for Prevention

Understanding California’s Child Care and School Immunization Requirements and Medical Exemptions
[Free CME available]

May 2019

Candace Gragnani, MD, MPH, FAAP

Franklin Pratt, MD, MPHTM, FACEP

Julia Heinzerling, MPH

Facebook  LinkIn  Tweeter  mail  Print  Print

 

This article is designed to help health care providers understand and navigate California’s child care and school immunization requirements (which will change on July 1, 2019) and use an evidence-based approach to immunizations and medical exemptions to ensure the best health for their patients. Pediatric immunization coverage levels in Los Angeles County have increased since personal beliefs exemptions (PBEs) for child care and school immunization requirements were eliminated as of January 1, 2016.1,2 Medical exemptions to required immunizations, however, have simultaneously increased. For instance, over the same timeframe, there was a 5-fold increase (0.1% to 0.5%) in permanent medical exemptions (PMEs) for LA County students entering kindergarten1,2

This article covers the following topics:

Note: This article is not intended to be an exhaustive review, but rather a summary of key requirements and expert guidance. Providers are encouraged to use their clinical judgment and consult evidence-based guidelines. For reference, links to recommendations from the Advisory Committee on Immunization Practices (ACIP), which have been adopted by the Centers for Disease Control and Prevention (CDC), and recommendations from the American Academy of Pediatrics (AAP), are included throughout.

 

Benefits of Maintaining High Immunization Rates

Maintaining high immunization rates protects immunized individuals from vaccine preventable diseases (VPD) and prevents the spread of these diseases to people who cannot be immunized. Examples of those who cannot be immunized include young infants as well as persons for whom immunization is contraindicated due to serious medical conditions and/or immunosuppression related to HIV, cancer, or other conditions. High coverage levels prevent VPD cases and outbreaks, decrease morbidity and mortality, and reduce absenteeism from school or work for people who were exposed to cases.

Providers should adhere to the ACIP recommended immunization schedules and follow expert guidance on vaccine contraindications and precautions to maintain high rates of immunization in Los Angeles County. It also remains vital for providers to openly discuss the benefits of immunizations and parents’/caregivers’ concerns and fears, including the possibility of adverse events.3

See the Rx for Prevention article, “Measles Outbreak: Communicating with Parents and Patients about Immunizations” for measles immunization talking points, a brief summary of vaccine communication techniques recommended by the CDC, and supporting resources.

 

Immunization Requirements for Child Care and School Attendance

California’s immunization requirements apply to children who attend a: (1) “pre-kindergarten” facility, which includes public or private child care centers, day nurseries, nursery schools, family day care homes, or development centers and (2) “TK/K-12” school, which includes transitional kindergarten and kindergarten through 12th grade. Children must meet all immunization requirements unless they have an appropriately documented medical exemption or a valid and pre-existing PBE that was granted prior to January 1, 2016.4 Other exceptions include students attending home-based private schools or participating in independent study programs that do not include classroom-based instruction.5

Unconditional and Conditional Admission

Per California law, parents/guardians must submit proof of immunization when4:

  • A child is newly admitted to a pre-kindergarten facility or TK/K-12 school
  • A child attending pre-kindergarten reaches the next immunization checkpoint (based on age)
  • A student advances to the 7th grade.

Depending on their immunization status, children will either be excluded from attendance until they meet all requirements or granted unconditional admission or conditional admission. Please note that there are special considerations for children with individualized education programs (IEPs) and children who are experiencing homelessness or are in foster care.

  • Unconditional Admission: Children are granted unconditional admission if their parent/guardian provides written documentation of receipt of all mandatory immunization doses except for those for which the child has: (1) a valid permanent medical exemption or (2) a valid PBE filed in California prior to January 1, 2016 for the current grade span (i.e., pre-kindergarten span; TK/Kindergarten through 6th grade span, or 7th through 12th grade span).4 PBEs are not accepted from other states or countries for transfer students.5
  • Conditional Admission: Under certain circumstances, children who have not received all required doses may attend a pre-kindergarten facility or TK/K-12 school while they catch up on immunizations. Conditional admission may be granted for a child who has not received all required immunization doses who: (1) has started all of the required vaccine doses for their age/grade span and is not due for additional doses at the time of admission, (2) is less than 18 months old and has received all required doses for his/her age but needs future doses, or (3) has written documentation from a licensed physician (MD or DO) for a temporary medical exemption for missing required doses.4 Continued attendance is dependent upon documented receipt of all remaining required doses. Providers should ensure patients receive required immunizations as soon as possible if the patient is participating in a catch-up plan. (See ACIP’s Catch-up Immunization Schedule.)

