and the intestines and feces of animals • Germ enters the body through cuts, punctures, burns, and other wounds • Disease can be prevented by vaccine • Vaccine given in combination with diphtheria and pertussis (DTaP, DT, Tdap, or Td) • Vaccine needs to be given periodically throughout lifetime • Required for school and child care attendance

9. Pertussis • Pertussis germ lives in mouth, nose, and throat of infected person • Spread by coughing and sneezing • Disease can be prevented by vaccine • Vaccine given in combination with diphtheria and tetanus (DTaP or Tdap) • Required for school and child care attendance

10. Hospital Respiratory Ward, 1952

11. Polio • Incidence decreasing • Viral infection spread through direct contact • Disease can be prevented by vaccine • Vaccinate children up to age 18 and also some international travelers • In Georgia, immunization against polio is required for child care and school attendance

12. Measles • Viral infection • Spread by coughing, sneezing, or talking • Disease can be prevented by vaccine • Vaccine given in combination with mumps and rubella vaccines (MMR or MMRV) • Required for school and child care attendance

13. Mumps • Viral infection • Spread by coughing, sneezing, or talking • Disease can be prevented by vaccine • Vaccine given in combination with measles and rubella vaccines (MMR or MMRV) • Proof of immunity or 2 doses of vaccine required for entrance to school after 7-1-07

14. Rubella • Viral infection • Spread by coughing, sneezing, or talking • Harmful to unborn infants • Disease can be prevented by vaccine • Vaccine given in combination with measles and mumps vaccines (MMR or MMRV) • In Georgia, immunizations against measles, mumps, and rubella are required for child care attendance and school entrance

15. Haemophilusinfluenzae type b (Hib) • Hib germ enters the body through nose and throat • Spread by direct contact • Hib vaccine responsible for dramatic decrease in incidence of disease • Vaccine given to infants and children under age 5 • Immunization required for child care attendance (includes 4 year Pre-K)

16. Viral infection which attacks the liver Fecal-oral route of infection Symptoms may include nausea, anorexia, fever, dark urine, and jaundice of skin and eyes. Symptoms uncommon in children, but can infect others As of 7-1-07, required for children born on or after 1-1-06 for school and childcare attendance Hepatitis A

17. Hepatitis B • Viral disease which attacks the liver • Spread by contact with infected body fluids or blood • Person may have disease and not have symptoms • Disease can be prevented by using universal precautions and by vaccine • Vaccine recommended for all infants and children and some adults • Immunization is required for child care attendance and entry to school

18. Varicella/chickenpox • Spread through coughing, sneezing, or contact with infected sores • Can be severe, especially in teens and adults • Can be prevented by a vaccine • Vaccine recommended for all persons over one year of age who have not had the disease • Vaccine or proof of immunity is required • For child care attendance (1 dose) • Entry to school (2 doses) • Entry to 6th grade (2 doses)

19. Caused by Streptococcus pneumoniae bacterium Droplet spread from person to person Invasive pneumococcal disease can result in pneumonia, bacteremia, or meningitis Pneumococcal disease kills more people in the United States each year than all other vaccine-preventable diseases combined As of 7-1-07 PCV13 vaccine is a requirement for all children under 5 years of age who attend child care facilities Pneumococcal Disease

20. 20th Century Peak & Current Morbidity for VPDs MMWR (Weekly), August 17, 2012, 61(32); 624-637

21. Low Rates of Childhood Vaccine Preventable Diseases • Vaccines work Goal of 100% compliance level* • Immunization Laws work • Partnerships work *http://health.state.ga.us/pdfs/prevention/immunization/Georgia%20Immunization%20Program%20Manual%20Complete%20Oct%202012.pdf

22. Georgia Requirements • Georgia law requires that all children attending a facility or school must be immunized according to the rules and regulations established by the Department of Public Health (DPH) • “Facility” is defined as any public or private child care center or nursery intended for the care, supervision, or instruction of children • “School” is defined as any public or private educational program or institution instructing children at any level or levels, kindergarten through twelfth grade • “New entrant” means any child entering any school or facility in GA for the 1st time or entering after having been absent from a GA school or facility for >12 mos. or 1 school year.

