Back-to-School Immunizations

Immunizations are one thing students need to check off their back-to-school list. Students who live in California, in particular, may not be allowed back to school this fall if they are not up-to-date with required immunizations. California Gov. Edmund G. Brown, Jr, signed SB 277 into law on June 30, 2015. This law requires all schoolchildren attending both private and public schools to be fully vaccinated regardless of parents’ personal or religious beliefs.¹The law comes after several recent outbreaks of vaccine-preventable illnesses due to lack of immunizations (most recently, measles). The law will allow for medical exemptions, but personal and religious exemptions will no longer be allowed, making it similar to laws in West Virginia and Mississippi.²It is important that health care providers understand valid reasons for medical waivers, which include cases in which the risks posed by immunization for a particular patient are greater than its potential benefits. This includes understanding clear contraindications.

Current State of Vaccine‑Preventable Diseases

California is setting a trend likely to sweep the nation. Advocates for improved health‑prevention strategies lobby for safer school environments, creating a hot legislative topic. This comes months after nearly 2 dozen Disneyland measles outbreaks resulted in hundreds of cases spreading across multiple states.³In Washington state, a woman died of measles complications in July 2015, the first US death from measles since 2003.⁴The patient was immunocompromised, making her susceptible to disease and complications, and hers was one of several cases of measles in her county this year.

Measles is not the only vaccine-preventable disease on the rise. The Centers for Disease Control and Prevention (CDC) reported 28,660 cases of pertussis during 2014, and the number continues to rise as case counts are reconciled.⁵The rates were highest in adolescents aged 13 to 16 years. This is consistent with waning immunity and the need for the tetanus, diphtheria, and pertussis booster (Tdap) due at ages 11 to 12 years.

Science continues to show that vaccines protect children from a number of dangerous diseases. They also protect others with weakened immune systems from disease exposure through what is known as herd immunity. The benefits of immunizations clearly outweigh the potential adverse effects.

Health Prevention in 2015

Allowing vaccine exemptions only for medical reasons is the newest trend to potentially increase immunization rates and make vaccine‑preventable diseases extinct. State public policies have been focusing on disease prevention. For example, the hepatitis B vaccine is often begun in infancy and is now mandatory in all states except Alabama, Montana, and South Dakota.⁶Hepatitis A vaccination is mandated for children entering day care in 20 states, and more than half that number also require the vaccination prior to grades kindergarten through 12.7 Daycare facilities also have mandates for rotavirus prevention in Idaho, Louisiana, Rhode Island, and West Virginia.⁸The pneumococcal conjugate vaccine is required for children in daycare in 37 states.⁹The polio vaccine is required for children in daycare in all states except Ohio.¹⁰The requirements for measles, mumps, and rubella (MMR) vaccination vary among states.

More recently, 23 states have mandated a single dose of the meningococcal vaccine beginning around 7th grade, with 7 states beginning as early as 6th grade if the date of birth is January 1, 1997, or later.¹¹A booster is required by grade 12. Human papillomavirus (HPV) will likely be one of the slowest vaccines to become mandated. Virginia was first to mandate HPV vaccination for girls in 2008, followed by the District of Columbia in 2009.¹²Most recently, Rhode Island was the first to mandate for both males and females beginning in August 2015, with a plan to have all 3 doses completed within 3 years.

The other vaccine that has been slow to be mandated is influenza. Although required by many universities, few require it for child care; New Jersey was the first in 2008, followed by Connecticut in 2011, New York City in 2014, and most recently, Rhode Island.¹³

It is important that advanced practice clinicians know and review their state requirements. Lobbying representatives as a vaccine advocate can influence practices at the local level. All childhood health care providers must be familiar with current immunization schedules. These are reviewed and updated regularly by the Advisory Committee on Immunization Practices (ACIP), a division of the CDC. The recommendations that follow are based on the CDC 2015 immunization guidelines.

