Health Advisory: Immunization Recommendations for Children and Adolescents Displaced by the January 12, 2010, Earthquake in Port-au-Prince, Haiti
February 19, 2010
To: Local Health Departments, Medical Providers, Public and Private Schools and Day Cares
From: NYSDOH Bureau of Immunization, NYCDOHMH Bureau of Immunization
Health Advisory: Immunization Recommendations for Children and Adolescents Displaced by the January 12, 2010, Earthquake in Port-au-Prince, Haiti. Please distribute to school nurses and medical providers.
The purpose of these recommendations is to provide guidelines to those institutions providing services to Haitian child and adolescent refugees who will be attending school in New York State.
Immunization records are unlikely to be available for a large number of displaced Haitian children and adolescents. Haiti provides the following vaccines as part of its routine immunization program: tuberculosis (BCG); diphtheria, tetanus, and pertussis (whooping cough) (DTwP); tetanus and diphtheria toxoids (Td); measles, rubella (MR); and oral poliovirus (OPV); Vitamin A is also given. Despite the presence of an immunization program, vaccination coverage rates are low for most of these vaccines listed above. Moreover, Haiti does not provide hepatitis A, hepatitis B, Haemophilus influenzae type b (Hib), mumps, varicella, rotavirus, meningococcal, pneumococcal vaccinations or a 2nd measles vaccine dose, all of which are considered to be routine childhood immunizations in the U.S.
Immunization Requirements for New School Entrants from Haiti
New York State Public Health Law (PHL) § 2164 ( http://www.nyhealth.gov/prevention/immunization/docs/2164.pdf ) requires immunization against poliomyelitis, mumps, measles, diphtheria, rubella, varicella, Haemophilus influenza type b (Hib), pertussis, tetanus, pneumococcal disease, and hepatitis B for all New York State students. Haitian children seeking admission to New York State schools should be allowed to attend school while the school ascertains the child's immunization status and the person in parental relation to the child arranges for immunizations, if necessary.
PHL § 2164 provides that no school shall allow a child to attend for more than 14 days without a proper certificate of immunization. However, when a student is transferring from another country, PHL§ 2164 states that a principal (or other designee) may allow that child to attend school for up to 30 days if there is evidence of a good faith effort to obtain immunizations or proof of past immunization via serologic testing. Although the 30 day grace period is within the school's discretion, we strongly recommend that schools permit each student the maximum allowable 30 days and continue to work with these students and their custodial guardian(s) on a case-by-case basis.
Many Haitian children will fall under the federal McKinney-Vento Homeless Education Assistance Act. Pursuant to the McKinney-Vento Act, a public school must immediately enroll a homeless child, even if the child is unable to produce records normally required for enrollment, including medical records and proof of immunization. If the child needs to obtain immunizations, or immunization/medical records, the enrolling school must immediately refer the child's parent or guardian to the school district's homeless liaison, who must assist the child's parent or guardian in obtaining the necessary immunizations or records. Where a student does not comply with immunization requirements, he or she may be excluded from school under PHL § 2164, as discussed above. Please note, however, that under 10 N.Y.C.R.R. § 66-1.3, a child should be considered in compliance with school immunization requirements, and should remain in school, if he or she has received at least one dose of each of the required vaccines and has appointments to return to his health care provider for the remainder of the required immunizations.
Consent to Immunizations
Haitian children coming to New York State may be unaccompanied by a parent or legally appointed guardian. Under PHL § 2504, a grandparent, adult brother, adult sister, adult aunt or adult uncle, who has assumed care of a child, may give effective consent for the immunization of a child. In addition, a person who has assumed the charge and care of the child because the child's parents or legal guardians have died, are living outside the state or their whereabouts are unknown – and, thus, may be considered the child's "custodian" – may give effective consent for the immunization of that child (see PHL § 2164 and § 2504).
Protocol for Displaced Students with Immunization Records
In general, when immunization records are available for displaced children and adolescents, written documentation of immunizations (if available) can be accepted as evidence of adequacy of previous immunization, if the vaccines, dates of administration, number of doses, intervals between doses, and age of the child at the time of immunization, are consistent and comparable to current US or World Health Organization schedules (http://elib2.cdc.gov:2801/cgi/content/full/2009/1/1.5.13). Call the New York State Department of Health (NYSDOH) Bureau of Immunization (BI) at 518-473-4437 or the New York City Department of Health and Mental Hygiene (DOHMH) Bureau of Immunization at 212-676-2323, if uncertain. When a child or adolescent's immunization records are available, he or she should receive any needed immunizations according to the recommended schedule or the recommended catch-up schedule in the United States for healthy children and adolescents ( http://www.cdc.gov/vaccines/recs/schedules/downloads/child/2010/10_catchup-schedule-pr.pdf).
Protocol for Displaced Students without Immunization Records
Given the limited data available regarding verification of immunization records in Haitian children and adolescents, and the known low vaccine coverage rates for children in Haiti, it will be necessary to immunize a child or adolescent who is lacking immunization records presumptively according to the Centers for Disease Control and Prevention's catch-up Immunization Schedule: http://www.cdc.gov/vaccines/recs/schedules/downloads/child/2010/10_catchup-schedule-pr.pdf.
New York State's laws and regulations require a certain number of doses of required vaccines ( http://www.nyhealth.gov/publications/2370.pdf). In some cases, this is less than the full recommended series by the Advisory Committee on Immunization Practices (ACIP). We recommend that these children get the full recommended series though fewer doses may be required for school. In addition, it is recommend these children and adolescents be vaccinated against rotavirus (if younger than 14 weeks of age), hepatitis A, human papillomavirus, and meningococcal meningitis, although these vaccinations are not required for admittance to either school or daycare.
It is also acceptable to perform serologic blood testing for certain antigens (i.e. measles, mumps, rubella, hepatitis A, hepatitis B, polio, tetanus and diphtheria) (CDC. General Recommendations on Immunization: http://www.cdc.gov/mmwr/PDF/rr/rr5515.pdf ). Serologic testing for hepatitis B surface antigen (HBsAg) and for hepatitis A IgM and IgG is recommended, to identify current, recent, or chronic infection. If serologic testing is not available and past receipt of vaccines cannot be documented, the child or adolescent in question needs to be given the full immunization series.
Immunocompromised Children and Adolescents
Immunocompromised individuals, such as HIV-infected children and adolescents, and those on systemic steroids, should not receive the live viral vaccines, rotavirus, and varicella. Seropositive children and adolescents may be able to receive MMR and varicella vaccine, depending on their immune status. These children should have their immune status evaluated by a medical provider who can provide guidance on which immunizations they can receive.
Documentation
Standard immunization practices should be followed for delivery of all vaccines, including provision of Vaccine Information Statements in the native language of the child or parents/guardian, if possible (http://www.immunize.org/vis/vis_haitian_creole.asp). It is critical that all vaccines administered be properly reported to the Health Department. Immunization records should be provided to the vaccinee or his/her parent.
For providers outside of New York City, immunizations should be reported to NYSDOH through the New York State Immunization Information System (NYSIIS): http://www.nyhealth.gov/prevention/immunization/information_system/. For additional information please call the NYSDOH BI at 518-473-4437.
For providers in New York City, immunizations should be reported to the DOHMH through the Citywide Immunization Registry (CIR) at H www.nyc.gov/health/cir. For more information on how to report or obtain CIR records call 212-676-2323.
In New York City, parents and/or guardians of school-aged Haitian evacuees should be told to call 311 to locate a clinic for medical examinations.
