Immunization Resources issuu by Jefferson County Public Health

Child Care Center Immunization Resource Binder June, 2016

jeffco.us/public-health

June 2016

Dear Child Care Center Director/Owner, Jefferson County Public Health is committed to supporting Child Care Centers, their staff and students around the county. Our goal to provide a variety of support and up-to-date resuorces to you in order to improve the health and safety of our children. Immunzation related information, rules and regulations is a continuosly changing arena. It can take a lot of time and research to keep up-to-date on the most current material. Jefferson Coutny Public Health has developed this Immiunzaiton Resource Binder to assist you and your Child Care Center staff in navigating the most up-to-date information. These resources are intended to supplement your current immunization knowledge regarding immunization requirements and vaccine safety while either refreshing or possibly introducing new resources, such as the Colorado Immunization Information System (CIIS) and Immunization Rate Calculation Guides. We have also included the 2015-2016 Immunization Course for Childcare Providers as an opportunity to get the latest immunization information as well as earn free contact hours from CDPHE. An online copy of this resource binder can be accessed here: http://issuu.com/jeffcoph/docs/immunization_issuu Additional immunization and disease control information is available as well as one-on-one Public Health Nurse consultations upon request. We hope that this manual as well as our services can be a resource to you, your staff and the children you serve. Please do not hesitate to contact us with questions. We are here to help! We look forward to working with you.

Sincerely,

Gwyn Rodman-Rice, RN, MPH Public Health Nurse 303-239-7035 grodman@jeffco.us

Lakewood Offices/Clinic Environmental Health Arvada WIC

Vickie Hayworth, RN Public Health Nurse 303-239-7032 vhaywort@jeffco.us

645 Parfet Street Lakewood, CO 80215 645 Parfet Street Lakewood, CO 80215 6303 Wadsworth Bypass Arvada, CO 80003

Katie VanHooosen, RN Public Health Nurse 303-239-7138 kvanhoos@jeffco.us

303.232.6301 – phone 303.232.6301 – phone 303.275.7510 – phone

303.239.7088 – fax 303.271.5760 – fax 303.275.7503 – fax

Table of Contents 1.

Immunization Requirements  Pertussis Information and Guidelines for Schools and Child Care Settings: August 2013  Colorado Immunization Requirements: 2016-2017 Letter to Parents  CDPHE Certificate of Immunization and Instructions  AAP General Health Appraisal Form  2016 Recommended Immunizations for Children from Birth Through 6 Years Old  CO School/Child Care FAQ: Medical and Non-medical Vaccine Exemptions  CO Parent/Guardian FAQ: Medical and Non-medical Vaccine Exemptions  Childcare Immunization Chart 2016-2017  “If You Choose Not to Vaccinate Your Child, Understand the Risks and Responsibilities”  “What if you don’t immunize your child?”  “Q&A Recommended Immunization Schedule: What you should know”  “Childhood Immunization Schedule: Why is it like that?” Vaccine Safety  “Understanding How Vaccines Work”  “Q&A Vaccine Ingredients: What you should know”  “Q&A Too Many Vaccines? What you should know”  “Q&A The Facts About Childhood Vaccines”  Immunization Vaccine Safety  Talking with Parents about Vaccines for Infants  Understanding Thimerosal, Mercury, and Vaccine Safety Adult Immunization Recommendations  “Do You Know Which Adult Vaccines You Might Need?”  2016 Recommended Immunization Schedule for Adults  Vaccines for Adults: You’re never too old to get immunized!  Cocooning Protects Babies Immunization Resources  Colorado Immunization Information System (CIIS)  CIIS Instructions for Child Care Centers (Read Only Users)  Using CIIS to Calculate Immunization Rates  Child Care Immunization Rate Guide  How to Find Immunization Records (English/Spanish)  Jefferson County Public Health Immunization Brochure (English/Spanish)  Jefferson County Public Health Services Brochure (English/Spanish)  Vaccine for Children Program Communicable Disease  Jefferson County Infectious Diseases: How they spread and how to stop them!  Jefferson County Immunization Poster- Infant (English/Spanish)  Jefferson County Immunization Poster- Kindergarten (English/Spanish)  “Protect Against Pertussis” (English/Spanish)  Influenza Poster  “Q&A Influenza: What you should know”  Infectious Diseases in Childcare and School Settings Manual (3/2016) Immunization Course for Childcare Providers  Child Care Immunization Manual/Course: Guidance for Childcare and Preschool Providers in Colorado (Version 2015-2016 School Year)

www.jeffco.us/health

Section One: Immunization Schedule and State Requirements            

Pertussis Information and Guidelines for Schools and Child Care Settings: August 2013 Colorado Immunization Requirements: 2016-2017 Letter to Parents CDPHE Certificate of Immunization and Instructions AAP General Health Appraisal Form 2016 Recommended Immunizations for Children from Birth Through 6 Years Old CO School/Child Care FAQ: Medical and Non-medical Vaccine Exemptions CO Parent/Guardian FAQ: Medical and Non-medical Vaccine Exemptions Childcare Immunization Chart 2016-2017 “If You Choose Not to Vaccinate Your Child, Understand the Risks and Responsibilities” “What if you don’t immunize your child?” “Q&A Recommended Immunization Schedule: What you should know” “Childhood Immunization Schedule: Why is it like that?”

For more information, please visit: http://vaccine.chop.edu http://www.cdc.gov/vaccines/schedules/index.html http://www.cdc.gov/vaccines/default.htm http://www.colorado.gov/cs/Satellite/CDPHE-DCEED/CBON/1251607754774 http://www2.aap.org/immunization/IZSchedule.html

Pertussis Information and Guidelines for Schools and Child Care Settings August 2013 The state of Colorado is experiencing a record number of cases of pertussis (also known as whooping cough). During 2012, 1505 cases of pertussis were reported in Colorado, with a rate of 29.4/100,000 population. In comparison, an average of 324 cases a year was reported during 2007-2011. The most recent year during which Colorado experienced a similar increase in numbers of pertussis cases was 2005; during which there was a total of 1383 cases with a rate of 29.7/100,000 population. There was one pertussis fatality in 2012 which was the first since 2005, when 2 infants died of the disease. So far in 2013, there have been 664 cases of pertussis reported through June 22 with a rate of 13.0/100,000, and are distributed throughout 31 Colorado counties. Most cases are reported from Jefferson County, (n=120), Boulder County (n=107), Arapahoe County (n= 68), Denver (n=63), Adams County (n=61), El Paso County (n=45), Weld County (n=39), Douglas County (n=35) and Larimer County (n=31). Rates of pertussis continue to be highest among infants < 6 months of age, followed by children 11-14 years and infants 6-11 months of age. Of the 32 cases < 6 months of age reported since January 1, 2013, 9 cases (28%) were hospitalized. For more information on pertussis, please go to: http://www.colorado.gov/cs/Satellite/CDPHE-DCEED/CBON/1251611026285 Colorado Immunization Law requires schools and child cares to review and collect up-to-date immunization records for children and adolescents, and it is strongly recommended that staff is up-todate on their immunizations as well. Immunizations offer protection for students and others in the community, particularly infants, who are most at risk of hospitalization and death from pertussis. It is extremely important to assure persons who have contact with infants are vaccinated against pertussis to protect infants who have not yet received the vaccine series. Because of the epidemic levels of pertussis, the Colorado Department of Public Health and Environment (CDPHE) is strongly recommending child care providers, school health officials and health care providers pay special attention to pertussis immunization status in addition to routine immunizations. Clinical Pertussis Information â&#x20AC;˘ â&#x20AC;˘

Incubation period: after exposure to pertussis, symptoms typically begin in 7-10 days. The illness typically progresses as follows: o Initial symptoms can include a runny nose, sneezing, low-grade fever, and mild cough which gradually become more severe over a period of 1-2 weeks. o The cough is characterized by coughing fits which may be followed by a high-pitched inspiratory whoop, vomiting, and/or a pause in breathing. This severe cough usually lasts 16 weeks and then gradually improves over a few weeks. o Note that young infants can present without classic cough symptoms and may present with gasping or apnea only.

• •

Infectious period: individuals with pertussis are contagious as soon as symptoms begin through the first 3 weeks of cough or until 5 full days of antibiotic treatment are completed. Testing and treatment: special testing is available through a health care provider to diagnose pertussis. The most common antibiotic used to treat pertussis is azithromycin, but several others are also effective. The role of schools and child care centers in preventing pertussis: Review, Evaluate, Exclude, and Distance (REED)

1. Review immunization records to assure that your students and teachers are appropriately vaccinated and meet state immunization requirements. Strongly encourage parents of infants, child care workers, and others who have contact with infants, receive the Tdap booster vaccine if they have not done so. Students and staff can be directed to their health care provider, local drugstore, or local health department to receive immunizations. o Colorado school and child care immunization requirements are available at: http://www.colorado.gov/cs/Satellite/CDPHE-DCEED/CBON/1251609960682 o Vaccination recommendations follow the Center for Disease control and Prevention guidelines:  DTaP vaccination of all infants at 2, 4 and 6 months (primary series)  DTaP booster for all children at age 12-15 months  DTaP booster for all children at age 4-6 years  Tdap booster for all adolescents at age 11-12 years  Tdap booster for adolescents 13-18 years who have never had a Tdap  Tdap booster for all adults one time (including those 65 years and older)  Tdap booster for all pregnant women with each pregnancy to increase protection for infants who are too young for vaccination 2. Fully vaccinated children and adults can still get pertussis. However, symptoms appear to be much less severe in fully vaccinated children. Evaluate students for pertussis if they have any of the following symptoms: o Severe cough – often accompanied by gagging, coughing fits, and/or vomiting o Persistent cough lasting longer than 14 days o Apnea (a pause in breathing) or gasping in infants Children and staff with these symptoms should be evaluated by a health care provider who can determine whether testing and treatment is appropriate. 3. Exclude: o Any child or adult diagnosed with pertussis must be excluded from school, child care, and extracurricular activities until they have completed 5 full days of antibiotics (return on 6th day after antibiotics were started) or until 21 days after the cough began if antibiotics are not taken. o Siblings of pertussis cases who also have a cough should stay home until they have completed 5 full days of antibiotics (return on 6th day after antibiotics were started). o If your school or child care has multiple cases of pertussis, this might represent an outbreak. Please consult your local health department or CDPHE to help determine if the following additional measures might be needed: o Exclusion of children with symptoms consistent with pertussis until the child is evaluated by a health care provider for appropriate testing and/or treatment. A note from a provider might be required to return to school. o Offering children and staff with immune system compromising conditions or who are pregnant alternative assignments (distance learning, duty reassignment). o These guidelines are especially important for employees in high-risk occupations (e.g. school teacher, school health care worker, child care center staff). 4. Encourage social Distancing in staff and students:

o o o o o

Frequent hand-washing. Covering the mouth and nose with the inner elbow (“Dracula Cough”) and not hands when sneezing and coughing. Increasing distance between desks in the classroom. Staying home from work, school, or daycare when ill. Avoiding close contact with sick people. Additional Recommendations

1. School and child care personnel should recommend Tdap vaccination for all staff who have not previously received it. o Consider adopting and enforcing a Tdap vaccination policy for your personnel. o Most school and child care workers with health insurance can receive a Tdap immunization at their provider's office with no out-of-pocket cost. Some Local Public Health Agencies (LPHAs) in Colorado are holding special Tdap immunization clinics for high risk clients, regardless of insurance status. Contact your LPHA for eligibility requirements and clinic times. 2. Educate yourself and school and child care staff on the signs and symptoms of pertussis. o Request that teachers help identify students exhibiting symptoms and send them to the school nurse or child’s health care provider for evaluation. For More Information For more information, please see the following websites or contact your local public health agency or CDPHE at 303-692-2700: o Pertussis outbreak and immunization informational posters are available free for schools and child cares. To order, please call the CDPHE Immunization Section at: 303-692-2650 o Infectious disease guidance for schools and child cares: http://www.colorado.gov/cs/Satellite/CDPHE-DCEED/CBON/1251607755294 o General pertussis information: fact sheets, sample contact notification letters and more: http://www.colorado.gov/cs/Satellite?c=Page&childpagename=CDPHEDCEED%2FCBONLayout&cid=1251611026285&pagename=CBONWrapper o Additional information on immunization schedules: http://www.cdc.gov/vaccines/schedules/ Suspected and known pertussis cases and pertussis outbreaks should be reported to public health. To report, please contact your local public health agency, or contact CDPHE at 303692-2700.

January 2016 Dear Parents of Students in Colorado Child Cares and Preschools (School Year 2016-17), Immunizations are an important part of our children’s and the community’s health. Colorado law requires children attending a licensed child care or preschool to be immunized against certain vaccine-preventable diseases. The purpose of this letter is to remind parents about the need for back-to-school immunizations and to provide immunization information. The chart on page 2 shows which vaccines are required for child care and preschool attendance, along with recommended vaccines which provide more protection against vaccine-preventable disease. There are no changes to the vaccines required from the previous school year. It is helpful to share this letter with your child’s healthcare provider or your local public health agency (LPHA) where your child receives immunizations. Colorado follows the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices schedule. This schedule is approved by the American Academy of Pediatrics, the American Academy of Family Physicians and the American College of Obstetricians and Gynecologists. This is the immunization schedule which will best protect your child from vaccine-preventable diseases and is the national standard for health care providers who vaccinate your children. Starting July 1, 2016, parents/guardians seeking non-medical (religious or personal belief) exemptions for prekindergarten children attending child care or preschool must submit non-medical exemption forms at each age when required vaccines are due: 2 months, 4 months, 6 months, 12 months and 18 months of age. Medical exemptions only need to be submitted once and require the signature of your child’s doctor or advanced practice nurse. To submit a non-medical or medical exemption, go to www.colorado.gov/vaccineexemption and follow the instructions. Children with an exemption may be kept out of child care or preschool during a disease outbreak. Parents may have questions or want more information about children’s immunizations and vaccine safety. Resources for parents about the safety and importance of vaccines are available at: www.ImmunizeForGood.com and www.colorado.gov/cdphe/immunization-education. Colorado law requires child cares and preschools to provide school-level immunization and exemption information to the Colorado Department of Public Health and Environment (CDPHE) by December 1, 2016. Immunization and exemption rates for most child cares and preschools will be posted on the CDPHE website as soon as they are verified. Many parents, especially those with children who can’t be vaccinated due to a medical issue, may want to know which schools are best protected against vaccine preventable disease. Please discuss your child’s vaccination needs with your child’s healthcare provider or LPHA and bring your child’s updated immunization records to school each time your child receives an immunization. To find your LPHA or learn about free or low cost vaccines, call the Family Health Line at 1-303-692-2229 or 1-800-688-7777. For questions about school immunization requirements, please contact your school. Sincerely,

Jamie D’Amico, RN, MSN, CNS CDPHE Immunization Branch - Schools and Community Coordinator 303-692-2957 | jamie.damico@state.co.us www.coloradoimmunizations.com

4300 Cherry Creek Drive S., Denver, CO 80246-1530 P 303-692-2000 www.colorado.gov/cdphe John W. Hickenlooper, Governor | Larry Wolk, MD, MSPH, Executive Director and Chief Medical Officer

1. This chart is a “guide” for childcare providers or parents/guardians to determine which vaccines children are required to have in order to be in compliance with state immunization requirements. Select the appropriate age range for the student from the left hand column. The number of required doses is located in each of the columns and vaccines are listed across the top of the page. Review the student’s immunization record with this chart to make sure they have at least the number of doses required. Colorado Board of Health has accepted the Advisory Committee on Immunization Practices (ACIP) schedule for those immunizations already “required” for attendance. Immunizations that are not required but recommended include: Rotavirus, Hepatitis A and Influenza vaccines. 2. Please follow the ACIP Immunization Schedule for specific guidance at: www.coloradoimmunizations.com, and click on Immunization Schedules. 3. If the student does not have the minimum number of doses, the parent/guardian is to be directly notified (in person, by phone, or by mail) that their child does not have the required minimum number of vaccine doses. Within 14 days of direct notification, the parent/guardian is to obtain the required vaccine(s) or makes a plan to do so providing written documentation of that plan. 4.

Colorado law allows for medical exemptions to be signed by a healthcare provider and non-medical exemptions (religious or personal) to be submitted by a parent/guardian.

Age of Child

By 1 mo. By 3 mos. By 5 mos. By 7 mos. By 16 mos. By 19 mos. By 2 years By K Entry

# of required doses DT, DTP, or DTaP Diphtheria, Tetanus and Pertussis 1 2 3 3 4 4 5/4

# of required doses IPV Polio 1 2 2 2 3 3 4/3

# of required doses MMR Measles, Mumps and Rubella 1+ 1 1 2

# of required doses Hib Haemophilus influenzae type b 1 2 3/2 4/3/2/1 4/3/2/1 4/3/2/1

# of required doses Hep B Hepatitis B

# of required doses Varicella Chickenpox

# of required doses PCV13 Pneumococcal Disease

1✍ 2✍ 2✍ 2✍ 2✍ 3✍ 3✍ 3✍

1* 1 1 2

1~ 2~ 3/2~ 4/3/2~ 4/3/2~ 4/3/2/1~ -



Five doses of DTaP vaccines are required at school entry in Colorado unless the 4th dose was given at 48 months of age or older (i.e., on or after the 4th birthday) in which case only 4 doses are required. There must be at least 4 weeks between dose 1 and dose 2, at least 4 weeks between dose 2 and dose 3, at least 4 months between dose 3 and dose 4, and at least 6 months between dose 4 and dose 5. The final dose must be given no sooner than 4 years of age (dose 4 may be given at 12 months of age provided there is at least 4 months between dose 3 and dose 4).



Four doses of Polio vaccine are required at school entry in Colorado. There must be at least 4 weeks between dose 1 and dose 2, at least 4 weeks between dose 2 and dose 3, and at least 6 months between dose 3 and dose 4. The final dose must be given no sooner than 4 years of age. A 4th dose is not required if the 3rd dose was administered at age 4 years or older and at least 6 months after the 2nd dose.

The first dose of MMR, vaccine given more than 4 days before the 1st birthday is not a valid dose and cannot be accepted. ACIP recommends that the 1st dose of MMR be given between 12 -15 months of age. The student is out of compliance if no record of MMR at 16 months of age.



The number of Hib doses required depends on the child’s current age and the age when the Hib vaccine was administered. If any dose is given at or over 15 months, the Hib requirement is met. For children who begin the series before 12 months, 3 doses are required, of which at least 1 dose must be administered at, or over, 12 months. If the 1st dose was given at 12 to 14 months, 2 doses are required. If the student’s current age is 5 years or older, no new or additional doses are required. The number of doses and the intervals may vary depending on the type of Hib vaccine.



The Hep B vaccine is the only immunization that can be given as a birth dose. The 2nd dose of Hep B is to be given at least 4 weeks after the 1st dose; 3rd dose to be given at least 16 weeks (4 months) after 1st dose; and last dose to be given at least 8 weeks after 2nd dose and at (24 weeks) almost 6 months of age or older.

If a child has had chickenpox disease and it is documented by a health care provider, that child has met the Varicella requirement. Varicella given more than 4 days before the 1st birthday is not a valid dose and cannot be accepted. ACIP recommends 1st dose between 12 – 15 months. The student is out of compliance if the 1st dose is not given at 16 months of age.

The number of doses of PCV13 depends on the student’s current age and the age when the 1st dose was administered. If the 1st dose was administered between 2 to 6 months of age, the student will receive 3 doses (2, 4 & 6 months) at least 4 -8 weeks apart, and booster dose between 12 – 15 months, at least 8 weeks after last dose. If started between 7 to 11 months of age, the student will receive 2 doses, at least 8 weeks apart, and a booster dose between 12 to 15 months of age. If the 1st dose was given between 12 to 23 months of age, 2 doses, at least 8 weeks apart, are required. Any dose given at 24 months through 4 years of age, the PCV vaccine requirement is met. No doses are required once the student turns 5 years of age.

Colorado Certificate of Immunization (CI) Instruction Guide

1. Identification Information Section Complete the section of the CI requesting documentation of name, date of birth and Parent/Guardian name. 2. Immunization Information Section Carefully copy information from the clinic or doctor’s immunization record onto the CI. Include the month/day/year of each immunization the child or student has received. Immunization “clinic records” from other states are acceptable documents. Certificates of Immunization from other states are not acceptable. NOTE: If you have access to the Colorado Immunization Information System (CIIS) and the student is included in the registry, you will be able to download a student’s immunization history on the CI document. 3. Signature Lines Section Signature lines are provided to help you keep track of when a child is up-to-date for his or her age. It is not required that you sign in this section. 4. Exemption Section (page 2 of the CI) Medical Exemption: Must be signed and dated by a MD, DO or advanced practice nurse licensed to practice medicine or osteopathic medicine. Medical exemptions signed by a MD, DO or advanced practice nurse from another state can be accepted by the child care or school. Non-Medical Exemptions (Religious or Personal): Must be signed by the parent/guardian or the emancipated student or student 18 years of age and older. Non-medical exemptions from another state are not accepted in Colorado. Specific exempted vaccines are identified by checking the appropriate boxes on the exemption section of the Certificate.

4300 Cherry Creek Drive S., Denver, CO 80246-1530 P 303-692-2000 www.colorado.gov/cdphe John W. Hickenlooper, Governor | Larry Wolk, MD, MSPH, Executive Director and Chief Medical Officer

Certificate of Immunization for Electronic Records

You may type in the boxes and print using the free Adobe Acrobat Reader. To save the completed form, you must have the full Acrobat program or Reader version 7 or greater. COLORADO LAW REQUIRES THAT THIS FORM BE COMPLETED FOR EACH STUDENT ATTENDING COLORADO SCHOOLS

Name_________________________________________________________________ Date of Birth _______________________________________

Parent/Guardian __________________________________________________________________________________________________________

COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT—CERTIFICATE OF IMMUNIZATION Hep B

Vaccine

Hepatitis B

DTaP

Diphtheria, Tetanus, Pertussis (pediatric)

Tdap

Tetanus, Diphtheria, Pertussis

Hib

Haemophilus influenzae type b

PCV

Pneumococcal Conjugate

Diphtheria, Tetanus (pediatric)

Tetanus, Diphtheria

IPV/OPV

Measles, Mumps, Rubella

Mumps

Measles

Rubella

Varicella

Chickenpox

HPV

Human Papillomavirus

MCV4/MPSV 4

Meningococcal

Flu

Influenza

Hep A

Titer Date

Polio

MMR

Rota

Enter the month, day and year each immunization was given

Provider Documentation Date of Disease Positive Screen Date

______________________________ _____________________________

Vaccines recorded below this line are recommended. Recording of dates is encouraged.

Rotavirus

Hepatitis A

Other

THIS SECTION CAN BE COMPLETED BY CHILD CARE/SCHOOL/HEALTH CARE PROVIDER  A) Child Care Up to Date

Up to date through 6 months of age for Colorado School Immunization Requirements

 B) Child Care Up to Date

Up to date through 18 months of age for Colorado School Immunization Requirements

 C) Child Care/Pre-school/Pre-K*

Up to date for Child Care/Pre-School/Pre-K for Colorado School Immunization Requirements

 D) Complete for K–5th Grade

Up to date for K–5th Grade for Colorado School Immunization Requirements

______________________________________________________________ Update Signature

Date

Update Signature

Date

Update Signature

Date

Update Signature

Date

______________________________________________________________ ______________________________________________________________ ______________________________________________________________

* If age 4 years and fulfills Requirements for Pre-School & Kindergarten, check BOTH Boxes C and D.

CDPHE-IMM CI-E-PDF RC Rev. 1/16

Name_________________________________________________________________ Date of Birth _______________________________________

Parent/Guardian __________________________________________________________________________________________________________

STATEMENT OF EXEMPTION TO IMMUNIZATION LAW

(DECLARACIÓN RESPECTO A LAS EXENCIONES DE LA LEY DE VACUNACIÓN)

IN THE EVENT OF AN OUTBREAK, EXEMPTED PERSONS MAY BE SUBJECT TO EXCLUSION FROM SCHOOL AND TO QUARANTINE.

SI SE PRESENTA UN BROTE DE LA ENFERMEDAD, ES POSIBLE QUE A LAS PERSONAS EXENTAS SE LES PONGA EN CUARENTENA O SE LES EXCLUYA DE LA ESCUELA.

MEDICAL EXEMPTION: The physical condition of the above named person is such that immunization would endanger life or health or is medically contraindicated due to other medical conditions.

EXENCIÓN POR RAZONES MÉDICAS: El estado de salud de la persona arriba citada es tal que la vacunación significa un riesgo para su salud o incluso su vida; o bien, las vacunas están contraindicadas debido a otros problemas de salud. Medical exemption to the following vaccine(s):

La exención por razones médicas aplica a la(s) siguiente(s) vacuna(s):

 Hep B  DTaP  Tdap  Hib  IPV  PCV  MMR  VAR

Signed (Firma) _______________________________________________________________ Physician (Médico)

Date (Fecha) ______________________________

RELIGIOUS EXEMPTION: Parent or guardian of the above named person or the person himself/herself is an adherent to a religious belief opposed

to immunizations.

EXENCIÓN POR MOTIVOS RELIGIOSOS: El padre o tutor de la persona arriba citada, o la persona misma, pertenece a una religión que se opone a la inmunización.

Religious exemption to the following vaccine(s):

Exención por motivos religiosos de la(s) siguiente(s) vacuna(s):

 Hep B  DTaP  Tdap  Hib  IPV  PCV  MMR  VAR Signed (Firma) _______________________________________________________________ Parent, guardian, emancipated student/consenting minor (Padre, tutor, estudiante emancipado o consentimiento del menor)

Date (Fecha) ______________________________

PERSONAL EXEMPTION: Parent or guardian of the above named person or the person himself/herself is an adherent to a personal belief opposed

to immunizations.

EXENCIÓN POR CREENCIAS PERSONALES: Las creencias personales del padre o tutor de la persona arriba citada, o la persona misma, se

oponen a la inmunización.

Personal exemption to the following vaccine(s):

Exención por creencias personales de la(s) siguiente(s) vacuna(s):

 Hep B  DTaP  Tdap  Hib  IPV  PCV  MMR  VAR

Signed (Firma) _______________________________________________________________ Parent, guardian, emancipated student/consenting minor (Padre, tutor, estudiante emancipado o consentimiento del menor)

Date (Fecha) ______________________________

At 1 month of age, HepB (1-2 months), At 2 months of age, HepB (1-2 months), DTaP, PCV, Hib, Polio, and RV At 4 months of age, DTaP, PCV, Hib, Polio, and RV At 6 months of age, HepB (6-18 months), DTaP, PCV, Hib, Polio (6-18 months), RV, and Influenza (yearly, 6 months through 18 years)* At 12 months of age, MMR (12-15

2016 Recommended Immunizations for Children from Birth Through 6 Years Old

Birth

HepB

month

†

months), PCV (12-15 months) , Hib (12-15 months), Varicella (12-15 months), HepA (12-23 months)§, and Influenza (yearly, 6 months through 18 years)* At 4-6 years, DTaP, IPV, MMR, Varicella, and Influenza (yearly, 6

months

HepB

months through 18 years)*

Is your family growing? To protect your new baby and yourself against whooping cough, get a Tdap vaccine in the third trimester of each pregnancy. Talk to your doctor for more details.

you don’t need to start over, just go back to your child’s doctor for the next shot. Talk with your child’s doctor if you have questions about vaccines.

For more information, call toll free 1-800-CDC-INFO (1-800-232-4636) or visit http://www.cdc.gov/vaccines

months

19–23 months

2–3

years

4–6

years

HepB RV

DTaP

Hib

PCV

IPV

DTaP

IPV

IPV Influenza (Yearly)*

Shaded boxes indicate the vaccine can be given during shown age range.

NOTE: If your child misses a shot,

MMR

Varicella

HepA§

FOOTNOTES:

* Two doses given at least four weeks apart are recommended for children aged 6 months through 8 years of age who are getting an influenza (flu) vaccine for the first time and for some other children in this age group. §

Two doses of HepA vaccine are needed for lasting protection. The first dose of HepA vaccine should be given between 12 months and 23 months of age. The second dose should be given 6 to 18 months later. HepA vaccination may be given to any child 12 months and older to protect against HepA. Children and adolescents who did not receive the HepA vaccine and are at high-risk, should be vaccinated against HepA.

If your child has any medical conditions that put him at risk for infection or is traveling outside the United States, talk to your child’s doctor about additional vaccines that he may need.

See back page for more information on vaccine preventable diseases and the vaccines that prevent them.

Vaccine-Preventable Diseases and the Vaccines that Prevent Them

Disease

Vaccine

Chickenpox

Varicella vaccine protects against chickenpox. Air, direct contact

Rash, tiredness, headache, fever

Diphtheria

DTaP* vaccine protects against diphtheria.

Air, direct contact

Sore throat, mild fever, weakness, swollen glands in neck

Hib

Hib vaccine protects against Haemophilus influenzae type b.

Air, direct contact

May be no symptoms unless bacteria enter the blood

Hepatitis A

HepA vaccine protects against hepatitis A.

