Immunization Is a Public Health Priority
Despite years of effort, immunization rates have not reached desired levels. Nationwide, low-income children and adolescents are less likely than their wealthier peers to have been fully immunized.(1) In California, more than 8% of children arrive at kindergarten without all required vaccines, and only 42% of children and adolescents are immunized against the flu in any given year.(2) The rates of other essential vaccinations–including human papillomavirus, meningococcal meningitis, and pertussis/whooping cough–are also too low. As a result, children and adolescents catch, suffer from, and pass on dangerous preventable illnesses.
School-Located Vaccination Increases Immunization Rates
School-located vaccination (SLV) programs and school-based health centers (SBHCs) improve adolescent vaccination rates, while simultaneously saving health care dollars for society. More specifically, recent research shows that:
- SLV is an effective way to increase immunization rates and prevent costly illness.(3,4,5,6)
- More than 80% of SBHCs offer important adolescent vaccinations, with the vast majority providing vaccinations to Medicaid covered (96%) and uninsured (98%) students.(7)
- Across a wide range of vaccinations—including Hep B, Tdap, MMR, and HPV—SBHCs can achieve significantly higher rates of full immunization than other types of providers.(8)
2019 Vaccination Update
Starting in the 2019-2020 school year, school immunization requirements now include: Two (rather than one) doses of chickenpox vaccine at
- TK/Kindergarten entry
- 7th grade advancement
- TK/K-12 admission or transfer
And 2 MMR doses and 3 Hepatitis B vaccine doses at admission or transfer for most K-12 students.
As these requirements reflect longstanding national recommendations, many children have already met these requirements.
SB 277 Vaccination Law (2015)
In 2015, California passed SB 277, one of the most comprehensive school immunization laws in the country. Starting July 1, 2016, all newly enrolled children in day care and school will need to be immunized, except those with medical exemptions.
What Has Changed?
The following changes went into effect in 2016:
- Parents can no longer use personal (including religious) belief exemptions to opt out of vaccinations required when enrolling in child care and public and private schools.
- Children with serious health issues can opt out by providing the school a medical exemption written by a licensed physician.
- Some children are exempt:
- Students in home-based private schools; and
- Students enrolled in an independent study program who do not receive classroom-based instruction.
- Students who qualify for individualized education programs (IEPs) will be allowed to access any special education and related services required by the IEPs, regardless of whether the students are vaccinated.
What About Children Who Currently Have Personal Belief Exemptions?
Unvaccinated kids can stay unvaccinated and still remain in school until the next “grade span,” as long as their exemption is on file before January 1, 2016.
Grade spans are defined as (a) birth to preschool, (b) kindergarten to grade six, and (c) grades seven to twelve. Students cannot enroll in a new school, change schools, or enter kindergarten or seventh grade without the mandatory vaccinations.
For example, a parent can still use a current personal belief exemption for a child in second grade if they remain at the same school they attended last year. Under the new law, the child will be allowed to remain in the same school without vaccinations until they reach the seventh grade. However, the same child will not be able to enroll in a different school without getting vaccinated first.
What Are the Mandatory Vaccinations?
Children must be immunized against 10 diseases: polio, diphtheria, tetanus, pertussis (whooping cough), measles, mumps, rubella, chicken pox, and bacterial meningitis (required for child care and preschool settings). Hepatitis B vaccination is required for students aged 4-6 admitted to California schools, it is not required after 7 years of age. Students entering seventh grade are required to have a Tdap booster (Tetanus, reduced diphtheria, and pertussis).
For more information, please see resources from the CDPH: Parents’ Guide to Immunizations Required for School Entry and New Pre-Kindergarten and School Immunization Requirements.
The California School Immunization Law requires that children receive a series of immunizations before entry to schools, child care centers, and family child care homes. The law also requires schools, child care centers, and family child care homes to enforce immunization requirements, maintain immunization records, and submit reports.
- Resources on school immunization from the California Department of Public Health: Child Care & Pre-School; K-12; 7th Grade; College.
- Guide to Immunizations Required for School Entry: Grades K-12 (CDPH); Pre-Teens (HHS); College (CDPH).
- Handy Worksheet for Parents to Track Their Child’s Immunizations and Development Milestones, CDC
- Other immunization resources for providers and parents can be found at www.shotsforschool.org.