Special Considerations

  • Children with individualized education programs (IEPs) should continue to receive all necessary services listed in the IEP, regardless of their immunization status.5 
  • Children who are homeless or in foster care who transfer into a new school can be admitted immediately, even if their immunization records are not available at the time of admission.5 If any required doses are found to be missing, health care providers should ensure that these students receive all required immunizations as soon as possible. (See ACIP’s Catch-up Immunization Schedule.)

Required Immunizations for Future School Years

On July 1, 2019, new California school immunization regulations will go into effect, which will change requirements for the 2019-2020 and future school years, including the number of doses and age restrictions for varicella immunization.4,6 See Table 1 and the “Summary of Changes to the California Immunization Requirements Starting July 1, 2019” box.

 

Table 1: California Immunization Requirements for Pre-Kindergarten and TK/K-12 School Attendance: 2019-2020 and Future School Yearsa

Click here to download Table 1 formatted for printing and posting.

Number of Required Dosesb,c

Pre-Kindergartend

 

Polio

DTaP

HepB

Hib

MMR

Varicella

Tdap

 

Cumulative Number of Doses Needed

Age at Admission/Checkpoints

2 through 3 months

1

1

1

1

 

 

 

4 through 5 months

2

2

2

2

 

 

 

6 through 14 months

2

3

2

2

 

 

 

15 through 17 months

3

3

2

1e
Given on or after 1st birthday

1
Given on or after 1st birthday

1f

 

18 months through 5 years

3

4

3

1e
Given on or after 1st birthday

1
Given on or after 1st birthday

1

 

Grades TK/K-12g

 

Polio

DTaP

HepB

Hib

MMR

Varicella

Tdap

Grade

TK/K-12 Admission

4h

5i

3j

 

2k

2l

 

7th-12th

 

 

 

 

 

 

1m

7th Grade Advancementn

 

 

 

 

 

2o

1m

 
  1. Adapted from California Code of Regulations Title 17, Division 1, Chapter 4, Subchapter 8.4
  2. Combination vaccines (e.g., MMRV) meet the requirements for individual component vaccines. Doses of DTP count towards the DTaP requirement.
  3. Any vaccine administered 4 or fewer days prior to the minimum age is valid.
  4. A pupil’s parent or guardian must provide documentation of a pupil’s proof of immunization to the governing authority no more than 30 days after a pupil becomes subject to any additional requirement(s) based on age, as indicated in this table.
  5. Per ACIP, 1 Hib dose is recommended for children who are unvaccinated at 15–59 months of age. For the Hib requirement, 1 Hib dose must be given on or after the 1st birthday regardless of previous doses. This is required only for children who have not reached the age of 5 years.
  6. As of July 2019, one varicella dose will be required at age 15 months through 5 years.
  7. Requirements for TK/K-12 admission also apply to transfer pupils.
  8. For the polio requirement, 3 doses of polio vaccine meet the requirement if at least 1 dose was given on or after the 4th birthday.
  9. For the DTaP requirement, 4 doses of DTaP vaccine meet the requirement if at least 1 dose was given on or after the 4th birthday. Three doses meet the requirement if at least 1 dose of Tdap, DTaP, or DTP vaccine was given on or after the 7th birthday. One or 2 doses of Td vaccine given on or after the 7th birthday count towards the requirement.
  10. For information regarding hepatitis B requirements for 7th grade admission, see Health and Safety Code § 120335, subdivision (c).
  11. Two doses of measles, 2 doses of mumps, and 1 dose of rubella vaccine meet the requirement, separately or combined. To meet the requirement, both doses must have been administered on or after the 1st birthday.
  12. As of July 2019, 2 doses of varicella will be required for all children entering transitional kindergarten/kindergarten through 12th grade and for 7th grade advancement, as opposed to the current requirement of a single dose of varicella for children 4 through 12 years of age and 2 doses of varicella for those 13 through 17 years of age.
  13. For 7th-12th graders, at least 1 dose of pertussis-containing vaccine is required on or after the 7th birthday.
  14. For children in ungraded schools, pupils 12 years and older are subject to the 7th grade advancement requirements.
  15. The varicella requirement for 7th grade advancement expires after June 30, 2025.