Direct contact, contaminated food or water

Hepatitis B

HepB vaccine protects against hepatitis B.

Contact with blood or body fluids

Influenza (Flu)

Flu vaccine protects against influenza.

Air, direct contact

Measles

MMR** vaccine protects against measles.

Air, direct contact

Mumps

MMR**vaccine protects against mumps.

Air, direct contact

Pertussis

DTaP* vaccine protects against pertussis (whooping cough).

Air, direct contact

Polio

IPV vaccine protects against polio.

Air, direct contact, through the mouth

Pneumococcal

PCV vaccine protects against pneumococcus.

Air, direct contact

Rotavirus

RV vaccine protects against rotavirus.

Through the mouth

Rubella

MMR** vaccine protects against rubella.

Air, direct contact

Tetanus

DTaP* vaccine protects against tetanus.

Exposure through cuts in skin

* DTaP combines protection against diphtheria, tetanus, and pertussis.

** MMR combines protection against measles, mumps, and rubella.

Disease spread by Disease symptoms

May be no symptoms, fever, stomach pain, loss of appetite, fatigue, vomiting, jaundice (yellowing of skin and eyes), dark urine May be no symptoms, fever, headache, weakness, vomiting, jaundice (yellowing of skin and eyes), joint pain Fever, muscle pain, sore throat, cough, extreme fatigue

Disease complications Infected blisters, bleeding disorders, encephalitis (brain swelling), pneumonia (infection in the lungs) Swelling of the heart muscle, heart failure, coma, paralysis, death Meningitis (infection of the covering around the brain and spinal cord), intellectual disability, epiglottitis (life-threatening infection that can block the windpipe and lead to serious breathing problems), pneumonia (infection in the lungs), death Liver failure, arthralgia (joint pain), kidney, pancreatic, and blood disorders Chronic liver infection, liver failure, liver cancer Pneumonia (infection in the lungs)

Encephalitis (brain swelling), pneumonia (infection in the lungs), death Meningitis (infection of the covering around the brain Swollen salivary glands (under the jaw), fever, and spinal cord) , encephalitis (brain swelling), inflam headache, tiredness, muscle pain mation of testicles or ovaries, deafness Severe cough, runny nose, apnea (a pause in Pneumonia (infection in the lungs), death breathing in infants) May be no symptoms, sore throat, fever, Paralysis, death nausea, headache May be no symptoms, pneumonia (infection Bacteremia (blood infection), meningitis (infection of in the lungs) the covering around the brain and spinal cord), death Rash, fever, cough, runny nose, pinkeye

Diarrhea, fever, vomiting

Severe diarrhea, dehydration

Children infected with rubella virus sometimes Very serious in pregnant women—can lead to miscar have a rash, fever, swollen lymph nodes riage, stillbirth, premature delivery, birth defects Stiffness in neck and abdominal muscles, Broken bones, breathing difficulty, death difficulty swallowing, muscle spasms, fever Last updated January 2016 • CS261834-D

Colorado School/Child Care FAQ Medical and Non‐medical Vaccine Exemptions What’s new? The Colorado Board of Health amended Rule 6 CCR 1009‐2 in April 2015. The updated rule requires parents/guardians exempting their children from school‐required vaccines for non‐medical reasons (religious or personal beliefs) to submit documentation of these exemptions more frequently. Starting in July 2016, parents/guardians seeking non‐medical exemptions for pre‐kindergarten children attending a licensed child care facility must submit non‐medical exemption forms at each age when required vaccines are due: 2 months, 4 months, 6 months, 12 months and 18 months of age. Parents/guardians seeking non‐medical exemptions for students in kindergarten through 12th grade must submit non‐medical exemption forms annually. Parents/guardians of students with medical exemptions only need to submit a medical exemption once.

Why did the Board of Health Rule change? In 2014, House Bill 14‐1288 required the Board of Health to promulgate rules regarding the frequency of submitting vaccine exe mption forms. Previous versions of Rule 6 CCR 1009‐2 required that parents/guardians submit signed statements of exemption for school entry but was silent as to the frequency of submission. Increasing the frequency aligns the efforts of parents/guardians claiming non‐medical exemptions with the efforts immunizing parents undertake to provide adequate evidence of immunization. This also provides schools, licensed child care facilities, and state and local public health with current and accurate exemption information for decision‐making during school outbreaks. Per Colorado law, students with exemptions may be excluded from school during an outbreak.

When does this change take effect? Beginning July 1, 2016, parents/guardians seeking medical and non‐medical exemptions for school entry will access the appropriate forms at www.colorado.gov/vaccineexemption .

Who does it affect? This rule change affects parents/guardians seeking medical and non‐medical (religious and personal belief) exemptions for children aged six weeks through 12th grade attending a Colorado school or licensed child care facility. This rule change also affects schools, licensed child care facilities and the state health department as the responsibility to collect exemption forms will transition to CDPHE.

Did the vaccine exemption form change? Yes. Vaccine exemptions will no longer be recorded on the official Certificate of Immunization. Beginning July 1, 2016, separate medical and non‐medical vaccine exemption forms will be available online at www.colorado.gov/vaccineexemption . ● For a medical exemption, the parent/guardian will download the form, take it to their healthcare provider for signature and return the form to CDPHE via fax or mail. ● For a non‐medical exemption, the parent/guardian will complete the form online. Once submitted, the non‐medical exemption form can be printed for the parent/guardian’s records. The non‐medical exemption form will be available in a mobile‐friendly format. ● Both medical and non‐medical exemption forms will be available in multiple languages.

●

If a family does not have access to the internet, medical and non‐medical exemption forms can be obtained by calling the Colorado Immunization Branch at 303‐692‐2700 or emailing CDPHE_vaccineexemption@state.co.us.

How do I submit an exemption form for a student or child in my school/childcare? You don’t. CDPHE will provide you with an instruction sheet to provide to parents/guardians with instructions for claiming a medical or non‐medical exemption through www.colorado.gov/vaccineexemption on a computer or mobile device.

How can I tell if an exemption has been submitted for a student or child in my school/childcare? Information from both the medical and non‐medical exemption forms will be transferred to the Colorado Immunization Information System (CIIS) for viewing by the school or childcare, unless the parent/guardian chooses to exclude their information from CIIS. In this case, information from the exemption forms will be housed in a separate, internal CDPHE database. Parents/guardians will then be responsible for ensuring a copy of the medical or non‐medical exemption form is submitted to the school or childcare. If you don’t already have access to CIIS, please contact CIIS School Coordinator Megan Berry for more information at megan.berry@state.co.us or (303) 692‐2736.

What happens if a parent says he/she plans to claim an exemption but does not submit an exemption form for his/her child? To be compliant with Colorado school immunization law, a child must either have received all required immunizations, have a written plan on file to obtain the required immunizations (in‐process), or have a medical or non‐medical exemption on file. According to Colorado school immunization law, schools and child care centers are required to exclude non‐compliant students from their facilities.

What is CIIS? CIIS stands for Colorado Immunization Information System. CIIS is a secure online database of immunization records for Colorado residents of all ages. CIIS allows healthcare providers, schools and child care providers to access immunization records to ensure children are fully immunized. Parents/guardians have the right to opt‐out, or keep a child’s immunization records out of the CIIS database. For more information about the CIIS opt‐out procedure, parents/guardians should visit www.ColoradoIIS.com .

Colorado Parent/Guardian FAQ Medical and Non‐medical Vaccine Exemption Background The Colorado Board of Health amended Rule 6 CCR 1009‐2 in April 2015. The updated rule requires parents/guardians exempting their children from school‐required vaccines for non‐medical reasons (religious or personal belief) to submit documentation of these exemptions more frequently. Starting July 2016, parents/guardians seeking non‐medical exemptions for pre‐kindergarten children attending a licensed child care facility must submit non‐medical exemption forms at each age when required vaccines are typically due: 2 months, 4 months, 6 months, 12 months and 18 months of age. Parents/guardians seeking non‐medical exemptions for students in kindergarten through 12th grade must submit non‐medical exemption forms annually. Parents/guardians of students with medical exemptions only need to submit a medical exemption once.

Why did the Board of Health Rule change? In 2014, House Bill 14‐1288 required the Board of Health to develop rules regarding the frequency of submitting vaccine exe mption forms. Previous versions of Rule 6 CCR 1009‐2 required that parents/guardians submit signed statements of exemption for school entry but was silent as to the frequency of submission. Increasing the frequency aligns the efforts of parents/guardians claiming non‐medical exemptions with the efforts immunizing parents undertake to provide adequate evidence of immunization. This also provides schools, child cares, and public health with current and accurate exemption information for decision‐making during school outbreaks. Per Colorado law, students with exemptions may be excluded from school/child care during an outbreak.

●

How do I submit a non‐medical exemption form for my child? ● ● ● ● ● ●

Visit the secure site www.colorado.gov/vaccineexemption on a computer or mobile device with internet access. Click on ‘ Click here to submit a non‐medical exemption form for school‐required vaccines. ’ Complete and submit the online form. Upon submission, you will have the option to print the completed form for your records. Non‐medical exemptions will be transferred to the Colorado Immunization Information System (CIIS) for viewing by the appropriate school or child care, unless the parent/guardian opts the student out of CIIS. If a student is opted out of CIIS, the parent/guardian is responsible for providing a copy of an official non‐medical exemption form to the school or child care or may authorize CDPHE to send the information to the school or child care.

How do I submit a medical exemption form for my child? ● ● ● ●

● ●

Visit www.colorado.gov/vaccineexemption on a computer or mobile device with internet access. Click on ‘ Click here to print a medical exemption form for school‐required vaccines. ’ Take the form to an advanced practice nurse or physician licensed to practice medicine or osteopathic medicine for completion. All information on the form must be completed. Incomplete forms will not be accepted. Return the form to CDPHE via: ○ Fax: 303.758.3640 A ttn: Colorado Immunization Branch ‐ Medical Exemption ○ Mail: Colorado Immunization Branch, Attn: Medical Exemption 4300 Cherry Creek Dr. S., Denver, CO 80246 Medical exemptions will be transferred to CIIS for viewing by the appropriate school or child care, unless the parent/guardian opts the student out of CIIS. If a student is opted out of CIIS, the parent/guardian is responsible for providing a copy of an official medical exemption form to the school or child care or may authorize CDPHE to send the information to the school or child care.

What safeguards are in place to ensure the information I submit is kept secure? Great care and consideration are put into ensuring the security of information submitted to and maintained by CDPHE. The online non‐medical exemption form is maintained by the Colorado Governor’s Office of Information Technology. Information submitted via this form is encrypted and resides behind a firewall that limits access to only authorized users. The CIIS database resides on a server housed in a secure location monitored 24/7. All sites that participate in CIIS agree to comply with security and confidentiality requirements. Access to data within CIIS is password‐protected, and every CIIS user is only able to view the information necessary to perform his/her job. All web page accesses and data updates are logged for audit tracking purposes. CIIS security policies and procedures comply with the security standards defined by the following agencies: U.S. Department of Health and Human Services, International Organization for Standardization, American National Standards Institute, National Institute of Standards and Technology, and National Infrastructure Protection Center.

I don’t have access to the internet; how can I access the exemption forms? The online non‐medical exemption form and downloadable medical exemption form are available 24/7. You may use a computer, smartphone or tablet with internet access or go to a public library, your child’s school library, a community center, faith center, etc., to access the forms. If none of these options are available to you, please contact the Colorado Immunization Branch at 303‐692‐2700 or emailing CDPHE_vaccineexemption@state.co.us for assistance.

My child already has a non‐medical exemption on file. Can’t I use that one? No. Beginning July 1, 2016, parents/guardians seeking non‐medical exemptions for school entry should use the online non‐medical exemption form located at www.colorado.gov/vaccineexemption . All previously‐submitted non‐medical exemptions will expire June 30, 2016.

My child already has a medical exemption on file. Can’t I use that one? Maybe. Parents/guardians of students with a previously submitted medical exemption do not need to submit a new medical exemption if none of their information has changed. A new medical exemption will need to be submitted if any of the following has occurred: ● The student has changed schools; ● The student’s name, address, phone number, etc. has changed; ● The student’s reason for claiming a medical exemption has changed; or ● The student is claiming a medical exemption from additional vaccines.

What happens if I plan to claim an exemption but don’t submit an exemption form for my child? To be compliant with Colorado school immunization law, a child must either have received all required immunizations, have a written plan on file to obtain the required immunizations (in‐process), or have a medical or non‐medical exemption on file. According to Colorado school immunization law, schools and child cares are required to exclude non‐compliant students from their facilities.

What is CIIS? CIIS stands for Colorado Immunization Information System. CIIS is a secure online database of immunization records for Colorado residents of all ages. CIIS allows healthcare providers, schools and child care providers to access immunization records to ensure children are fully immunized. Exemptions from school‐required immunizations are also documented in CIIS. Parents/guardians have the right to opt‐out, or keep a child’s immunization information out of the CIIS database. For more information about the CIIS opt‐out procedure, parents/guardians should visit www.ColoradoIIS.com .

Child Care Immunization Chart 2016-2017 Immunization Chart of Required Vaccines for Child Care, Preschool and K-Entry 1. This chart is a “guide” for childcare providers or parents to determine which vaccines children are required to have in order to be in compliance with state immunization requirements. Select the appropriate age range for the child from the left hand column. The number of required doses are located in each of the columns and vaccines are listed across the top of the page. Review the child’s immunization record with this chart to make sure they have at least the number of doses required. Colorado Board of Health has accepted the Advisory Committee on Immunization Practices (ACIP) schedule for those immunizations already “required” for attendance. Immunizations that are not required but recommended include Rotavirus, Hepatitis A and Influenza vaccines. 2. Please follow the ACIP Immunization Schedule for specific guidance on our webpage, www.coloradoimmunizations.com, and click on Immunization Schedules. 3.

If the child does not have the minimum number of doses, the parent is to be directly notified (in person, by phone, or by mail) that their child does not have the required minimum number of vaccine doses. Within 14 days of direct notification, the parent is to obtain the required vaccine(s) or makes a plan to do so providing written documentation of that plan.

Colorado law allows for medical exemptions to be signed by a healthcare provider and non-medical exemptions (religious or personal) to be submitted online by a parent or guardian.

Age of Child By 1 mo. By 3 mos. By 5 mos. By 7 mos. By 16 mos. By 19 mos. By 2 years K Entry By 4 - 6yrs

# of required doses DT, DTP, or DTaP Diphtheria, Tetanus Pertussis

# of required doses Polio Polio

# of required doses MMR Measles Mumps Rubella

# of required doses Hib Haemophilus influenzae type b

# of required doses Hep B Hepatitis B

# of required doses Varicella Chickenpox

# of required doses PCV13 Pneumococcal Disease

1 2 3 3 4 4

1 2 2 2 3 3

1+ 1 1

1 2 3/2♥ 4/3/2/1♥ 4/3/2/1♥ 4/3/2/1♥

1 2 2 2 2 3 3

1* 1 1

1~ 2~ 3/2~ 4/3/2~ 4/3/2~ 4/3/2/1~

5/4♦

4/3♣

3

♥

The number of Hib doses required depends on the child’s current age and the age when the Hib vaccine was administered. If any dose is given at or over 15 months, the Hib requirement is met. For children who begin the series before 12 months, 3 doses are required, of which at least 1 dose must be administered at, or over, 12 months. If the 1st dose was given at 12 to 14 months, 2 doses are required. If the current age is 5 years or older, no new or additional doses are required. The number of doses and the intervals may vary depending on the type of Hib vaccine.

The number of doses of pneumococcal conjugate vaccine (PCV13) depends on the student’s current age and the age when the 1st dose was administered. If the 1st dose was administered between 2 to 6 months of age, the child will receive 3 doses (2, 4 & 6 months) at least 4 -8 weeks apart, and booster dose between 12 – 15 months, at least 8 weeks after last dose. If started between 7 to 11 months of age, the child will receive 2 doses, at least 8 weeks apart, and a booster dose between 12 to 15 months of age. If the 1st dose was given between 12 to 23 months of age, 2 doses, at least 8 weeks apart, is required. Any dose given at 24 months through 4 years of age, the PCV vaccine requirement is met. No doses are required once the child turns 5 years of age.

♦

Five doses of pertussis, tetanus, and diphtheria vaccines are required at school entry in Colorado unless the 4th dose was given at 48 months of age or older (i.e., on or after the 4th birthday) in which case only 4 doses are required. There must be at least 4 weeks between dose 1 and dose 2, at least 4 weeks between dose 2 and dose 3, at least 4 months between dose 3 and dose 4, and at least 6 months between dose 4 and dose 5. The final dose must be given no sooner than 4 years of age (dose 4 may be given at 12 months of age provided there is at least 4 months between dose 3 and dose 4).

♣

Four doses of polio vaccine are required at school entry in Colorado. There must be at least 4 weeks between dose 1 and dose 2, at least 4 weeks between dose 2 and dose 3, and at least 6 months between dose 3 and dose 4. The final dose must be given no sooner than 4 years of age. A fourth dose is not required if the 3rd dose was administered at age 4 years or older and at least 6 months after the 2nd dose.

If a child has had chickenpox disease and it is documented by a health care provider, that child has met the varicella requirement. Varicella given more than 4 days before the 1st birthday is not a valid dose and cannot be accepted. ACIP recommends 1st dose between 12 – 15 months. The student is out of compliance if 1st dose not given at 16 months of age.



Updated 1/4/2016

| information for parents |

If You Choose Not to Vaccinate Your Child, Understand the Risks and Responsibilities. Reviewed March 2012

If you choose to delay some vaccines or reject some vaccines entirely, there can

be risks. Please follow these steps to protect your child, your family, and others.

With the decision to delay or reject vaccines comes an important responsibility that could save your child’s life, or the life of someone else. Any time that your child is ill and you: • call 911; • ride in an ambulance; • visit a hospital emergency room; or • visit your child’s doctor or any clinic you must tell the medical staff that your child has not received all the vaccines recommended for his or her age. Keep a vaccination record easily accessible so that you can report exactly which vaccines your child has received, even when you are under stress.

Telling health care professionals your child's vaccination status is essential for two reasons: • When your child is being evaluated, the doctor will need to consider the possibility that your child has a vaccinepreventable disease. Many of these diseases are now uncommon, but they still occur.

CS233434S

• The people who help your child can take precautions, such as isolating your child, so that the disease does not spread to others. One group at high risk for contracting disease is infants who are too young to be fully vaccinated. For example, the measles vaccine is not usually recommended for babies younger than 12 months. Very young babies who get measles are likely to be seriously ill, often requiring hospitalization. Other people at high risk for contracting disease are those with weaker immune systems, such as some people with cancer and transplant recipients.

Before an outbreak of a vaccinepreventable disease occurs in your community: • Talk to your child’s doctor or nurse to be sure your child’s medical record is up to date regarding vaccination status. Ask for a copy of the updated record. • Inform your child’s school, childcare facility, and other

caregivers about your child’s vaccination status. • Be aware that your child can catch diseases from people who don’t have any symptoms. For example, Hib meningitis can be spread from people who have the bacteria in their body but are not ill. You can’t tell who is contagious.

When there is vaccine-preventable disease in your community: • It may not be too late to get protection by getting vaccinated. Ask your child’s doctor. • If there are cases (or, in some circumstances, a single case) of a vaccine-preventable disease in your community, you may be asked to take your child out of school, childcare, or organized activities (for example, playgroups or sports). • Your school, childcare facility, or other institution will tell you when it is safe for an unvaccinated child to return. Be prepared to keep your child home for several days up to several weeks. • Learn about the disease and how it is spread. It may not

be possible to avoid exposure. For example, measles is so

contagious that hours after an infected person has left

the room, an unvaccinated person can get measles just by

entering that room. • Each disease is different, and the time between when your child might have been exposed to a disease and when he or she may get sick will vary. Talk with your child’s doctor or the health department to get their guidelines for determining when your child is no longer at risk of coming down with the disease.

Be aware.

If you know your child is exposed to a vaccine-preventable disease for which he or she has not been vaccinated: • Learn the early signs and symptoms of the disease. • Seek immediate medical help if your child or any family

members develop early signs or symptoms of the disease. IMPORTANT: Notify the doctor’s office, urgent care facility, ambulance personnel, or emergency room staff that your child has not been fully vaccinated before medical staff have contact with your child or your family members. They need to know that your child may have a vaccinepreventable disease so that they can treat your child correctly as quickly as possible. Medical staff also can take simple precautions to prevent diseases from spreading to others if they know ahead of time that their patient may have a contagious disease. • Follow recommendations to isolate your child from others, including family members, and especially infants and people with weakened immune systems. Most vaccine-preventable diseases can be very dangerous to infants who are too young to be fully vaccinated, or children who are not vaccinated due to certain medical conditions. • Be aware that for some vaccine-preventable diseases, there are medicines to treat infected people and medicines to keep people they come in contact with from getting the disease.

4 Any vaccine-preventable disease can strike at any time in the U.S. because all of these diseases still circulate either in the U.S. or elsewhere in the world.

• Ask your health care professional about other ways to protect your family members and anyone else who may come into contact with your child.

4 Sometimes vaccine-preventable diseases cause outbreaks, that is, clusters of cases in a given area.

• Your family may be contacted by the state or local health

department who track infectious disease outbreaks in the

community.

4 Some of the vaccine-preventable diseases that still circulate in the U.S. include whooping cough, chickenpox, Hib (a cause of meningitis), and influenza. These diseases, as well as the other vaccine-preventable diseases, can range from mild to severe and life-threatening. In most cases, there is no way to know beforehand if a child will get a mild or serious case. 4 For some diseases, one case is enough to cause concern in a community. An example is measles, which is one of the most contagious diseases known. This disease spreads quickly among people who are not immune.

If you travel with your child: • Review the CDC travelers’ information website

(http://www.cdc.gov/travel) before traveling to learn about

possible disease risks and vaccines that will protect

your family. Diseases that vaccines prevent remain

common throughout the world, including Europe. • Don't spread disease to others. If an unimmunized person develops a vaccine-preventable disease while traveling, to prevent transmission to others, he or she should not travel by a plane, train, or bus until a doctor determines the person is no longer contagious.

For more information on vaccines, ask your child's health care professional, visit www.cdc.gov/vaccines or call 800-CDC-INFO (800-232-4636)

. . .

Your child will be left at risk of catching the disease.

Your child will be an infectious disease threat to others.

Your child may have to be excluded from school or child care.

what to do . . . We strongly encourage you to immunize your child. Please discuss any concerns you have with a trusted healthcare provider or call the immunization coordinator at your local or state health department. Your vaccination decision affects not only the health of your child, but also all of your family, your child’s friends and their families, and your community.

For more information about vaccines, go to • Immunization Action Coalition www.immunize.org and www.vaccineinformation.org • Centers for Disease Control and Prevention www.cdc.gov/vaccines CDC-INFO Contact Center: (800) 232-4636 • American Academy of Pediatrics www.aap.org/immunization • National Network for Immunization Information www.nnii.org • Vaccine Education Center at the Children’s Hospital of Philadelphia www.vaccine.chop.edu Immunization Action Coalition 1573 Selby Avenue, Suite 234 Saint Paul, MN 55104 phone: (651) 647-9009 fax: (651) 647-9131 www.immunize.org www.vaccineinformation.org This brochure was originally created by the California Department of Public Health (CDPH), Immunization Branch, and was modified with permission by the Immunization Action Coalition (IAC). The content was reviewed by the Centers for Disease Control and Prevention, December 2011. It may be reproduced without permission. If you alter it, please acknowledge it was adapted from CDPH and IAC.

www.immunize.org/catg.d/p4017.pdf • Item #P4017 (12/11)

Wh at if ...

then ...

you don’t immunize your child

What .if What if you don’t immunize your child? Parents, please consider the consequences of not immunizing your child. Your vaccination decision affects not only the health of your child, but also the health

of your family, your child’s friends and their families, and your community.

...

Without immunizations your child is at risk for catching a vaccine-preventable disease.

Vaccines were developed to protect people from dangerous and often fatal diseases. Vaccines are safe and effective, and vaccine-preventable diseases are still a threat. • Influenza or “flu” is a serious respiratory disease that can be deadly. Healthy infants and toddlers are especially vulnerable to the complications of influenza. Tragically, every year in the United States children die from influenza. • Pertussis or “whooping cough” is an extremely dangerous disease for infants. It is not easily treated and can result in permanent brain damage or death. Since the 1980s, the number of cases of pertussis has increased, especially among babies younger than 6 months and teenagers. In 2010, several states reported an increase in cases and outbreaks of pertussis, including a state-wide epidemic in California. Many infants died from whooping cough during this epidemic. • Measles is dangerous and very contagious. It is still common in many countries and is easily brought into the United States by returning vacationers and foreign visitors. The number of reported measles cases began to decline rapidly during the 1990s. Recently, vaccine hesitancy among parents in the United States and abroad has led to a growing number of children and teens who are under-vaccinated and thus, unprotected from measles. Unfor-

tunately, measles cases are on the rise across this country and worldwide. • Chickenpox is very contagious. Before the development of a vaccine, about 100 people died every year in the United States from chickenpox. Most were previously healthy. Children with chickenpox need to be kept out of day care or school for a week or more so they don’t spread the disease to others.

Without immunizations your child can infect others.

Children who are not immunized can readily transmit vaccine-preventable diseases throughout the community. • Unvaccinated children can pass diseases on to babies who are too young to be fully immunized. • Unvaccinated children pose a threat to children and adults who can’t be immunized for medical reasons. This includes people with leukemia and other cancers, immune system problems, and people receiving treatment or medications that suppress their immune system.

• Unvaccinated children can infect the small percentage of children who do not mount an immune response to vaccination.

Without immunizations your child may have to be excluded from school or child care.

During disease outbreaks, unimmunized children may be excluded from school or child care until the outbreak is over. This is for their own protection and the protection of others. It can cause hardship for the child and parent.

Recommended Immunization Schedule: What You Should Know VA C C I N E E D U C AT I O N C E N T E R

Vo l u m e 1 , F a l l 2 0 1 2 Although only one version of the immunization schedule is endorsed by the Centers for Disease Control and Prevention (CDC), the American Academy of Pediatrics (AAP) and the American Academy of Family Physicians (AAFP), some parents prefer to be selective about which vaccines their children receive and when. Unfortunately, this approach can leave children susceptible to certain diseases at a time when they most need protection; worse, some children never catch up completely. Q. Who determines when vaccines are added to the immunization schedule?

Q. How can the recommended schedule be appropriate for all children?

A. Before a vaccine can be added to the immunization schedule, it must be licensed by the Food and Drug Administration (FDA). Scientists at the FDA closely monitor and review vaccine trials; sometimes they request additional studies before making a decision. The FDA determines whether the vaccine is safe and whether it works (efficacy). Studies prior to licensure often last five to 10 years and are extensive. For example, if all of the paperwork from the pre-licensure studies of one of the rotavirus vaccines was piled up, the stack would be higher than the Empire State Building.

A. A common misconception is that the recommended immunization schedule is determined using a one-size-fits-all approach. These concerns are based on misconceptions about how vaccines work and misconceptions about the schedule itself:

Once a vaccine is licensed, experts from the CDC, AAP and AAFP independently review data from scientific studies to determine whether or not a vaccine should be added to the immunization schedule. Not only will they look at the safety and efficacy of the vaccine, they will also look at disease rates and susceptible populations to determine if the vaccine is needed in the community and, if so, who should get it. Their recommendations are compiled to create the immunization schedule. If a vaccine is recommended at an age when other vaccines are already given, concomitant use studies will be required to make sure the vaccine works and is safe when given as part of the existing schedule. If these studies reveal any negative consequences of giving certain vaccines together, restrictions will be placed on their use. For example, concomitant use studies have shown that if two live viral vaccines (for example, measles, mumps and rubella [MMR] and chickenpox vaccines) are given on the same day or separated by at least one month, no problems occur; however, if they are given between one and 28 days of each other, the immune response to the one administered later will be diminished. This is reflected on the schedule, so that healthcare providers administer the vaccines correctly.

• Vaccines and drugs aren’t distributed in the body in the same manner. Medications must be distributed throughout the bloodstream to have the desired effect, so dosing is determined by body size. This is similar to the effects of a glass of alcohol on a large man compared with a small woman. In contrast, vaccines work by introducing cells of the immune system, known as B and T cells, to the parts of a virus or bacteria that cause disease. These cells are typically “educated” near the site the vaccine is given. Once they are equipped to recognize the agent that causes illness, they travel throughout the body. These educated patrol cells are known as memory cells; it typically takes about a week to 10 days after immunization for the memory response to develop. • The immunization schedule is confusing. For this reason, it is often described more simply in terms of the age at which each vaccine is given. However, healthcare providers who administer vaccines know that many rules exist regarding when and if a vaccine can be given based on individual situations. Illnesses, allergies, age and health conditions all influence whether someone is able to get a vaccine. In fact, the published immunization schedule for children from birth through 18 years of age is four pages long and is supported by a 64-page document on general recommendations as well as vaccine-specific recommendations. Documents describing specific vaccines are typically 25 to 40 pages long.