- Growing Up with Vaccines: What should parents know?, CDC
Other Useful Websites
- California Immunization Coalition
- California Immunization Registry – CDPH
- EZIZ – CDPH
- Vaccine Information Statements in Multiple Languages – Immunization Action Coalition
Flu Affects Millions of Children and Youth Each Year
Each year, 5-20% of people living in the United States contract seasonal influenza.1 While most people quickly recover their health, on average seasonal flu hospitalizes 200,000 and kills 23,600 people annually.2 Young children, pregnant women, the elderly, and people with other health conditions are particularly vulnerable.3
Pandemic flus—such as the 2009-2010 H1N1 (swine) flu—are even more dangerous because they are caused by viruses to which people have very little or no immunity. These viruses spread easily and rapidly.
Fortunately, by promoting vaccination and following other prevention guidelines, we can avoid unnecessary illness and even death. Although most children and youth are themselves at relatively low risk for flu-related complications, they spend a lot of time with younger siblings, pregnant mothers, and grandparents—making flu prevention critical.
Schools and School-Located Vaccination Clinics Can Stop Flu Spreading
According the U.S. Department of Health and Human Services, schools can play a critical role in:
- Encouraging flu vaccination for all students and those staff who are recommended for vaccination;
- Suggesting early treatment for people at higher risk for flu complications;
- Facilitating use of respiratory etiquette and hand hygiene by students and staff;
- Ensuring that sick students and adults do not come to the facility; and
- Separating sick and well people as soon as possible.4
School-based health centers (SBHCs) can run school-located vaccination (SLV) clinics. Research shows that SLV can be an effective way to increase immunization rates.5,6,7 SLV also makes sense financially: rigorous cost-benefit analysis shows that school-based influenza vaccination programs pay for themselves by the end of the flu season’s “peak week,” and, over the course of an entire flu season, save society money by preventing illness.(8)
Resources for Practice
Flu Prevention and Treatment
School-based health centers (SBHCs) should provide seasonal flu vaccine. The CDC has recently expanded the recommended ages for influenza vaccination of children to include all children aged six months through 18 years.
- Seasonal Influenza Resources for Health Professionals, CDC
- Seasonal Influenza Resources for Schools, CDC
- EZIZ.org, California Department of Public Health
- Seasonal Influenza Resources, National Association of School Nurses
School-Located Vaccination Clinics
School-located vaccination (SLV) clinics can play a critical role in reducing the spread of flu, including during flu pandemics, as described in this report from the U.S. Department of Health and Human Services.
- Influenza SLV: Information for Planners, U.S. Department of Health and Human Services
- Seasonal Influenza SLV: Information for Planners, CDC
- SLV Clinic Planning Considerations Memo, CDC
- SLV Clinic Planning Summary, National Association of School Nurses
Prevention & Treatment
- Hand Washing Posters
- Flu Information and Prevention Resources for Families
- How to Clean and Disinfect Schools school guide
- Teaching Children About Flu toolkit
(1) U.S. Department of Health and Human Services: http://www.flu.gov/.
(2) U.S. Department of Health and Human Services: http://www.flu.gov/.
(3) U.S. Department of Health and Human Services: http://www.flu.gov/.
(4) U.S. Department of Health and Human Services: http://www.flu.gov/professional/school/index.html.
(5) Frieden, T. (2010). Memorandum Report: 2009 H1N1 School-Located Vaccination Program Implementation, OEI-04-10-00020.
(6) Gupta, R., Isaac, B., & Briscoe, J. (2010). A Local Health Department’s School-Located Vaccination Experience with H1N1 Pandemic Flu Vaccine. Journal of School Health. 80(7): 325.
(7) Lindley, M.C., Boyer-Chu, L., Fishbein, D.B., Kolasa, M., et al. (2008). The Role of Schools in Strengthening Delivery of New Adolescent Vaccines. Pediatrics. 121: S46-S55.
(8) Schmeir, J., Li, S., King, J.C., Nichol, K., et al. (2008). Benefits and Costs of Immunizing Children against Influenza at School: An Economic Analysis based on a Large-Cluster Controlled Clinical Trial. Health Affairs. W96-W104.
Background and Risk Factors
Human papillomavirus (HPV) is the most common sexually transmitted infection. Seventy nine million Americans, most in their late teens and early 20s, are infected with HPV.1 Most people with HPV do not know they are infected because they never develop symptoms. A person can get HPV by having vaginal, anal, or oral sex with someone who has the virus. There are many different types of HPV, some cause health problems including genital warts and cancers. Now there are vaccines that can stop these health problems from happening.
