Diseases and Vaccines

What are the diseases that the Tdap vaccine prevents?

• Pertussis – also known as whooping cough, is a contagious disease that causes violent coughing fits that make it hard to breathe. It spreads easily when someone with the disease coughs or sneezes. The symptoms can last for months. Whooping cough is particularly dangerous for young babies.
• Tetanus – causes a severe, painful tightening (spasms) of muscles, including of the jaw (‘lockjaw’), which can limit swallowing and breathing.
• Diphtheria – is a throat infection that can lead to breathing problems, paralysis, heart failure and death.

What are Tdap, Td and related vaccines?
A) Vaccines for adolescents and adults:

1) Tdap vaccine is a booster shot to protect adolescents and adults against tetanus, diphtheria and pertussis (whooping cough). The name Tdap stands for
T         Tetanus toxoid
d          reduced diphtheria toxoid
ap       acellular pertussis vaccine

Tdap is routinely administered on or after the 10th birthday. A dose of Tdap vaccine given on or after the 7th birthday meets the new school requirement.

2) Td vaccine, invented before Tdap, protects persons 7 years and older against tetanus and diphtheria. Td vaccine does not protect against pertussis and so does not meet the new school Tdap requirement.

B) Vaccines for younger children:

3) DTaP vaccine protects infants and younger children against the same diseases - tetanus, diphtheria and pertussis (whooping cough) – as the Tdap booster shot given at older ages. The DTaP vaccine is intended for children younger than 7 years of age.

4) DTP (or DPT) is an older version of the DTaP vaccine that is still given to young children outside of the United States.

5) DT vaccine protects infants and younger children against tetanus and diphtheria. DT does not protect against pertussis. DT does not meet the new school Tdap requirement.

Where can children get vaccinated?
Children should visit their regular doctor or health care provider to get their Tdap shot and other immunizations as soon as possible to avoid the back-to-school rush. The Vaccines for Children Program (VFC) offers free or low cost vaccines for eligible patients 18 years and younger. If your child/student is eligible for Medi-Cal, you can find a VFC provider near you by visiting http://shotsforschool.org/parentinfo.html#vfc_locations or calling 1-877-243-8832. For uninsured or underinsured patients, parents can find a list of federally qualified health centers in their area at http://www.oshpd.ca.gov/RHPC/Clinics/FQHCS.html. Some local health departments and pharmacies may also offer the Tdap vaccine and other immunizations. For more information, please contact your local health department.

Are there other immunizations for preteen or teenage children?
Preteens and teens are also recommended to receive vaccines against meningococcal disease (brain or blood infection), flu (influenza), HPV (human papillomavirus, a cause of cervical cancer), and any vaccine they may have missed during childhood, including two doses of MMR and varicella. The recommended vaccine schedule may be found at http://www.getimmunizedca.org/. Schools should encourage parents to discuss these immunizations with their healthcare provider. Health care providers should use every opportunity, including sport physicals, to immunize against these dangerous diseases.

I have additional questions about pertussis, including immunization, diagnostic testing, disease reporting, treatment and prophylaxis and infection control measures.
Check the Clinical FAQs to see if your question is addressed.

---

Tdap Requirement and Documentation

What is the new Tdap requirement for 7th Graders?

• For the 2012-2013 school year, and all future school years, all students entering, advancing or transferring into 7th grade will need proof of an adolescent whooping cough booster immunization (called “Tdap”) for school in the fall.

Who is affected by the Tdap requirement?
All public and private schools are affected by the law, including but not limited to

• Charter schools
• Community schools
• Juvenile court schools
• Other alternative school settings

Students who are affected by the law include but are not limited to:

• International or exchange students
• Children in foster care
• Homeless students (see below)
• Students transferring from outside of California to a school in California at any time during the school year

Students who are NOT affected but who are still strongly recommended to receive Tdap include those

• Attending summer school or camp
• 18 years and older

For 2012-2013 and future years, are students transferring into the 8th through 12th grades from out of state subject to the pertussis booster requirement?