Q. How do we know who should get a vaccine? Q. How are the amounts of immunological components in a vaccine determined? A. Vaccine doses are not chosen arbitrarily. During the four phases of vaccine development, different doses are tested to determine the lowest effective dose for the target group. For example, the rotavirus vaccine was tested at quantities as low as one-tenth the current dose and up to 10 times the current dose. Vaccine developers must practice good medicine and good economics. Giving larger doses of active ingredients than required would increase the side effects and giving too little of the vaccine would lessen efficacy. It’s a fine balance.

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A. A vaccine is added to the immunization schedule only after it has been studied in people who will receive it. Before a vaccine can be licensed, it must undergo rigorous scientific study to make sure that it is safe and that it works in the age group for which it will be used. One might reasonably ask, then, how we know which age group might need to receive the vaccine. The answer is that scientists and public health officials perform “epidemiologic studies,” which determine who gets a disease (susceptibility), when they get it (seasonality), how many people get it (morbidity), and how many people die from it (mortality). All of this information provides scientists and public health officials with a good understanding of how the disease is affecting communities and which individuals would benefit the most from a vaccine.

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Recommended Immunization Schedule: What You Should Know Q. Why are multiple doses of some vaccines necessary?

Q. Why are so many vaccines necessary?

A. Most vaccines require more than one dose. This happens for a few reasons, including the type of vaccine, the level of disease in the community and the nature of immunity:

A. While it may seem like a lot of vaccines when you are watching your baby get multiple shots during the course of several office visits, the reality is that vaccines only protect babies from a small fraction of the potential disease-causing agents in the environment. The good news is that vaccines have been developed for the most deadly diseases, increasing life expectancy and decreasing infant mortality rates in the countries that use them.

• Vaccines that are given as live, weakened versions of the virus (e.g., MMR and chickenpox) usually require fewer doses because they reproduce at low levels in the body. The advantages are that the resulting immune response will be more robust in terms of quantity and diversity of antibodies. In contrast, when the vaccine is made from polysaccharides, individual proteins or toxoids (e.g., Haemophilus influenzae type B, hepatitis B, tetanus and pertussis), the immune response is limited to the specific antigens and the levels of antibody tend to be lower, so additional doses are needed to boost the immune response.

Q. Wouldn’t it be better for children to get some of these diseases naturally?

• When a vaccine is first made available, levels of disease in the community are typically high, so a child who was immunized will come in contact with the organism (i.e., virus or bacteria), but does not get sick. Even though as parents and healthcare providers, we often do not know about these encounters, they serve to boost the child’s immunity to that organism. However, after the vaccine has been available for several years, the levels of disease in the community are reduced making these anonymous encounters less frequent. As a result, immunity may wane making a second dose of vaccine necessary. This is what happened following introduction of the measles and chickenpox vaccines, so children are now recommended to get one dose around 12 to 15 months of age and a second dose before starting school around 4 to 6 years of age.

A. For each virus or bacteria, a specific level of immunity is needed to avoid getting sick. Once this protective level is reached, any additional protection doesn’t make much difference. Vaccines are designed to introduce enough viral or bacterial antigens to induce protective immunity but not enough to cause symptoms of disease. So, while getting the disease usually creates better immune responses, not much is gained in terms of protection as compared with vaccination and the price paid for natural infection can be great in terms of suffering and, sometimes, death.

• As people get older, their immune systems may not be able to fend off bacterial and viral encounters as readily as they once did. For example, most of us have the virus that causes chickenpox living silently in cells of our nervous system. This virus can also cause shingles, but shingles only occurs if our immune system fails to keep the virus “in check,” such as during times of high stress, compromised immunity or with increasing age. For this reason, people 60 years and older are recommended to get a shingles vaccine. The shingles vaccine uses the same virus as the chickenpox vaccine given to children; however, to be effective, the shingles vaccine contains about 14 times the amount of virus compared with the children’s version.

Selected Resources and References

Q. When is it OK to use a different vaccine schedule?

Offit PA, Moser CA. The Problem With Dr. Bob’s Alternative Vaccine Schedule. Pediatrics. 2009;123(1):164-9.

A. Children who have certain health conditions or acute illnesses may not be able to get vaccines according to the routine schedule. Contraindications are reasons not to get one or more vaccines; they include things like having an allergic reaction to a previous dose of vaccine or not getting a live virus vaccine, such as MMR or chickenpox, when receiving chemotherapy. Precautions are reasons to delay getting one or more vaccines either because of an increased chance of experiencing a severe side effect or a situation that may compromise the ability of the vaccine to work. Examples of precautions can include situations such as moderate or severe illness, recent blood transfusion, uncontrolled seizures or unstable neurological condition. If you are concerned about conditions that might delay or prevent getting vaccines, talk to your healthcare provider or contact your local health department.

Immunization schedules are available on the CDC website at http://www.cdc.gov/vaccines/schedules/index.html. Immunization recommendations are available on the CDC website at http://www.cdc.gov/vaccines/pubs/ACIP-list.htm. Centers for Disease Control and Prevention. General Recommendations on Immunization: Recommendations of the Advisory Committee on Immunization Practices. Morbidity and Mortality Weekly Report 60. 2011;RR02:1-60. Cohn M, Langman RE. The protection: the unit of humoral immunity selected by evolution. Immunol Rev. 1990;115:11-147.

Offit PA, Moser CA. Vaccines and Your Child: Separating Fact from Fiction. New York: Columbia University Press; 2011. Offit PA, Quarles J, Gerber MA, Hackett CJ, Marcuse EK, Kollman TR, Gellin BG, Landry S. Addressing parents’ concerns: Do multiple vaccines overwhelm or weaken the infant’s immune system? Pediatrics. 2002;109(1):124-129. Plotkin SA, Orenstein WA, Offit PA. Vaccines, 5th Ed. London: Elsevier/Saunders; 2008. Ramsay DS, Lewis M. Developmental changes in infant cortisol and behavioral response to inoculation. Child Dev. 1994;65:1491-1502. Tonegawa S, Steinberg C, Dube S, Bernardini A. Evidence for somatic generation of antibody diversity. Proc Natl Acad Sci USA. 1974;71:4027-4031.

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This information is provided by the Vaccine Education Center at The Children’s Hospital of Philadelphia. The Center is an educational resource for parents and healthcare professionals and is composed of scientists, physicians, mothers and fathers who are devoted to the study and prevention of infectious diseases. The Vaccine Education Center is funded by endowed chairs from The Children’s Hospital of Philadelphia. The Center does not receive support from pharmaceutical companies.

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The Childhood Immunization Schedule: Why Is It Like That? Q1: Who decides what immunizations children need ? A: Each year, top disease experts and doctors who care for children work together to decide what to recommend that will best protect U.S. children from diseases. The schedule is evaluated each year based on the most recent scientific data available. Changes are announced in January, if needed. The schedule is approved by the American Academy of Pediatrics, the Centers for Disease Control and Prevention, and the American Academy of Family Physicians. Q2: How are the timing and spacing of the shots determined? A: Each vaccine dose is scheduled using 2 factors. First, it is scheduled for the age when the body’s immune system will work the best. Second, it is balanced with the need to provide protection to infants and children at the earliest possible age. Q3: Why are there so many doses? A: Researchers are always studying how well vaccines work. For many vaccines three or four doses are needed to fully protect your child. The doses need to be spaced out a certain amount to work the best. Q4: Why is the schedule “one size fits all?” Aren’t there some children who shouldn’t receive some vaccines? A: Your child’s health and safety are very important to your child’s doctor. The schedule is considered the ideal schedule for healthy children but there may be exceptions. For example, your child might not receive certain vaccines if she has allergies to an ingredient in the vaccine, or if she has a weakened immune system due to illness, a chronic condition, or another medical treatment. Sometimes a shot needs to be delayed for a short time, and sometimes not given at all. Your pediatrician stays updated about new exceptions to the immunization schedule. This is one reason your child’s complete medical history is taken at the pediatrician’s office, and why it is important for your child’s health care providers to be familiar with your child’s medical history. Q5: Why can’t the shots be spread out over a longer period of time? There are 25 shots recommended in the first 15 months of life; why not spread these out over 2 or 3 years? A: First, you would not want your child to go unprotected that long. Babies are hospitalized and die more often from some diseases, so it is important to vaccinate them as soon as it is safe. Second, the recommended schedule is designed to work best with a child’s immune system at certain ages and at specific times. There is no research to show that a child would be equally protected against diseases with a very different schedule. Also, there is no

scientific reason why spreading out the shots would be safer. But we do know that any length of time without immunizations is a time without protection. Q6: I’ve seen another schedule in a magazine that allows the shots to be spread out. It was developed by a pediatrician. Why can’t I follow that schedule? My child would still get his immunizations in time for school. A: There is no scientific basis for such a schedule. No one knows how well it would work to protect your child from diseases. And if many parents in any community decided to follow such a schedule, diseases will be able to spread much more quickly. Also, people who are too sick or too young to receive vaccines are placed at risk when they are around unvaccinated children. For example, following one alternative schedule would leave children without full polio protection until age 4. Yet it would take only one case of polio to be brought into the U.S. for the disease to take hold again in this country. This schedule also delays the measles vaccine until age 3. We have already seen outbreaks of measles in some parts of the country because children were not immunized. This is a highly infectious disease that can cause serious harm--even death. The reason we recommend vaccines when we do is because young children are more vulnerable to these diseases. Pediatricians want parents to have reliable, complete, and science-based information, so that they can make the best decision for their child about vaccination. Q7: Isn’t it possible that my child has natural immunity to one or more diseases? If he does, can’t he skip the shot? A: Tests that check for immunity to certain diseases do not work well in young children. Q8: Isn’t it overwhelming to a child’s immune system to give so many shots in one visit? A: Infants and children are exposed to many germs every day just by playing, eating, and breathing. Their immune systems fight those germs, also called antigens, to keep the body healthy. The amount of antigens that children fight every day (2,000-6,000) is much more than the antigens in any combination of vaccines on the current schedule (150 for the whole schedule). So children’s immune systems are not overwhelmed by vaccines. Q9: There are no shots given at 9 months, other than maybe flu vaccine or catch-up vaccines. Why not give some at that visit instead of at 6 months or 12 months? A: Waiting until 9 months would leave the child unprotected from some diseases, but 9 months is too early for some of the 12-18 month vaccines. For example, it is too early for the live measles, mumps, rubella and varicella vaccines, since some infants might have a bit of protection left from their mother during the pregnancy, and that protection could make the vaccine less effective. The information contained in this publication should not be used as a substitute for the medical care and advice of your pediatrician. There may be variations in treatment that your pediatrician may recommend based on individual facts and circumstances.

Section Two: Vaccine Safety       

“Understanding How Vaccines Work” “Q&A Vaccine Ingredients: What you should know” “Q&A Too Many Vaccines? What you should know” “Q&A The Facts About Childhood Vaccines” Immunization Vaccine Safety Talking with Parents about Vaccines for Infants Understanding Thimerosal, Mercury, and Vaccine Safety

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Understanding How Vaccines Work

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vaccine-preventable diseases, and vaccine safety:

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Last reviewed March 2012

Diseases that vaccines prevent can be dangerous, or even deadly. Vaccines greatly reduce the risk of infection by working with the body’s natural defenses to safely develop immunity to disease. This fact sheet explains how the body fights infection and how vaccines work to protect people by producing immunity.

The Immune System—

The Body’s Defense Against Infection

To understand how vaccines work, it is helpful to first look at how the body fights illness. When germs, such as bacteria or viruses, invade the body, they attack and multiply. This invasion is called an infection, and the infection is what causes illness. The immune system uses several tools to fight infection. Blood contains red blood cells, for carrying oxygen to tissues and organs, and white or immune cells, for fighting infection. These white cells consist primarily of B-lymphocytes, T-lymphocytes, and macrophages: • Macrophages are white blood cells that swallow up and digest germs, plus dead or dying cells. The macrophages leave behind parts of the invading germs called antigens. The body identifies antigens as dangerous and stimulates the body to attack them. • Antibodies attack the antigens left behind by the macrophages. Antibodies are produced by defensive white blood cells called B-lymphocytes. • T-lymphocytes are another type of defensive white blood cell. They attack cells in the body that have already been infected.

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The first time the body encounters a germ, it can take several days to make and use all the germ-fighting tools needed to get over the infection. After the infection, the immune system remembers what it learned about how to protect the body against that disease.

The body keeps a few T-lymphocytes, called memory cells that go into action quickly if the body encounters the same germ again. When the familiar antigens are detected, B-lymphocytes produce antibodies to attack them.

How Vaccines Work

Vaccines help develop immunity by imitating an infection. This type of infection, however, does not cause illness, but it does cause the immune system to produce T-lymphocytes and antibodies. Sometimes, after getting a vaccine, the imitation infection can cause minor symptoms, such as fever. Such minor symptoms are normal and should be expected as the body builds immunity. Once the imitation infection goes away, the body is left with a supply of “memory” T-lymphocytes, as well as B-lymphocytes that will remember how to fight that disease in the future. However, it typically takes a few weeks for the body to produce T-lymphocytes and B-lymphocytes after vaccination. Therefore, it is possible that a person who was infected with a disease just before or just after vaccination could develop symptoms and get a disease, because the vaccine has not had enough time to provide protection.

Types of Vaccines Scientists take many approaches to designing vaccines. These approaches are based on information about the germs (viruses or bacteria) the vaccine will prevent, such as how it infects cells and how the immune system responds to it. Practical considerations, such as regions of the world where the vaccine would be used, are also important because the strain of a virus and environmental conditions, such as temperature and risk of exposure, may be different in various parts of the world. The vaccine delivery options available may also differ geographically. Today there are five main types of vaccines that infants and young children commonly receive:

• Live, attenuated vaccines fight viruses. These vaccines contain a version of the living virus that has been weakened so that it does not cause serious disease in people with healthy immune systems. Because live, attenuated vaccines are the closest thing to a natural infection, they are good teachers for the immune system. Examples of live, attenuated vaccines include measles, mumps,

| Types of Vaccines | continued  and rubella vaccine (MMR) and varicella (chickenpox) vaccine. Even though these vaccines are very effective, not everyone can receive them. Children with weakened immune systems—for example, those who are undergoing chemotherapy—cannot get live vaccines. • Inactivated vaccines also fight viruses. These vaccines are made by inactivating, or killing, the virus during the process of making the vaccine. The inactivated polio vaccine is an example of this type of vaccine. Inactivated vaccines produce immune responses in different ways than live, attenuated vaccines. Often, multiple doses are necessary to build up and/or maintain immunity. • Toxoid vaccines prevent diseases caused by bacteria that produce toxins (poisons) in the body. In the process of making these vaccines, the toxins are weakened so they cannot cause illness. Weakened toxins are called toxoids. When the immune system receives a vaccine containing a toxoid, it learns how to fight off the natural toxin. The DTaP vaccine contains diphtheria and tetanus toxoids. • Subunit vaccines include only parts of the virus or bacteria, or subunits, instead of the entire germ. Because these vaccines contain only the essential antigens and not all the other molecules that make up the germ, side effects are less common. The pertussis (whooping cough) component of the DTaP vaccine is an example of a subunit vaccine. • Conjugate vaccines fight a different type of bacteria. These bacteria have antigens with an outer coating of sugar-like substances called polysaccharides. This type of coating disguises the antigen, making it hard for a young child’s immature immune system to recognize it and respond to it. Conjugate vaccines are effective for these types of bacteria because they connect (or conjugate) the polysaccharides to antigens that the immune system responds to very well. This linkage helps the immature immune system react to the coating and develop an immune response. An example of this type of vaccine is the Haemophilus influenzae type B (Hib) vaccine.

Vaccines Require More Than One Dose There are four reasons that babies—and even teens or adults for that matter—who receive a vaccine for the first time may need more than one dose: • For some vaccines (primarily inactivated vaccines), the first dose does not provide as much immunity as possible. So, more than one dose is needed to build more complete immunity. The vaccine that protects against the bacteria Hib, which causes meningitis, is a good example.

• In other cases, such as the DTaP vaccine, which protects against diphtheria, tetanus, and pertussis, the initial series of four shots that children receive as part of their infant immunizations helps them build immunity. After a while, however, that immunity begins to wear off. At that point, a “booster” dose is needed to bring immunity levels back up. This booster dose is needed at 4 years through 6 years old for DTaP. Another booster against these diseases is needed at 11 years or 12 years of age. This booster for older children—and teens and adults, too—is called Tdap. • For some vaccines (primarily live vaccines), studies have shown that more than one dose is needed for everyone to develop the best immune response. For example, after one dose of the MMR vaccine, some people may not develop enough antibodies to fight off infection. The second dose helps make sure that almost everyone is protected. • Finally, in the case of the flu vaccine, adults and children (older than 6 months) need to get a dose every year. Children 6 months through 8 years old who have never gotten the flu vaccine in the past or have only gotten one dose in past years need two doses the first year they are vaccinated against flu for best protection. Then, annual flu shots are needed because the disease-causing viruses may be different from year to year. Every year, the flu vaccine is designed to prevent the specific viruses that experts predict will be circulating.

The Bottom Line

Some people believe that naturally acquired immunity—immunity from having the disease itself—is better than the immunity provided by vaccines. However, natural infections can cause severe complications and be deadly. This is true even for diseases that most people consider mild, like chickenpox. It is impossible to predict who will get serious infections that may lead to hospitalization. Vaccines, like any medication, can cause side effects. The most common side effects are mild. However, many vaccine-preventable disease symptoms can be serious, or even deadly. Although many of these diseases are rare in this country, they do circulate around the world and can be brought into the U.S., putting unvaccinated children at risk. Even with advances in health care, the diseases that vaccines prevent can still be very serious – and vaccination is the best way to prevent them.

Adapted from the National Institute of Allergy and Infectious Diseases, Understanding Vaccines http://www.niaid.nih.gov/topics/vaccines/ For more information on vaccines call 800-CDC-INFO (800-232-4636) or visit http://www.cdc.gov/vaccines.

Vaccine Ingredients: What you should know

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Vo l u m e 2 , F a l l 2 0 1 2 Some parents are concerned about ingredients contained in vaccines, specifically aluminum, mercury, gelatin and antibiotics. However, parents can be reassured that ingredients in vaccines are minuscule and necessary. Q. Why is aluminum in vaccines?

Q. Why is gelatin in vaccines?

A. Aluminum is used in vaccines as an adjuvant. Until recently, it was the only class of adjuvants approved for use in the United States. In 2009, a second adjuvant, known as monophosphoryl lipid A, was also approved for use in the United States. Adjuvants enhance the immune response by allowing for lesser quantities of active ingredients and, in some cases, fewer doses. Aluminum Aluminum salts have been used as adjuvants in vaccines in the United States since the 1930s. Some people wonder whether aluminum in vaccines is harmful — the facts are reassuring. First, aluminum is present in our environment; the air we breathe, the water we drink and the food we eat all contain aluminum. Second, the quantity of aluminum in vaccines is small. For example, in the first six months of life, babies receive about 4 milligrams* of aluminum if they get all of the recommended vaccines. However, during this same period they will ingest about 10 milligrams of aluminum if they are breastfed, 40 milligrams if they are fed regular infant formula, and up to 120 milligrams if they are fed soy-based infant formula. Some people wonder about the difference between aluminum injected in vaccines versus aluminum ingested in food. Typically, infants have between one and five nanograms (billionths of a gram) of aluminum in each milliliter of blood. Researchers have shown that after vaccines are injected, the quantity of aluminum detectable in an infant’s blood does not change and that about half of the aluminum from vaccines is eliminated from the body within one day. In fact, aluminum causes harm only when kidneys are not functioning properly or at all (so aluminum cannot be effectively eliminated) AND large quantities of aluminum, such as those in antacids, are administered. Monophosphoryl lipid A Monophosphoryl lipid A was isolated from the surface of bacteria and detoxified, so that it cannot cause harm. This adjuvant has been tested for safety in tens of thousands of people and is currently used in one of the HPV vaccines (i.e., Cervarix).

A. Gelatin is used in some vaccines as a stabilizer. Stabilizers are added to vaccines to protect the active ingredients from degrading during manufacture, transport and storage. Gelatin, which is made from the skin or hooves of pigs, is concerning because some people (about 1 of every 2 million) might have a severe allergic reaction to it. Also, because religious groups, such as Jews, Muslims and Seventh Day Adventists follow dietary rules that prohibit pig products, some parents are concerned about using vaccines that contain gelatin. However, all religious groups have approved the use of gelatin-containing vaccines for their followers for several reasons: First, vaccines are injected, not ingested (except the rotavirus vaccine, which does not contain gelatin). Second, gelatin in vaccines has been highly purified and hydrolyzed (broken down by water), so that it is much smaller than that found in nature; therefore, religious leaders believe it to be different enough that it does not break the religious dietary laws. Finally, leaders from these religious groups believe that the benefits of receiving vaccines outweigh adherence to religious dietary laws.

*A milligram is one-thousandth of a gram and a gram is the weight of one-fifth of a teaspoon of water.

Q. Why is formaldehyde in vaccines? A. Formaldehyde is a by-product of vaccine production. Formaldehyde is used during the manufacture of some vaccines to inactivate viruses (like polio and hepatitis A viruses) or bacterial toxins (like diphtheria and tetanus toxins). While most formaldehyde is purified away, small quantities remain. Because formaldehyde is associated with the preservation of dead bodies, its presence in vaccines seems inappropriate. However, it is important to realize that formaldehyde is also a by-product of protein and DNA synthesis, so it is commonly found in the bloodstream. The quantity of formaldehyde found in blood is 10 times greater than that found in any vaccine.

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Q. What about the cumulative effect of vaccine ingredients when my child receives multiple vaccines in a single day? A. Questions about the cumulative effect when multiple vaccines are given on the same day are reasonable. However, several sources of information provide reassurance: • A study by Michael Smith and Charles Woods showed that 7- to 10-year-old children who received vaccines according to the recommended schedule as infants did not have neuropsychological delays, such as speech and language delays, verbal memory, fine motor coordination, motor or phonic tics, and intellectual functioning. • If a new vaccine is added to the schedule at a time when other vaccines are given, studies must be completed to show that neither vaccine interferes with the safety or ability of the other to work. Known as concomitant use studies, these studies are numerous and extensive, offering additional information regarding interference of vaccine ingredients or effects caused by too much of an ingredient. • Studies of the immune system estimate that we can respond to about 10,000 different immunologic components at any one time; the number of immunologic components contained in all of the vaccines recommended for young children today is less than 200 immunologic components. • Finally, additives in vaccines, such as aluminum, have been studied regarding how they are processed in the body as well as what levels are toxic. For example, people who suffer toxic effects of aluminum must have had longterm exposure to aluminum (months or years) as well as non-functioning or improperly functioning kidneys. With all of this information, we can conclude that multiple vaccines given in one day are not overwhelming an infant’s immune system.

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Vaccine Ingredients: What you should know Q. Why is mercury in vaccines?

Q. Do ingredients in vaccines cause allergic reactions?

A. Mercury is contained in some multi-dose preparations of influenza vaccine as a preservative. Preservatives prevent contamination with bacteria. Early in the 20th century, most vaccines were packaged in vials that contained multiple doses. Doctors and nurses would draw up a single dose and place the vaccine back in the refrigerator. Unfortunately, sometimes bacteria would inadvertently enter the vial and cause abscesses at the site of injection or bloodstream infections that were occasionally fatal. Preservatives, originally added in the 1930s, solved this problem. The most common preservative used was thimerosal, a mercury-containing compound. As more vaccines were given, children received greater quantities of thimerosal. By the late 1990s, the American Academy of Pediatrics and the Public Health Service requested that mercury be removed from vaccines to make “safe vaccines safer.” No evidence existed to suggest that thimerosal was causing harm, but they wanted to be cautious. Unfortunately, their caution worried parents who wondered whether mercury in vaccines was causing subtle signs of mercury poisoning or autism. Addressing these concerns, scientists performed several studies, all of which showed that thimerosal at the level contained in vaccines hadn’t caused harm. Further, because mercury is a naturally occurring element found in the earth’s crust, air, soil and water, we are all exposed to it. In fact, infants who are exclusively breastfed ingest more than twice the quantity of mercury than was contained in vaccines. Today, breastfed infants ingest 15 times more mercury in breast milk than is contained in the influenza vaccine.

A. In addition to gelatin, other ingredients in vaccines such as egg proteins, antibiotics and yeast proteins might cause an allergic reaction. Latex used in vaccine packaging is also a concern related to allergies. Egg proteins Because the influenza and yellow fever vaccines are grown in eggs, the final products may contain egg proteins. Advances in protein chemistry have resulted in significantly lower quantities of egg proteins in the influenza vaccine; therefore, people with egg allergies can now get influenza vaccine. However, it is recommended that egg-allergic vaccine recipients remain in the office for 30 minutes after getting the influenza vaccine in case of any reaction. Antibiotics Antibiotics are used to prevent bacterial contamination during production of some vaccines. However, the types of antibiotics used in vaccines, such as neomycin, streptomycin, polymyxin B, chlortetracycline and amphotericin B, are not those to which people are usually allergic. Yeast proteins A couple of viral vaccines are made in yeast cells; these include hepatitis B vaccine and one of the human papillomavirus vaccines (i.e., Gardasil). Although the vaccine is purified away from the yeast cells, about 1 to 5 millionths of a gram remain in the final product. The good news is that people who are allergic to bread or bread products are not allergic to yeast, so the risk of allergy from yeast is theoretical. Latex packaging A small number of vaccines are packaged with materials that include latex. While it is rare that patients have a reaction to latex in vaccine packaging, people with latex allergies should consult with their allergy doctor before getting any vaccines packaged in this way.

Q. Are some vaccines made using fetal cells? A. Fetal cells are used to make five vaccines: rubella, chickenpox, hepatitis A, shingles and rabies. Fetal cells used to grow the vaccine viruses were isolated from two elective abortions performed in Sweden and England in the early 1960s. Further abortions are not necessary as the cells isolated in the 1960s continue to be maintained in laboratory cultures. Some parents wonder why scientists would choose to use fetal cells at all. There are several reasons for this. First, viruses, unlike bacteria, require cells to grow, and human cells are often better than animal cells at supporting the growth of human viruses. Second, fetal cells are different from other types of cells in that they are virtually immortal, meaning they can reproduce many, many times before dying. Other cells reproduce only a limited number of times before they die. Some questions have been raised regarding the use of vaccines grown in fetal cells by people whose religious beliefs are against abortions. In 2005, when Pope Benedict XVI was head of the Catholic Church’s Congregation of the Doctrine of Faith, this question was addressed; it was determined that parents who chose not to give vaccines derived from these cells would be in “more proximate cooperation with evil” than those who gave their children the vaccines in question because of the life-saving nature of vaccines. Similarly, the National Catholic Bioethics Center determined that use of vaccines grown in fetal cells isolated from historic abortions was morally acceptable.

Selected References Aluminum: Baylor NW, Egan W, Richman P. Aluminum salts in vaccines — U.S. perspective. Vaccine. 2002;20:S18-S23. Formaldehyde: Epidemiology of chronic occupational exposure to formaldehyde: report of the ad hoc panel on health aspects of formaldehyde. Toxicology and Industrial Health. 1988;4:77-90. Gelatin: Atkinson WL, Kroger AL, and Pickering LK. General Immunization Practices. In: Plotkin SA, Orenstein WA, and Offit PA, eds., Vaccines Sixth Edition. Saunders Elsevier, 2012. Cumulative effects: Smith MJ and Woods CR. On-time vaccine receipt in the first year does not adversely affect neuropsychological outcomes. Pediatrics. 2010;125(6):1134-1141. Thimerosal: Gerber, JS and Offit, PA. Vaccines and autism: A tale of shifting hypotheses. Clinical Infectious Diseases. 2009;48:456-461. Fetal cells: Offit PA. Vaccinated: One man’s quest to defeat the world’s deadliest diseases. New York: Harper Perennial, 2007. Allergic reactions: Offit PA, Jew RK. Addressing parents’ concerns: do vaccines contain harmful preservatives, adjuvants, additives, or residuals? Pediatrics. 2003;112:1394-1401. Multiple Vaccines: Offit PA, Quarles J, Gerber MA, Hackett CJ, Marcuse EK, Kollman TR, Gellin BG, Landry S. Addressing parents’ concerns: Do multiple vaccines overwhelm or weaken the infant’s immune system? Pediatrics. 2002 Jan;109(1):124-129.

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Too Many Vaccines? What you should know VA C C I N E E D U C AT I O N C E N T E R

Vo l u m e 2 , S p r i n g 2 0 1 2 Today, young children receive vaccines to protect them against 14 different diseases. Because some vaccines require more than one dose, children can receive as many as 26 inoculations by 2 years of age and up to five shots at one time. For this reason, some parents now ask their doctors to space out, separate or withhold vaccines. The concern that too many vaccines might overwhelm a baby’s immune system is understandable, but the evidence that they don’t is reassuring. Q. What are the active components in vaccines? A. Vaccines contain parts of viruses or bacteria that induce protective immune responses. These active ingredients are called immunological components. Vaccines that protect against bacterial diseases are made from either inactivated bacterial proteins (e.g., diphtheria, tetanus and whooping cough [pertussis]) or bacterial sugars called polysaccharides (e.g., Haemophilus influenzae type b [Hib] and pneumococcus). Each of these bacterial proteins or polysaccharides is considered an immunological component, meaning that each evokes a distinct immune response. Vaccines that protect against viral diseases (e.g., measles, mumps, rubella, polio, rotavirus, hepatitis A, hepatitis B, chickenpox and influenza) are made of viral proteins. Just like bacterial proteins, viral proteins induce an immune response.

