Immunization Requirements for Childcare Facilities

1. Immunization Requirements for Childcare Facilities Montana DPHHS Immunization Program April 2012

2. Overview • Importance of Immunizing Children and Adults • Immunization Requirements for Child Care • Immunization Record Keeping • Auditing Immunization Records • Enforcement of Immunization Requirements • Immunization Information System and Parent Consent • Tools and Resources for Child Care Providers • References

3. Why Immunize?

4. Importance of Vaccination • Not vaccinated and exposed. • Might not be strong enough to fight the disease • Many children died • Some of the same diseases still exists. • Now protected by vaccines. Center of Disease Control (CDC)--Vaccinations

5. Continued…. • Immunizing individually helps protect the health of your community • Those who are too young • Medical reasons • People who received a vaccine, but did not develop immunity By immunizing, you can slow down or stop disease outbreaks. Center of Disease Control (CDC)--Vaccinations

6. Are Diseases Becoming Rare Due to Vaccinations? • Yes! Some of the diseases are becoming rare. • Polio • Diptheria • Smallpox eradicated • Why? Because we are getting vaccinated! • Example: Bailing out a boat with a slow leak • Bail fast and hard • Leak hasn’t stopped • The water might be back up to the same level as you first started. Center of Disease Control (CDC)--Vaccinations

7. Continued… • “Stop the Leak” by eliminating the disease • Important to keep immunizing not only children but adults too! • If we stop vaccinating • Takes away the protection • More people will be infected • Disease will spread • Disease will make a comeback • Epidemics • Death

8. Adult Vaccination Information • Some vaccines lose immunity for adults • Pertussis (Whooping cough) • Passed on to a newborn • No warning signs • Advisory Committee on Immunization Practices (ACIP) • Recommendation for adults >19 should receive one dose of Tdap (tetanus, diptheria, and pertussis) in their adult lifetime. • Continue to receive a Td (tetanus and diptheria) every ten years. • Talk with your provider The Montana State Immunization Program strongly recommends adults who have close contact with infants, such as parents, childcare providers, and healthcare personnel receive a Tdap.

9. Let’s Get Vaccinated!! • Vaccinate for you, but also to protect our future children. • Continued Efforts to eradicate disease--smallpox (“stopped the leak”) • Keep vaccinating other diseases like polio or meningitis won’t cripple or kill future children. Vaccinations are one of the best ways to put an end to the serious effects of certain diseases.

10. Immunization Rules and Requirements

11. Immunization Requirements for Registered or Licensed Child Care Facilities Administrative Rules of Montana (ARM) 37.95.140 Immunization Before a child under the age of 5 may attend a Montana child care facility, that facility must be provided with documentation showing that the child has been immunized as required for the child’s age group against MMR (Measles, Mumps, Rubella), Polio, Varicella, Diphtheria, Pertussis, Tetanus, and Haemophilus influenzae type b (Hib). Unless the child qualifies for conditional attendance. Before a child between the ages of 5 and 12 years may attend a child care facility providing care to school aged children, that facility must also be provided with documentation that the child has been immunized as required for the child’s age group, unless child qualifies for conditional attendance.

12. Additional Rules to Think About ARM 37.95.140 (6) Immunization • Continue to attend childcare, must continue to be immunized according to IZ schedule. • Child must be immediately excluded from facility if not vaccinated with all of the requirements or does not have on file at the facility a record of medical exemption or conditional enrollment form. ARM 37.95.140 (11) Immunization • Maintain a written record of immunization status on each enrolled child and staff member. • Must make the immunization records available during normal working hours to Montana State Department or the Local Health Authority. ARM 37.95.140 (12) Immunization • Child attending a childcare facility is not required to have any IZ that are medically contraindicated. • Need a written and signed statement from physician (medical exemption form).

13. IZ Requirements for Child Care

14. Raise your paws for Questions???

15. Understanding IZ Doses and Disease Measles Chickenpox (varicella) Haemophilus type B

16. Understanding the Hib Dose • What is Hib? • A severe bacterial infection particularly among infants. • PREVENTS: • Meningitis (an infection of the covering of the brain and spinal cord), • Pneumonia (lung infection), • Epiglottitis (a severe throat infection), • and other serious infections. • Hib vaccine brands and doses: • ActHib requires 3 doses and 1dose after 12 months of age. • Pedvax Hib requires 2 doses and 1 dose after 12 months of age. • Other vaccine names you might see: • Comvax—2 dose (contains Hib and Hepatitis B) • Pentacel—3 dose (contains DTaP, Polio, and Hib) • *TriHibit—1 dose (can only be given for final booster dose) • Hiberix—1 dose (can only be given for final booster dose) • * Discontinued Contact your county health department when you have questions regarding the Hib schedule.