Additional information and resources regarding California requirements, including Frequently Asked Questions (FAQs) and a webinar, can be found at www.shotsforschool.org.

 

Summary of Changes to the California Immunization Requirements Starting July 1, 20197

See the California Department of Public Health’s New Regulations FAQs for additional details.

Pre-Kindergarten

  • Varicella: Varicella vaccine is now required at 15 months and older (as opposed to 18 months and older).
  • Records: As children age into new requirements, parents have 30 days to submit updated records showing the child has met the new immunization requirements for age. For example, if an up-to-date child turns 18 months old, caregivers have 30 days from the day the child turns 18 months old to submit new records showing the child has received the 4th dose of DTaP and the 3rd dose of Hepatitis B.

TK/K-12

  • Varicella: Proof of 2 (as opposed to 1) doses of varicella vaccine is required at admission or transfer for TK/K-12 students and 7th grade advancement.
  • MMR: Proof of 2 MMR doses is required at admission or transfer for TK/K-12 students. New requirements can also be met by 2 doses of measles vaccine, 2 doses of mumps vaccine, and 1 dose of rubella vaccine.
  • Hepatitis B: Proof of 3 hepatitis B doses is required for most TK/K-12 students at admission or transfer.

 

Screening for Required Immunizations

When screening patients for required immunizations for pre-kindergarten or school entry, only doses that are recorded on a written record that lists the patient’s name, birth date, vaccine given, date administered (month/day/year), and vaccine administrator should be considered valid.4 Records accessed via the California Immunization Registry or other state immunization registries should also be considered valid.8 See the Red Book for guidance regarding reviewing records of students arriving from outside of the United States.

Parental reports of prior immunization or childhood illnesses should not be considered sufficient evidence of immunity.9 In addition, receipt of homeopathic preparations does not satisfy immunization requirements since California regulations define vaccine as “an immunization administered in the United States of America or other countries that is recommended by the federal Advisory Committee on Immunization Practices for the prevention of the respective diseases identified in section 120335 of the Health and Safety Code.”4

Serologic testing is not routinely recommended in lieu of routine vaccination. Though serologic testing can be considered as an alternative for certain antigens, commercial laboratory testing might not be readily available and may not be sufficiently sensitive or standardized for detection of vaccine-induced immunity (except for hepatitis B vaccination at 1-2 months after the final dose).13 Thus, serologic evaluation and deferral of immunization can be considered for specific cases9 and would require a written medical exemption from the patient's physician. For information on the use of serologic testing and immunization records in special circumstances, see the Red Book and guidelines from the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices.

 

Medical Exemptions to Required Immunizations

California law allows children to be exempted from one or more immunization requirement(s) if they have a valid temporary or permanent medical exemption on file. Only physicians (MD or DO) can provide written documentation of a medical exemption and starting in July 1, 2019, exemptions will only be accepted if issued by a physician who is licensed to practice in the state of California.4,6

California’s school immunization law does not define specific clinical criteria for medical exemptions. When evaluating a patient for a medical exemption, physicians should use their best clinical judgment; adhere to contraindications and precautions; and consider pertinent medical history, physical findings, and/or diagnostic studies. Physicians should also consider the duration of the contraindication when providing a medical exemption, as few contraindications are considered permanent and a temporary medical exemption will allow for the vaccine to be reconsidered at a later date.

 

Documenting Medical Exemptions

Documentation in the Patient’s Medical Record

When a medical exemption is provided, the patient’s medical record should clearly document findings, describe the reason for the medical exemption, specify the duration of the exemption, and demonstrate that it is consistent with standards of care for contraindications and precautions.10,11

Documentation for School Admission

In addition to documenting the exemption in the medical record, the physician should provide the parent/guardian with a written statement of the exemption for submission to school. Current law requires written documentation for medical exemptions to include: (1) a general statement that a physical or medical condition exists that medically exempts the patient from immunization(s), (2) the specific immunization(s) from which the patient is exempted, and (3) the expected duration of exemption.6

Starting on July 1, 2019, the written statement for temporary and permanent medical exemptions will require the following4:

  • The specific nature of the physical or medical circumstance (not simply the presence of one) exempting the patient from the immunization(s)
  • The expected duration of the specific physical or medical circumstance, specifying the probable timeframe for temporary exemptions or that the circumstance is permanent
  • The specific required vaccine(s) from which the patient is exempt
  • For temporary medical exemptions, the expiration date for each vaccine exemption, which now cannot exceed 12 months from the date that the exemption was signed.

