Welcome to the
California Immunization Coalition
Education Hour
1
.
New School Rules: What Providers
and Parents Need to Know
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
Scott Clark
Associate Director, Medical & Regulatory Policy
California Medical Association
CIC Education Hour, October 28, 2015
Senate Bill 277
Senators Richard Pan, MD & Ben Allen
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• Withdrawn October 16
SB 277
Removes the personal belief
exemption (PBE) from school
vaccination requirements
Allows exemptions only for medical
reasons
SB 277
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
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
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
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
FAQ available at
www.cmanet.org
Scott Clark
[email protected]
916-551-2887
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
Randy Bergen, MD
Pediatric Infectious Disease
Kaiser Permanente, Walnut Creek
14 October 29, 2015
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© Kaiser Permanente 2010-2011. All Rights Reserved.
Objective
Understand the process for determining
medical exemption from immunization
Third Agenda
Fourth Agenda
Fifth Agenda
15 October 29, 2015
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© 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
Be Clear About Your Role
Clinicians provide health care.
Schools enforce the law.
16 October 29, 2015
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© 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
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 October 29, 2015
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© 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
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 October 29, 2015
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© 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
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 October 29, 2015
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© 2014 Regional Health Education, The Permanente Medical Group, Inc.
Vaccines Required for Childcare / Preschool
20 October 29, 2015
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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
© 2015 Regional Health Education, The Permanente Medical Group, Inc.
www.shotsforschool.org/child-care/
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
www.shotsforschool.org/k-12/
21 October 29, 2015
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© 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
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)
www.shotsforschool.org/k-12/
22 October 29, 2015
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© 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
School requirements are only a subset of all
routinely recommended vaccines
- Number and timing of doses may vary
23 October 29, 2015
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© 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
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 vaccinehesitant parents as a substitute for PBEs.
24 October 29, 2015
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© 2014 Regional Health Education, The Permanente Medical Group, Inc.
The Providers Role
Clinicians need to
– Be clear on what constitutes a medical
contraindication
– Communicate his or her assessment to parents
25 October 29, 2015
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© 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
What Qualifies as a
Medical Exemption?
26 October 29, 2015
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© 2014 Regional Health Education, The Permanente Medical Group, Inc.
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 October 29, 2015
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© 2014 Regional Health Education, The Permanente Medical Group, Inc.
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 October 29, 2015
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© 2015 Regional Health Education, The Permanente Medical Group, Inc.
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
29 October 29, 2015
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© 2015 Regional Health Education, The Permanente Medical Group, Inc.
Example 1:
Mild or Moderate Local Reaction
 CDC and ACIP– No
 AAP– No
 Vaccine Package Inserts – No
30 October 29, 2015
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© 2014 Regional Health Education, The Permanente Medical Group, Inc.
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 October 29, 2015
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© 2014 Regional Health Education, The Permanente Medical Group, Inc.
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 October 29, 2015
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© 2014 Regional Health Education, The Permanente Medical Group, Inc.
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 October 29, 2015
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© 2014 Regional Health Education, The Permanente Medical Group, Inc.
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
34 October 29, 2015
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© 2014 Regional Health Education, The Permanente Medical Group, Inc.
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
35 October 29, 2015
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© 2014 Regional Health Education, The Permanente Medical Group, Inc.
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
36
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© 2014 Regional Health Education, The Permanente Medical Group, Inc.
October 29, 2015
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 October 29, 2015
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© 2015 Regional Health Education, The Permanente Medical Group, Inc.
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
38 October 29, 2015
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© 2015 Regional Health Education, The Permanente Medical Group, Inc.
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 October 29, 2015
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© 2015 Regional Health Education, The Permanente Medical Group, Inc.
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.
40 October 29, 2015
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© 2014 Regional Health Education, The Permanente Medical Group, Inc.
Resources
41
Centers for Disease Control and Prevention
www.cdc.gov/vaccines/recs/vac-admin/contraindications.htm
Centers for Disease Control and Prevention
www.cdc.gov/vaccines/recs/vac-admin/contraindications-vacc.htm
Shots for School
www.shotsforschool.org/laws/exemptions/
www.EZIZ.org
A one stop shop
for immunization
training and
resources –
including the
updated
California
Immunization
Handbook!
Immunization Action Coalition
www.immunize.org/catg.d/p4065.pdf
Vaccine Adverse Events Reporting System
VAERS
www.cdc.gov/vaccinesafety/ensuringsafety/monitoring/vaers/index.html
Tweet and Follow
Twitter @ImmunizeCA
Facebook ImmunizeCA
Question and Answer
Session
49
Please Complete
Online Evaluation!
50
Thank you
 Health Net of California, Inc.
 Kaiser Permanente, Northern California
 California Medical Association
 California Department of Public Health
Immunization Branch