Preschool/Elementary School

By the time children begin school, most are protected from 14 diseases, if properly vaccinated according to the CDC recommendations. To begin school between the ages of 4 and 6 years, children should be vaccinated with the boosters of diptheria, tetanus, and pertussis (DTaP), inactivated poliovirus, MMR, and varicella (VAR).¹⁴DTaP has a higher concentration of diphtheria toxoid than Tdap. There is an increased risk of local reactions in patients older than 6 years, so it should only be given through that age. If a child is only starting their vaccines prior to beginning school, refer to the catch-up schedule to plan and complete additional vaccines as indicated. Additionally, an annual flu vaccine is recommended. For those receiving the flu vaccine for the first time, 2 doses given at least 4 weeks apart are recommended for children aged 6 months through 8 years. In October 2014, ACIP approved a new flu vaccine schedule. For the first time, it recommended that children aged 2 through 8 years be vaccinated with the live attenuated vaccine (LAIV) if not contraindicated.¹⁵

Middle School

As mentioned earlier, protection from some earlier vaccines fades and booster doses are necessary. At ages 11 and 12 years, the Tdap booster is given to protect from whooping cough, tetanus, and diphtheria. The meningitis conjugate vaccine (MCV) is also initiated to prevent 2 of the 3 most common causes of meningococcal disease in the United States, Serogroups C and Y, which are serious and often life-threatening. Serogroup B meningococcal disease is currently not covered in the recommended vaccine schedule.¹⁶A single dose of influenza vaccine should also be provided annually to middle schoolers. This is also a good time to ask about hepatitis A vaccine for those who did not previously receive it.

HPV infections can cause cancer. HPV vaccines are now available in either 2-, 4-, or 9-strain coverage and should be initiated in both boys and girls as soon as they reach the age of 11 to 12 years. The vaccine is indicated for use through age 26 years. The 2-strain (2-valent, or 2v) HPV vaccine is only indicated for girls and women as it lacks coverage of the viral strains that can cause cancer in men. ACIP does not otherwise recommend one HPV vaccine over another; the choice is at the discretion of the health care provider. HPV vaccination includes a 3-shot series. If a male is vaccinated with the 4vHPV vaccine or a female is vaccinated with either 2vHP or 4vHPV, the 9vHPV vaccine is not indicated despite the additional strain coverage.

High School

The annual influenza vaccine is recommended. An MCV booster shot is recommended at age 16 years. Teens who received the MCV vaccine for the first time at ages 13 through 15 years will need a 1-time booster dose between the ages of 16 and 18 years. If the first dose is not given until age 16 years, only 1 shot is needed.

College

A young adult headed off to college today is typically between 19 and 26 years of age.¹⁷A tetanus shot is due every 10 years, and a Tdap is preferred for the first adult dose rather than the tetanus diphtheria (Td) vaccine. If a Td vaccine was given instead, the vaccine should be repeated with the Tdap, with no minimal interval from the Td dose. Because of declining immunity in the years after immunization, in 2005, ACIP recommended that persons aged 19 to 64 years receive a single dose of Tdap in place of a Td booster.¹⁸

A Tdap booster is recommended in the third trimester of pregnancy for each pregnancy. In 2011 and again in 2012, ACIP revised its recommendation on Tdap for pregnant women: “Women should receive a single dose of Tdap during each pregnancy, preferably at 27 to 36 weeks’ gestation.”¹⁹

If the HPV vaccine series was not completed after initiation in early childhood, young adulthood is a great time to reintroduce and complete the series, as it is only indicated through age 26 years. Most colleges require proof of 2 doses of MMR and 2 doses of VAR, but the actual requirements depend on the school. Laboratory evidence may also be required for certain vaccinations, particularly those who study the health sciences. A best practice is to check your state registry to prevent duplications when possible. If vaccination records are not accessible, vaccines may be readministered.²⁰

Pearls of Scheduling Vaccines

There is no limit to how many vaccines can be given on 1 date, but each vaccine must be administered separately. When giving multiple live vaccines, they must be given on the same day, otherwise they should be separated by 4 weeks.²¹Live vaccines include LAIV, MMR, VAR, and yellow fever (for children traveling to certain countries). If a tuberculin skin test (TST) is needed, it may be done on the same day as live vaccines. However, if a 2-step TST is required, wait to administer the live vaccine when placing the second TST. Live measles vaccine in the MMR prior to the TST can reduce the reactivity of the skin test due to mild suppression of the immune system.²²