Students transferring from outside of California, including from other countries, are required to meet the Tdap requirement upon admission into any of the 8th through 12th grades at a California school. Students age 18 years and older are recommended to have the pertussis booster vaccine but it is not required for admission for those students.

When should children get vaccinated with Tdap?
Now. Unimmunized children are at risk for catching pertussis, getting really sick and missing weeks of school. Encourage parents to beat the rush by making an appointment for their incoming 7th grader to get a Tdap booster shot now. Children as young as 10 years old are recommended to get vaccinated with Tdap. This will protect them against the ongoing threat of whooping cough and will meet the Tdap school requirement for when they are in 7th grade. Ask parents to keep documentation of the child’s Tdap booster shot in a safe place. Children will need proof of their immunization for school.

What immunization (vaccine, shot) is necessary to meet the new requirements?
Students affected by the new requirements need documentation of one dose of Tdap to begin classes in the new school year.

Meets 7th - 12th Grade Requirement	Vaccine	When given?
YES, meets the requirement.	Tdap Adacel Boostrix	Given on or after the 7th birthday
NO, does not meet requirement.	Td DECAVAC TENIVAC DT DTaP or DTP given before the 7th birthday (usual age limit) History of pertussis disease Results of blood tests for immunity to pertussis

CDPH currently recommends that all children receive a dose of Tdap vaccine at age 10 years or older. Tdap vaccine given on or after the 7th birthday meets the new school requirement. A dose of DTaP or DTP given at age 7 years or older will also meet the requirement, but it is not licensed for use or recommended for children 7 years of age or older.

Immunization before the 7th birthday does not fulfill the requirement, even if given immediately before the 7th birthday.

What if a child received a Tdap booster shot before their 10th birthday?
Children who received a dose of Tdap on or after their 7th birthday will be considered to have met the new school requirement. However, CDPH recommends that children receive Tdap on or after their 10th birthday to provide better protection throughout their adolescent years.

What if a child received a pertussis shot (Tdap or DTaP) before their 7th birthday?
Immunization before the 7th birthday does not fulfill the requirement, even if given immediately before the 7th birthday.

What if my patient had whooping cough as an infant or child?
Any protection or immunity to pertussis that a child received from having had pertussis as an infant/child will have worn off by middle school, leaving that child vulnerable again to catching pertussis. Booster immunization with Tdap is recommended by state and national authorities and required for school.

Instead of getting a Tdap booster to meet the new requirement, can a student get a blood test to check for protection (immunity) against pertussis?
No. Testing for immunity to pertussis is not reliable and will not meet the new school requirement.

Should teachers, other school staff and family members also get the Tdap vaccine?
Although school staff and parents are not required to receive the Tdap vaccine, CDPH recommends that all persons 10 years of age and older get vaccinated with Tdap now if they haven’t done so already.  This will protect them against the ongoing threat of pertussis as well as help protect their close contacts, including young infants for whom pertussis is most severe and sometimes fatal. 

Why should children get vaccinated with Tdap?
In addition to it being a new requirement for school, children who get a Tdap booster shot will be better protected during their school years. Immunization helps protect others within the home, in the community, and at school. Immunizations also help prevent school closures. Many schools in California suffered from outbreaks of whooping cough. Students got very sick and parents missed work and lost wages because they needed to stay home and care for their sick children. In some cases, schools had to close because so many teachers were home sick.

Why was the Tdap requirement added?
The new immunization requirement is intended to reduce the spread of whooping cough in California. In recent years the United States has seen an increase in whooping cough. In 2010, California had the most cases of whooping cough reported in over 60 years.

Prior to entering kindergarten, most children are fully protected against diphtheria, tetanus, and pertussis after receiving the DTaP vaccine in early childhood. However, immunity to these diseases wears off, leaving adolescents vulnerable once again. A booster dose of Tdap during adolescence helps to protect students and their close contacts, including young infants for whom pertussis is most severe and sometimes fatal.