In some instances, students with medical exemptions on file prior to July 1, 2019 will need to be reevaluated. For instance, if a temporary medical exemption has expired or if a prior exemption does not meet the new requirements when the child is admitted at a pre-kindergarten facility or TK/K-12 school, the child will need to be reassessed by a physician and if appropriate, issued a new medical exemption.7

 

Guidance for Contraindications and Precautions

Understanding the contraindications and precautions for required school entry immunizations is vital to ensuring safe receipt of recommended doses and appropriate medical exemptions for patients at risk of serious adverse reactions. A vaccine contraindication is a condition that “increases the chances of a serious adverse reaction to a vaccine for patients with that condition,” while a precaution is a condition that “might increase the chance or severity of an adverse reaction, or that might compromise the ability of the vaccine to produce immunity.”12

Vaccines that are contraindicated should never be given while the contraindication persists13 and medical exemptions should be provided for contraindicated doses. If a patient has a condition considered to be a precaution to a vaccine, that vaccine should not be given, unless the physician believes the benefit of vaccine-induced protection outweighs the risk of an adverse reaction, or the condition has resolved.12,13 Temporary medical exemptions should be given for temporary precautions.

There are few permanent contraindications and precautions to vaccines. Most contraindications and precautions are temporary and the vaccine can be given when the condition no longer exists.13 (See Tables 2 and 3.) Only 4 conditions are generally considered to be permanent contraindications and of those, 2 are for rotavirus, which is not required for pre-kindergarten or TK/K-12 school entry12:

  • All vaccines: Severe (anaphylactic) allergic reaction to a vaccine component or following a prior dose of the same vaccine
  • Pertussis-containing vaccines: Encephalopathy occurring within 7 days of pertussis immunization not due to another identifiable cause
  • Rotavirus vaccine: Severe combined immunodeficiency
  • Rotavirus vaccine: History of intussusception

Family medical history can be a factor in granting medical exemptions from certain required immunizations10 (see Table 2). Per ACIP recommendations, there is no family history that would provide a permanent contraindication to any immunization required for pre-kindergarten or TK/K-12 school attendance. However, a family history of hereditary or congenital immunodeficiency is a temporary contraindication to MMR and varicella immunizations, until an individual has clinical or laboratory proven immunocompetence. In addition, a family history of seizures is a precaution to MMRV combination vaccines.13 For these specific vaccines and scenarios, medical exemptions may be indicated.

 

Table 2: Contraindications to Immunizations Required for Pre-Kindergarten and TK/K-12 School Entrya

Click here to download Table 2 formatted for printing and posting.

Indication for Medical Contraindication

Contraindicated Immunizations

For Immunizations Required for Pre-Kindergarten and TK/K-12 School Entry

Permanent Contraindications

Severe allergic reactionb to a vaccine component or a previous dose of vaccine

DTaP, Tdap, DT, Td, Hib, HepBc, IPV, MMR, Varicella

Encephalopathy (e.g., coma, decreased level of consciousness, or prolonged seizures) not attributable to another identifiable cause within 7 days of a prior dose of:

  • DTP or DTaP (for DTaP) or
  • DTP, DTaP, or Tdap (for Tdap).

DTaP, Tdap

Temporary Contraindications

Younger than 6 weeks old

Hib

Primary or acquired severe immunodeficiency or individuals with HIV who are severely immunocompromisedd

Varicella, MMR

Family history of hereditary or congenital immunodeficiency in a first-degree relative (e.g., parent or sibling) until patient has laboratory or clinical evidence verifying immunocompetencee