A vaccine that prevents the types of genital HPV that cause most cases of cervical cancer, anal cancer, and genital warts is now available. The vaccine, Gardasil®, is given in three shots over six months.
The vaccine is routinely recommended for 11 and 12-year-old girls, and also for young women age 13 through 26 who have not yet been vaccinated and who are not yet sexually active or who just recently became sexually active. The vaccine was also recently recommended by the Centers for Disease Control and Prevention for 11 and 12-year-old boys, and also for young men age 13 through 26 who have not yet been vaccinated and who are not yet sexually active or who just recently became sexually active. To learn more about the new vaccine recommendations for both boys and girls, visit the CDC’s website.
Minors aged 12 and over may now consent to the HPV vaccine in California. Learn more about minors’ ability to consent to this vaccine, as well as other STD prevention services, with the passage of AB 499 in October, 2011.
Recommend Barrier Birth Control Methods
Recommend latex condoms and dental dams as well as mutually monogamous relationships to students. These can lower their chances of getting HPV. HPV can infect areas not covered by a condom, so condoms do not fully protect against HPV.
(1) Centers for Disease Control and Prevention. (2019). Genital HPV Infection – Fact Sheet. https://www.cdc.gov/std/hpv/stdfact-hpv.htm
Meningococcal Meningitis (Neisseria meningitides) is the leading cause of bacterial meningitis among U.S. toddlers, children, and adolescents. Meningococcal disease can cause meningitis (swelling of the brain or spinal cord) or meningococcemia (blood infection). In 2017, there were about 350 reported cases of meningococcal disease reported. The rates of meningococcal disease are highest in children under 1 year old, with the second highest rate among adolescents and young adults. Young people ages 16 through 23 years old have the highest rates of meningococcal disease.1 Even with antibiotic treatment, 10 to 15 in 100 people with meningococcal disease will die. Among survivors, 1 in 5 will have permanent complications, such as loss of limb(s), deafness, nervous system problems, or brain damage.2
Symptoms and Risk Factors
Early symptoms can resemble the flu, making diagnosis difficult. Symptoms include fever, headache, stiff neck, nausea and vomiting, and rash. The disease is spread through close, personal contact and exchange of respiratory secretions. Common everyday activities can put adolescents at increased risk for infection. These activities include:
- Sharing drinking glasses and eating utensils;
- Living in close quarters; and
- Smoking (or being exposed to smoke).
Meningococcal disease can occur at any point during the year, though late-winter and early-spring are when most cases occur. Once diagnosed with meningococcal disease, early antibiotic treatment is critical. Close contacts, such as family and friends, should receive preventive antibiotics to stop further spread of the disease.
School-based health centers can help protect children and adolescents against meningitis by providing outreach and education to parents and students, as well as by vaccinating patients. SBHCs should consider pairing patients’ mandated Tdap booster with the meningococcal vaccine whenever possible. (See below for a recent update to the meningococcal booster recommendations for adolescents.)
The American Academy of Pediatrics has endorsed the Advisory Committee on Immunization Practices (ACIP) recommendation for the use of meningococcal conjugate vaccine as a booster dose in 16-18 year olds. The ACIP concluded that a booster dose is the best immunization strategy to help protect adolescents during the entire period of increased risk and provide more opportunities to increase immunization rates. For additional information about these new recommendations, please see the AAP policy statement; and Morbidity and Mortality Weekly Report.
Off to College Meningococcal Vaccine Campaign
This fact sheet, from the California Department of Public Health, is designed for students heading off to college. It explains the risks of meningococcal meningitis and recommends that all college-bound students get immunized.
The 16 Vaccine
The 16 Vaccine is an educational initiative for the CDC-recommended second dose of meningococcal meningitis vaccine. The website includes social media resources.
(1) Centers for Disease Control and Prevention. (2019). Meningococcal Disease Surveillance. https://www.cdc.gov/meningococcal/surveillance/index.html
(2)Centers for Disease Control and Prevention. (2019). Meningococcal Disease Diagnosis & Treatment. https://www.cdc.gov/meningococcal/about/diagnosis-treatment.html
Background and Symptoms
Pertussis (also known as whooping cough) is a highly communicable, vaccine-preventable disease that lasts for many weeks and is typically manifested in children with spasms of severe coughing, whooping, and associated vomiting. It is caused by Bordetella Pertussis, a bacteria that is transmitted through direct contact with mucous, saliva and other discharge from the nose and mouth. Major complications are most common among infants and young children, and include hypoxia, apnea, pneumonia, seizures, encephalopathy, and malnutrition. Young children can die from pertussis.