What can schools accept as proof of immunization?
Any immunization record [‘yellow card’, CAIR record (see below), computer printout, immigration record etc.] that includes the following information is acceptable:

• Student’s name
• Date of birth
• Vaccine name or abbreviation,
• Date vaccine administered
• Name (written or stamp) of the clinic, office, or doctor administering the vaccine. 

I can’t tell from the immunization record whether or not the student received Tdap. What should I do?
If it is unclear which vaccine the student has received, schools will need clarifying information from the vaccine provider.

Is Tdap required for a student whom recently caught whooping cough or experienced a case of whooping cough in the past?
Past illness with pertussis is not an exemption to the law. Tdap immunization is typically recommended even for those who have had pertussis.

How long do students have to wait after their last tetanus shot before getting their required dose of Tdap?
According to state and national recommendations, the dose of Tdap required for the school law may be given at any time after the last tetanus shot.

Where can schools get materials to meet the new Tdap requirement?
Local health departments are the only source of the following materials for schools:

• Tdap requirement sticker for the Blue Card (PM 286 S)
• Personal Belief Exemption Form  

Please contact your local health department’s Immunization Program to request initial or additional supplies.  Schools should not try to produce their own versions of these forms or use other forms.

The California Immunization Registry (CAIR) can also be used to print out Blue Cards with the Tdap sticker format; most Tdap information may be filled in automatically if the child has had a dose of Tdap recorded in CAIR. 

Where can schools get Blue Cards?
Most students will have a Blue Card in their cumulative file from the time that they were admitted to Kindergarten. Students new to California will need a Blue Card. Additional Blue Cards may be obtained from the local health department’s Immunization Program or can be printed from the California Immunization Registry (CAIR) if the student’s immunizations have been recorded in CAIR.

---

California Immunization Registry (CAIR)

May schools use (CAIR) to view or print Tdap immunization records?
Schools that use CAIR are able to check the records of students whose medical providers also use CAIR. The Tdap requirement documentation (‘Blue Card’ with Tdap information) is available through CAIR.  Schools that do not already use CAIR may inquire with the CAIR Help Desk at 1-800-578-7889 about becoming authorized users of CAIR.

Does a Blue Card printed by CAIR need a school Tdap sticker (PM 286 S)?
Blue Cards printed by CAIR since December 2010 usually do not need a Tdap sticker. CAIR is now programmed to print the Tdap information, including assessment of having received Tdap at the appropriate age, on the upper left front corner of the Blue Card. School staff members assessing CAIR Blue Cards still will need to enter their name and complete information about students with exemptions in the upper left front corner.

What should schools do with the previous copies of Blue Cards when retaining a new copy printed in CAIR for the Tdap requirement?
Compare the records. If all information on previous copies of the Blue Card is found on the new CAIR Blue Card, old copies may be destroyed. If not, or if you are unsure, keep the old copies as well in the permanent record.

---

Non-compliance and Special Cases

Is there a grace period/extension to get the shot AFTER school starts?
No. As of now, there is no grace period or extension like the previous school year (2011-12). Under current law, schools do not have the option to provide a grace period. All 7th grade students will need to show proof of Tdap immunization or submit an exemption before starting the 2012-13 school year and all future school years.

What if the student is homeless and subject to the McKinney-Vento Act?
Children affected by the McKinney-Vento Homeless Assistance Act are not specially exempt from the Tdap law vaccination requirements. CDPH has notified local health departments in California to promptly identify and immunize students affected by the McKinney-Vento Act. CDPH recommends that schools work closely with local health departments as needed to give Tdap to unimmunized homeless children. Local health departments can provide information about clinics and other accommodations for urgently needed immunizations.