Q. Do children encounter more immunological components from vaccines today than they did 30 years ago? A. No. Although children receive more vaccines now than ever before, most people would probably be surprised to learn that the number of immunological components in vaccines has dramatically decreased. Thirty years ago, children received vaccines which protected against seven diseases: measles, mumps, rubella, diphtheria, tetanus, pertussis and polio. The total number of bacterial and viral proteins contained in these vaccines was a little more than 3,000. Today, children receive vaccines that protect against 14 diseases, but the total number of immunological components in these vaccines is only about 150. This dramatic reduction is the result of scientific advances that have allowed for purer, safer vaccines.

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Q. Can too many vaccines overwhelm an infant’s immune system? A. No. Compared to the immunological challenges that infants handle every day, the challenge from the immunological components in vaccines is minuscule. Babies begin dealing with immunological challenges at birth. The mother’s womb is a sterile environment, free from viruses, bacteria, parasites and fungi. But after babies pass through the birth canal and enter the world, they are immediately colonized with trillions of bacteria, which means that they carry the bacteria on their bodies but aren’t infected by them. These bacteria live on the skin, nose, throat and intestines. To make sure that colonizing bacteria don’t invade the bloodstream and cause harm, babies constantly make antibodies against them. Colonizing bacteria aren’t the only issue. Because the food that we eat and the dust that we breathe contain bacteria, immunological challenges from the environment are unending. Viruses are also a problem. Children in the first few years of life are constantly exposed to a variety of different viruses that cause runny noses, cough, congestion, fever or diarrhea. Given that infants are colonized with trillions of bacteria, that each bacterium contains between 2,000 and 6,000 immunological components and that infants are infected with numerous viruses, the challenge from the 150 immunological components in vaccines is minuscule compared to what infants manage every day.

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Too Many Vaccines? What you should know Q. How many vaccines can children effectively handle at one time?

Q. What is the harm of separating, spacing out or withholding vaccines?

A. A lot more than they’re getting now. The purpose of vaccines is to prompt a child’s body to make antibodies, which work by preventing bacteria and viruses from reproducing themselves and causing disease. So, how many different antibodies can babies make? The best answer to this question came from a Nobel Prize-winning immunologist at the Massachusetts Institute of Technology named Susumu Tonegawa, who first figured out how people make antibodies.

A. Delaying vaccines can be risky. The desire by some parents to separate, space out or withhold vaccines is understandable. This choice, however, is not necessarily without consequence.

Tonegawa discovered that antibodies are made by rearranging and recombining many different genes, and found that people can make about 10 billion different antibodies. Given the number of antibody-producing cells in a child’s bloodstream, and the number of immunological components contained in vaccines, it is reasonable to conclude that babies could effectively make antibodies to about 100,000 vaccines at one time. Although this number sounds overwhelming, remember that every day children are defending themselves against a far greater number of immunological challenges in their environment.

Q. How do we know that multiple vaccines can be given safely? A. The Food and Drug Administration (FDA) requires extensive safety testing before vaccines are licensed. Before a new vaccine can be licensed by the FDA, it must first be tested by something called “concomitant use studies.” Concomitant use studies require new vaccines to be tested with existing vaccines. These studies are performed to make sure the new vaccine doesn’t affect the safety or effectiveness of existing vaccines given at the same time, and vice versa. Because concomitant use studies have been required for decades, many studies have been performed showing that children can be inoculated with multiple vaccines safely.

First, delaying vaccines only increases the time during which children are susceptible to certain diseases, some of which are still fairly common. Chickenpox, whooping cough (pertussis), influenza and pneumococcus still cause hospitalizations and deaths in previously healthy children every year. And before the chickenpox vaccine, every year about 70 children died from the disease. Second, spacing out or separating vaccines will require children to visit the doctor more often for shots. Researchers have found that children experience similar amounts of stress, as measured by secretion of a hormone called cortisol, whether they are getting one or two shots at the same visit. This study suggests that although children are clearly stressed by receiving a shot, two shots aren’t more stressful than one. For this reason, more visits to the doctor created by separating or spacing out vaccines will actually increase the trauma of getting shots.

References Offit PA, Quarles J, Gerber MA, et al. Addressing parents’ concerns: Do multiple vaccines overwhelm or weaken the infant’s immune system? Pediatrics. 2002;109:124-9. Tonegawa S, Steinberg C, Dube S, Bernardini A. Evidence for somatic generation of antibody diversity. Proc Natl Acad Sci USA. 1974;71:4027-31. Cohn M, Langman RE. The protecton: the unit of humoral immunity selected by evolution. Immunol Rev. 1990;115:9-147. Ramsay DS, Lewis M. Developmental changes in infant cortisol and behavioral response to inoculation. Child Dev. 1994;65:1491-502.

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The Facts About Childhood Vaccines VA C C I N E E D U C AT I O N C E N T E R

Vo l u m e 7 , F a l l 2 0 1 2 Q. How can parents sort out conflicting information about vaccines?

Q. Do vaccines contain additives?

A. Decisions about vaccine safety must be based on well-controlled scientific studies. Parents are often confronted with “scientific” information found on television, on the Internet, in magazines and in books that conflicts with information provided by healthcare professionals. But few parents have the background in microbiology, immunology, epidemiology and statistics to separate good scientific studies from poor studies. Parents and physicians benefit from the expert guidance of specialists with experience and training in these disciplines. Committees of these experts are composed of scientists, clinicians and other caregivers who are as passionately devoted to our children’s health as they are to their own children’s health. They serve the Centers for Disease Control and Prevention (www.cdc.gov/vaccines), the American Academy of Pediatrics (www.aap.org) and the Infectious Diseases Society of America (www.nnii.org), among other groups. These organizations provide excellent information to parents and healthcare professionals through their Web sites. Their task is to determine whether scientific studies are carefully performed, published in reputable journals and, most importantly, reproducible. Information that fails to meet these standards is viewed as unreliable. When it comes to issues of vaccine safety, these groups have served us well. They were the first to figure out that intestinal blockage was a rare consequence of the first rotavirus vaccine, and the vaccine was quickly discontinued. And they recommended a change from the oral polio vaccine, which was a rare cause of paralysis, to the polio shot when it was clear that the risks of the oral polio vaccine outweighed its benefits. These groups have also investigated possible relationships between vaccines and asthma, diabetes, multiple sclerosis, SIDS and autism. No studies have reliably established a causal link between vaccines and these diseases — if they did, the questioned vaccines would be withdrawn from use.

A. Many vaccines contain trace quantities of antibiotics or stabilizers. Antibiotics are used during the manufacture of vaccines to prevent inadvertent contamination with bacteria or fungi. Trace quantities of antibiotics are present in some vaccines. However, the antibiotics contained in vaccines (neomycin, streptomycin or polymyxin B) are not those commonly given to children. Therefore, children with allergies to antibiotics such as penicillin, amoxicillin, sulfa, or cephalosporins can still get vaccines. Gelatin is used to stabilize live viral vaccines and is also contained in many food products. People with known allergies to gelatin contained in foods may have severe allergic reactions to the gelatin contained in vaccines. However, this reaction is extremely rare.

Q. Are vaccines still necessary? A. Although several of the diseases that vaccines prevent have been dramatically reduced or eliminated, vaccines are still necessary: • to prevent common infections Some diseases are so common in this country that a choice not to get a vaccine is a choice to get infected. For example, choosing not to get the pertussis (whooping cough) vaccine is a choice to risk a serious and occasionally fatal infection. • to prevent infections that could easily re-emerge Some diseases in this country continue to occur at very low levels (for example, measles, mumps and Haemophilus influenzae type b, or Hib). If immunization rates in our schools or communities are low, outbreaks of these diseases are likely to occur. This is exactly what happened in the late 1980s and early 1990s when thousands of children were hospitalized with measles and more than 120 died. Children were much more likely to catch measles if they weren’t vaccinated. Recent measles outbreaks in Europe also provide evidence of how quickly a disease can re-emerge. • to prevent infections that are common in other parts of the world Although some diseases have been completely eliminated (polio) or virtually eliminated (diphtheria) from this country, they still occur commonly in other parts of the world. Children are paralyzed by polio in India and sickened by diphtheria in India and other countries in the southeastern region of Asia. Because there is a high rate of international travel, outbreaks of these diseases are only a plane ride away. Centers for Disease Control and Prevention. Epidemiology and Prevention of Vaccine-Preventable Diseases. 12th Edition. Atkinson W, Wolfe S, Hamborsky J, eds. Washington, DC: Public Health Foundation; 2011.

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Offit PA, Jew RK. Addressing parents’ concerns: Do vaccines contain harmful preservatives, adjuvants, additives, or residuals? Pediatrics 2003,112:1394-1401. American Academy of Pediatrics. In Pickering LK, ed. Red Book: 2012 Report of the Committee on Infectious Diseases. 29th Edition. Elk Grove Village, IL.

Q. Are vaccines safe? A. Because vaccines are given to people who are not sick, they are held to the highest standards of safety. As a result, they are among the safest things we put into our bodies. How does one define the word safe? If safe is defined as “free from any negative effects,” then vaccines aren’t 100 percent safe. All vaccines have possible side effects. Most side effects are mild, such as fever, or tenderness and swelling where the shot is given. But some side effects from vaccines can be severe. For example, the pertussis vaccine is a very rare cause of persistent inconsolable crying, high fever or seizures with fever. Although these reactions do not cause permanent harm to the child, they can be quite frightening. If vaccines cause side effects, wouldn’t it be “safer” to just avoid them? Unfortunately, choosing to avoid vaccines is not a risk-free choice — it is a choice to take a different and much more serious risk. Discontinuing the pertussis vaccine in countries like Japan and England led to a tenfold increase in hospitalizations and deaths from pertussis. Recently, a decline in the number of children receiving measles vaccine in the United Kingdom and the United States led to an increase in measles hospitalizations. When you consider the risk of vaccines and the risk of diseases, vaccines are the safer choice. Plotkin S, et al. Vaccines. 6th Edition. Philadelphia, PA: W.B. Saunders and Co., 2012.

Q. Do children get too many shots? A. Newborns commonly manage many challenges to their immune systems at the same time. Because some children could receive as many as 25 shots by the time they are 2 years old and as many as five shots in a single visit to the doctor, many parents wonder whether it is safe to give children so many vaccines. Although the mother’s womb is free from bacteria and viruses, newborns immediately face a host of different challenges to their immune systems. From the moment of birth, thousands of different bacteria start to live on the surface of the skin and intestines. By quickly making immune responses to these bacteria, babies keep them from invading the bloodstream and causing serious diseases. In fact, babies are capable of responding to millions of different viruses and bacteria because they have billions of immunologic cells circulating in the bodies. Therefore, vaccines given in the first two years of life are a raindrop in the ocean of what an infant’s immune system successfully encounters and manages every day. Offit PA, et al. Addressing parents’ concerns: Do vaccines weaken or overwhelm the infant’s immune system? Pediatrics. 2002;109:124-129.

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Q. Is the amount of aluminum in vaccines safe?

Q. Does my child need to still get vaccines if I am breastfeeding?

A. Yes. All of us have aluminum in our bodies and most of us are able to process it effectively. The two main groups of people who cannot process aluminum effectively are severely premature infants who receive large quantities of aluminum in intravenous fluids and people who have long-term kidney failure and receive large quantities of aluminum, primarily in antacids. In both cases the kidneys are not working properly or at all and the people are exposed to large quantities of aluminum over a long period of time. The amount of aluminum in vaccines given during the first six months of life is about 4 milligrams, or four-thousandths of a gram. A gram is about one-fifth of a teaspoon of water. In comparison, breast milk ingested during this period will contain about 10 milligrams of aluminum and infant formulas will contain about 40 milligrams. Soy-based formulas contain about 120 milligrams of aluminum. When studies were performed to look at the amount of aluminum injected in vaccines, the levels of aluminum in blood did not detectably change. This indicates that the quantity of aluminum in vaccines is minimal as compared with the quantities already found in the blood.

A. Yes. The types of immunity conferred by breastfeeding and immunization are different. Specifically, the antibodies that develop after immunization are made by the baby’s own immune system and, therefore, will remain in the form of immunologic memory; this is known as active immunity. In contrast, antibodies in breast milk were made by the maternal immune system, so they will provide short-term protection, but will not last more than a few weeks. These antibodies are usually not as diverse either, so the baby may be protected against some infections but remain susceptible to others. Immunity generated from breast milk is called passive immunity. Passive immunity was practiced historically when patients exposed to diphtheria were given antitoxin produced in horses; antitoxins to snake venoms are also an example of passive immunity.

Baylor NW, Egan W, Richman P. Aluminum salts in vaccines – U.S. perspective. Vaccine. 2002;20:S18-S23. Bishop NJ, Morley R, Day JP, Lucas A. Aluminum neurotoxicity in preterm infants receiving intravenous-feeding solutions. New Engl J Med. 1997;336:1557-1561. Committee on Nutrition: Aluminum toxicity in infants and children. Pediatrics. 1996;97:413-416. Ganrot PO. Metabolism and possible health effects of aluminum. Env. Health Perspective. 1986;65:363-441. Keith LS, Jones DE, Chou C. Aluminum toxicokinetics regarding infant diet and vaccinations. Vaccine. 2002;20:S13-S17. Pennington JA. Aluminum content of food and diets. Food Additives and Contam. 1987;5:164-232. Simmer K, Fudge A, Teubner J, James SL. Aluminum concentrations in infant formula. J Peds and Child Health. 1990;26:9-11.

Q. Do vaccines cause autism? A. Carefully performed studies clearly disprove the notion that vaccines cause autism. Because the signs of autism may appear in the second year of life, at around the same time children receive certain vaccines, and because the cause of autism is unknown, some parents wondered whether vaccines might be at fault. These concerns focused on three hypotheses — autism was caused by the measles-mumps-rubella (MMR) vaccine, thimerosal, an ethylmercury-containing preservative used in vaccines, or receipt of too many vaccines too soon. A large body of medical and scientific evidence now strongly refutes these notions. Multiple studies have found that vaccines do not cause autism. These studies included hundreds of thousands of children, occurred in multiple countries, were conducted by multiple investigators and were well controlled. Andrews N, et al. Thimerosal exposure in infants and developmental disorders: a retrospective cohort study in the United Kingdom does not show a casual association, Pediatrics. 2004;114;584-591. Dales L, et al. Time trends in autism and in MMR immunization coverage in California. JAMA. 2001;285:1183-1185. Fombonne E, et al. Pervasive developmental disorders in Montreal, Quebec, Canada: Prevalence and links with immunizations, Pediatrics. 2006;118:139-150. Herron J, Golding J, and ALSPAC Study Team. Thimerosal exposure in infants and developmental disorders: a prospective cohort study in the United Kingdom does not show a casual association, Pediatrics. 2004;114;577-583. Hviid A, et al. Association between thimerosal-containing vaccine and autism, JAMA. 2003;290:1763-1766. Kaye JA, et al. Measles, mumps, and rubella vaccine and incidence of autism recorded by general practitioners: a time-trend analysis. Brit Med J. 2001;322:460-463. Madsen K. Thimerosal and occurrence of autism: Negative ecological evidence from Danish population-based data, Pediatrics. 2003;112:604-606. Madsen, KM, et al. A population-based study of measles, mumps, rubella vaccination and autism, N Engl J Med. 2002;347:1477-1482. Taylor, B, et al. Autism and measles, mumps, and rubella vaccine: no epidemiologic evidence for a causal association. Lancet. 1999;351:2026-2029. Smith MJ and Woods CR. On-time vaccine receipt in the first year does not adversely affect neuropsychological outcomes. Pediatrics. 2010;125(6):1134-1141. Verstraeten T, et al. Safety of thimerosal-containing vaccines: a two-phased study of computerized health maintenance organization databases, Pediatrics. 2003;112:1039-1048.

Q. How can a “one-size-fits-all” approach to vaccines be OK for all children? A. The recommended immunization schedule is not the same for all children. In fact, recommendations for individual vaccines often vary based upon individual differences in current and long-term health status, allergies and age. Each vaccine recommendation, often characterized by a single line on the immunization schedule, is supported by about 25 to 40 additional pages of specific instructions for healthcare providers who administer vaccines. In addition, an approximately 60-page document titled “General Recommendations on Immunization” serves as the basis for all vaccine administration. The recommendations are updated as needed by the CDC and a comprehensive update is published every few years. Q. What is the harm of separating, spacing out or withholding some vaccines? A. Although the vaccine schedule can look intimidating, it is based upon the best scientific information available and is better tested for safety than any alternative schedules. Experts review studies designed to determine whether the changes are safe in the context of the existing schedule. These are called concomitant-use studies. Separating, spacing out or withholding vaccines causes concern because infants will be susceptible to diseases for longer periods of time. When a child should receive a vaccine is determined by balancing when the recipient is at highest risk of contracting the disease and when the vaccine will generate the best immune response. Finally, changing the vaccine schedule requires additional doctor’s visits. Research measuring cortisol, a hormone associated with stress, has determined that children do not experience more stress when receiving two shots as compared with one shot. Therefore, an increased number of visits for individual shots will mean an increase in the number of stressful situations for the child without benefit. In addition, there is an increased potential for administration errors, more time and travel needed for appointments, potentially increased costs and the possibility that the child will never get some vaccines Cohn M, Langman RE. The protection: the unit of humoral immunity selected by evolution. Immunol Rev. 1990;115:9-147. Offit PA, Quarels J. Gerber MA, et al. Addressing parents’ concerns: Do multiple vaccines overwhelm or weaken the infant’s immune system? Pediatrics. 2002;109:124-129. Ramsay DS, Lewis M. Developmental changes in infant cortisol and behavioral response to inoculation. Child Dev. 1994;65:1491-1502. Tonegawa S, Steinberg C, Dube S, Bernardini A. Evidence for somatic generation of antibody diversity. Proc Natl Acad Sci USA. 1974;71:4027-4031.

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Immunization

Vaccine Safety

ARE VACCINES SAFE? The United States currently has the safest, most effective vaccine supply in history. Years of testing are required by law before a vaccine can be licensed. Once in use, vaccines are continually monitored for safety and efficacy. The Centers for Disease Control and Prevention (CDC) and the Food and Drug Administration (FDA) continually work to make already safe vaccines even safer. Before vaccines are licensed, the FDA requires they be extensively tested to ensure safety. This process can take 10 years or longer. Once a vaccine is in use, CDC and FDA monitor its side effects through the Vaccine Adverse Event Reporting System (VAERS) and the Vaccine Safety Data Link. Any hint of a problem with a vaccine prompts further investigations by CDC and FDA. If researchers find that a vaccine may be causing a side effect, CDC and FDA will initiate actions appropriate to the nature of the problem. This may include the changing of vaccine labels or packaging, distributing safety alerts, inspecting manufacturers’ facilities and records, withdrawing recommendations for the use of the vaccine, or revoking the vaccine’s license. For more information about VAERS, visit www.vaers.hhs.gov or call the toll-free VAERS information line at 1-800-822-7967.

IS IT SAFE TO VACCINATE MY CHILD? In the vast majority of cases, vaccines are effective and cause no side effects or only mild reactions such as fever or soreness at the injection site. Very rarely, people experience more serious side effects, like allergic reactions. Be sure to tell your healthcare provider if your child has health problems or known allergies to medications or food. Severe reactions to vaccines occur so rarely that the risk is usually difficult to calculate. In the rare event that a child is injured by a vaccine, he or she may be compensated through the National Vaccine Injury compensation Program (VICP). For more information about VICP, visit www. hrsa. gov/vaccinecompensation or call 1-800-338-2382.

Some people

should not get certain vaccines or should wait to get them. For instance, children with weak immune systems, as occurs with cancer patients, often need to wait to be vaccinated. Similarly, if a person has had a severe allergic reaction to a vaccine, she or he should not receive another dose. However, a person with a mild, c ommon illness, such as a cold with a low-grade fever, does not have to wait to be vaccinated. Ask your healthcare provider for more information.

Diphtheria  Tetanus  Pertussis  Measles  Mumps  Rubella  Polio  Hib  Hepatitis A & B  Varicella  PNEUMOCOCCAL DISEASE  INFLUENZA  MENINGOCOCCAL DISEASE  Rotavirus  Human Papillomavirus

WHAT IF I DON’T VACCINATE MY CHILD? Be aware of the risks.

Immunizations, like any medication, can cause side effects. However, a

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decision not to immunize a child also involves risk. It is a decision to put the child and others who come into contact with him or her at risk of contracting a disease that could be dangerous or deadly. Consider measles. One out of 17 children with measles gets pneumonia. For every 1,000 children who get the disease, one or two will die from it. Thanks to vaccines, we have few cases of measles in the U.S. today. However, the disease is extremely contagious, and each year dozens of cases are imported from abroad into the U.S., threatening the health of people who have not been vaccinated and those for whom the vaccine was not effective. Unvaccinated children are also at risk from meningitis (swelling of the lining of the brain) caused by Hib (a severe bacterial infection), bloodstream infections caused by pneumococcus, deafness caused by mumps, and liver cancer caused by hepatitis B virus.

Immunization

Vaccine Safety

Some people

WHAT IF I DON’T VACCINATE MY CHILD? Be aware of the risks.

Immunizations, like any medication, can cause side effects. However, a

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And visit our website at

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| information for health care professionals | Reviewed March 2012

Talking with Parents about Vaccines for Infants Strategies for Health Care Professionals Immunization professionals and parents agree: times have changed. Because of questions or concerns about vaccines, well-child visits can be stressful for parents. As their infant’s health care provider, you remain parents’ most trusted source of information about vaccines. This is true even for parents with the most questions and concerns. Your personal relationship uniquely qualifies you to help support parents in understanding and choosing vaccinations.

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However, time for infant health evaluation at each well visit is at a premium, as you check physical, cognitive, and other milestones and advise parents on what to expect in the coming months. Therefore, making time to talk about vaccines may be stressful for you. But when an infant is due to receive vaccines, nothing is more important than making the time to assess the parents’ information needs as well as the role they desire to play in making decisions for their child’s health, and then following up with communication that meets their needs.

THIS RESOURCE COVERS: 4 What you may hear from parents about their vaccine safety questions and how to effectively address them 4 Proven communication strategies and tips for having a successful vaccine conversation with parents

When it comes to communication, you may find that similar information—be it science or anecdote or some mix of the two—works for most parents you see. But keep a watchful eye to be sure that you are connecting with each parent to maintain trust and keep lines of communication open.

4 This brochure is part of a comprehensive set of educational materials for health care professionals and parents available at http://www.cdc.gov/vaccines/conversations

We hope that these brief reminders—and the materials that you, your staff, and parents can find on our website— will help ensure your continued success in immunizing infants and children. Success may mean that all vaccines are accepted when you recommend them, or that some vaccines are scheduled for another day. If a parent refuses to vaccinate, success may simply mean keeping the door open for future discussions about choosing vaccination.

Nurses, physician assistants, and other office staff play a key role in establishing and maintaining a practice-wide commitment to communicating effectively about vaccines and maintaining high vaccination rates: from providing parents with educational materials, to being available to answer their questions, to making sure that families who may opt for extra visits for vaccines make and keep vaccine appointments.

What You May Hear From Parents As you plan for responding to parents’ concerns, it may be useful to think of parental questions in the following categories. Questions about whether vaccines cause autism Parents may encounter poorly designed and conducted studies, misleading summaries of well-conducted studies, or anecdotes made to look like science—claiming that vaccines cause autism. Many rigorous studies show that there is no link between MMR vaccine or thimerosal and autism. Visit http://www.cdc.gov/vaccines/ conversations for more information to help you answer parents’ questions on these two issues. If parents raise other possible hypotheses linking vaccines to autism, four items are key: (1) patient and empathetic reassurance that you understand that their infant’s health is their top priority, and it also is your top priority, so putting children at risk of vaccine-preventable diseases without scientific evidence of a link between vaccines and autism is a risk you are not willing to take; (2) your knowledge that the onset of regressive autism symptoms often coincides with the timing of vaccines but is not caused by vaccines; (3) your personal and professional opinion that vaccines are very safe; and (4) your reminder that vaccine-preventable diseases, which may cause serious complications and even death, remain a threat.

“All those people who say that the MMR vaccine causes autism must be on to something.” “Autism is a burden for many families and people want answers—including me. But well designed and conducted studies that I can share with you show that MMR vaccine is not a cause of autism.”

Questions about whether vaccines are more dangerous for infants than the diseases they prevent Today, parents may not have seen a case of a vaccine-preventable disease firsthand. Therefore, they may wonder if vaccines are really necessary, and they may believe that the risks of vaccinating infants outweigh the benefits of protecting them from infection with vaccine-preventable diseases. Visit http://www.cdc.gov/vaccines/ conversations for up-to-date information on diseases and the vaccines that prevent them that you can share with parents. You may be able to provide information from your own experience about the seriousness of the diseases, the fact that cases and outbreaks of vaccine-preventable diseases are occurring now in the U.S., and that even when diseases are eliminated in the U.S., they can make a rapid return in children and adults who are not immunized if travelers bring the diseases into the U.S. You also can remind parents about ongoing efforts to ensure the safety of vaccines, including the large-scale reporting system, Vaccine Adverse Event Reporting System (http://www.vaers.hhs.gov), used 2

to alert FDA and CDC to any possible problems with a vaccine so that they can be studied in more detail. “What are all these vaccines for? Are they really necessary?” “I know you didn’t get all these vaccines when you were a baby. Neither did I. But we were both at risk of serious diseases like Hib and pneumococcal meningitis. Today, we’re lucky to be able to protect our babies from 14 serious diseases with vaccines.”

Questions about the number of vaccines and vaccine ingredients Some parents may have a general concern that there are too many vaccines. With respect to timing and spacing of vaccines, the childhood vaccine schedule is designed to provide protection at the earliest possible time against serious diseases that may affect infants early in life. The Childhood Immunization Schedule fact sheet (http://www.cdc.gov/vaccines/conversations) may be useful for those parents, as well as for parents who have specific questions. Some parents may be able to specify their concerns: whether each vaccine is needed, whether giving several vaccines at one time can cause harm, whether vaccine ingredients are harmful, or how well each vaccine works. For these parents, you can specifically reinforce the seriousness of the diseases prevented by vaccines, and share your knowledge that no evidence suggests that a healthy child’s immune system will be damaged or overwhelmed by receiving several vaccines at one time. Understanding Vaccine Ingredients (http://www.cdc.gov/ vaccines/conversations) can help you counter myths that have circulated about vaccine ingredients. You may need to share with some parents that not only should each vaccine series be started on time to protect infants and children as soon as possible, but each multi-dose series must be completed to provide the best protection. “I’m really not comfortable with my 2-month-old getting so many vaccines at once.” “There’s no proven danger in getting all the recommended 2-month vaccines today. Any time you delay a vaccine you leave your baby vulnerable to disease. It’s really best to stay on schedule. But if you’re very uncomfortable, we can give some vaccines today and schedule you to come back in two weeks for the rest, but this is not recommended.

Questions about known side effects

Questions about unknown serious adverse events

It is reasonable for parents to be concerned about the possible reactions or side effects listed on the Vaccine Information Statements, especially fever, redness where a shot was given, or fussiness that their child may experience following vaccination. Remind parents to watch for the possible side effects and provide information on how they should treat them and how they can contact you if they observe something they are concerned about. To reinforce how rare serious side effects really are, share your own experience, if any, with seeing a serious side effect from a vaccine.

Parents who look for information about vaccine safety will likely encounter suggestions about as-yet-unknown serious adverse events from vaccines. It is not unreasonable that parents find this alarming. You can share what the world was like for children before there were vaccines. And you can share that increases in health problems such as autism, asthma, or diabetes don’t have a biologic connection to vaccination. We have no evidence to suggest that vaccines threaten a long, healthy life. We know lack of vaccination threatens a long and healthy life.

“I’m worried about the side effects of vaccines. I don’t want my child to get any vaccines today.” “I’ll worr y if your child doesn’t get vaccines today, because the diseases can be very dangerous— most, including Hib, pertussis, and measles, are still infecting children in the U.S. We can look at the Vaccine Information Statements together and talk about how rare serious vaccine side effects are.”

“You really don’t know if vaccines

cause any long-term effects.”

“We have years of experience with vaccines and no reason to believe that vaccines cause long-term harm. I understand your concern, but I truly believe that the risk of diseases is greater than any risks posed by vaccines. Vaccines will get your baby off to a great start for a long, healthy life.”