Varicella, MMR

Pregnancy

Varicella, MMR

 
  1.  Recommendations were derived from the following sources: American Academy of Pediatrics’ Red Book,9 Centers for Disease Control and Prevention’s Epidemiology and Prevention of Vaccine-Preventable Diseases,12 Advisory Committee on Immunization Practices’ General Best Practice Guidelines for Immunization13 and Immunization Action Coalition’s Guide to Contraindications and Precautions to Commonly Used Vaccines.14
  2. Severe allergic reaction may include symptoms of anaphylaxis, such as hives, wheezing or trouble breathing, circulatory collapse, or shock.
  3. Hypersensitivity to yeast is also considered a contraindication to Hepatitis B immunization.
  4. For individuals with severe immunodeficiency or HIV, see ACIP recommendations regarding severe immunocompromise and the approach to proper immunization. Note that in some instances, specific immunodeficiencies might result in permanent contraindication to certain vaccines.
  5. While ACIP lists family history of hereditary or congenital immunodeficiency in a first-degree relative until the patient has laboratory or clinical evidence of immunocompetence as a contraindication to both MMR and varicella immunizations,13 the Red Book only explicitly references it as a contraindication to varicella immunization.9

 

Table 3: Precautions to Immunizations Required for Pre-Kindergarten and TK/K-12 School Entrya

Click here to download Table 3 formatted for printing and posting.

Indication for Precaution

Applicable Immunizations

For Immunizations Required for Pre-Kindergarten and TK/K-12 School Entry

Moderate or severe illness, with or without fever

DTap, Tdap, DT, Td, IPV, Hib, HepB, MMR, Varicella

Latex allergy15

DTap, Tdap, DT, Td, IPV, Hib, HepB, MMR, Varicella
History of anaphylactic latex allergies: Avoid using vaccines supplied in vials or syringes that contain natural rubber or latex, unless the benefits of immunization outweigh the risk of an allergic reaction. Note: patients with latex allergies that are not anaphylactic in nature (e.g., contact allergy to latex gloves) may be immunized as usual.

See the CDC’s “List of Latex in Vaccine Packaging.”

Guillain-Barre syndrome within 6 weeks after a prior dose of a vaccine containing tetanus-toxoid

DTaP, Tdapb, DT, Td

History of Arthus-type hypersensitivity reactions after prior dose of vaccine containing tetanus-toxoid or diphtheria-toxoid

DTaP, Tdapc, DT, Td
Defer immunization for at least 10 years after last vaccine containing tetanus-toxoid.

Progressive or unstable neurological disease, like uncontrolled seizures and progressive encephalopathy

DTaPd, Tdap
Defer immunization for patients with suspected or evolving neurological disease until the condition has been clarified and stabilized and a treatment regimen has been established.

Infantile spasms

DTaP
Defer immunization until a treatment plan is in place and the patient is stable.

Personal or family history of seizures

MMRV
Administer MMR and varicella vaccines as separate injections for the first dose in children 12-47 months of age if there is a personal or family history of seizures.12

Receipt of antibody-containing blood product(s) in the last 11 monthse

MMR, Varicella

History of thrombocytopenic purpura and/or thrombocytopenia in isolation or after prior MMR

MMR

Need for tuberculin skin testing (TST) or Interferon Gamma Release Assay (IGRA)

MMR
Administer MMR the same day as TST or IGRA testing or delay testing for 4-6 weeks after immunization.f

Untreated or suspected active tuberculosis

MMR
Delay MMR for those with untreated active TB until initiation of anti-tuberculosis therapy.  

Receipt of specific antivirals (e.g., acyclovir, famciclovir, or valacyclovir) 24 hours prior to immunization

Varicella
Consider avoiding use of specified antivirals
(e.g.,
acyclovir, famciclovir, or valacyclovir) for
14 to 21 days after immunization.
g