Precautions and Contraindications

There are very few reasons for a delay of immunization or for medical waiver. Health care providers must screen patients prior to vaccination. It is important to understand precautions and contraindications to ensure appropriate immunizations are provided, not withheld. When screening, vital signs, including temperature, should not be obtained prior to immunization as there is no particular number that warrants a red light.²³However, if the child has a moderate or severe acute illness, vaccination may be deferred until the patient’s condition has improved. For patients with a latex allergy, check the package insert to see if the syringe or vial contains any latex. For patients with an egg allergy, there is 1 formula of influenza vaccine available, but it is only approved for individuals 18 years or older.¹⁵

Women of childbearing age should be asked whether they may be pregnant prior to being given any vaccine for which contraindications or precautions are advised. The patient’s response should be documented in the medical record. Advise patients who are not currently pregnant to avoid pregnancy for 1 month following the MMR vaccination. Only if the patient is uncertain whether she is pregnant and the vaccines to be administered are live virus vaccines (ie, LAIV, MMR, VAR, or yellow fever) should a pregnancy test be performed.¹⁹

Medical Exemption

A medical exemption should only occur for the period of time the vaccine needs to be deferred. For example, if a child received a transfusion of blood or blood products or was given immune globulin within 1 year, certain live vaccines may need to be deferred. If the patient is taking an antiviral drug in the previous 24 to 48 hours, both the LAIV and VAR vaccines may need to be deferred.²⁴Current ACIP recommendations and the American Academy of Pediatrics’ “Red Book” are both excellent sources for the most current information. Under certain circumstances, live vaccines should be postponed, such as after chemotherapy or long-term high-dose steroid therapy has ended.

Conclusion

It will take increased effort to eradicate vaccine-preventable illnesses, not only by immunizing health care providers, but also through public health policy. Before signing a medical waiver for a patient, be certain there is a clear indication to withhold or delay immunizations. Have a conversation with parents about vaccination, providing an effective interaction while addressing parental concerns.²⁵In doing so, advanced practice clinicians are able to uphold the law while helping to prevent disease in children and providing safe school settings, especially for those children who are immunocompromised and at risk.

Amy Warner, DNP, FNP-C, ACNS-BC, is dual board-certified as a clinical nurse specialist and family nurse practitioner and has 23 years of health care experience. She is a clinical educator with the Healthcare Clinic in Walgreens and resides in Atlanta, Georgia. Amy’s background includes family practice, comprehensive preventive health screenings, and occupational health. She is most passionate about disease prevention and health strategies.

References

1) California Governor Jerry Brown signs mandatory vaccine law.Time.com.June 30, 2015. http://time.com/3941832/jerry-brown-signs-vaccine-law/.

2) Lantos JD, Jackson MA, Harrison CJ. Why we should eliminate personal belief exemptions to vaccine mandates.J Health Polit Policy Law.2012;37(1):131-140. doi:10.1215/03616878-1496038.

3) Halsey NA, Salmon DA. Measles at Disneyland, a problem for all ages.Ann Intern Med.2015;162(9):655-656. doi:10.7326/M15-0447.

4) Bellisle M. First person dies of measles in U.S. since 2003.Time.Com.July 2, 2015. http://time.com/3945056/measles-death-washington/?xid=emailshare.

5) Pertussis outbreak trends. Centers for Disease Control and Prevention website.www.cdc.gov/pertussis/outbreaks/trends.html. Updated March 11, 2015. Accessed July 10, 2015.

6) State information: hepatitis B prevention mandates for daycare and K-12. Immunization Action Coalition website.www.immunize.org/laws/hepb.asp. Updated January 15, 2015. Accessed July 10, 2015.

7) State information: hepatitis A prevention mandates for daycare and K-12. Immunization Action Coalition website. www.immunize.org/laws/hepa.asp. Updated January 15, 2015. Accessed July 10, 2015.

8) State information: rotavirus prevention mandates for children in daycare facilities. www.immunize.org/laws/rotavirus.asp. Updated February 2, 2015. Accessed July 10, 2015.

9) State information: pneumococcal conjugate vaccine mandates for children in daycare. Immunization Action Coalition website. www.immunize.org/laws/pneuconj.asp. Updated January 15, 2015. Accessed July 10, 2015.