Communication Strategies—How to Have a Successful Dialogue A successful discussion about vaccines involves a two-way conversation, with both parties sharing information and asking questions. These communication principles can help you connect with parents by encouraging open, honest, and productive dialogue. Take advantage of early opportunities such as the prenatal, newborn, 1-week, and 1-month visits to initiate a dialogue about vaccines. These also are good opportunities to provide take-home materials or direct parents to immunization websites that you trust. This gives parents time to read and digest reputable vaccine information before the first and all future immunizations. And when parents have questions, you can build on the reputable information that they already have reviewed. With parents who have many questions, consider an extended visit to discuss vaccinating their child.

Take time to listen. If parents need to talk about vaccines, give them your full attention. Despite a full schedule, resist the urge to multi-task while a parent talks. Maintain eye contact with parents, restate their concerns to be sure you understand their viewpoint, and pause to thoughtfully prepare your reply. Your willingness to listen will likely play a major role in helping parents with their decisions to choose vaccination.

Solicit and welcome questions. If parents seem concerned about vaccines but are reluctant to talk, ask them open-ended questions and let them know that you want to hear their questions and concerns.

Put yourself in parents’ shoes and acknowledge parents’ feelings and emotions, including their fear and desire to protect their children. Remind parents that you know why they are concerned—their infant’s health is their top priority. Remind them that it is yours, too.

Keep the conversation going. If parents come to you with a long list of questions or information from the Web or other sources, don’t interpret this as a lack of respect for you. Instead, acknowledge that spending time to research vaccines means that this is an important topic for the parents. If you appear offended by questions, or if you imply that a parent’s questions are uncalled for, dialogue may shut down and trust may be eroded. 3

options to distract from the pain of the shot, including telling a favorite story, singing, or taking deep breaths and blowing out the pain. After the shots, toddlers can be praised for getting through the shots and reassured that everything is okay.

After the Office Visit Document parents’ questions and concerns. A thorough record of your discussion will be an invaluable reference during the child’s future visits.

Follow up. Science versus anecdote? Too much science will frustrate some parents. Too little science will frustrate others. For some parents, too much anecdotal information won’t hit the mark. For others, a story from your experience about an unprotected child who became ill, or knowing that children in your family have received all of their vaccines, will be exactly on target. Which approach to use will depend on your knowledge of the family. Watch and listen. Be prepared to use the mix of science and personal stories that will be most effective in addressing parents’ questions.

Acknowledge benefits and risks. Always discuss honestly the known side effects caused by vaccines. But don’t forget to remind parents of the overwhelming benefit of preventing potentially serious diseases with vaccines. It’s honest to say that not vaccinating is a risk that will worry you.

Respect parents’ authority. Many parents today want to work in partnership with their child’s physician. Of course, you work in partnership with parents every day, for example, by eliciting reports from them about how their infants are progressing. By talking respectfully with parents about their immunization concerns, you can build on this partnership, build trust, and support parents in the decision to choose vaccination.

Reduce the stress of shots. Show parents ways they can make the vaccination visit less stressful for the child. It can begin by reinforcing that crying is a normal response for the child and suggesting that they stay calm so that the child does not become aware of their stress. For infants, you can suggest that parents use a favorite blanket or toy to distract the baby from the pain of the shots, and that they touch and soothe the baby, talk softly, and smile and make eye contact during the shots. After shots for infants, mothers may wish to cuddle or breastfeed. For toddlers, there are many more

If parents express extreme worry or doubt, contact them a few days after the visit. A caring call or e-mail will provide comfort and reinforce trust.

What If Parents Refuse to Vaccinate? Excluding children from your practice when their parents decline immunizations is not recommended. It can put the child at risk of many different health problems—not just vaccine-preventable diseases. Remember, unvaccinated infants did not decide for themselves to remain unvaccinated. They need your care. Make sure that parents are fully informed about clinical presentations of vaccine-preventable diseases, including early symptoms. Diseases like pertussis and measles are highly contagious and may present early as a non-specific respiratory illness. Parents who refuse vaccines should be reminded at every visit to call before bringing the child into the office, clinic, or emergency department when the child is ill so appropriate measures can be taken to protect others. When scheduling an office visit for an ill child who has not received vaccines, take all possible precautions to prevent contact with other patients, especially those too young to be fully vaccinated and those who have weakened immune systems. If a parent refuses to vaccinate, you can share the fact sheet If You Choose Not to Vaccinate Your Child, Understand the Risks and Responsibilities (http://www.cdc.gov/vaccines/conversations), which explains the risks involved with this decision including risks to other members of their community, and the additional responsibilities for parents, including the fact that, when their child is ill, they should always alert health care personnel to their child’s vaccination status to prevent the possible spread of vaccine-preventable diseases. You also can tell the parent that you would like to continue the dialogue about vaccines during the next visit, and then make sure to do so. You may wish to have them sign AAP ’s Refusal to Vaccinate form (http://www.aap.org/ immunization/pediatricians/pdf/refusaltovaccinate.pdf ) each time a vaccine is refused so that you have a record of their refusal in their child’s medical file.

Remember, not all parents want the same level of medical or scientific information about vaccines. By assessing the level of information that a particular parent wants, you can communicate more effectively and build trust. For the information resources mentioned in this sheet, and others, look for Provider Resources for Vaccine Conversations with Parents at http://ww.cdc.gov/vaccines/conversations or call 800-CDC-INFO (800-232-4636). These resources are free to download and ready for color or black and white printing and reproduction. 4

Understanding Thimerosal,

Mercury, and Vaccine Safety

➤ For more information on vaccines, vaccine-preventable diseases, and vaccine safety:

http://www.cdc.gov/vaccines/conversations

Last reviewed Februar y 2013

Why is thimerosal used in some vaccines? Because it prevents the growth of dangerous microbes, thimerosal is used as a preservative in multi-dose vials of flu vaccines, and in two other childhood vaccines, it is used in the manufacturing process. When each new needle is inserted into the multi-dose vial, it is possible for microbes to get into the vial. The preservative, thimerosal, prevents contamination in the multi-dose vial when individual doses are drawn from it. Receiving a vaccine contaminated with bacteria can be deadly. For two childhood vaccines, thimerosal is used to prevent the growth of microbes during the manufacturing process. When thimerosal is used this way, it is removed later in the process. Only trace (very tiny) amounts remain. The only childhood vaccines today that have trace amounts of thimerosal are one DTaP and one DTaP-Hib combination vaccine.

Why was thimerosal removed from vaccines given

to children?

In 1999, the Food and Drug Administration (FDA) was required by law to assess the amount of mercury in all the products the agency oversees, not just vaccines. The U.S. Public Health Service decided that as much mercury as possible should be removed from vaccines, and thimerosal was the only source of mercury in vaccines. Even

Influenza vaccination recommended for U.S. children ages 6 through 23 months old. Thimerosal is used as a preservative in multi-dose vials to prevent contamination of the vial when individual vaccine doses are drawn from it. Single-dose vials without thimerosal are available.

Influenza vaccination recommended for all U.S. children ages 6 months through 18 years.

All childhood vaccines with thimerosal as a preservative have passed their expiration date and are no longer available in the U.S. The amount of mercury in vaccines recommended for children is close to zero.

Manufacturing of childhood vaccines with thimerosal as a preservative ceases.

Manufacturers begin to phase out use of thimerosal as a preservative in childhood vaccines.

Thimerosal is a compound that contains mercury. Mercury is a metal found naturally in the environment.

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Public Health Service (PHS) and American Academy of Pediatrics (AAP) recommend removing thimerosal as a preservative from childhood vaccines as a precautionary measure.

Food and Drug Administration (FDA) announces results of its review of total amount of ethylmercury from thimerosal preservative in childhood vaccines.

What is thimerosal? Is it the same as mercury?

•

| questions and answers |

•

Thimerosal is a mercur y-containing compound that prevents the growth of dangerous bacteria and fungus. It is used as a preservative for flu vaccines in multi-dose vials, to keep the vaccine free from contamination. Thimerosal is also used during the manufacturing process for some vaccines to prevent the growth of microbes. In 1999, as a precautionar y measure, the U.S. Public Health Ser vice recommended removing thimerosal as a preservative from vaccines to reduce mercury exposure among infants as much as possible. Today, except for some flu vaccines in multi-dose vials, no recommended childhood vaccines contain thimerosal as a preservative. In all other recommended childhood vaccines, no thimerosal is present, or the amount of thimerosal is close to zero. No reputable scientific studies have found an association between thimerosal in vaccines and autism. There are two different compounds that contain mercury: ethylmercur y and methylmercury. The low levels of ethylmercury in vaccines are broken down by the body differently and clear out of the blood more quickly than methylmercury.

•

| questions and answers | continued  though there was no evidence that thimerosal in vaccines was dangerous, the decision to remove it was a made as a precautionary measure to decrease overall exposure to mercury among young infants. This decision was possible because childhood vaccines could be reformulated to leave out thimerosal without threatening their safety, effectiveness, and purity. Today, no childhood vaccine used in the U.S.—except some formulations of flu vaccine in multi-dose vials—use thimerosal as a preservative.

Why is thimerosal still in some flu vaccines that children may receive? To produce enough flu vaccine for the entire country, some of it must be put into multi-dose vials. When each individual vaccine dose is drawn from the vial with a fresh needle, it is possible for microbes to get into the vial. So, this preservative is needed to prevent contamination of the vial when individual doses are drawn from it. Children can safely receive flu vaccine that contains thimerosal. Flu vaccine in single-dose vials that does not contain thimerosal also is available.

Was thimerosal in vaccines a cause of autism? Reputable scientific studies have shown that mercury in vaccines given to young children is not a cause of autism. The studies used different methods. Some examined rates of autism in a state or a country, comparing autism rates before and after thimerosal was removed as a preservative from vaccines. In the United States and other countries, the number of children diagnosed with autism has not gone down since thimerosal was removed from vaccines.

What keeps today’s childhood vaccines from becoming contaminated if they do not contain thimerosal as a preservative? The childhood vaccines that used to contain thimerosal as a preservative are now put into single-dose vials, so no preservative is needed. In the

What is the difference between ethylmercury

and methylmercury?

When learning about thimerosal and mercury it is important to understand the difference between two different compounds that contain mercury: ethylmercury and methylmercury. They are totally different materials. Methylmercury is formed in the environment when mercury metal is present. If this material is found in the body, it is usually the result of eating some types of fish or other food. High amounts of methylmercury can harm the nervous system. This has been found in studies of some populations that have long-term exposure to methylmercury in foods at levels that are far higher than the U.S. population. In the United States, federal guidelines keep as much methylmercury as possible out of the environment and food, but over a lifetime, everyone is exposed to some methylmercury. Ethylmercury is formed when the body breaks down thimerosal. Low-level ethylmercury exposures from vaccines are very different from long-term methylmercury exposures because ethylmercury is broken down by the body differently and clears out of the blood more quickly.

past, the vaccines were put into multi-dose vials, which could become contaminated when new needles were used to get vaccine out of the vial for each dose.

Was thimerosal used in all childhood vaccines? No. A few vaccines contained other preservatives, and they still do. Some other vaccines, including the measles, mumps, and rubella vaccine (MMR) never contained any preservative or any mercury.

| the science | The studies below are examples of some of the different methods that researchers have used to examine thimerosal safety in vaccines. Researchers have looked at very large groups, such as all children born in a six-year period in Denmark, as well as smaller, defined groups, such as children diagnosed with autism in California. In some of the studies, researchers compared rates of autism among those who were vaccinated with thimerosal-containing vaccines and those who were not. Researchers consistently found that children who received thimerosal in vaccines were not more likely to have autism than those who did not. Thimerosal Exposure in Infants and Developmental Disorders: A Retrospective Cohort Study in the United Kingdom Does Not Support a Causal Association by Nick Andrews et al. Pediatrics. September 2004. Vol 114: pages 584–591. http://pediatrics.aappublications.org/cgi/content/ full/114/3/584 Pervasive Developmental Disorders in Montreal, Quebec, Canada: Prevalence and Links with Immunizations by Eric Frombonne et al. Pediatriacs. July 2006. Vol 118: e139-e150. http://pediatrics.aappublications.org/cgi/content/full/118/ 1/e139 Association between Thimerosal-Containing Vaccine and Autism by Anders Hviid et al. Journal of the American Medical Association. October 2003. Vol 290: pages 1763–1766. http://jama.ama-assn.org/cgi/content/full/290/13/1763 Immunization Safety Review: Vaccines and Autism. Institute of Medicine. The National Academies Press: 2004. http://www.iom.edu/Reports/2004/Immunization-Safety Review-Vaccines-and-Autism.aspx Prenatal and Infant Exposure to Thimerosal from Vaccines and Immunoglobulins and Risk of Autism by Cristofer Price et al. Pediatrics. September 2010. Vol 126: pages 656-664. http://pediatrics.aappublications.org/cgi/reprint/peds.2010 0309v1 Continuing Increases in Autism Reported to California’s Developmental Services System by Robert Schechter et al. Archives of General Psychiatr y. January 2008. Vol 65: pages 19-24. http://archpsyc.ama-assn.org/cgi/content/ full/65/1/19 Early Thimerosal Exposure and Neuropsychological Outcomes at 7 to 10 Years by William Thompson et al. The New England Journal of Medicine. September 2007. Vol 357: pages 1281 1292. http://www.nejm.org/doi/pdf/10.1056/NEJMoa071434

For more information on vaccines call 800-CDC-INFO (800-232-4636) or visit http://www.cdc.gov/vaccines.

Section Three: Adult Immunization Recommendations    

“Do You Know Which Adult Vaccines You Might Need?” 2016 Recommended Immunization Schedule for Adults Vaccines for Adults: You’re never too old to get immunized! Cocooning Protects Babies

For more information, please visit: http://www.cdc.gov/vaccines/schedules/hcp/adult.html http://www.vaccineinformation.org/adults/

Do You Know Which Adult Vaccines You Might Need? Vaccines are recommended for all adults based on factors such as age, travel, occupation, medical history, and vaccines they have had in the past. Below are the main vaccines you might need. But, this list may not include every vaccine that you need. Find out which vaccines you need by taking the quiz at: www.cdc.gov/vaccines/AdultQuiz/

ALL adults 19 and older, including pregnant women, need: Influenza vaccine every year • A flu vaccine is especially important for people with chronic health conditions, pregnant women, and older adults

Tetanus, diphtheria, and pertussis (whooping cough) vaccine (Tdap) • Adults should get a one-time dose of Tdap. Adults can get Tdap no matter when they got their last tetanus vaccine (Td), which is given every 10 years Pregnant women should get Tdap to protect themselves and their newborn babies from whooping cough In addition to influenza and Tdap vaccines, you may also need other vaccines depending on your age or other factors. Flip the page to learn more.

Talk to your healthcare provider about which vaccines are right for you. National Center for Immunization and Respiratory Diseases Immunization Services Division CS241285

In addition to influenza and Tdap vaccines, you may also need other vaccines depending on your age… Young adults not yet vaccinated need: { Human papillomavirus (HPV) vaccine series (3 doses) if you are: • Female age 26 or younger Male age 21 or younger Male age 26 or younger who has sex with men, who is immunocompromised, or who has HIV

Adults born in the US in 1957 or after need: { Measles, mumps, rubella (MMR) vaccine* • Adults should get at least one dose of MMR vaccine, unless they’ve already gotten this vaccine or have immunity to measles, mumps, and rubella

Adults born in the US in 1980 or after need: {{ Varicella “chickenpox” vaccine* • Adults should get 2 doses of chickenpox vaccine unless they’ve already gotten both doses or have immunity to chickenpox

Adults 60 years of age and older need: { Zoster “shingles” vaccine* (1 dose)

Adults 65 years of age and older need: { Pneumococcal polysaccharide vaccine (1 dose)

You may also need other vaccines if you… Are a healthcare worker: { Hepatitis B vaccine series

Do not have a spleen or your spleen does not work well:

Measles, mumps, rubella (MMR) vaccine*

{ Hib vaccine

Varicella vaccine*

{ Meningococcal vaccine

Have heart disease or chronic lung disease: { Pneumococcal polysaccharide vaccine

Have type 1 or type 2 diabetes: { Hepatitis B vaccine series Pneumococcal polysaccharide vaccine

Have a weakened immune system or have HIV: { Hepatitis B vaccine series Hib vaccine Both types of pneumococcal vaccines

Have chronic liver disease: { Hepatitis A vaccine series Hepatitis B vaccine series Pneumococcal polysaccharide vaccine

{ Both types of pneumococcal vaccines

Are a man who has sex with men: { Hepatitis A vaccine series { Hepatitis B vaccine series { Human papillomavirus (HPV) vaccine series

Are a laboratory worker and may be routinely exposed to isolates of Neisseria meningitidis, or specimens potentially containing hepatitis A or hepatitis B virus: { Hepatitis A vaccine series { Hepatitis B vaccine series { Meningococcal vaccine

Are a college freshman living in a residence hall: { Meningococcal vaccine

Are planning to travel outside of the US: * Live vaccines should not be given to people who have a very weakened immune system, including those with a CD4 count less than 200, or to pregnant women.

See http://wwwnc.cdc.gov/travel/page/vaccinations.htm for more information.

To learn more about all vaccines, visit www.cdc.gov/vaccines. For more information, please call 1-800-CDC-INFO (800-232-4636) or visit www.cdc.gov/info

INFORMATION FOR ADULT PATIENTS If you are this age,

2016 Recommended Immunizations for Adults: By Age

talk to your healthcare professional about these vaccines Flu Influenza

Td/Tdap Tetanus, diphtheria, pertussis

Shingles Zoster

Pneumococcal

PCV13

PPSV23

Meningococcal MenACWY or MPSV4

MenB

MMR Measles, mumps, rubella

HPV Human papillomavirus for women

Chickenpox Varicella

Hepatitis A Hepatitis B

for men

Hib Haemophilus influenzae type b

19 - 21 years

22 - 26 years

27 - 49 years

50 - 59 years

60 - 64 years

1 or 2 doses

65+ year

More Information:

You should get flu vaccine every year.

You should get a Td booster every 10 years. You also need 1 dose of Tdap. Women should get a Tdap vaccine during every pregnancy to protect the baby.

You should get shingles vaccine even if you have had shingles before.

You should get 1 dose of PCV13 and at least 1 dose of PPSV23 depending on your age and health condition.

You should get this vaccine if you did not get it when you were a child. You should get HPV vaccine if you are a woman through age 26 years or a man through age 21 years and did not already complete the series.

For more information, call 1-800-CDC-INFO (1-800-232-4636) or visit www.cdc.gov/vaccines Recommended For You: This vaccine is recommended for you unless your healthcare professional tells you that you cannot safely receive it or that you do not need it. May Be Recommended For You: This vaccine is recommended for you if you have certain risk factors due to your health, job, or lifestyle that are not listed here. Talk to your healthcare professional to see if you need this vaccine.

If you are traveling outside the United States, you may need additional vaccines. Ask your healthcare professional about which vaccines you may need at least 6 weeks before you travel.

CS262412

INFORMATION FOR ADULT PATIENTS If you have this health condition,

2016 Recommended Immunizations for Adults: By Health Condition

talk to your healthcare professional about these vaccines Flu Influenza

Td/Tdap Tetanus, diphtheria, pertussis

Shingles Zoster

Pneumococcal

PCV13

PPSV23

Meningococcal MenACWY or MPSV4

MenB

MMR Measles, mumps, rubella

HPV Human papillomavirus for women

Chickenpox Varicella

Hepatitis A

Hepatitis B

for men

Hib Haemophilus influenzae type b

Pregnancy SHOULD NOT GET VACCINE

Weakened Immune System

SHOULD NOT GET VACCINE

HIV: CD4 count less than 200 HIV: CD4 count 200 or greater Kidney disease or poor kidney function Asplenia (if you do not have a spleen or if it does not work well) Heart disease Chronic lung disease Chronic alcoholism Diabetes (Type 1 or Type 2) Chronic Liver Disease

More Information:

You should get flu vaccine every year.

You should get a Td booster every 10 years. You also need 1 dose of Tdap vaccine. Women should get Tdap vaccine during every pregnancy.

Recommended For You: This vaccine is recommended for you unless your healthcare professional tells you that you cannot safely receive it or that you do not need it.

You should get shingles vaccine if you are age 60 years or older, even if you have had shingles before.

You should get 1 dose of PCV13 and at least 1 dose of PPSV23 depending on your age and health condition.

You should get Hib vaccine if you do not have a spleen, have sickle cell disease, or received a bone marrow transplant.

For more information, call 1-800-CDC-INFO (1-800-232-4636) or visit www.cdc.gov/vaccines May Be Recommended For You: This vaccine is recommended for you if you have certain other risk factors due to your age, health, job, or lifestyle that are not listed here. Talk to your healthcare professional to see if you need this vaccine.

YOU SHOULD NOT GET THIS VACCINE

CS262412

Vaccinations for Adults

You’re never too old to get immunized! Getting immunized is a lifelong, life-protecting job. Don’t leave your healthcare provider’s office without making sure you’ve had all the vaccinations you need.

Vaccine

Do you need it?

Hepatitis A (HepA)

Maybe. You need this vaccine if you have a specific risk factor for hepatitis A virus infection* or simply want to be protected from this disease. The vaccine is usually given in 2 doses, 6–18 months apart.

Hepatitis B (HepB)

Maybe. You need this vaccine if you have a specific risk factor for hepatitis B virus infection* or simply want to be protected from this disease. The vaccine is given in 3 doses, usually over 6 months.

Human papillomavirus (HPV)

Maybe. You need this vaccine if you are a woman age 26 years or younger or a man age 21 years or younger. Men age 22 through 26 years with a risk condition* also need vaccination. Any man age 22 through 26 who wants to be protected from HPV may receive it, too. The vaccine is given in 3 doses over a 6-month period.

Influenza

Yes! You need a dose every fall (or winter) for your protection and for the protection of others around you.

Measles, mumps, Maybe. You need at least 1 dose of MMR if you were born in 1957 or later. You may also need a rubella (MMR) 2nd dose.* Meningococcal (MenACWY [MCV4], MenB, MPSV4)

Maybe. You may need MenACWY and/or MenB vaccine if you have one of several health conditions, for example, if you don’t have a functioning spleen. You need MenACWY if you are age 21 or younger and a first-year college student living in a residence hall and you either have never been vaccinated or were vaccinated before age 16.* You should consider MenB if you are age 23 or younger (even if you don’t have a high-risk medical condition).

Pneumococcal (Pneumovax [polysaccharide vaccine, PPSV]; Prevnar [conjugate vaccine] PCV)

Maybe. If you are age 65 years (or older), you need both pneumococcal vaccines, Prevnar (if you haven’t had it before) and Pneumovax. Get Prevnar first and then get Pneumovax 1 year later. If you are younger than age 65 and have certain high-risk conditions (for example, asthma, heart, lung, or kidney disease, immunosuppression, or lack of a functioning spleen, or are a smoker),* you need 1 or both vaccines. Talk to your healthcare provider to find out when you need them.*

Tetanus, diphtheria, whooping cough (pertussis) (Tdap, Td)

Yes! All adults who have not yet received a dose of Tdap, as an adolescent or adult, need to get Tdap vaccine (the adult whooping cough vaccine). And, all women need to get a dose during each pregnancy. After that, you need a Td booster dose every 10 years. Consult your healthcare provider if you haven’t had at least 3 tetanus and diphtheria toxoid-containing shots sometime in your life or if you have a deep or dirty wound.

Varicella (Chickenpox)

Maybe. If you’ve never had chickenpox or were vaccinated but received only 1 dose, talk to your healthcare provider to find out if you need this vaccine.*

Zoster (shingles) Maybe.* If you are age 60 years or older, you should get a 1-time dose of this vaccine now. Hib (Haemophilus Maybe. Some adults with certain high-risk conditions, for example, lack of a functioning spleen, need influenzae type b) vaccination with Hib. Talk to your health care provider to find out if you need this vaccine. * Consult your healthcare provider to determine your level of risk for infection and your need for this vaccine.

Are you planning to travel outside the United States? Visit the Centers for Disease Control and Prevention’s (CDC) website at wwwnc.cdc.gov/travel/ destinations/list for travel information, or consult a travel clinic. Technical content reviewed by the Centers for Disease Control and Prevention

Saint Paul, Minnesota 651- 647- 9009 • www.immunize.org • www.vaccineinformation.org •

www.immunize.org/catg.d/p4030.pdf • Item #P4030 (3/16)

Cocooning Protects Babies Everyone in a baby’s life needs to get vaccinated against whooping cough and flu! What is cocooning? Babies younger than 6 months old are more likely to develop certain infectious diseases than older children. Cocooning is a way to protect babies from catching diseases from the people around them – people like their parents, siblings, grandparents, friends, child-care providers, babysitters, and healthcare providers. Once these people are vaccinated, they are less likely to spread these contagious diseases to the baby. They surround the baby with a cocoon of protection against disease until he or she is old enough to get all the doses of vaccine needed to be fully protected.

How can we protect babies against whooping cough? • All children should be vaccinated on schedule with DTaP (the childhood whooping cough vaccine). • All teenagers and adults need a one-time dose of Tdap vaccine (the teen and adult whooping cough vaccine). • Pregnant women should receive a Tdap vaccination in each pregnancy, preferably during the 3rd trimester. This will protect the pregnant woman as well as her baby!

How can we protect babies against flu?

Why is cocooning important?

Everyone age 6 months and older needs to receive flu

Babies less than 6 months old are too young to have received all the doses of vaccine that are needed to protect them from whooping cough (pertussis), flu (influenza), and other dangerous diseases. To be fully protected, babies need to get all the vaccine doses in a series – not just the ﬁrst dose.

vaccine every year.

Unvaccinated adults and family members, including parents, are often the ones who unknowingly spread dangerous diseases to babies. Currently, towns and cities across the nation have had whooping cough outbreaks. Influenza outbreaks happen every year.

How can we protect babies? Everyone has the opportunity to protect babies by getting vaccinated themselves. Cocooning is an easy and effective way that people can work together to prevent the spread of whooping cough and flu to babies.

information from trusted sources � Video: Surround Your Baby with Protection

(about whooping cough) http://cocooning.preventpertussis.org From the Texas Department of State Health Services

� Diseases and the Vaccines That Prevent Them

www.cdc.gov/vaccines/hcp/patient-ed/conversations/ prevent-diseases/index.html From the Centers for Disease Control and Prevention

� Vaccine Educational Materials for Parents

www.chop.edu/service/vaccine-education-center/ order-educational-materials From the Vaccine Education Center, Children’s Hospital of Philadelphia

� Vaccine Information Website

www.vaccineinformation.org From the Immunization Action Coalition

� Cocooning and Tdap Vaccination Web Section

(cocooning information about whooping cough) www.immunize.org/cocooning From the Immunization Action Coalition

Technical content reviewed by the Centers for Disease Control and Prevention

Immunization Action Coalition 1573 Selby Avenue • St. Paul, MN 55104 • 651-647-9009 • www.immunize.org • www.vaccineinformation.org www.immunize.org/catg.d/p4039.pdf • Item #P4039 (3/13)

Section Four: Immunization Resources        

Colorado Immunization Information System (CIIS) CIIS Instructions for Child Care Centers (Read Only Users) Using CIIS to Calculate Immunization Rates Child Care Immunization Rate Guide How to Find Immunization Records (English/Spanish) Jefferson County Public Health Immunization Brochure (English/Spanish) Jefferson County Public Health Services Brochure (English/Spanish) Vaccine for Children Program

For more information, please visit: http://jeffco.us/public-health/healthy-families/immunizations/ http://www.cdc.gov/vaccines/programs/vfc/index.html http://www.colorado.gov/cs/Satellite/CDPHE-DCEED/CBON/1251607754827 http://www.colorado.gov/cs/Satellite/CDPHE-DCEED/CBON/1251609960816 http://www.immunizeforgood.com/

Colorado Immunization Information System Keeping track of shot records has never been easier! The Colorado Immunization Information System (CIIS), also known as Colorado’s immunization registry, is a confidential, secure, web‐based system that collects vaccination information for Coloradans of all ages. This free web application helps healthcare providers, schools, child care centers, and universities keep better track of shots their clients or students have received and which ones they are still missing. CIIS can help your site track immunizations by:  Providing free and secure 24/7 access to immunization records online  Allowing you to check and print immunization records and exemptions for children at your site  Showing which children are missing required immunizations or have incomplete immunization records  Letting you print the Certificate of Immunization form

Child Care Centers, Head Start Facilities, and Schools now have access to CIIS!

Colorado Immunization Information System Frequently Asked Questions What can the Colorado Immunization Information System (CIIS) do for my site? CIIS simplifies immunization record‐keeping by providing a single online location to maintain all shot records electronically, provides easy access and reliable immunization histories for your students in the system, and helps you determine if your students have been appropriately immunized.

How much does it cost to participate in CIIS? There is NO fee for access to or use of CIIS! The CIIS staff provide online training and ongoing technical support for you and your staff at no cost to you.