Pregnancyh

IPV

Temperature of 105°F or higher within 48 hours of a prior dose of DTaP or DTPi

DTaP

Use of aspirin or aspirin-containing productsj

Varicella

  1. Recommendations were derived from the following sources: American Academy of Pediatrics’ Red Book,9 Centers for Disease Control and Prevention’s Epidemiology and Prevention of Vaccine-Preventable Diseases,12 Advisory Committee on Immunization Practices’ General Best Practice Guidelines for Immunization,13 and Immunization Action Coalition’s Guide to Contraindications and Precautions to Commonly Used Vaccines.14
  2. The decision to give additional doses of DTaP should be made on the basis of consideration of the benefit of further immunization versus the risk of recurrence of GBS. For example, completion of the primary series in children is justified.9
  3. Note that a history of extensive limb-swelling after DTP, DTap, or Td that is not an Arthus-type reaction is not a contraindication to Tdap immunization.13
  4. While progressive or unstable neurologic disease is a precaution to DTaP, a family history (i.e., siblings or parents) of seizures or a personal history of well-controlled seizures is not. For children with a family or personal history of seizures, acetaminophen dosed prior to administering DTaP and thereafter every 4 hours for 24 hours can be considered.9
  5. See ACIP recommendations for additional details on recommended vaccine intervals and considerations when receiving immune products.
  6. While ACIP recommends postponing the TST or IGRA for at least 4 weeks after immunization (if MMR cannot be administered on the same day as the TST or IGRA),13 the Red Book recommends delaying testing for 4-6 weeks after immunization.9
  7. While ACIP recommends avoiding specific antivirals (e.g., acyclovir, famciclovir, or valacyclovir) for 14 days after varicella immunization,13 the Red Book recommends avoiding specific antivirals up to 21 days after immunization.9
  8. While ACIP considers pregnancy to be a precaution for IPV,13 the Red Book does not mention pregnancy as a precaution for IPV.9
  9. While ACIP does not list temperature of 105°F or higher within 48 hours of a prior dose of DTaP/DTP as a precaution for future DTaP immunizations,13,16 the Red Book does.9
  10. While ACIP lists use of aspirin or aspirin-containing products as a precaution for varicella immunization,13 the Red Book does not.9

 

Misperceptions Regarding Contraindications

Patients, parents, and health care providers may misperceive certain conditions to be contraindications to immunization. This can lead to missed opportunities to immunize. Common misperceptions that providers may encounter are listed below. For a complete list, see ACIP guidelines and the Red Book.

 

Table 4: Common Misconceptions about Medical Contraindications to Immunizations Required for Pre-Kindergarten and TK/K-12 School Entrya

Click here to download Table 4 formatted for printing and posting.

System

 

 Conditions Commonly Misperceived as Contraindications or Precautions to Immunizations Required for Pre-Kindergarten and TK/K-12 School Entry

Infectious Disease

  • Mild acute illnesses (e.g., low-grade fevers, colds, upper respiratory illness, diarrhea, or otitis media)
  • Recent exposure to an infectious illness
  • Recent resolution of an infectious illness
  • Current antimicrobial therapy
  • Asymptomatic or mildly symptomatic HIV infectionb

Allergy,  Immunology, and Other

  • Breastfeeding
  • Presence of a breastfeeding, pregnant, unimmunized, or immunosuppressed person in the household
  • Asthma11
  • Eczema11
  • Allergy to products not contained in the vaccine (e.g., penicillin, duck, or feather allergy)
  • Family history of allergies
  • Family history of adverse vaccine reaction unrelated to immunosuppression
  • History of receiving allergen extract immunotherapy
  • Non-severe or non-anaphylactic allergic reaction to a vaccine component
  • History of mild to moderate local reaction after a prior vaccine dose (e.g., soreness or swelling/redness at the injection site)
  • Autoimmune disease (e.g., Type I diabetes, IBD, vasculitis, vitiligo, celiac disease)c
  • Fussiness, mild drowsiness, or fever <105°Fdafter a previous dose of DTaP or DTP
  • Hypotonic, hyporesponsive episode within 48 hours of a previous dose of DTaP or DTP
  • History of inconsolable crying for at least 3 hours within 48 hours of a previous dose of DTP or DTaP
  • Family history of adverse reaction to DTP or DTaP
  • Previous receipt of oral poliovirus vaccine

Neurological

  • Family history of Sudden Infant Death Syndrome (SIDS)
  • Family history of seizures. See exception for MMRV.
  • Seizure with or without fever within 3 days after receiving a prior dose of DTaP or DTPe
  • Stable neurological condition (e.g., well-controlled seizures, cerebral palsy, and developmental delays including autism)
  • History of brachial neuritis

Development

  • Preterm birth, with exceptions for hepatitis Bf
  • Speech delay11
  • Learning disabilities11
  • Autism Spectrum Disorders (ASD)11
  • Attention-Deficit/Hyperactivity Disorder (ADHD)11
 