23. DPH Rules and Regulations • Provide definition of terms • Stipulate the specific requirements • List required vaccines or • Acceptable proof of immunity • Define medical and religious exemptions • Provide directions for issuing, maintaining, and inspecting certificates

24. Responsibilities Associated withImmunization Requirements • Physicians and Public Health Clinics: • Know current legal requirements for attendance and accurately completing the certificate • Administering immunizations according to the current Recommended Childhood and Adolescent Immunization Schedule • Report the occurrence of any disease listed on the “Notifiable Disease List” • Report any adverse event following the administration of a vaccine to VAERS • Child Care and School : • Review the certificates for validity prior to accepting • Develop a system for immunization certificate management/Tickler system • Have certificates available for inspection and audit by health officials • Report the occurrence of any disease listed on the “Notifiable Disease List”

25. Responsibilities of Parents or Caregivers • Take child to health care provider well check ups and immunizations at the recommended times • Review all vaccine facts that they receive before their child is immunized • Discuss any questions or concerns about vaccines with the child’s doctor or nurse • Keep child’s personal immunization record and take it with them on each visit to the health care provider to be assessed and updated • Mark the child’s vaccination due date and stay on schedule • Obtain appropriate certificate for child care and school attendance from health care provider • Give a copy of the certificate to each facility the child attends

26. Vaccine Requirements • Consistent with the Recommended Childhood and Adolescent Immunization Schedule • Children are required to be age appropriately immunized against each of these diseases: Hepatitis B Polio Diphtheria Measles Tetanus Mumps* Pertussis Rubella HaemophilusInfluenzae type b Hepatitis A Varicella (chicken pox)* Pneumococcal disease • AS OF 7-1-07 *2 doses Mumps PCV13 if <5 yrs. old *2 doses Varicella Hep A if born after 1-1-06

27. School Vaccine Requirements • A “new entrant” enrolling in a Georgia school at any grade or level, must be age appropriately immunized with all the required vaccines. • The number of doses for each vaccine depends on the child’s age at the time of school entry* • Once enrolled and a “Complete for School” certificate is on file, further immunizations may be recommended but are not required. • Exception: Recheck measles, mumps, varicella immunity status at entry to 6th grade

28. Child Care Vaccine Requirements • The number of doses for each required vaccine depends on the child’s age at the time of child care attendance. • If under 4 years of age, child will always need more doses and Certificate of Immunization should have a current “Expiration Date” indicated. • If 4 years or older, and has met all requirements, and has a Certificate of Immunization marked as “Complete for School,” child is considered adequate for both school and child care.

29. 2013 Immunization Schedules • Children • 0-18 years • Catch-Up schedule for children • 4 months -18 years Be sure to review the “Notes” section – many changes

30. Form 3231 as of 8-1-12 REQUIRED RECOMMENDED

31. Policy Guide 3231 REQ

32. Policy Guide 3231 REQ

33. Standards for Issuing and Filing Certificates of Immunization (Policy Guide 3231 INS and 3231 REQ) • Who is required to have a certificate • Who may issue certificates • How certificates are to be reviewed, filed and maintained • How health care providers are to complete the certificates • What exemptions are acceptable • How health care providers may order certificates • Required doses for each of the vaccines

34. Certificate of Immunization (Form 3231) • A child must have a certificate on file at each facility or school he attends • Photocopies of appropriately completed and signed certificates are acceptable • If a certificate is not on file for each child attending, the facility is held legally responsible • A licensed Georgia physician, APRN, PA or public health official is responsible for the interpretation of and compliance with the requirements for vaccines and completing the certificate • Only physician offices and health clinics can obtain blank certificates

35. Policy Guide 3231 INS

36. Age of Child “Marks the Spot” • If child is under four years of age, a certificate: • Must be marked with a “Date of Expiration” • Must have vaccine administration dates, year of diagnosis, positive serology, disease history, or medical exemption • If child is over four years of age, a certificate must be completed with: • Vaccine administration dates, and /or year of disease diagnosis, positive serology, disease history, or medical exemption; and • A “Date of Expiration”; or • A mark in the “Complete for School Attendance” box

37. Certificate Expiration Date • Expires on the date entered as “Expiration Date” • Must be replaced with a current certificate within 30 days after the expiration date, or child is excluded from attending • Allows for a child who does not meet all the immunization requirements to attend child care or school while he is catching up • Required for all children under four years of age • Required if a medical exemption for a vaccine(s) is marked • Should not be completed if “Complete for School” is marked