How is information in CIIS kept confidential? CIIS must protect the privacy of all users, including children, families and providers. Access to the system must be authorized by CIIS and users must sign an agreement and follow strict confidentiality and security policies. These policies are available on the Confidentiality/Security page of our website at www.ColoradoIIS.com. Additionally, all users access CIIS through a unique user name and password that allows CIIS to generate an audit trail of actions taken by any user in the system.

Who has access to information in CIIS? The Immunization Registry Act (CRS § 25‐4‐2403) allows immunization practitioners, clinics, schools (child care centers and head start facilities), individuals/parents, health insurers, the Department of Health Care Policy and Financing, hospitals, or entities that have contracted with CDPHE to send immunization data and access immunization information in CIIS. It is a crime to disclose CIIS information inappropriately.

Can Individuals/Parents get immunization records directly from CIIS? Yes. Individuals/Parents may request copies of their/their child’s immunization record by completing the CIIS Record Release Form. More Information can be found on our webpage through the Parents and Patients tab> How do I request an Immunization Record from CIIS? tab on our website. Please contact the CIIS Help Desk before requesting a record.

Do Individuals/Parents have the right to exclude their/their child’s information from CIIS? Yes. Individuals/Parents have the right to opt‐out and remove their/their child’s immunization data from the registry at any time. It is the individual’s/parent’s responsibility to complete and send the Opt‐Out Form to CIIS. Individuals who request to opt‐out of the registry may access the Opt‐Out Form from the Opt‐out and Rescind Opt‐Out Procedures under the Polices and Procedure tab on our website.

What type of equipment do I need in order to participate in CIIS? In order to participate in CIIS, you will need one or more computers with internet connectivity and printing capabilities. CIIS works properly with an unmodified version of Internet Explorer (IE) 7.0 and 8.0, Safari 5.0 and Mozilla Firefox 4.0.

How do I access CIIS? Interested participants are encouraged to visit our webpage www.ColoradoIIS.com or contact CIIS: CIIS School Coordinator 303‐691‐4073 lorin.scott‐okerblom@state.co.us

CIIS Help Desk 1‐888‐611‐9918 cdphe.ciis@state.co.us

To begin the implementation process, your site will be required to sign a Letter of Agreement with CIIS stating that you will keep the information confidential and not share it with any unauthorized person, as well as complete the appropriate online training prior to being allowed access to the system.

Colorado Immunization Information System (CIIS) Instructions for Child Care Centers (Read-Only Users) The CIIS School Application web address is: https://ciis.state.co.us/school CIIS Read-Only Users: Can view patient immunization records and print immunization certificates and may have the ability to enroll students and run reports (e.g., Immunization Rates report). How to log‐in to CIIS: 1. Enter the CIIS website address in your browser. 2. Enter your current CIIS User Name and Password. Note: User Name is NOT case sensitive; however, the system will auto‐convert it to all caps. The password IS case sensitive. 3. Click the “Log In” button or hit the Enter key on your keyboard. Note: When you first log‐in to CIIS, the system will prompt you to change your password and to answer password security questions.

Note: If you forget your password in CIIS, you can click the “Forgot Password?” link located on the CIIS Login screen to reset your own password. You must have answered your password security questions in order to utilize this feature. The Help icon, located on most screens within CIIS, gives you more information about the topics on the screen.

Default Provider/Clinic and School District/School Due to how CIIS is configured, all Childcare Users will have a default Provider and Clinic show up at the top of the Home Screen. Your default Provider should always be “Colorado School District,” and your default Clinic should always be “Colorado School.” Initially, your default School District will also say “Colorado School District” and your default School will say “Colorado School.” Note: Your Childcare center will be able update the default School District and School with which you are associated. To do so, your CIIS Site Administrator will need to send an email to the main CIIS email box: CDPHE.CIIS@state.co.us indicating which CIIS users should be associated with the appropriate Childcare Center. It is possible for CIIS users to be associated with more than one School/Childcare Center/Head Start within the system. Being associated with your childcare center will allow you to enroll students in CIIS and run school reports (e.g. Student Roster, CIIS Immunization Rates reports). How to search for a student: 1. Click the “Patients” link located in the left‐hand menu. Doing so will navigate you to the Search screen. 2. Enter your search criteria and click the “Search” button.

Tip: The most effective way to search for a student is to enter the first few letters of the student name and the DOB in the search criteria boxes. If the student is not returned in the search try using other fields in the search box. 3. Once you locate your patient in the search results, click the corresponding radio button to select your patient.

Important: When you first select your patient in search results (by clicking the radio button), you must click one of the gray buttons beneath the search results to navigate to the corresponding module/screen (e.g., Immunizations, Demographics), before you can use the menu on the left‐hand side of your screen to navigate between modules for your patient. Once you have “activated” the patient using one of the gray buttons on the Search Results screen, you can then use the links in the left‐hand menu. How to view patient demographics: Click the “Demographics” link or button to open the Demographics screen for your patient.

How to view a patient’s record: Click the “Immunizations” link or button once you have selected your patient. You can view/print the patient’s record on the Immunizations Home screen, as well as view recommended vaccines and immunization details for the patient. 1

How to print a patient’s record: There are several places in CIIS from which you can print a patient’s record. Links to immunization records and certificates are located on the following screens: • Search Results screen (located at the top and bottom of the screen). • Demographics screen (located at the top and bottom of the screen). • Immunizations Home screen (located at the top of the screen). • Reports/Forms screen (located at the top of the screen). To print a patient record, navigate to the top of one of the above screens. You will see a list of immunization certificates that can be printed (e.g. Immunization Record (Yellow Card), College Certificate of Immunization,

School Certificate of Immunization). Click on the immunization certificate you want to print. Next, click on the icon.

Enrolling a patient as a student in your school district/school: 1. Search for the patient you want to work with and select the radio button for the correct patient. 2. Click the “Education” button located on the Search Results screen. 3. Click “Add School Enrollment” on the Education screen. 4. Enter enrollment information (required fields in bold) on the Add Education screen, and click the “Create” or “Update” button to save the record. Tip: Double-clicking in date fields will auto-populate today’s date.

Note: Enrolling patients as students in your childcare will allow you to run Student Roster and Immunization Rates reports. Before using this feature, users should be associated with the appropriate Childcare Center. Please refer to the Default Provider/Clinic and School District/School section of this document for further information.

For further questions and information on additional CIIS childcare user training, please contact your CIIS Coordinator or CIIS User Support at 1-888-611-9918 option #1 or 303-692-2437 option #2. Additional CIIS training materials can be found at: www.ColoradoIIS.com. Once you are on the website, click on the “Training” link. Next, click on the link “For childcare providers” and you will see the links to various training materials, including the CIIS online training video, webinars and job aids.

August 2015 2

Calculating Immunization Rates for Child Cares and Schools Using the Colorado Immunization Information System In May 2014, the Colorado General Assembly passed House Bill 14-1288 (HB-1288). Signed by Governor Hickenlooper, HB-1288 will take effect on July 1, 2014. Per HB-1288, “each school¹ shall make the immunization and exemption rates of their enrolled student population publicly available, upon request” and the Colorado Department of Public Health and Environment shall “provide assistance to schools with the analysis and interpretation of the immunization data.” This guide explains how to use CIIS to calculate an immunization rate for child cares or schools. Please note that CIIS strictly follows the current Advisory Committee on Immunization Practices (ACIP) recommended immunization schedule. CIIS does not take into account the ACIP catch-up schedules for 0 – 18 year olds. In order to run the CIIS Immunization Rates report for your school or child care, your CIIS user account must be associated with the school or child care at which you work. After you log-in to CIIS, the home screen will show what facilities your user account is associated with as demonstrated below:

If your account is not associated correctly or is only associated with a generic “Colorado School District” and “Colorado School,” please contact Lorin Scott-Okerblom to update your account settings prior to performing any of the other steps in this guide. Lorin Scott-Okerblom, MPH Health Educator 303-691-4073 lorin.scott-okerblom@state.co.us To run a CIIS Immunization Rates report for your school or child care, you must first enroll all your students in your school or child care through the Education module within CIIS. ¹ Defined as a public, private, or parochial nursery school, day care center, child care facility, family child care home, foster care home, Head

Start program, kindergarten, or elementary or secondary school through grade twelve, or a college or university. “School” does not include a public services short-term child care facility as defined in section 26-6-102 (6.7), C.R.S., a guest child care facility as defined in section 26-6-102 (5), C.R.S., a ski school as defined in section 26-6-103.5 (6), C.R.S., or college or university courses which are offered off-campus; or are offered to nontraditional adult students, as defined by the governing board of the institution; or are offered at colleges or universities which do not have residence hall facilities.

Step 1: Enrollment Instructions 1. Log-in to CIIS at https://ciis.state.co.us/school. 2. In the left hand menu, click Patient and then the Search link to search for a child at your facility. 3. Enter the first few letters of the childâ&#x20AC;&#x2122;s first name and the date of birth in the Search Criteria box, and click the Search button. 4. Select the child by clicking on the radio button to the left of their name. 5. Once you have selected the child, click the Education button located below the search results.

6. On the Education screen, click the Add School Enrollment button to enroll a child at your school or child care. Note: If you enroll a child in a new school or child care, it will automatically un-enroll the child from the school or child care where they were previously enrolled and add them to your location. A child cannot be enrolled at more than location at any given time. If you would like to see all the students enrolled at your facility, you can run the Student Roster report located in the Reports/Forms module in CIIS. For instructions with this report, please see pages 8-9.

7. Select the school or child care the child attends from the drop down menus and enter the date the child was enrolled at this location in the Enrollment Date box. Complete the other fields if the information is available.

Note: Schools are required to follow the Family Educational Rights and Privacy Act (FERPA) regulations when entering information into CIIS. The FERPA fields can be used to record consent information. Child cares do not need to complete this section.

8. Click the Create button to save this enrollment information. If you are ready to enroll another child at your school or child care, return to Step 2 in this process. Continue these steps for each enrollment until all of your students are enrolled in your school or child care.

Step 2: Immunization Rates Report Instructions Once you have enrolled all the children at your school or child care, you can run the Immunization Rates report. 1. Click on the Reports/Forms link in the left-hand menu. 2. In the School Nurse section, click on the Immunization Rates link.

3. Complete the Report Selection Criteria. a. Select your school or child care location from the drop down menu. b. Make sure that Appropriate Statistics Summary is selected as the Report Type.

4. Choose the age range that you would like to review and enter this information in the Age Range boxes. Make sure you choose the correct Unit of Measurement (UOM). You can enter the age in months or years. a. If you are a school with grades K-12, please enter information in the Grade Range filter and Age Range filter. 5. In the As of Date Range, enter the date you are running the report in both the From and Through boxes. This will calculate the immunization rate for your school or child care as of this date.

6. Using the Immunization Rates Chart below, review the number of required doses for each vaccine for your selected age range. Example: If you are reviewing children 15 through 18 months of age from the chart, 2 doses of Hep B, 4 doses of DTaP, 2 doses of Polio, 1 dose of MMR (and so on) would be required for the child to be considered up- to-date. Be sure to review the entire row from left to right so that you capture the number of all of the required vaccines.

See chart on next page. Note: The Immunization Rates Chart is used ONLY to calculate the immunization rates using the minimum required doses for children to be up to date. In order for a child to be protected from disease, make sure the ACIP Immunization Schedule is followed. Please visit this website for more information on the immunization schedule: http://www.cdc.gov/vaccines/schedules/easy-to-read/index.html.

Hep B

Age of Child

Hepatitis B

DT, DTP, or DTaP, Tdap Diphtheria, Tetanus, & Pertussis

IPV

MMR

Inactivated Polio Vaccine

Measles, Mumps, & Rubella

Varicella

Hib

PCV7 or PCV13

Chickenpox

Haemophilus influenzae type b

Pneumococcal Disease

Minimum # of required doses

0 – 3 mos.

1 (optional)

4 – 5 mos.

6 – 7 mos. 8 – 11 mos.

12 – 14 mos.

15 – 18 mos. 19 mos. – 48 mos. (4 years)

4°

5 – 6 years

7-12 years

13 – 18 years

1 Tdap*

* DT, DTP, DTaP – 5 doses are required; however, if the 4th dose is given on or after the 4th birthday, the child has met the requirement. 1 dose of Tdap is required for 6-12th grades. + Polio (IPV) – 4 doses are required, however, if the 3rd dose if given on or after the 4th birthday, the child has met the requirement. ^ The number of Hib doses required depends on the child’s current age and when the Hib vaccine was administered: • If any dose is given at or over 15 months, the Hib requirement is met. • Children who begin the series before 12 months, 3 doses are required and at least one dose must be at or over 12 months. • If the 1st dose was given at 12 to 14 months, 2 doses are required. • If the current age is 5 years or older, no new additional doses are required. ° The number of doses of pneumococcal conjugate vaccine (PCV7 or PCV13) depends on the child’s current age when the 1st dose was administered: • If the 1st dose was given between 2 to 6 months of age, the child will receive 3 doses plus an additional dose between 12 to 15 months of age. • If started between 7 to 11 months of age, the child will receive 2 doses plus an additional dose between 12 to 15 months of age. • If the 1st dose was given between 12 to 23 months of age, 2 doses, 2 months apart are required. • Any dose given at 24 months through 4 years of age, PCV vaccine requirement is met. • No doses required once the child turns 5 years of age.

Note: Some children may be up-to-date on their vaccinations, even if they do not have the required number of doses for each vaccine. Please also use the above footnotes for more guidance. 7. Based on your review in Step 6, enter the number of required doses for your selected age range in the Doses by Vaccine Series boxes on the Report Selection Criteria screen in CIIS. a. Following the example above, you would enter 4 in the DTaP/Tdap box because the chart states that the number of required DTaP doses for 15-18 month olds is 4.

8. After you have entered everything in the Report Selection Criteria, click the Run Report button.

The system will generate the Immunization Rates – Appropriate Immunizations report as a PDF in a new window. This report will show: • The total number of children in the age group you selected. (Total Patients) • The total number of children in this age group that are up-to-date on their immunizations along with the percentage of children who are up-to-date. (Patients GIVEN appropriate number of doses of all indicated antigens) • The total number of children in this age group that are NOT up-to-date on their immunizations along with the percentage of children who are not up-to-date. (Patients NOT GIVEN appropriate number of doses of all indicated antigens) • A breakdown of up-to-date numbers and percentages by vaccine.

In this example report, only 25% of the children enrolled at Children’s Day Care are up-to-date on the required immunizations. As noted in the Immunization Rates Chart on page 5, immunization requirements differ by the child’s age. If you have multiple age groups that attend your facility, you will need to run a CIIS Immunization Rates report for each age group individually and then tally the total for your entire facility. Example: If you have children aged 4 months through 4 years at your child care center, you will need to run the CIIS Immunization Rates report for the following age groups: 4-5 months, 6-7 months, 8-11 months, 15-18 months, and 19 months – 48 months (4 years). These reports will show you the number of children that are up-to-date in each age group. To calculate the immunization rates for your entire facility (all age groups combined): • Add up the total number of children at your facility. • Add up the total number of children from each age group that are up-to-date on their immunizations. • Use the box below to calculate your facility’s overall immunization rate. Up-to-Date Immunization Rate: Total number of children up-to-date: _____ ÷ Total number of children: _____ =_____ × 100 = ______ % Currently, there is no way for schools or child cares to calculate exemption rates in CIIS. To calculate exemption rates for your facility: • •

Add up the total number of children at your facility. Add up the total number of children that have exemptions. Exemption Rate: Total number of children with exemptions: _____ ÷ Total number of children: _____ =_____ × 100 = ______ %

Student Roster Report Instructions If you have enrolled all the children at your school or child care, you can run the Student Roster report to see all the students that you have previously enrolled. 1. Click on the Reports/Forms link in the left-hand menu. 2. In the School Nurse section, click on the Student Roster link.

3. Select your facility name from the School District and School drop down menus.

If you would like to filter the Student Roster results, â&#x20AC;˘ Grade Range: will allow you to filter results by children in certain grades. â&#x20AC;˘ Age Range: will allow you to filter results by children that are certain ages. 4. Under the Group Report Totals By, select the radio button next to School District/School. 5. In the Enrollment Open as of field, enter the date you are running the report. 6. The Sort by section will allow you to choose how you want the report results to be sorted. Select the radio button next to the order in which you would like your results sorted. 7. After you have entered the above information, click the Run Report button.

The system will generate the Student Roster report as a PDF in a new window. This report will show: • A list of children that are enrolled in the facility you selected. • Age or Grade of the child depending on what you choose on the Report Selection Criteria page. • Child’s Date of Birth. • Enrollment Date: the date that the child was enrolled at your facility in CIIS. • Un-enrollment Date: the date the child will be leaving your facility (if applicable). • Most recent FERPA Date: the date when school staff received FERPA consent and entered it into CIIS. • Total number of patients for the selected age group at you facility.

Child Care and School Immunization Rates Guide (Counting Doses/Creating Rates)

In May 2014, the Colorado General Assembly passed House Bill 14-1288 (HB-1288). Signed by Governor Hickenlooper, 1 HB-1288 will take effect on July 1, 2014. Per HB-1288, “each school shall make the immunization and exemption rates of their enrolled student population publicly available, upon request” and the Colorado Department of Public Health and Environment shall “provide assistance to schools with the analysis and interpretation of the immunization data.” The table below indicates the number of doses of vaccine a student needs based on their age. To determine if a student is considered current on all age-appropriate vaccines for the purpose of calculating an immunization rate, compare the student’s current immunization record with the number and type of vaccines they should have for their current age. Denote the immunizations the student has received on the WORKSHEET TO DETERMINE IMMUNZATION STATUS OF STUDENTS AND CALCULATE RATES and mark if they are current. Repeat this process for each student enrolled in your school.

Hep B Age of Student

By 4 mos. By 6 mos. By 8 mos. By 15 mos. By 19 mos. 2-4 years Kindergarten 6th - 12th Grade

Hepatitis B

DT, DTP, or DTaP, Tdap Diphtheria, Tetanus, Pertussis

IPV

MMR

Inactivated Polio Vaccine

Measles, Mumps, Rubella

Varicella

Hib

PCV7 or PCV13

Chickenpox

Haemophilus influenzae type b

Pneumococcal Disease

Required number of doses 1 2 2 2

Required number of doses 1 2 3 3

Refer to footnote^ Refer to footnote^

Refer to footnote° Refer to footnote°

Required number of doses 1 2 3 3

Required number of doses 1 2 2 2

Required number of doses 0 0 0 1

3 3

4 4 or 5*

3 3 or 4+

1 2

Primary Series 3 or 4+ 2 2 0 0 + 1 Tdap* * DT, DTP, DTaP - 5 doses are required however, if the 4th dose is given on or after the 4th birthday, the child has met the requirement. Tdap - One dose of Tdap is required for 6th - 12th grades. +IPV - 4 doses are required however, if the 3rd dose is given on or after the 4th birthday, the child has met the polio requirement. ^The number of Hib doses required depends on the child’s current age and the age when the Hib vaccine was administered: If any dose is given at or over, 15 months, the Hib requirement is met. Children who begin the series before 12 months, 3 doses are required, and at least 1 dose must be at, or over, 12 months. If the 1st dose was given at 12 to 14 months, 2 doses are required. If the current age is 5 years or older, no new or additional doses are required. °The number of doses of pneumococcal conjugate vaccine (PCV7 or PCV13) depends on the student’s current age and the age when the 1st dose was administered. If the 1st dose was administered between 2 to 6 months of age, the child will receive 3 doses plus an additional dose between 12 to 15 months of age. If started between 7 to 11 months of age, the child will receive 2 doses plus an additional dose between 12 to 15 months of age. If the 1st dose was given between 12 to 23 months of age, 2 doses, 2 months are required. Any dose given at 24 months through 4 years of age, the PCV vaccine requirement is met. No doses required once the child turns 5 years of age.

Defined as a public, private, or parochial nursery school, day care center, child care facility, family child care home, foster care home, Head Start program, kindergarten, or elementary or secondary school through grade twelve, or a college or university. “School” does not include a public services short-term child care facility as defined in section 26-6-102 (6.7), C.R.S., a guest child care facility as defined in section 26-6-102 (5), C.R.S., a ski school as defined in section 26-6-103.5 (6), C.R.S., or college or university courses which are offered off-campus; or are offered to nontraditional adult students, as defined by the governing board of the institution; or are offered at colleges or universities which do not have residence hall facilities.

WORKSHEET TO DETERMINE IMMUNZATION STATUS OF STUDENTS AND CALCULATE RATES In May 2014, the Colorado General Assembly passed House Bill 14-1288 (HB-1288). Signed by Governor Hickenlooper, HB-1288 will take effect on July 1, 2014. Per HB-1288, “each school 1 shall make the immunization and exemption rates of their enrolled student population publicly available, upon request” and the Colorado Department of Public Health and Environment shall “provide assistance to schools with the analysis and interpretation of the immunization data.” Please note that this tool is meant to provide a very simple manual method to determine immunization and exemption rates for schools that do not have another process in place. This method is not consistent with all of the requirements of the ACIP recommended schedule of immunizations and only takes into account the number of doses a student has received; not whether the doses were given at the correct age or meets minimum interval requirements. 1. Use this worksheet to record the number of doses of vaccine each student has received. 2. Make a check √ in the one appropriate column to the right if the child is In Process (does not have all required doses but has a plan in place), has claimed a Medical, Religious or Personal Exemption, or has No Record on file. 3. If the student has received the correct number of doses of all the required vaccines, check the Up to Date column to the far right. 4. Use additional worksheets as needed to record all your enrolled students. 5. On the subtotal line of each page, count the number of students, the number of students claiming an exemption, and the number of students fully up to date. 6. Use the final page summary table to calculate your rates. Required by 4 months • 1-DTap • 1 Polio • 1 Hib • 1 Hep B • 1 PCV

Required by 6 months • 2 DTap • 2 Polio • 2 Hib • 2 Hep B • 2 PCV

Required by 8 months • 3 DTap • 2 Polio • 2 Hib • 3 Hep B • 3 PCV

Required by 15 months • 3 DTap • 2 Polio • 2 Hib • 3 Hep B • 3 PCV13 • 1 MMR • 1 Varicella

Required by 19 months • 4 DTap • 3 Polio • 3 Hib • 3 Hep B • 4 PCV13 • 1 MMR • 1 Varicella

Required for Kindergarten entry (K-5th Grades) • 4/5 DTap • 3/4 Polio • 3 Hep B • 2 MMR • 2 Varicella

Required for 6th – 12th Grades • 4/5 DTap plus one Tdap • 3/4 Polio • 3 Hep B • 2 MMR • 1-2 Varicella

Please see ACIP schedule/catch up schedule for additional guidance: http://www.cdc.gov/vaccines/schedules/ Name/initials column is optional for individual student identification.

[Check one correct column for each student] Name or initials

Age

Subtotal

# Hep B

# DTaP/ Tdap

# Polio

# MMR

# VAR

# HIB

# PCV

In Process (√)

Medical, Religious or Personal Exemption(√)

No Record (√)

Up to Date (√)

Subtotals : 3

IMMUNIZATION AND EXEMPTION RATE SUMMARY REPORT FOR YOUR CHILD CARE/SCHOOL 1. Add the subtotals from the worksheets to get the total number of students, the total number of students with exemptions and the total number of students that are up to date. 2. Fill in the table below with the totals for your facility. 3. Calculate the rates for your facility using the guidance below.

All Students: Total # Exemptions

Total # Students

Immunization Rate = Total # Up To Date รท Total # of students

Exemption Rate

Total # Up to Date

= _______ multiply by 100 to get a percentage __________%

= Total # Exemptions รท Total # of students = _______ multiply by 100 to get a percentage __________%

Note: The rate of up to date students plus the rate of students with exemptions will not always total 100% unless you have no in-process students and have an immunization record or exemption on every student. For comments or questions, please email cdphe.dcdimmunization@state.co.us

Can’t find your old immunization records? Where to begin to look for lost immunization records

Check your home: ask your parents, look in baby books, old baby files or filing cabinets Contact the last or most recent place you were vaccinated: family doctor, local health department immunization clinic, student health services, travel clinic, military, or other healthcare provider Contact the last or most recent place that required an immunizations record: child care center, school, college/university, workplace Contact State or Local Health Department Immunization Registries (in counties and states where you have been vaccinated before): 

Jeﬀerson County Immunization Clinic: 303-232-6301 www.jeﬀco.us/health



Colorado: 303-692-2437 www.colorado.gov www.cdphe.state.co.us



Other states: 1-800-CDC-INFO www.cdc.gov

No national organization maintains immunization records here in the United States. In most states it is the responsibility of the parent or individual to keep a record of their immunizations. Some doctors’ oﬃces, schools and clinics may keep records for a short period of time, check with individual providers for exact amount of time.

¿No encuentra su tarjeta de vacunas? Donde comenzar a buscar su tarjeta de vacunas

Busque en su casa; pregunte le ha su padres, busque en los libros de bebé, en archivos de bebé o en gabinetes de archivos. Contacte el último o más reciente lugar que usted recibió vacunas; su medico, el departamento de salud publica la clínica de vacunas, los servicios de salud para estudiantes, la clínica de viajes, el militar u otro proveedor de cuidado de salud. Contacte el ultimo o mas reciente lugar que requiero la tarjeta de vacunas; la guardería, la escuela, el colegio / universidad, lugar de empleo. Contacte el estado o el registro de vacunas de su Departamento de Salud (en condados y estados donde usted se ha vacunado); 

Condado de Jeﬀerson la clínica de vacunas: 303-232-6301 www.jeﬀco.us/health



Colorado: 303-692-2437 www.colorado.gov www.cdphe.state.co.us



Otros estados: 1-800-CDC-INFO www.cdc.gov

Ninguna organización nacional mantiene la información de vacunas en los Estados Unido. En casi todos los estados es la responsabilidad del padre o individual que mantengan la tarjeta de vacunas. Unas oficinas de doctores, escuelas y clínicas pueden mantener la información de vacunas por un tiempo corto, pregunte con cada individual para estar seguro cuanto tiempo mantienen la información de vacunas.

Can’t find your old immunization records? It’s important to keep immunization records for you and your child. You may need these records for child care, school, camp, college, the military, travel, or employment. If you don’t have these records, you can...

Check your home, ask your parents, look in baby books, old baby files or filing cabinets.

Contact the last or most recent place you were vaccinated: family doctor, local health department immunization clinic, student health services, travel clinic, military, or other healthcare provider.

Other JCPH Services Birth & Death Certificates Emergency Preparedness Environmental Health Family Planning Food Safety Health Care Resources Health Education Preventive Screenings

Immunizations

STD / HIV Counseling & Testing WIC (Women, Infants & Children)

Contact the last or most recent place that required an immunization record: child care center, school, college/university, or workplace.

Contact State or Local Health Department Immunization Registries (in counties and states where you have been vaccinated before).

Bring Your Immunization Record to Each Visit CIIS

Colorado Immunization Information System: Keeps track of your immunization records electronically.

Public Health, Every day, Everywhere, Everyone

Jefferson County Public Health 645 Parfet Street Lakewood, CO 80215 (303) 232-6301 Fax: (303) 239-7088 jeffco.us/public-health January 2016

Jefferson County Public Health 303-239-7078 Recorded Information Line: 303-239-7187 Recorded Information Line Spanish: 303-239-7192

jeffco.us/public-health Public Health, Every day, Everywhere, Everyone

The only way to protect yourself from certain diseases is to get immunized. Immunizations don't stop after childhood, it’s important to stay up-to-date at every age. Certain diseases like whooping cough, measles and chicken pox, can spread rapidly. Immunizations protect loved ones and your community from disease, including the vulnerable members such as infants and others who may not be able to immunized. It only takes a small number of unprotected people to cause a disease outbreak. Some vaccines need more than one dose to be effective. If a person hasn’t received all of the scheduled doses they need, they can still get seriously ill.

Included is a list of some of the available immunizations at Jefferson County Public Health. For the most current immunization schedule, please visit the Centers for Disease Control and Prevention (CDC) website - www.cdc.gov/vaccines.

ld Tee n Ad u lt *

Available Immunizations C hi

Protect Yourself, Your Family and Your Community

Diphtheria, Tetanus & Pertussis (DTaP)



Polio (IPV)

  

Measles, Mumps & Rubella (MMR)

  

Haemophilus Influenza (Hib)



Hepatitis B (Hep B)

  

Varicella (Chicken Pox)

  

Pneumococcal Disease (PCV 13 or PPSV23)



Hepatitis A (Hep A)

  

Rotavirus (Rota)



Influenza (Flu)

  



Tetanus, Diphtheria & Pertussis (Td/Tdap)

 

Human Papillomavirus (HPV)

 

Meningococcal (MCV)

 

Shingles (Zoster)



Hepatitis A&B (Twinrix)



*Tdap and Flu vaccines are strongly recommended during PREGNANCY.  Vaccines may be recommended depending on the individual’s occupation or situation. JCPH Immunization Program also provides travel vaccines such as Typhoid and Yellow Fever.

Location and Fees JCPH offers low cost immunizations for adults and children that vary depending on the vaccine requested and insurance coverage. Service will not be denied due to inability to pay for any childhood vaccine and fees may be waived. All immunizations are provided by appointment only. Medicaid, Medicare, CHP+ and some health insurance accepted, please check when making your appointment. Please call for more information and to schedule an appointment.