17. Continued…. Children 8 through 11 months of age must also have or begin the Hib vaccination series in order to attend a childcare facility. One dose is required after 12 months of age and must meet the Advisory Committee on Immunization Practices (ACIP) recommended interval. This is in accordance with ACIP guidelines and child care (ARM 37.95.140). However, if you have a child who is at least 12 months old but less than 60 months of age and has not received any Hib vaccine, the child must receive onedoseprior to entry. *Hib vaccine is not required or recommended for children 5 years of age and older.

18. Varicella (Chickenpox) • Also known “Chickenpox” • become deadly for infants • immunocompromized • 12 months of age or older • Given too early—may require revaccination • 1 dose is required for childcare • ACIP recommends 2 doses • administered 4-6 yrs of age • boosts immunity • ARM 37.95.140 states:All children by 19 months of age must receive one dose of Varicella vaccine.If a parent indicates the child has had “chickenpox,” the parent will need to provide proof from the health care provider or a lab test can be done to prove immunity. If the parent is not able to document that the child has had chickenpox, the child will need to receive the varicella vaccination. • If you have a child who is greater than 19 months of age attending your child care facility and cannot provide documented immunity or has not received the varicella vaccine, these children are still required to have the varicella vaccination.

19. Pertussis (Whooping Cough) • Pertussis is most severe for babies • infants younger than 1 year of age are usually hospitalized. • 1 in 5 infants get pneumonia. • 1 in 100 will have convulsions. • Can be deadly, especially in infants. Pertussis spreads by coughing or sneezing while in close contact with others. Many infants who get pertussis are infected by parents, older siblings, or other caregivers who might not even know they have the disease. http://soundsofpertussis.com/#/whatispertussis

20. Immunization Requirements for Childcare Workers ARM 37.95.184 (2-c) Health Habits • Every employee, volunteer, or resident at a child care facility must show proof, prior to commencing work: • MMR (unless born before 1957) • Td (every 10 yrs) Remember!When your Td comes due, consider adding the pertussis (whooping cough) component to your Td shot. Pertussis can be easily passed on from an adult to an infant with out even knowing it. State and local public health officials strongly recommend and encourage all adults to consider getting the Tdap. This is not a requirement for childcare.

21. Influenza • What is Influenza? • Also called the “flu” • Contagious respiratory illness • Caused by influenza viruses • How sick can a person get? • Cause mild to severe illness • Hospitalization • Can lead to death • Can influenza spread before I have symptoms? • Yes--Can be passed on before you even know you are sick • While you are sick • Infect others beginning 1 day before you develop symptoms • and up to 5-7 days after becoming ill. • People with weakened immune systems might infect others for a longer period of time.

22. Continued… • How does influenza or “flu” spread? • Droplets are produced when you cough, sneeze, or talk • Possibly by touching a surface or object • Rubbing the eyes, touching mouth, or breathed in by the nose. • How can I prevent the spread of influenza? • Cough into your elbow • Cover your sneeze • Wash your hands with warm water and soap thoroughly • Disinfect surfaces and objects • #1 Best Way to Prevent Influenza is…GET YOUR FLU SHOT ANNUALLY!

23. Raise those paws if you have Questions????

24. Required Forms

25. Certificate of Immunization (HES-101)“White Handout”

26. Each child should have HES-101 on file. • Four Sections to form: • Demographic info • Immunization • Instructions • Medical Exemption • HES-101 may not be filled out by a parent! • Only by: • Childcare provider • School • Health Care professional • Forms to keep with HES-101: • Conditional Attendance • Religious Exemption • Medical Exemption • History of Varicella Form • Original IZ Record

27. Medical Exemption: Section IV • Must be signed by an MD or a DO • Chiropractors, Nurse Practitioners, Physician Assistants, or Naturopathic Doctors cannot sign off on any medical exemption. • Physician Letter of medical exemption. Double Check Your Medical Exemption! • Did the physician mark which immunization(s) the child is exempt from? • Is the HES-101 signed by an MD or DO? • Is this permanent or temporary exemption? • If you have questions about the validity of the exemption, contact your local health department.

28. Conditional Attendance Form (HES-103) “Green Handout”

29. Conditional Enrollment If a child has not completed the minimum vaccination series required by ARM 37.95.140, a Conditional Attendance Form, No. HES-103, must be completed. • ARM 37.95.140 (9 a, b, c) Immunization states: • 9. A child may conditionally attend a child care facility if: • The child has received at least 1 dose of each of the vaccines required for the child’s age • A form prescribed by the DPHHS documenting the child’s conditional immunization status is on file a the child care facility and is attached to the DPHHS Montana Certificate of Immunization (HES-101); and • The child is not past due for the next required dose (as noted on the conditional form) of the vaccine in question.

30. Filling out the Conditional Attendance Form (HES-103) • Section I– Completed by childcare provider • Notice to parent • Prior to child attending • Recommend handout childcare IZ requirements to parents • Section II & III– Agreement • Completed by physician/county health • Doses Due Schedule • Parent and health official signature and date • A copy of the form should be returned back to you. • Parent Copy • County Health Copy • Kept with HES-101 • Keep up-to-date by getting IZ record • Review and send out reminders • Child may be excluded if IZ schedule not followed.