38. Certificates Marked “Complete for School Attendance” • Do not expire • May be issued only to children who: • Are four years of age or older; and • Have met all the requirements for school attendance as outlined in the Policy Guide 3231REQ; and • Have all the required vaccine administration dates or natural immunity dates filled in; and • Do not have a “Date of Expiration” completed

39. Immunity and Medical Exemptions Medical Exemption Serology Diagnosed History

40. Exemptions • Medical: • Should be used only when there is a physical disability or condition that contraindicates immunization for that specific vaccine • Should be documented in the medical exemption box indicated for each vaccine • Should be reviewed annually

41. Exemptions • Religious: • Not documented on the certificate • No special certificate available or needed • Documented by a notarized affidavit stating that immunization conflicts with the parent/guardian’s religious belief • Notarized statement should be kept on file by the school or facility in lieu of a Certificate of Immunization • Do not expire

42. Evidence of Varicella Immunity • Documentation of age-appropriate vaccination: • Preschool-aged children > 12 months: 1 dose • School-aged children, adolescents and adults: 2 doses • Laboratory evidence of immunity or laboratory confirmation of disease • Born in US before 1980 • A healthcare provider diagnosis or verification of varicella or healthcare provider verification of history of varicella disease. For mild or atypical case: • Assessment by physician is recommended to determine: • Epidemiological link to typical case • Laboratory evidence of immunity if titer done at time of disease • History of herpes zoster based on healthcare provider diagnosis

43. Guidelines for Public Health Clinics Documentation of Varicella Immunity • Documentation of age-appropriate immunization • Laboratory evidence of immunity • Born in the US before 1980 • Licensed healthcare provider diagnosis of disease or documentation of history of disease • Typical case history • Recollection of typical symptoms • Documentation made by LICENSED medical personnel • Mild or atypical case history • Assessment should be made by licensed med. personnel • Epidemiology link to a typical case or lab-confirmed atypical case • History of shingles based on healthcare provider diagnosis

44. 6th Grade Requirement • Proof of Measles, Mumps, and Varicella Immunity required for all students entering 6th grade or age equivalent grade • Supplemental Certificate, Form 3189, no longer needed. Document on Form 3231.

45. To be valid, certificates must be current Certificate becomes invalid on the “Date of Expiration” Child must submit a current certificate within 30 days after the expiration date or be excluded from attendance Facility or school is responsible for notifying parent/guardian of an upcoming expiration date and requesting a current certificate be submitted Any school/facility official who does not enforce the requirements shall be guilty of a misdemeanor Maintenance of Certificates

46. Filing of Certificates • All children enrolled must have a valid Certificate of Immunization on file • Certificates must be available for inspection by health officials • If child attends more than one facility, a photocopy to the second facility is acceptable • If child leaves or transfers to another school or facility, the certificate should be given to a parent/guardian or sent to the new school/facility • In the case of religious exemption, a dated notarized statement must be on file

47. Tickler Filing System • Immunization Guidelines for Child Care Facility Operators & School Personnel (Form 3258) provides “how to” instructions • Tickler system is method for filing and maintaining current certificates (set up by month and year) • Remind parents or care givers • Give parents information sheet about requirements • Document follow-up • Enforce requirements

48. Public Health Responsibilities • Auditing child care facilities and schools • Educating all partners regarding recommended schedule and requirements for attendance • Providing surveillance and outbreak control of all “notifiable diseases”

49. Immunization Audits • What is the total number of children enrolled? • How many children have “valid” certificates (up to date) certificates? • For a child care, how many children have a certificate marked with a current “Date of Expiration”? • For a child care/ school facility, how many children are marked as “Complete for School Attendance”? • How many children have certificates with expired “Date of Expiration”? • How many children have certificates “Complete” but missing required doses? • For a child care facility or school, how many have been enrolled less than the allowed waiver time period? • How many children have nothing on file? • How many children have religious exemptions? • How many medical exemptions?

50. Immunization InventoriesChildcare Facilities • Prior to 07/01/2007: • Based on rules and regulations in operation at that time • Educate operators and parents of new requirements • On or After 07-01-2007: • Base on the revised rules and regulations and documentation should be on Form 3231 (Revised 8/2012) with following exceptions: • Children who have certificates that will expire after 7/1/07 are considered to be current until the “Date of Expiration”. • Children who are enrolled in both school and child care or “after school” programs and have “Complete for School” certificates on file at both facilities, do not need to obtain a revised certificate.