LAKEWOOD CLINIC: 645 Parfet Street Lakewood, CO 80215 (303) 239-7078

Jefferson County Public Health frequently called numbers:

Jefferson County Public Health

Locations

Administration

303-232-6301

After Hours Answering Services

303-232-6301

Billing, Patient Accounts

303-232-6301

Clinic Appointments

303-239-7078

Communicable Disease Control

303-239-7086

Epidemiology (Disease surveillance)

303-271-5742

Emergency Preparedness & Response

303-271-8391

Healthy Communities / Medicaid

303-239-7041

Environmental Health Services

303-232-6301

HCP Children with Special Needs

303-239-7014

Health Education

303-275-7555

HIV/AIDS Prevention (recorded)

303-239-7036

HIV Counseling & Testing

303-239-7078

Immunizations, Recorded Information

303-239-7187

Injury Prevention

303-239-7045

Medical Records

303-239-7158

Septic System Inspections

303-239-7070

Tobacco Prevention

303-275-7555

STD Clinic

303-239-7078

Vital Records, Birth & Death Certificates

303-271-6450

Jefferson County Public Health

WIC Supplemental Food Program

303-271-5780

645 Parfet Street, Lakewood, CO 80215

Administration 645 Parfet Street, Lakewood, CO 80215 Lakewood 645 Parfet Street, Lakewood, CO 80215 Arvada - WIC 6303 Wadsworth Bypass, Arvada, CO 80003

Public Health...

Edgewater - WIC 1711 A & B Sheridan Blvd , Edgewater, CO 80214 Lakewood - WIC 645 Parfet Street, Lakewood, CO 80215 Vital Records 800 Jefferson County Pkwy. Ste. 1300, Golden, CO 80401 Emergency Preparedness 800 Jefferson County Pkwy. Golden, CO 80401

Every day, Everywhere, Everyone

Jefferson County Public Health 303-232-6301 jeffco.us/public-health

303-232-6301 jeffco.us/public-health

Public Health... Every day, Everywhere, Everyone

May 2015

Public Health...Every day, Everywhere, Everyone

Environmental Health Consumer Protection-303-232-6301 • Food safety and sanitation • Temporary food events inspections • Child care center inspections • Pools, camps, penal facilities • Educational classes for restaurant workers • Foodborne illness investigations • School safety • Establishment plan reviews • Emergency preparedness and response Environmental Protection-303-232-6301 • • • • • • • • • • •

Hazardous materials Groundwater Engineering Pollution prevention Solid waste Environmental site assessments Water quality Air quality Radon mitigation ISDS/OWTS inspection and review Zoonosis (animal-borne disease control)

Health Promotion Nutrition Services 303-239-7143 • Nutrition education and counseling • Breastfeeding classes and resources • WIC Program (Women, Infants, Children) • Nutrition Services for Children with Special Needs Health Education 303-275-7555 • Tobacco-use reduction (education, prevention, cessation and control) • Teen health and teen outreach • Resource library • Capacity building and technical assistance Health Communications 303-239-7137 • Public information, graphic design, multimedia, web site, educational and informational materials

Administrative Services Financial Management and Budgeting Agency Management and Support • Facility management, computer support, agency courier, purchasing, legal services. Epidemiology • Disease surveillance and control 303-271-5742 • Health data and statistics 303-271-8393

Emergency Preparedness and Response 303-271-8391 Vital Records 303-271-6450 • Birth and death certificates

Community Health Clinical Services 303-239-7078 • Family Planning • HIV Counseling and Testing • Immunizations • Sexually transmitted disease testing and treatment • TB skin testing • Adult physical examinations Communicable Disease Prevention & Control 303-239-7086 Health Care Access-303-232-6301 • Healthy Communities/Medicaid • HCP -Children with Special Needs • Referral to community resources Public Health Nurse Home Visits • Prenatal Plus-303-275-7511 • Nurse Family Partnership–303-239-7074 Public Health Nursing Across the Lifespan 303-239-7045 • Community Partnerships and Outreach • Public Health Nurse and Human Services Collaboration • Injury Prevention • Cavity Free at Three-dental screenings

Jefferson County Public Health números más frequentes

Jefferson County Public Health

Localidades

Administración

303-232-6301

Servicio de Conntestación Automática

303-232-6301

Facturas, Cuentas de Paciente

303-232-6301

Citas para las Clínicas

303-239-7078

Control de las Enfermedades Transmisibles

303-239-7086

Epidemiología (Vigilancia de las Enfermedades)

303-271-5742

Preparación y Respuesta ante Emergencias

303-271-8391

Comunidades Saludables/ Medicaid

303-239-7041

Servicios de la Salud Ambiental

303-232-6301

HCP Niños con Necesidades Especiales

303-239-7014

Educación de Salud

303-275-7555

Prevención del VIH/SIDA (pregrabado)

303-239-7036

Asesoriamiento y Pruebas para el VIH

303-239-7078

Inmunizaciones, Información Grabada

303-239-7187

Prevención de Lesiones

303-239-7045

Historias Clínicas

303-239-7158

Inspecciones de Sistema Séptico

303-239-7070

Prevención de Tabaco

303-275-7555

Clínica para Enfermedades de Transmisión Sexual

303-239-7078

Documentos Vitals, Partidas de Nacimiento y de Defunción

303-271-6450

WIC Programa de Alimentos Suplementales

303-271-5780

Administración 645 Parfet Street, Lakewood, CO 80215 Lakewood 645 Parfet Street, Lakewood, CO 80215 Arvada - WIC 6303 Wadsworth Bypass, Arvada, CO 80003

La Salud Pública...

Edgewater - WIC 1711 A & B Sheridan Boulevard, Edgewater, CO 80214 Vital Records (Documentos Vitals) 800 Jefferson County Pkwy. Ste. 1300, Golden, CO 80401 Preparación para Emergencias 800 Jefferson County Pkwy. Ste. 1300, Golden, CO 80401

Jefferson County Public Health 645 Parfet Street Lakewood, CO 80215

Todos los días, En todas partes, Para todos

Jefferson County Public Health 303-232-6301 jeffco.us/public-health

(303) 232-6301 jeffco.us/public-health La salud pública...cada día, donde quiera, para todos

Mayo 2015

Salud Pública… todos los días, en todas partes, para todos

Salud Ambiental Protección para Consumidores-303-232-6301 • Seguridad de los alimentos y saneamiento • Inspección temporal de eventos de comida • Inspecciones de centros de cuidado infantil • Piscinas, campamentos, instalaciones penales • Clases educativas para trabajadores de restaurantes • Investigaciones de enfermedades transmitidas por alimentos • Seguridad en la escuela • Evaluaciones de planes de establecimientos • Preparación y respuesta de emergencias

Protección Ambiental-303-232-6301 • • • • • • • • • •

Materiales peligrosos Agua subterránea Ingeniería Prevención de polución Desperdicios sólidos Evaluaciones ambientales Calidad del agua Calidad del aire Mitigación de radón ISDS/OWTS Inspección y evaluación de sistemas para el tratamiento de desperdicios humanos • Zoonosis ( control de enfermedades transmitidas por animales)

Promoción de la Salud

Salud Comunitaria

Servicios Nutricionales 303-239-7143

Servicios de la Clínica 303-239-7078

• Asesoría y educación de nutrición • Recursos y clases de lactencia • El Programa WIC (para mujeres, bebés y niños) • Servicios nutricionales para niños con necesidades especiales

Educación de Salud 303-275-7555* • Reducción del uso del tabaco (educacion, prevencion, control y cesación) • Salud para adolescents • Biblioteca de recusrsos • Asistencia técnica *Deje un mensaje, y un miembro del personal que habla español responderá a su llamada.

Comunicaciones de Salud 303-239-7137 • Información pública, diseño gráfico, multimedia,

página web, materiales educativos e informativos

Servicios Administrativos Administración Financiera y de Presupuestos Agencia de Administración y Apoyo • Administración de instalaciones, soporte de computadoras, agencia de correo, compras, servicios jurídicos.

Epidemiología • Datos y estadísticas de salud 303-271-8393 • Supervisión y control de enfermedades 303-271-5742

Preparación y Respuesta de Emergencia 303-271-8391 Documentos Vitales 303-271-6450 • Certificados de nacimiento y de fallecimiento

• • • •

Planificación familiar Asesoriamiento y pruebas para el VIH Vacunas Pruebas y tratamiento para infecciones transmitidas sexualmente • Prueba de tuberculosis • Chequeo fisico para adultos

Prevención y Control de Enfermedades Transmisibles 303-239-7086 Acceso al Cuidado de Salud 303-232-6301 • Comunidades saludables/Medicaid • HCP– Niños con necesidades especiales • Recursos comunitarios de salud

Vistas a Domicilio de las Enfermeras de Salud Pública Prenatal Plus-303-239-7135 Nurse Family Partnership-303-239-7074

Enfermeras de Salud Pública 303-239-7045 • Asociación Comunitaria • Enfermeras de Salud Pública y Colaboración de Servicios Humanos • Prevención de Lesiones • Cavity Free at Three-exámenes dentales

Vaccines for Children Program (VFC) Information for Parents from CDC G e t

H e l p

P a y i n g

f o r

YO U R

How can I get help paying for my child’s vaccines? Since 1994, parents have been protecting their children through the VFC Program. This program provides free vaccines to children whose parents need help paying for them.

Is my child eligible for the VFC Program? Your child is eligible if it is before his or her 19th birthday, and if he or she is one of the following: ► Medicaid-eligible ► Uninsured ► American Indian or Alaska Native ► Underinsured (Underinsured children are only eligible for VFC Vaccines through Federally Qualified Health Centers and Rural Health Clinics.)

What do you mean by “underinsured?” Underinsured means your child has health insurance, but it won’t cover the vaccine(s) because: ► It doesn’t cover any vaccines. ► It doesn’t cover certain vaccines. ► It covers vaccines, but it has a fixed dollar limit or cap for vaccines. Once that fixed dollar amount has been reached, your child is eligible.

Where can I go to get my child vaccinated? Ask your doctor if he or she is a VFC Program provider. There are over 40,000 doctors enrolled in the VFC Program nationwide.

C h i l d ’ s

V a cc i n e s !

How much will I have to pay? All vaccines are free through the VFC Program, saving you $100 or more on some vaccines. Even though you’re saving a great deal of money by getting free vaccines, there can be other costs to the VFC visit: ► Doctors can charge a fee to give each shot. However, VFC vaccines cannot be denied to an eligible child if the family cannot afford the fee. ► There can be a fee for the office visit. ► There can be fees for non-vaccines services, like an eye exam or a blood test.

My child’s doctor isn’t a VFC provider. Where can I take my child for vaccines? If your child’s doctor isn’t a VFC provider, you can take your child to one of the following places to get VFC vaccines: ► Public Health Clinic ► Federally Qualified Health Center (FQHC) ► Rural Health Clinic (RHC) The best place to take your child depends on where you live and how your child is eligible for the VFC Program. Before you go, contact your state’s VFC coordinator and ask where you should take your child for vaccines. You can find your state’s VFC coordinator at this website: www.cdc.gov/vaccines/ programs/vfc/contacts-state.html. Or call 1-800CdC-info (232-4636). Ask for the phone number for your state’s VFC coordinator.

For more information about the VFC Program, you can go to CDC’s VFC webpage at www.cdc.gov/vaccines/ programs/vfc/ or call 1-800-CdC-info (232-4636) and ask for information about the VFC Program. May 2011

CS204495-C

Section Five: Communicable Disease       

Jefferson County Infectious Diseases: How they spread and how to stop them! Jefferson County Immunization Poster- Infant (English/Spanish) Jefferson County Immunization Poster- Kindergarten (English/Spanish) “Protect Against Pertussis” (English/Spanish) Influenza Poster “Q&A Influenza: What you should know” Infectious Diseases in Childcare and School Settings Manual (3/2016)

For more information, please visit: http://vaccine.chop.edu http://www.cdc.gov/pertussis/ http://www.cdc.gov/flu/index.htm http://jeffco.us/public-health/healthy-families/immunizations/

Prevent the spread of infectious diseases

Decrease your risk of infecting yourself or others: ◦

◦

Wash your hands often. This is especially important before and after preparing food, before eating and after using the toilet. Get vaccinated. Immunization can drastically reduce your chances of contracting many diseases. Make sure to keep your recommended vaccinations, as well as your children’s, up-to-date. Use antibiotics sensibly. Only take antibiotics when necessary. And if they’re prescribed, take them exactly as directed — don’t stop taking them early because your symptoms have abated. Stay at home if you have signs and symptoms of an infection. Don’t go to work if you’re vomiting, have diarrhea or are running a fever. Don’t send your child to school if he or she has these signs and symptoms, either. Be smart about food preparation. Keep counters and other kitchen surfaces clean when preparing meals. In addition, promptly refrigerate leftovers — don’t let cooked foods remain at room temperature for an extended period of time. Disinfect the ‘hot zones’ in your home. These include the kitchen and bathroom — two rooms that can have a high concentration of bacteria and other infectious agents. Practice safe sex. Use condoms if you or your partner has a history of sexually transmitted diseases or high-risk behavior — or abstain altogether. Don’t share personal items. Use your own toothbrush, comb or razor blade. Avoid sharing drinking glasses or dining utensils. Travel wisely. Don’t ﬂy when you’re ill. With so many people conﬁned to such a small area, you may infect other passengers in the plane. And your trip won’t be comfortable, either. Depending on where your travels take you, talk to your doctor about any special immunizations you may need. Keep your pets healthy. Bring your pet to a veterinarian for regular care and vaccinations. Feed your pet a healthy diet and keep your pet’s living area clean.

Public Health...Every day, Everywhere, Everyone

Food Contamination

Another way disease-causing germs can infect you is through food and water. Common-vehicle transmission allows the germs to be spread to many people through a single source. Food is the vehicle that spreads the germs and causes the illness. For instance, contamination with Escherichia coli (E. coli) is common. E. coli is a bacterium present in certain foods — such as undercooked hamburger or unwashed fruits or vegetables. When you eat foods contaminated with E. coli, chances are you’ll experience an illness — also commonly referred to as food poisoning.

Jefferson County Public Health

Infectious Diseases: How they spread and how to stop them!

Adapted from content provided by The Mayo Clinic.

Jefferson County Public Health Lakewood

Arvada Edgewater

(303) 232-6301

Jefferson County Public Health

303-232-6301

jeffco.us/public-health

jeffco.us/public-health January 2014

Public Health...Every day, Everywhere, Everyone

Infectious diseases spread through contact! From the person snifﬂing next to you in line, to the raw chicken on your cutting board, or the doorknob leading into your ofﬁce, everyday life is full of potential infectious hazards. With germs so common and seemingly everywhere, the question is: How do you get around them and protect yourself? Knowing how germs spread, can help you stop them in their tracks. Find out how infectious disease is transmitted and what you can do to minimize your risk of infection. Direct Contact

The easiest way to catch most infectious diseases is by coming in direct contact with someone, (person, animal, or for an unborn child, the mother) who is infected.

Three different ways infectious disease can be spread through direct contact are:

•

Person to person.

The most common way for infectious disease to spread is through the direct transfer of bacteria, viruses or other germs from one person to another.

This can occur when an individual with the bacterium or virus touches, coughs on or kisses someone who isn’t infected. These germs can also spread through the exchange of body ﬂuids from sexual contact or a blood transfusion.

•

Animal to person.

•

Mother to unborn child.

Pets can carry many germs. Being bitten or scratched by an infected animal can make you sick and, in extreme circumstances, may even cause death. Handling animal waste can be hazardous, too. You can become infected by scooping your cat’s litter box or by cleaning bat or mouse droppings in your house, garage or cabin. A pregnant woman may pass germs that cause infectious diseases on to her unborn baby. Germs can pass through the placenta. Germs can also be passed along during labor and delivery. Indirect Contact

Disease-causing organisms can also be passed along by indirect contact. Many germs can linger on an inanimate object, such as a tabletop, doorknob or faucet handle. When you touch the same doorknob grasped by someone infected with the ﬂu or a cold, for example, you can pick up the germs he or she left behind. If you then touch your eyes, mouth or nose before washing your hands, you may become infected.

Infectious diseases spread through vectors and vehicles!

Bites and stings

Some germs rely on insects — such as mosquitoes, ﬂeas, lice or ticks — to move from host to host. These carriers are known as vectors. Mosquitoes can carry the malaria parasite or West Nile virus, and deer ticks may carry the bacterium that causes Lyme disease.

The vector-borne spread of germs happens when an insect that carries the germ on its body or in its intestinal tract lands on you or bites you. The germs travel into your body and can make you sick. Sometimes the germs that cause infectious disease need the insect for speciﬁc biological reasons. They use the insect’s body to multiply, which is necessary before the germs can infect a new host.

Infectious diseases spread through the air!

Droplet transmission When you cough or sneeze, you send out droplets into the air around you. When you’re sick with a cold or the ﬂu — or any number of other illnesses — these droplets contain the germ that caused your illness. Spread of infectious disease in this manner is called droplet spread or droplet transmission. Droplets travel only about three feet because they’re usually too large to stay suspended in the air for a long time. However, if a droplet from an infected person comes in contact with your eyes, nose or mouth, you may soon experience symptoms of the illness. Crowded, indoor environments may promote the chances of droplet transmission — which may explain the increase in respiratory infections in the winter months. Particle transmission Some disease-causing germs travel through the air in particles considerably smaller than droplets. These tiny particles remain suspended in the air for extended periods of time and can travel in air currents. If you breathe in an airborne virus, bacterium or other germ, you may become infected and show signs and symptoms of the disease. Tuberculosis and SARS are two infectious diseases usually spread through the air, in both particle and droplet forms.

Love Them, Protect Them, Immunize Them

Immunize Your Child Now! Immunizations are the most important action parents can take to protect their children against 14 serious childhood diseasesâ&#x20AC;&#x201D;including the flu.

Make sure your children get all their shots by age 2. 2 HAV

3 HBV

(diphtheria, tetanus, pertussis)

(Hepatitis A)

(Hepatitis B)

4 Hib

1 MMR

3 IPV

(haemophilus influenza B)

(measles, mumps, rubella)

(polio)

4 PCV7

2 Influenza

1 Varicella

(pneumonia)

(influenza)

(chickenpox)

4 DtaP

Please call your doctor for an appointment. If you do not have a family doctor, you can receive these shots at the Jefferson County Public Health at:

303-232-6301

3 Rotavirus (rotavirus) Immunization recommendations are subject to change

5/11

303-232-6301

www.childrensimmunization.org

Ámelos.

Protéjalos.

Vacúnelos.

Lleve a su niño/a para vacunas hoy mismo! Estas son las acciónes mas importantes que pueden tomar los padres para proteger a sus niños contra 14 enfermedades graves de la niñez – incluyendo la gripe.

Asegurese que sus niños hayan recibido todas las vacunas al cumplir los 2 años. 2 HAV

3 HBV

(difteria-tétano-tos ferina)

(Hepatitis A)

(Hepatitis B)

4 Hib

1 MMR

3 IPV

(haemophilus influenza B)

(sarampión-paperas-rubéola)

(polio)

4 PCV7

2 Influenza

1 Varicella

(pneumonia)

(influenza)

(chickenpox)

4 DtaP

3 Rotavirus

Por favor llame a su doctor para pedir una cita. Si no tiene un doctor para su familia, su niño(a) puede recibir estas vacunas en El Departamento de Salud Pública y Medio Ambiente de Jefferson County:

303-232-6301

(rotavirus) Recomendaciones para vacunes están disponible de cambiar.

303-232-6301 5/11

www.childrensimmunization.org

Love Them, Protect Them, Immunize Them

Immunize Your Child Now!

Immunizations are the most important action parents can take to protect their children against 13 serious childhood diseasesâ&#x20AC;&#x201D;including the flu.

Make sure your children are ready for kindergarten entry. 5/4 DtaP

(diphtheria, tetanus, pertussis)

4 PCV13

(pneumonia)

4/3 IPV (polio)

3 HBV

Hepatitus B

4 Hib

(haemophilus influenza B)

2 MMR

(measles, mumps, rubella)

2 HAV

(Hepatitis A)

2 Varicella

(chickenpox)

Please call your doctor for an appointment. If you do not have a family doctor, you can receive these shots at the Jefferson County Public Health at:

303-232-6301

Influenza

Immunization recommendations are subject to change.

303-232-6301 12/12

www.childrensimmunization.org

Ámelos.

Protéjalos.

Vacúnelos.

Lleve a su niño/a para vacunas hoy mismo! Estas son las acciónes mas importantes que pueden tomar los padres para proteger a sus niños contra 13 enfermedades graves de la niñez – incluyendo la gripe.

Asegúrese de que sus niños estén listos para comenzar el kinder. 5/4 DtaP

(diphtheria, tetanus, pertussis)

4 PCV13

(pneumonia)

4/3 IPV (polio)

3 HBV

Hepatitus B

4 Hib

(haemophilus influenza B)

2 MMR

(measles, mumps, rubella)

2 HAV

(Hepatitis A)

2 Varicella

(chickenpox)

Por favor llame a su doctor para pedir una cita. Si no tiene un doctor para su familia, su niño(a) puede recibir estas vacunas en Salud Pública del Condado Jefferson.

303-232-6301

Influenza

Recomendaciones para vacunes están disponible de cambiar.

303-232-6301 12/12

www.childrensimmunization.org

Protect Against Pertussis Parents, Teachers, Friends Learn about

Pertussis

Pertussis (whooping cough) is a highly contagious respiratory disease often distinguished by the severe and long-lasting cough of those infected. It is named after the "whoop" sound children and adults make when they try to breathe in during or after a severe coughing spell.

Symptoms: Pertussis usually starts with cold or flu-like symptoms such as runny nose, sneezing, fever and a mild cough. These symptoms can last up to two weeks and are followed by increasingly severe coughing spells. Fever, if present, is usually mild.

How It is Spread: Pertussis (whooping cough) is caused by a bacteria that is found in the mouth, nose and throat of an infected person, and is spread through close contact with discharges from the respiratory tract of infected persons, i.e. when an infected person talks, sneezes, or coughs. Older children and adults commonly spread the disease to infants for whom it can be particularly dangerous and even fatal.

Controlling Spread: Infected family members can spread pertussis throughout the household. If a family member has been diagnosed with pertussis, it is important to discuss with your healthcare provider who may have been exposed and who might benefit from antibiotic therapy to prevent further spread.

How To Prevent Pertussis: The best prevention is immunization. The Colorado Department of Public Tdap booster vaccines Health and Environment is recommending the following: • • • • •

DTaP DTaP DTaP Tdap Tdap

vaccination of all infants at 2, 4 and 6 months vaccination booster for all children at age 12-15 months vaccination booster for all children at age 4-6 years vaccination booster for all adolescents at age 11-12 years vaccination booster for adolescents 13-18 years (who have not received a Tdap booster) • Tdap vaccination for pregnant women during each pregnancy In addition, people who are caring for an infant or are a member of a household with an infant, should be vaccinated. This includes: • All adult infant care providers with Tdap vaccine • Under-immunized preadolescents (ages 7-10 years) with Tdap vaccine.

protect older children and adults from pertussis! Ask your healthcare provider about them or call JCPH Immunization Program at 303-232-6301

Healthy habits

such as washing hands regularly, covering your mouth and nose when coughing or sneezing; avoiding touching eyes, nose and mouth and staying home when ill help to prevent the spread of pertussis and other respiratory illnesses.

Jefferson County Public Health Public Health . . . Everyday, Everywhere, Everyone 303-232-6301 www.jeffco.us/health July 2013

Protéjase Contra la Tos Ferina Padres, Maestros, Amigos ¿Qué es la tos ferina? La tos ferina es una enfermedad contagiosa de las vías respiratorias que se distingue por ataques de tos severos e incontrolables.

Síntomas: Los primeros síntomas de la tos ferina son leves y se asemejan a los del resfriado común incluyendo estornudos, secreción nasal, fiebre no muy alta y tos leve. Al cabo de dos semanas la tos se vuelve intensa y se caracteriza por episodios rápidos y numerosos.

¿Cómo se transmite? La tos ferina es causada por una bacteria que se encuentra en la boca, nariz y garganta de la persona infectada. Se transmite de persona a persona por el contacto directo con moco, secreciones nasales y de la garganta de las personas infectadas. Con frecuencia, los adultos o los hermanos mayores transmiten la tos ferina a los bebes para los cuales la enfermedad puede ser grave e incluso causarles la muerte.

¿Cómo prevenir la propagación de la tos ferina? Si algún miembro de su familia es diagnosticado con tos ferina es importante que hable con su doctor a cerca de las personas que tuvieron contacto con la persona infectada. Su doctor decidirá quien necesita recibir tratamiento antibiótico contra la tos ferina.

¿Cómo prevenir la tos ferina? La vacunación es la mejor forma de prevención contra la tos ferina. El Departamento de Salud Pública y Ambiental del estado de Colorado recomienda lo siguiente: • • • • • •

DTaP DtaP DTaP Tdap Tdap

vacunar a los bebes de 2, 4, y 6 meses vacuna de refuerzo para los niños de 12-15 meses vacuna de refuerzo para los niños de 4-6 años vacuna de refuerzo para los adolescentes de 11-12 años vacuna de refuerzo para los adolescentes de 13-18 años quienes no hayan recibido la vacuna de refuerzo anteriormente Tdap vacuna de las mujeres embarazadas durante cada embarazo

Las personas que cuidan bebes o niños y cualquier miembro de la familia que tenga contacto con ellos debe vacunarse contra la tos ferina: • •

Todos los adultos que cuiden bebes o niños deben vacunase Los adolescentes entre las edades de 7 a 10 años deben recibir la vacuna Tdap si no están completamente vacunados

¡La vacuna de refuerzo Tdap protege a niños y adultos contra la tos ferina! Pregúntele a su doctor sobre el programa de vacunación o llame directamente al 303-232-6301

Hábitos de higiene

como lavarse las manos frecuentemente, cubrirse la boca cuando tosa o estornude, no tocarse los ojos, la nariz o la boca y quedarse en casa cuando se sienta enfermo son medidas que ayudan a prevenir el contagio de la tos ferina y otras enfermedades respiratorias. Jefferson County Public Health 303-232-6301

www.jeffco.us/health

July 2013

Do you feel sick?

Go Home You may have the flu if you have fever or chills AND a cough or sore throat.

If you think you have the flu, stay home except to get medical care. For more information visit www.flu.gov www.jeffco.us/health 303-271-5700 CS206260-B

Influenza: What you should know VA C C I N E E D U C AT I O N C E N T E R

Vo l u m e 1 1 , F a l l 2 0 1 4 Seasonal epidemics of influenza (flu) occur every year in the United States, beginning in the fall. Typically, the epidemics cause thousands to tens of thousands of deaths and about 200,000 hospitalizations each year. Since the 1940s, a vaccine has been available to prevent influenza; unfortunately, the vaccine is not used as much as it should be. To prevent the hospitalizations and deaths caused every year by influenza virus, the Centers for Disease Control and Prevention has recommended that all U.S. citizens more than 6 months of age receive the influenza vaccine. This recommendation has the potential to save thousands of lives.

Q. What is influenza (flu)?

Q. How is the vaccine made?

A. Influenza (flu) is a virus that infects the nose, throat, windpipe and lungs. The virus is highly contagious and is spread from one person to another by coughing, sneezing or talking. Influenza infections typically occur between October and April each year.

A. Traditionally two types of influenza vaccines have been available, often referred to by their method of administration — the shot or the nasal spray. However, in recent years, more vaccine choices have become available, so describing them by the way they are administered is insufficient.

Q. What are the symptoms of influenza? A. Typical symptoms of influenza include fever, chills, muscle aches, congestion, cough, runny nose and difficulty breathing. Other viruses can cause symptoms similar to influenza. But, influenza virus is a more common cause of severe, fatal pneumonia. Most, but not all, people who die from influenza are older than 65. Sadly, last year about 100 children died as a result of influenza. Children younger than 4 often require hospitalization because of high fever, wheezing, croup or pneumonia. Because influenza is a virus, it can’t be successfully treated with antibiotics. While some antiviral medications are available by prescription, not all strains of influenza are susceptible to them, and they work best when used early in the infection.

Q. Who should get the influenza vaccine? A. The influenza vaccine is recommended for everyone 6 months of age and older. Children under 9 years of age require two doses of influenza vaccine separated by four weeks if they have never received an influenza vaccine or have an uncertain vaccination history. The nasal version (FluMist®) is only recommended for healthy people between 2 and 49 years of age and has the advantage of inducing an excellent immune response without requiring a shot. The nasal spray version is preferred for children between 2 and 8 years of age because children are better protected. However, vaccination should not be delayed if this version is unavailable; it is more important to be immunized as soon as possible.