  1. Recommendations were derived from the following sources: American Academy of Pediatrics’ Red Book,9 Centers for Disease Control and Prevention’s Epidemiology and Prevention of Vaccine-Preventable Diseases,12 Advisory Committee on Immunization Practices’ General Best Practice Guidelines for Immunization13 and the What You STILL Need to Know About Medical Contraindications to Immunization Under SB 277 presentation (Randy Bergen, MD).11
  2. For individuals with severe immunodeficiency or HIV, see ACIP recommendations regarding severe immunocompromise and the approach to proper immunization.
  3. Autoimmune/inflammatory syndrome induced by adjuvants (ASIA) is a proposed syndrome that consists of four autoimmune/autoinflammatory conditions, one of which is post-vaccination phenomena, believed to occur in genetically predisposed individuals after exposure to environmental triggers.17 These triggers are believed to include things like pollutants, aluminum salts, and adjuvants found in some vaccines. The exact role of specific vaccines and vaccine-adjuvants in these processes has not been clearly delineated or defined, nor have the appropriateness of proposed diagnostic criteria for ASIA been validated or fully evaluated in the pediatric population.17 There are no current ACIP recommendations specifically regarding the consideration of ASIA when determining patient eligibility for immunizations.13
  4. Neither ACIP nor the Red Book list temperature of lower than 105°F after a prior dose of DTaP/DTP as a precaution for future DTaP immunizations.9,13,16 However, the Red Book, but not ACIP, lists temperature of 105°F or higher within 48 hours of a prior dose of DTaP/DTP as a precaution for future DTaP immunizations.9,13,16
  5. While ACIP lists a history of seizure with or without fever within 3 days of a prior dose of DTP or DTaP as a condition that is commonly misperceived to be a contraindication to DTaP and Tdap immunization,13,16 the Red Book does not comment on this specifically.9
  6. Hepatitis B immunization should be deferred for infants weighing <2,000 g if the mother is documented to be HBsAg- negative. Immunization should commence at chronological age 1 month or at hospital discharge. For infants born to HBsAg-positive women, hepatitis B immune globulin and hepatitis B vaccine should be administered within 12 hours after birth, regardless of weight.13

 

Screening for Contraindications and Precautions

Providers should screen for contraindications and precautions before each vaccine dose is administered and reassess for vaccine eligibility if doses were delayed due to a temporary contraindication or precaution. Consider using a screening checklist, such as the Immunization Action Coalition’s Screening Checklist for Contraindications to Vaccines for Children and Teens.

 

 
Immunization Action Coalition Screening Checklist

Immunization Action Coalition Screening Checklist

Click the image for a printable version in English with additional instructions for healthcare professionals or visit the webpage to download the checklist in 9 other languages.

Reproduced with permission from the Immunization Action Coalition.18

 

Conclusion

Recent policy changes, along with the combined efforts of physicians and other health care providers, public health, and community partners, have led to increases in pediatric immunization rates in LA County. However, it remains as important as ever for health care providers to understand California’s immunization requirements, openly discuss recommendations with parents and caregivers, and have cogent reasons for granting medical exemptions after thoroughly evaluating for contraindications and precautions. These actions will help to ensure that children receive all immunizations that are recommended for them and that children who cannot be vaccinated due to contraindications or precautions are protected by community immunity.

 

Resources

Immunization Recommendations

Childcare and School Immunization Requirements

Communicating with Parents and Caregivers

 

  Continuing Medical Education
 
 
 

Continuing Medical Education

To obtain CME click here.

 