31. Religious Exemption Form (HES-114) “Yellow Handout”

32. Hib is the only IZ exemption allowed for religious purposes. • Signature from parent/legal guardian • Sworn and notarized yearly • Review yearly • Handout new form • Keep with HES-101 • Outbreak occurs child may be excluded from care

33. History of Varicella “Chickenpox” Form (DPHHS-115)“Purple Handout”

34. Use to show history of chickenpox disease. • Child has received vaccine, no form needed. • Keep with HES-101. • Signed by a health care provider. • Examination date • or • Laboratory test • Only needs to be completed once.

35. Let’s “paws” for Questions!

36. Who will be reviewing my Immunization Records?

37. Reviewing Records • Who is reviewing IZ records and why? • County Public Health Departments • Immunization Action Plan (IAP) • Contract between DPHHS and County Health • 1 review 1x year per provider • Do I need to do anything prior to my IZ record review? • HES 101 completed on each child enrolled • Conditionals are current • Religious exemption for Hib has been notarized annually • Records should be up-to-date according to the child’s age • Records should be organized The Montana Department of Public Health and Human Services is working closely with public health jurisdictions to improve immunization coverage rates. These efforts include working with facilities to assess immunization records and enforce laws and rules related to immunization in child care facilities and other settings.

38. Quick items to note: • Allow county health department access to review all immunization records, including worker’s immunization records. • County health will call to schedule a visit. They should not just show up unannounced. • Please try to have some space available for public health nurse to review records. • Open up communication between you and county health if you are concerned about record keeping. • Consult with your public health nurse if you need help with immunization translation. • When reviewing, the public health nurse should not remove original records from the child care facility. • The child care provider is not required to make photo copies of immunization records and send them to the health department.

39. Enforcement If you are a child care centerand the public health nurse finds incomplete immunization record(s), the center’s director will be informed and given 7 days to correct the non-compliance records and obtain the documentation to update the record. 2. If the record(s) is not complete after this time, the public health nurse will formally notify the center director of this issue. Another 7 day time period may be granted and the center director should be informed that non-compliance after this time may result in the child being excluded from the facility. 3. Should the center director not comply after the 2nd 7 day period, the public health nurse may order the exclusion of the child from the facility, and may make a formal referral to the Montana State Child Care Licensing Program. The local licensor will contact the center director and advise that continued non-compliance may result in negative licensing action.

40. Enforcement Continued… For the family/group programswhere public health nurses are providing consulting services pertaining to immunization, the same process will be followed except that it will be the Montana State Child Care Licensing Program may order the exclusion of the child who does not have up-to-date immunization records.

41. REMEMBER! Reviewing records on a frequent basis, will ensure that children attending your facility are in compliance with the immunization rules. Recommend: • Center– 4 times or more times a year • # of new enrolled children • # of conditionals • Group- 2-3 times a year • Family- 1-2 times a year

42. Questions???

43. Montana Immunization Information System(imMTrax)“Blue Handout”

44. State Immunization Information System (IIS) • What is IIS? • Secure/Confidential/Statewide web-based information system • imMTrax • Stores Immunization records (name, gender, DOB, address, and phone #) • Only authorized healthcare professionals have access • How does imMTrax benefit you? • Lost IZ record • Move to another town or state • Will not be over immunized • Charged for additional immunizations at doctors office • Can anyone be in imMTrax? YES!!! • Not only for children • Encourage all teens and adults • Completely voluntary (you give consent) • AND IT IS FREE!

45. Parent Approval for Release of Information • In order for a child care provider to call the county health department regarding missing immunizations, the parent/legal guardian of the child must sign a release of information for their child. • Encourage you to have parents fill out consent • Return consent to you • Work with county health re: consent and IZ info • Hand out the Parent Information Pamphlet. • Questions call IZ program 444-5580

46. Tools and Resources

47. Example Policy for Immunizations • This is your IZ policy! • Short or long • Add or take away language • Review it with staff • Put in easy to access location • Recommend adding: • Routine check of current immunizations on enrolled children and staff • State how often to check • Add annual influenza among those eligible to receive it • Every worker receive 1 dose of Tdap

48. Child Care Immunization Schedule • Easy to read immunization schedule • Follows child care requirements ARM37.95.140 . • Back of schedule has vaccine descriptions • Download schedule at www.immunization.mt.gov or you can order them by calling 444-5880

49. Vaccine Names and Their Components • Contains vaccine brand names. • Easier to transfer information to HES-101 You can download this form at www.immunization.mt.gov

50. Resources • Immunization Web Page • www.immunization.mt.gov Child Care Licensing Booklet Contact Suzi Gravely at 444-2010 to order a booklet or visit the Child Care Licensing website to view Regulation Booklet at www.dphhs.mt.gov/earlychildhood/licensingregulations.shtml