In 2010, California had the highest number of pertussis cases–9,143, including 10 infant deaths–since 1947. According to the CDC, the 2014 pertussis outbreak in California reported incidence more than five time greater than baseline levels.1
The pertussis vaccination series can begin when an infant is 6 weeks of age. Infants are not protected until the initial series of three shots is complete. Neither vaccination nor illness from pertussis provides lifetime immunity. The series of shots that most young children receive wears off by the time they finish middle school.
The California Department of Public Health (CDPH) recommends that all patients indicated for immunization against tetanus, diphtheria or pertussis be immunized with DTaP if aged 6 weeks through 6 years and Tdap if aged 7 years and older. (Tdap is now required for school entry in grades 7-12; more on the new requirement is included below.)
CDPH recommends that all patients without documentation of full immunization against pertussis be immunized at the earliest opportunity. The following groups are of particularly high priority for pertussis immunization:
- Women of childbearing age (especially adolescents);
- Other people in close contact with infants;
- Health care personnel; and
- Patients with wounds.
New Tdap Immunization Requirement
All students entering or advancing to grades 7 through 12 in the 2011-12 school year are now required to be immunized with a pertussis (whooping cough) vaccine booster called Tdap. School-based health centers can play a lead role in ensuring all targeted students in their school district have received the Tdap booster on or after their 7th birthday, and that they have submitted the required proof to their school.
Resources for Providers
For provider information and educational materials for families and schools, go to www.ShotsForSchool.org.
Key Steps for Providers
Take these steps to ensure adolescent patients are protected against pertussis and are ready for school entry:
- Send reminder and recall phone calls and notices NOW to your patients who have not yet received a Tdap booster, including those who have received a dose of Td but not Tdap.
- If you use the California Immunization Registry, check out its new reports that provide rosters of patients who have and have not received Tdap to assist you with reminders.
- Immunize with Tdap at every opportunity, including sports physicals and visits for mild illness or injury, and give other recommended immunizations: meningococcal conjugate, HPV, influenza, and any catch-up doses of varicella, MMR, and hepatitis B.
- Provide clear and accurate documentation about Tdap immunization for your patients and your partner schools. Vaccines have similar names and abbreviations (e.g., Tdap, Td, DTaP, DT, etc.), which can be confusing to the school staff who will be keeping records for the new law.
- Post downloadable electronic banners on your school health center website and in electronic newsletters to help notify your patients.
(1) Centers for Disease Control and Prevention. (2014). Pertussis Epidemic – California, 2014. https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6348a2.htm
(1) Child Trends Data Bank: http://www.childtrendsdatabank.org/?q=node/71.
(2) California Health Interview Survey, 2009.
(3) Frieden, T. (2010). Memorandum Report: 2009 H1N1 School-Located Vaccination Program Implementation, OEI-04-10-00020.
(4) Gupta, R., Isaac, B., & Briscoe, J. (2010). A Local Health Department’s School-Located Vaccination Experience with H1N1 Pandemic Flu Vaccine. Journal of School Health. 80(7): 325.
(5) Lindley, M.C., Boyer-Chu, L., Fishbein, D.B., Kolasa, M., et al. (2008). The Role of Schools in Strengthening Delivery of New Adolescent Vaccines. Pediatrics. 121: S46-S55.
(6) Schmeir, J., Li, S., King, J.C., Nichol, K., et al. (2008). Benefits and Costs of Immunizing Children against Influenza at School: An Economic Analysis based on a Large-Cluster Controlled Clinical Trial. Health Affairs. W96-W104.
(7) Federico, S.G., Abrams, L., Everhart, R.M., Melinkovich, P., et al. (2010). Addressing Adolescent Immunization Disparities: A Retrospective Analysis of School-Based Health Center Immunization Delivery. American Journal of Public Health. 100(9): 1630-1634.
(8) Daley, M.F., Curtis, C.R., Pyrzanowski, J., Barrow, J., et al. (2009). Adolescent Immunization Delivery in School-Based Health Centers: A National Survey. Journal of Adolescent Health. 45: 445-452.