References

  1. California Department of Public Health, Immunization Branch. 2015-2016 Kindergarten Immunization Assessment. http://eziz.org/assets/docs/shotsforschool/2015-16CAKindergartenSummaryReport.pdf. Accessed October 14, 2018.
  2. California Department of Public Health, Immunization Branch. 2017-2018 Kindergarten Immunization Assessment - Executive Summary. https://www.cdph.ca.gov/Programs/CID/DCDC/CDPH Document Library/Immunization/2017-2018KindergartenSummaryReport.pdf. Accessed October 1, 2018.
  3. Kimmel SR, Wolfe RM. Communicating the benefits and risks of vaccines. J Fam Pract. 2005;54(1 Suppl):S51-7.
  4. California Code of Regulations Title 17, Division 1, Chapter 4, Subchapter 8. California Department of Public Health, Vaccines for Children Program website. http://eziz.org/assets/docs/shotsforschool/IMM-1080.pdf. Accessed October 5, 2018.
  5. California Department of Public Health, Immunization Branch. Senate Bill 277 Frequently Asked Questions. http://eziz.org/assets/docs/shotsforschool/SB277_FAQ.pdf. Updated January 2, 2018. Accessed December 6, 2018.
  6. California Code of Regulations Title 17, Division 1, Chapter 4, Subchapter 8 (with Amendments). California Department of Public Health website. https://www.cdph.ca.gov/Programs/OLS/CDPH%20Document%20Library/DPH-11-004.RegText.pdf. Updated April 13, 2018. Accessed December 4, 2018.
  7. California Department of Public Health, Immunization Branch. New regulations (July 1, 2019) FAQs. https://www.shotsforschool.org/laws/regs2019/#Q3. Accessed March 12, 2019.
  8. California Department of Public Health, Immunization Branch. Pre-kindergarten (Child Care) and School Immunization Requirements: California Immunization Handbook for Pre-Kindergarten (Child Care) Programs and Schools. 10th ed. July 2019. http://eziz.org/assets/docs/shotsforschool/IMM-365.pdf. Accessed March 27, 2019.
  9. Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2018-2021 Report of the Committee on Infectious Diseases. 31st ed. Itasca, IL: American Academy of Pediatrics; 2018.
  10. Clark S. New school rules: What providers and parents need to know. Webinar presented at: California Immunization Coalition Education Hour; October 28, 2015. http://www.immunizeca.org/wp-content/uploads/2015/10/Medical-Exemptions-SB277-final.pdf. Accessed October 9, 2018.
  11. Bergen R. Not-so-new school rules: What you STILL need to know about medical contraindications to immunization under SB 277. Presented at: California Immunization Coalition Summit; April 17, 2018.
  12. Centers for Disease Control and Prevention. General recommendations on immunization. In: Hamborsky J, Kroger A, Wolfe S, eds. Epidemiology and Prevention of Vaccine-Preventable Diseases. 13th ed. Washington D.C.: Public Health Foundation; 2015. https://www.cdc.gov/vaccines/pubs/pinkbook/genrec.html.
  13. Ezeanolue E, Harriman K, Hunter P, Kroger A, Pellegrini C. General Best Practice Guidelines for Immunization: Best Practices Guidance of the Advisory Committee on Immunization Practices (ACIP). https://www.cdc.gov/vaccines/hcp/acip-recs/general-recs/index.html. Accessed October 8, 2018.
  14. Immunization Action Coalition. Guide to Contraindications and Precautions to Commonly Used Vaccines. www.immunize.org/catg.d/p3072a.pdf. Accessed October 8, 2018.
  15. Ask the experts: precautions and contraindications. Immunization Action Coalition website. http://www.immunize.org/askexperts/precautions-contraindications.asp, Item #P3702a. Updated March 13, 2019. Accessed April 5, 2019.
  16. Liang JL, Tiwari T, Moro P, et al. Prevention of pertussis, tetanus, and diphtheria with vaccines in the United States: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2018;67(2):1-44. doi:10.15585/mmwr.rr6702a1
  17. Esposito S, Prada E, Mastrolia MV, Tarantino G, Codecà C, Rigante D. Autoimmune/inflammatory syndrome induced by adjuvants (ASIA): clues and pitfalls in the pediatric background. Immunol Res. 2014;60(2-3):366-375. doi:10.1007/s12026-014-8586-0
  18. Immunization Action Coalition. Screening checklist for contraindications to vaccines for children and teens. www.immunize.org/catg.d/p4060.pdf. Accessed October 8, 2018.
 

Subscribe to Rx for Prevention button


Author Information:

Candace Gragnani, MD, MPH, FAAP
Preventive Medicine Fellow, University of California,
Los Angeles

Franklin Pratt, MD, MPHTM, FACEP
Medical Director

Julia Heinzerling, MPH
Special Assistant to the Chief Medical Officer,
Bureau of Disease Control

County of Los Angeles
Department of Public Health

ip@ph.lacounty.gov

www.publichealth.lacounty.gov/ip


Acknowledgments:

The authors would like to thank the following people for their contributions including article review:

Randy Bergen, MD
The Permanente Medical Group

Wendi Cate, MA
Los Angeles County
Department of Public Health

James D. Cherry, MD, MSc
David Geffen School of Medicine
University of California,
Los Angeles

Alice A. Kuo, MD, PhD, FAAP
University of California,
Los Angeles

Priyanka Fernandes, MBBS, MPH
University of California,
Los Angeles


Rx for Prevention, 2019
May;9(1).


Published: May 1, 2019