10) School vaccination requirements, exemptions and web links. Centers for Disease Control and Prevention website. www2a.cdc.gov/nip/schoolsurv/schImmRqmtReport.asp?s=grantee&d=4&w=WHERE%20a.gradeID=1%20AND%20a.vaccineID=10. Updated July 11, 2011. Accessed July 10, 2015.

11) State information: meningococcal state mandates for elementary and secondary schools. Immunization Action Coalition website.www.immunize.org/laws/menin_sec.asp. Updated January 15, 2015. Accessed July 10, 2015.

12) State information: HPV mandates for children in secondary schools. Immunization Action Coalition website.www.immunize.org/laws/hpv.asp. Updated February 2, 2015. Accessed July 10, 2015.

13) State information: states with influenza vaccine mandates for children. Immunization Action Coalition website. www.immunize.org/laws/flu_childcare.asp. Updated January 15, 2015. Accessed July 10, 2015.

14) Strikas RA;Centers for Disease Control and Prevention (CDC);Advisory Committee on Immunization Practices (ACIP);ACIP Child/Adolescent Immunization Work Group. Advisory Committee on Immunization Practices recommended immunization schedules for persons aged 0 through 18 years--United States, 2015.MMWR Morb Mortal Wkly Rep.2015;64(4):93-94.

15) Grohskopf LA, Olsen SJ, Sokolow LZ, et al. Prevention and control of seasonal influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices (ACIP)—United States, 2014-15 influenza season. Centers for Disease Control and Prevention website. www.cdc.gov/mmwr/preview/mmwrhtml/mm6332a3.htm. Updated August 15, 2014. Accessed July 10, 2015.

16) Folaranmi T, Rubin L, Martin SW, Patel M, MacNeil J. Use of serogroup B meningococcal vaccines in persons aged ≥10 years at increased risk for serogroup B meningococcal disease: recommendations of the advisory committee on immunization practices, 2015.MMWR Morb Mortal Wkly Rep. 2015;64(22);608-612. www.cdc.gov/mmwr/preview/mmwrhtml/mm6422a3.htm. Accessed July 25, 2015.

17) Kim D K, Bridges CB, Harriman, KH;Centers for Disease Control and Prevention (CDC);Advisory Committee on Immunization Practices (ACIP);ACIP Adult Immunization Work Group. Advisory committee on immunization practices recommended immunization schedule for adults aged 19 years or older--United States, 2015.MMWR Morb Mortal Wkly Rep.2015;64(4):91-92.

18) Combined Tdap vaccine. Centers for Disease Control and Prevention website. www.cdc.gov/vaccines/vpd-vac/combo-vaccines/DTaP-Td-DT/tdap.htm. Updated May 22, 2014. Accessed July 10, 2015.

19) Guidelines for vaccinating pregnant women. Centers for Disease Control and Prevention website. www.cdc.gov/vaccines/pubs/preg-guide.htm. Updated October 10, 2014. Accessed July 10, 2015.

20) Vaccination records for kids. Centers for Disease Control and Prevention website.www.cdc.gov/vaccines/parents/record-reqs/immuniz-records-child.html. Updated May 18, 2012. Accessed July 10, 2015

21) General recommendations on immunization: epidemiology and prevention of vaccine-preventable diseases. Centers for Disease Control and Prevention website.www.cdc.gov/vaccines/pubs/pinkbook/genrec.html. Updated May 15, 2015. Accessed July 10, 2015

22) Ask the experts: diseases & vaccines: measles, mumps, and rubella. Immunization Action Coalition website.www.immunize.org/askexperts/experts_mmr.asp. Accessed July 10, 2015.

23) Ask the experts: topics: precautions and contraindications. Immunization Action Coalition website.www.immunize.org/askexperts/precautions-contraindications.asp. Accessed July 10, 2015.

24) Contraindications and precautions to commonly used vaccines in adults: United States, 2015. Centers for Disease Control and Prevention website.www.cdc.gov/vaccines/schedules/hcp/imz/adult-contraindications-shell.html. Updated February 3, 2015.

25) Leask J, Kinnersley P, Jackson C, Cheater F, Bedford H, Rowles G. Communicating with parents about vaccination: a framework for health professionals.BMC Pediatr.2012;12:154. doi:10.1186/1471-2431-12-154.