Excerpt from the McKinney-Vento Homeless Assistance Act: 42 U.S.C. Section 11432(g):
“If the child or youth needs to obtain immunizations or immunization or medical records, the enrolling school shall immediately refer the parent or guardian of the child or youth to the local educational liaison OPAD designated by the school district who shall assist in obtaining necessary immunizations or immunization or medical records.”

What if the student is in foster care?
Children in foster care are not exempt from the Tdap law vaccination requirements. Under California Education Code Sections 48853.5 (d) and 49069.5 (e) as amended by AB 490 (Steinberg, 2003), a child in foster care in California who is transferring between schools must be immediately enrolled in the new school regardless of whether the pupil’s records from the school last attended, including immunization records, are present. If absent, the pupil’s records need to be requested from the old school within two business days, and then provided to the new school within an additional two days. Children in foster care who are transferring mid-year from another school in California will have been subject to the Tdap law at the prior school. CDPH recommends that schools work closely with local health departments as needed to give Tdap to unimmunized children in foster care. Local health departments can provide information about clinics and other accommodations for urgently needed immunizations.

What about children in special education or children with individualized education programs (IEPs)?
Children in special education and children with IEPs are not exempt from the Tdap law vaccination requirements.

---

Exemptions

What exemptions are available under California law?
California law describes two exemptions to student immunization requirements:

• Personal Beliefs Exemption: A parent or guardian may have a child exempted from required immunizations if immunization is contrary to his/her beliefs. Schools have standardized procedures for parents and guardians who request a personal beliefs exemption. Exemptions to immunization should not be taken because of convenience. Unimmunized students are at greater risk of contracting diseases and spreading them to their families, schools and communities. Schools should maintain an up-to-date list of students with exemptions, so that these students can be excluded from school quickly if an outbreak occurs.
• Medical exemptions: Physicians (MD or DO) may grant in writing an exemption for students for whom immunizations are not medically indicated, which occurs infrequently.

---

Reporting

What information will schools need to report to CDPH for the new Tdap requirement?
By November 1, 2012, schools with students in 7th grade will need to report to CDPH the numbers of students in each grade that have met the Tdap requirement by 1) being immunized; 2) receiving a medical exemption 3) declaring a personal beliefs exemption.  Affected schools will receive additional information about the reporting requirement and procedures later in 2012.

---

Next Steps

How can my school get ready for the new Tdap requirement?

• Get the word out now: Several tools are now featured on http://www.shotsforschool.org/. Remind parents and guardians of all current 6th grade students that Californians 10 years and older are recommended to be vaccinated with Tdap now if they haven’t received it yet to protect them against the ongoing threat of pertussis and to help meet the new Tdap requirement. Families should not wait until the fall to get their children immunized with Tdap.
• Repeat these messages throughout 2012 using school
• Newsletters
• Websites
• Email and phone message systems
• Other school communications.
• Plan admissions procedures for 2012-2013:
• Information and training materials on how to document the new Tdap requirement are available at http://www.shotsforschool.org/.
• If not already using CAIR, consider becoming a user – call the CAIR Help Desk at 1-800-578-7889

What if my school is interested in having a School-based Vaccination Clinic?
While the Immunization Branch advocates for students to receive their immunizations in their medical home and encourage schools to inform and promote receiving the required Tdap dose at medical homes to parents and students, there may be situations where schools and school districts are considering school-located clinics to immunize students. At present, CDPH’s only available source of Tdap vaccine for school-located clinics is the Vaccines for Children (VFC) Program for VFC-eligible students only. Schools can receive VFC vaccine by enrolling in the program directly or by working with their local health department. Schools enrolling in the VFC Program will be responsible for complying with all VFC requirements including: screening for VFC eligibility, obtaining appropriate vaccine storage refrigerators, monitoring vaccine temperature at least twice daily, offering all age-appropriate vaccines, and having a Chief Physician to sign as the responsible physician. Schools that are interested in having school-based clinics, should contact their local health department prior to planning any clinics. More information on the VFC Program can be found at http://www.eziz.org/.

---