• Trivalent inactivated influenza vaccine – This is the traditional influenza vaccine shot that has been used in the past; it is made by taking three different influenza viruses, growing them (individually) in eggs, purifying them and completely inactivating them with the chemical formaldehyde. A few brands of this vaccine are available with specific ages for use; however, this version is typically given to the broadest group of individuals, including infants. • Quadrivalent inactivated influenza vaccine – This version is made in the same way as the trivalent version; however, it contains four types of influenza viruses. This vaccine is given as a shot and can be used for people 6 months and older. • Cell culture-based influenza vaccine – This version currently contains three different influenza viruses and is made in a manner similar to the other inactivated vaccines; however, instead of growing the viruses in eggs (avian cells), they are grown in mammalian cells. This vaccine represents an advance in technology because it contains less egg protein than the version grown in eggs. It is given as a shot. • Recombinant influenza vaccine – This version of influenza vaccine contains only one surface protein of the virus known as hemagglutinin. The protein is produced by inserting the gene for hemagglutinin into an insect virus that then produces large quantities of the hemagglutinin protein. The protein is purified and used as the vaccine. First available in the fall of 2013, this version represents an advance in technology because it is the first egg protein-free influenza vaccine. This version is given as a shot and can be used in people between 18 and 49 years of age. It currently contains three types of influenza virus. • Live weakened influenza vaccine – This is the traditional nasal spray version of the influenza vaccine; however, it now contains four types of influenza viruses instead of three. The viruses are live, weakened influenza viruses that can grow in the lining of the nose, but not in the lungs. Therefore, the vaccine induces an excellent protective immune response without causing disease. This version is grown in eggs, and as in previous years, can only be used in healthy, non-pregnant 2- to 49-year-olds.

more4

For the latest information on all vaccines, visit our website:

vaccine.chop.edu

Influenza: What you should know Q. Does the influenza vaccine work? A. The influenza vaccine typically prevents about 70 of every 100 people who receive it from developing moderate-to-severe influenza infection; even though the vaccine might not completely prevent influenza infection, it will still lessen the length and severity of the illness.

Q. What is the difference between epidemic, or seasonal, influenza and pandemic influenza? A. Every year in the United States and throughout the world, influenza viruses cause epidemics. Because many people have some immunity, yearly epidemics don’t infect everyone.

A. Immunizations should be administered throughout the season because the peak incidence of influenza can occur as late as February or March.

A pandemic is a worldwide epidemic caused when new strains of influenza virus form. This happens when genetic material from both human and animal strains of influenza mix. Because virtually no one is immune to these new viruses, they have the potential to sweep across the world unchecked. Typically, many more people become ill and die during pandemics than during yearly epidemics.

Q. If I got the influenza vaccine last year, do I need this year’s influenza vaccine?

In 2009 a pandemic centered on the novel H1N1 strain. Luckily, this new strain was not as fatal as some previous pandemic strains. Still, 60 million people in the United States became ill, 270,000 were hospitalized and about 12,000 died. Of those who died, between 1,100 and 1,200 were children, about 10 times the number who die during a normal influenza season.

Q. When should I get the influenza vaccine?

A. Yes, getting the current vaccine is still of benefit for a few reasons. First, some people are not protected after getting the vaccine, so another dose will increase their chance of being protected. Second, antibody levels wane, particularly in the elderly, so another dose will boost antibody levels before the start of influenza season. Finally, sometimes influenza virus changes significantly from one year to the next, so immunization or natural infection the previous year is not protective.

Q. Are the influenza vaccines safe? A. Yes. Influenza vaccine shots can cause pain, redness or tenderness at the site of injection as well as muscle aches and low-grade fever, but because the vaccine viruses are completely inactivated or the vaccine contains only individual proteins, they cannot possibly cause influenza. The live, weakened vaccine can cause mild congestion and runny nose. However, because the live, weakened vaccine has been modified so that it cannot grow in the lungs, it cannot possibly cause pneumonia. Although most versions of the influenza vaccine are made in eggs and some people are severely allergic to eggs, the quantity of egg proteins is typically insufficient to cause a severe allergic response. But just to be sure, adults 1849 years old with severe egg allergies that result in a drop in blood pressure or difficulty breathing should get the egg-free (recombinant) version. Those younger than 18 or older than 49 with severe allergies should consult an allergist, and people of all ages with less severe allergies, such as those who get hives, can get other versions of influenza vaccine; it is suggested that they remain at the provider’s office for 30 minutes after receiving an egg-based version.

Q. Does the influenza vaccine contain thimerosal? A. Some multi-dose preparations of the inactivated influenza vaccine given as a shot still contain a small quantity of the mercury-based preservative known as thimerosal. However, the quantity contained in vaccines does not cause harm. Influenza infections can cause severe illness and death, so the benefits of receiving the vaccine clearly outweigh the theoretical risks. This information is provided by the Vaccine Education Center at The Children’s Hospital of Philadelphia. The Center is an educational resource for parents and healthcare professionals and is composed of scientists, physicians, mothers and fathers who are devoted to the study and prevention of infectious diseases. The Vaccine Education Center is funded by endowed chairs from The Children’s Hospital of Philadelphia. The Center does not receive support from pharmaceutical companies.

Q. Can pregnant women get the influenza vaccine? A. Yes, in fact, this is one of two vaccines that pregnant women are urged to get during pregnancy; the other is Tdap. Because pregnant women are more likely to experience complications and hospitalization as a result of infection with influenza, it is important for them to be immunized. Pregnant women should receive the influenza shot, not the nasal spray and should be immunized early in the pregnancy to afford the longest period of protection.

Q. Can I avoid getting the vaccine and the virus by washing my hands and staying away from others who are ill? A. While careful hand-washing, covering coughs and sneezes, and staying home when ill can help prevent the spread of disease, we cannot be certain that others will do the same. Further, not everyone infected with influenza realizes they are transmitting it since infected people begin to spread the virus a day or two before they have symptoms. So, while these measures can reduce your chance of getting influenza, and in fact helped to stem transmission during the pandemic of 2009, they can only do so much to prevent influenza infections. The reality is that the only way to ensure protection from a specific disease is to have immunity acquired through immunization or previous exposure to the disease.

VA C C I N E E D U C AT I O N C E N T E R

vaccine.chop.edu The Children’s Hospital of Philadelphia, the nation’s first pediatric hospital, is a world leader in patient care, pioneering research, education and advocacy. ©2014 The Children’s Hospital of Philadelphia, All Rights Reserved. • 9480/NP/07-13

Infectious Diseases in Child Care and School Settings

Guidelines for

CHILD CARE PROVIDERS, SCHOOL NURSES AND OTHER PERSONNEL

Communicable Disease Branch 4300 Cherry Creek Drive South Denver, Colorado 80246-1530 Phone: (303) 692-2700 Fax: (303) 782-0338

Updated March 2016

Acknowledgements These guidelines were compiled by the Communicable Disease Branch at the Colorado Department of Public Health and Environment. We would like to thank many subject matter experts for reviewing the document for content and accuracy. We would also like to acknowledge Donna Hite; Reneâ&#x20AC;&#x2122; Landry, RN, BSN; Kate Lujan, RN, MPH; Kathy Patrick, RN, MA, NCSN, FNASN; Linda Satkowiak, ND, RN, CNS, NCSN; Jennifer Ward, RN, BSN; and Cathy White, RN, MSN for their comments and assistance in reviewing these guidelines. Special thanks to Heather Dryden, Administrative Assistant in the Communicable Disease Branch, for expert formatting assistance that makes this document readable.

Revisions / Updates Date

Description of Changes

Pages/Sections Affected

2012

Major revision to content and format; combine previous separate guidance documents for child care and schools into one document

Throughout

Dec 2014

Updated web links due to CDPHE website change; updated several formatting issues; added hyperlinks to table of contents; no content changes

Throughout

May 2015

Added updated FERPA letter from the CO Dept of Education; added links to additional info to the animal contact section in the introduction; added new bleach concentration disinfection guidance

Introduction

Oct 2015

Corrected reporting information for aseptic meningitis

Aseptic Meningitis

Jan 2016

Added information on animals in child care centers; updated bleach recommendations and EPA cleaners link; ensured that these guidelines are consistent with the new child care center regulations; updated reportable disease list; guidance on Clostridium difficile

Introduction, various sections

These guidelines are not a substitute for the

School and Child Care Facility Health and Sanitation Regulations

Child Care Regulations: https://www.colorado.gov/pacific/cdphe/child-care School Regulations: https://www.colorado.gov/pacific/cdphe/schools

Table of Contents (alphabetically by disease name) Diseases in bold are conditions reportable to public health in Colorado. Any outbreak, regardless of etiology or setting, is reportable to public health. Diseases with an asterisk (*) are vaccine preventable diseases. Acknowledgements .................................................................................................. 2 Diseases Grouped by Type of Spread.............................................................................. 5 INTRODUCTION ....................................................................................................... 6 Infectious Disease in Child Care and School Settings ....................................................................... 6 Public Health Reporting Requirements, Case Investigation, and Outbreak Investigation ........................... 6 Schools, Public Health Reporting, and FERPA ............................................................................... 7 Informing Parents of Illness in the Facility .................................................................................. 12 Exclusion Guidelines for Children and Staff ................................................................................ 12 Considerations for Developmentally Disabled or Immunocompromised Children .................................... 13 Illness Transmission ............................................................................................................. 13 Appropriate Antibiotic Use ..................................................................................................... 15 Disease Prevention: Handwashing ............................................................................................ 15 Disease Prevention: Immunizations .......................................................................................... 15 Disease Prevention: Covering Coughs ........................................................................................ 16 Disease Prevention: Food Safety .............................................................................................. 16 Disease Prevention: The Facility Environment ............................................................................. 17 Resources ......................................................................................................................... 20

Animal Bites/Rabies .............................................................................................. 22 Bacterial Meningitis............................................................................................... 24 Bed Bugs............................................................................................................. 25 Campylobacter .................................................................................................... 26 Chickenpox (Varicella)* & Shingles (Herpes Zoster) ......................................................... 27 Chlamydia .......................................................................................................... 29 Clostridium Difficile .............................................................................................. 30 CMV (Cytomegalovirus) ........................................................................................... 32 Common Cold ....................................................................................................... 33 Croup ................................................................................................................ 34 Cryptosporidium .................................................................................................. 35 E. coli O157 & Other Shiga Toxin-Producing Bacteria ..................................................... 36 Fifth Disease ........................................................................................................ 38 Genital Herpes (Herpes Simplex Virus (HSV)) .................................................................. 39 Genital Warts (Human Papillomavirus (HPV)).................................................................. 40 Giardia .............................................................................................................. 41 Gonorrhea .......................................................................................................... 42 Hand, Foot and Mouth Disease ................................................................................... 43 Head Lice (Pediculosis) ........................................................................................... 44

Hepatitis

Hepatitis A* ..................................................................................................... 46 Hepatitis B* ..................................................................................................... 47 Hepatitis C ...................................................................................................... 48 Herpes (Cold Sores, Fever Blisters) ............................................................................. 49 HIV and AIDS ....................................................................................................... 50 Impetigo ............................................................................................................. 51 Influenza* .......................................................................................................... 52 Measles (Rubeola)*................................................................................................ 54 Meningitis

Bacterial Meningitis* .......................................................................................... 24 Viral Meningitis (Aseptic Meningitis) ......................................................................... 81 Molluscum Contagiosum........................................................................................... 55 Mononucleosis ...................................................................................................... 56 MRSA (Methcillin Resistant Staphylococcus aureus) & Staphylococcus aureus ............................ 57 Mumps* ............................................................................................................. 58 Norovirus and Other Viral Gastroenteritis ...................................................................... 59 Pertussis (Whooping Cough)* ................................................................................... 60 Pink Eye (Conjuctivitis) ........................................................................................... 61 Pinworm ............................................................................................................. 62 Pubic Lice (Crabs) ................................................................................................. 63 Rashes ............................................................................................................... 64 Ringworm (Tinea) .................................................................................................. 66 Roseola (Sixth Disease)............................................................................................ 67 Rotavirus ............................................................................................................ 68 RSV (Respiratory Syncytial Virus) ................................................................................ 69 Rubella (German Measles)* ...................................................................................... 70 Salmonella .......................................................................................................... 71 Scabies .............................................................................................................. 72 Sexually Transmitted Infections (general) ................................................................... 74 Shigella.............................................................................................................. 74 Shingles (Herpes Zoster) & Chickenpox (Varicella)* ......................................................... 27 Streptococcal Sore Throat (Strep Throat) ...................................................................... 76 Syphilis .............................................................................................................. 77 Tetanus* ............................................................................................................ 78 Tuberculosis ....................................................................................................... 79 Viral Meningitis (Aseptic Meningitis) ............................................................................ 81 Whooping Cough (Pertussis)* ................................................................................... 60 Infectious Disease in School Settings | Summary Chart ...................................................... 82

Diseases Grouped by Type of Spread Droplet Transmission / Infectious Discharges

Chickenpox (Varicella) .................................................................................................................... 27 Common Cold .............................................................................................................................. 34 Croup ........................................................................................................................................ 35 Fifth Disease ................................................................................................................................ 39 Hand, Foot and Mouth Disease (HFMD) .................................................................................................. 44 Influenza .................................................................................................................................... 53 Meningitis (Bacterial) ...................................................................................................................... 23 Meningitis (Viral) ........................................................................................................................... 82 Mumps ....................................................................................................................................... 59 Pink Eye (Conjunctivitis) .................................................................................................................. 62 RSV (Respiratory Syncytial Virus) ........................................................................................................ 70 Rubella (German Measles) ................................................................................................................ 71 Strep Throat (Streptococcal Sore Throat) .............................................................................................. 77 Whooping Cough (Pertussis) .............................................................................................................. 61

Airborne Transmission

Measles (Rubeola) .......................................................................................................................... 55 Tuberculosis................................................................................................................................. 80

Fecalâ&#x2020;&#x2019;Oral Spread

Campylobacter ............................................................................................................................. 26 Clostridium Difficile ....................................................................................................................... 30 Cryptosporidium ............................................................................................................................ 36 E. coli (including E. coli O157) & Other Shiga Toxin-Producing Bacteria ........................................................... 37 Giardia ....................................................................................................................................... 42 Hand, Foot and Mouth Disease (HFMD) ................................................................................................. 44 Hepatitis A .................................................................................................................................. 47 Meningitis (Viral) ........................................................................................................................... 82 Norovirus and Other Viral Gastroenteritis .............................................................................................. 60 Pinworm ..................................................................................................................................... 63 Rotavirus .................................................................................................................................... 69 Salmonella .................................................................................................................................. 72 Shigella ...................................................................................................................................... 75

Skin Contact / Direct Contact

Animal Bites/Rabies ....................................................................................................................... 21 Bed Bugs ..................................................................................................................................... 25 Chickenpox (Varicella) & Shingles (Herpes Zoster) .................................................................................... 27 Head Lice (Pediculosis) .................................................................................................................... 45 Herpes (Cold Sores, Fever Blisters) ...................................................................................................... 50 Impetigo ..................................................................................................................................... 52 Molluscum Contagiosum ................................................................................................................... 56 MRSA ......................................................................................................................................... 58 Ringworm (Tinea) .......................................................................................................................... 67 Scabies ....................................................................................................................................... 73 Staphylococcus aureus..................................................................................................................... 58 Tetanus ...................................................................................................................................... 79

Blood / Body Secretions Contact

CMV (Cytomegalovirus) .................................................................................................................... 33 Hepatitis B .................................................................................................................................. 48 Hepatitis C .................................................................................................................................. 49 HIV and AIDS ................................................................................................................................ 51 Mononucleosis .............................................................................................................................. 57

Sexually Transmitted Diseases

Chlamydia ................................................................................................................................... 29 Genital Herpes .............................................................................................................................. 40 Genital Warts ............................................................................................................................... 41 Gonorrhea ................................................................................................................................... 43 Hepatitis B .................................................................................................................................. 48 HIV and AIDS ................................................................................................................................ 51 Pubic Lice (Crabs) .......................................................................................................................... 64 Syphilis....................................................................................................................................... 78

INTRODUCTION Infectious Disease in Child Care and School Settings Infectious diseases are caused by organisms such as bacteria, viruses and parasites. Some infectious diseases can be spread from one person to another. Illnesses caused by infectious diseases are a common occurrence in children in child care and school settings. Child care providers, school personnel, and school nurses should be aware of infectious diseases that affect children, and be familiar with how to minimize their spread. These guidelines address infectious diseases often seen in children, and provide ways to prevent, reduce, and control their spread. Most cases of illness are isolated to one child, but occasionally an outbreak of a particular disease can occur in a child care or school setting. Suspected outbreaks of any disease must be reported to the state or local public health agency within 24 hours. These guidelines are based on current health information. Recommendations for handling infectious disease issues in child care and school settings may change as new information becomes available. In addition, new infectious disease concerns sometimes emerge. The Communicable Disease Branch at the Colorado Department of Public Health and Environment (CDPHE) is available to assist child care providers, school personnel, and school nurses when infectious disease issues arise, and can be reached at 303-692-2700. Local public health agencies are available for consultation on infectious disease issues, as well. Contact information for Colorado local public health agencies can be found at: https://www.colorado.gov/pacific/cdphe/find-your-local-publichealth-agency

Public Health Reporting Requirements, Case Investigation, and Outbreak Investigation By law, certain diseases and conditions are reportable to public health for surveillance purposes and so disease control measures can be implemented. Per Colorado regulation 6 CCR 1009-1 “Rules and Regulations Pertaining to Epidemic and Communicable Disease Control,” persons treating or having knowledge of a reportable disease, whether the disease is suspected or confirmed, must report the case to the state or local public health agency. This includes schools and child care providers. A list of diseases and conditions reportable in Colorado is available on page 8 of this document, and also at the following website: https://www.colorado.gov/pacific/cdphe/report-a-disease. This website also contains links to the Colorado statutes and regulations that address disease reporting. When a suspected or confirmed case is reported, public health agencies may conduct an investigation to confirm the diagnosis, assess treatment options (if applicable), determine the cause of the illness, and implement appropriate methods of disease control. Group outbreaks resulting from any cause, including foodborne outbreaks, must be reported to the state or local public health agency within 24 hours. For the purposes of public health reporting, an outbreak is defined as two or more persons ill with similar symptoms within a similar time frame. In an outbreak situation, the state or local public health agency will typically work with the child care facility or school to achieve the following: • • • • •

Control and prevent further spread of disease; Identify ill persons so they can receive proper treatment if indicated; Attempt to identify the source of the outbreak; Identify infection risk factors; Evaluate existing prevention strategies.

Child care facilities and schools can also contact the state and/or local public health agencies about infectious conditions that are not reportable, especially if the facility has questions about notifying parents, exclusion, and disease control measures. Per the Colorado “Rules and Regulations Governing the Health and Sanitation of Child Care Facilities in the State of Colorado” (available at https://www.colorado.gov/pacific/cdphe/child-care), in addition to consulting with the state or local public health agency, child care facilities should also consult with their child care health consultant about any type of communicable disease issue, case, or outbreak. Child care facilities are inspected routinely by either the state or local public health agency to ensure compliance with the health and sanitation regulations. These inspections are typically conducted by Environmental Health Specialists employed at the state/local public health agency. It is acceptable for a child care facility to report cases of illness or outbreaks to the Environmental Health Specialist who conducts the health and sanitation inspections.

Typically, the Environmental Health Specialist will then consult with the public health nurse or epidemiologist within his/her public health agency to determine the best course of action.

To report a suspected or confirmed disease case or outbreak, please contact your local public health agency (contact information can be found at: https://www.colorado.gov/pacific/cdphe/find-your-local-public-health-agency), or CDPHE at 303692-2700 or 800-866-2759 (after-hours 303-370-9395). To the extent it is available, the following information should be reported for all suspected or confirmed cases: Diagnosis Patientâ&#x20AC;&#x2122;s name Date of birth Gender Race and ethnicity Address Phone number Parent/Guardian name Name and address of the responsible health care provider Laboratory test results Case suspected or confirmed

Schools, Public Health Reporting, and FERPA Regarding student confidentiality and privacy, the federal Family Educational Rights and Privacy Act (FERPA) prohibits sharing of health-related information except in certain well-defined circumstances, including, but not limited to: specified officials for audit or evaluation purposes, and appropriate officials in cases of health and safety emergencies. Notifying the state or local public health agency of an urgent reportable disease in a student or an outbreak in a school does not breach FERPA confidentiality laws. In these situations, schools may disclose personally identifiable information to public health officials without prior parent consent. See pages 9-11 for a memo from the Colorado Department of Education that addresses FERPA and public health reporting.

Informing Parents of Illness in the Facility When a child care facility or school has a child or staff member ill with an infectious disease, the question often comes up as to whether the facility needs to send a letter home to parents/guardians of other children, or post a notice at the facility informing parents/guardians of the illness. This is often dependent on the disease, the potential risk of spread to others, the presence of symptoms in other children/staff, and policies in place at the facility. Public health can assist a facility in determining whether or not a letter or notice is necessary.

Exclusion Guidelines for Children and Staff EXCLUDING CHILDREN Excluding (defined as keeping a child from attending the child care or school setting) a child who has an infectious disease from attending child care or school may decrease the spread of illness to others. The decision to exclude is typically based on the disease, and should be made in conjunction with the school nurse or the child care health consultant, the state or local public health agency, health care professionals, and/or parents/guardians. Exclusion recommendations are included for each disease or condition addressed in these guidelines. In situations in which a child does not have a diagnosed disease/condition, but has signs or symptoms indicative of a potentially infectious disease, exclusion may also be warranted. Generally, if any of the following conditions apply, exclusion from child care or school should be considered: • The child does not feel well enough to participate comfortably in usual activities. • The child requires more care than the child care or school personnel are able to provide. • The child is ill with a potentially contagious illness, and exclusion is recommended by a health care provider, the state or local public health agency, or these guidelines. • The child has signs or symptoms of a possible severe illness, such as trouble breathing. In cases in which unvaccinated children are exposed to a vaccine preventable disease (such as measles, mumps, rubella, and pertussis), the state or local public health agency should be consulted in order to determine if exclusion of unvaccinated children is necessary. The chart below lists common symptoms that could possibly be related to an infectious disease. The chart indicates whether it is recommended to exclude a child exhibiting a particular symptom from child care or school. If a child is excluded based on symptoms (and not a diagnosed illness), the child should be allowed to return to child care or school once symptoms have subsided, or a health care provider clears the child or determines the illness is not communicable, provided that the child can participate in routine activities.

SYMPTOM

EXCLUSION GUIDELINES

Cough

Exclusion is recommended if the child is experiencing severe, uncontrolled coughing or wheezing, having difficulty breathing, becoming red or blue in the face, making high-pitched whooping sounds after coughing, or vomiting after coughing.

Diarrhea

Exclusion is recommended if any of the following conditions apply: the child has other symptoms along with the diarrhea (such as vomiting, fever, abdominal pain, jaundice, etc.), the diarrhea cannot be contained in a toilet, there is blood or mucous in the stool, or the child is in diapers.

(defined as stools that are more frequent and looser than usual) Earache

No exclusion is necessary.

Fever

No exclusion is necessary, unless the child has symptoms in addition to the fever, such as a rash, sore throat, vomiting, diarrhea, behavior changes, stiff neck, difficulty breathing, etc.

(defined as a temperature over 101°F orally)

SYMPTOM

EXCLUSION GUIDELINES

Headache

No exclusion is necessary, unless the headache is severe and accompanied by additional symptoms like vision problems, stiff neck, or behavior change.

Jaundice or unusual color of the skin, eyes, stool, or urine

Exclusion is recommended until a medical exam indicates the child does not have hepatitis A.

Mouth sores

Exclusion is recommended if the child is drooling uncontrollably.

Rash

Exclusion is recommended if the child has symptoms in addition to the rash such as behavior change, fever, joint pain, or bruising not associated with injury, or if the rash is oozing or causes open wounds. See page 65 for additional information on rashes.

Stomach ache / Abdominal pain

Exclusion is recommended if the pain is severe, if the pain appears after an injury, or if the child had symptoms in addition to the stomach ache (such as vomiting, fever, diarrhea, jaundice, etc.)

Swollen glands

Exclusion is recommended if the child has symptoms in addition to the swollen glands such as difficulty breathing or swallowing, fever, etc.

Vomiting

Exclusion is recommended if the child has vomited more than two times in 24 hours, if the vomit appears bloody, if the child has a recent head injury, or if the child has symptoms in addition to the vomiting (such as fever, diarrhea, etc.).

What • • •

to do when a child has symptoms while at the school or child care facility: Inform the school nurse, child care health consultant, or designated staff of the symptoms. Separate the ill child from the other children. Inform the ill child’s parents/guardians of the symptoms. If it is determined that the child needs to be excluded, keep the ill child separated from other children until the parent/guardian can pick up the child. • Take the child's temperature. • If a child is coughing or sneezing, remind her/him to cover her/his mouth and to wash her/his hands afterward. • After you touch an ill child, avoid touching other children until you have washed your hands.

EXCLUDING STAFF Occasionally, child care and school personnel become ill with an infectious disease. When this occurs, the child care facility or school should consult with the state or local public health agency to determine whether the ill staff member can work. If ill with diarrhea or vomiting, child care and school personnel should not work until at least 48 hours after the last episode of vomiting or diarrhea. This is especially important for staff that work in food service or handle food in any manner, and for staff that work with infants and toddlers (including staff that prepare and serve bottles to infants/toddlers).

Considerations for Developmentally Disabled or Immunocompromised Children Disease control guidelines for developmentally disabled or immunocompromised children may be different than the guidelines presented in this document. In situations where a developmentally disabled or immunocompromised child has an infectious disease or is exposed to another child with an infectious disease, the child care health consultant or school nurse should be consulted. The state or the local public health agency is also available for consultation.

Illness Transmission Infectious diseases can be spread in a variety of ways, referred to as transmission routes.

DROPLET TRANSMISSION / INFECTIOUS DISCHARGES Diseases with respiratory tract symptoms (runny nose, cough, sore throat, sneezing) are often spread by droplets containing viruses or bacteria or by surfaces contaminated with nose/throat discharges from infected persons. Droplets are generated during coughing, sneezing, or talking. These “large” droplets generally travel less than three feet before falling to the ground and do not remain suspended in the air. Before falling to the ground, droplets may be deposited on the mucous membranes of the eye, nose, or mouth of another person within three feet, resulting in disease transmission. In addition, sick persons, especially children, will often contaminate their hands and other objects with infectious nose/throat discharges. When another person comes in contact with these objects and then touches their eyes, mouth, or nose, he/she can become infected. This type of transmission route is common in child care and school settings. Some of the infections passed in this way are the common cold, chickenpox, croup, fifth disease, hand, foot and mouth disease, influenza, meningitis (viral and bacterial), mumps, rubella, pertussis (whooping cough), pink eye (conjunctivitis), rubella, RSV, and strep throat. AIRBORNE TRANSMISSION This mode of transmission is rare and only a few diseases are spread by this route (such as measles and tuberculosis). Airborne transmission occurs when an infected person coughs, sneezes, or talks and generates very small respiratory particles (droplet nuclei) containing viruses or bacteria. These small particles remain suspended in the air for long periods and can be widely dispersed by air currents. When another person inhales these small particles, they can potentially become ill. FECAL → ORAL TRANSMISSION Intestinal tract infections are often spread through oral ingestion of viruses, bacteria, or parasites found in the stool of an infected person or animal. This type of transmission happens when objects contaminated with microscopic amounts of human or animal feces are placed in the mouth. In child care and school settings, sites frequently contaminated with feces are hands, diaper changing tables, classroom floors, faucet handles, toilet flush handles, toys and tabletops. Fecal→oral transmission can also occur when food or water is contaminated with microscopic amounts of human or animal feces and are then ingested. Organisms spread by this transmission route include: Campylobacter, Clostridium difficile, Cryptosporidium, Shiga toxin-producing E. coli (which includes E. coli O157:H7), Giardia, hepatitis A, Salmonella, Shigella, and a variety of intestinal viruses like norovirus. Other infections like hand, foot and mouth disease, and viral meningitis can also be spread through this route. SKIN CONTACT / DIRECT CONTACT Some infections can be spread directly by skin-to-skin contact, or indirectly by contact with contaminated surfaces like clothing. Chickenpox (varicella), shingles (herpes zoster), herpes, head lice, impetigo, molluscum contagiosum, MRSA, ringworm, scabies, and tetanus are all spread this way. BLOOD / BODY SECRETIONS CONTACT Some infections are transmitted when a cut or mucous membranes (linings of various body parts and internal organs) comes in contact with an infected person's blood or other body secretions like saliva, urine, and seminal and cervical fluids. This type of transmission is very rare in child care and school settings. Diseases such as hepatitis B, hepatitis C, and the human immunodeficiency virus (HIV) can be spread by contact with infected blood. Infected children can possibly transmit these infections through biting if there is visible blood mixed with their saliva (i.e. from bleeding gums). CMV (cytomegalovirus) can be spread by body secretions like urine and saliva, and mononucleosis and some forms of bacterial meningitis can be spread by saliva. SEXUALLY TRANSMITTED DISEASES These diseases are most commonly transmitted by sexual contact, including genital-to-genital, oral-to-genital, or genital-to-anal contact. The STIs described in this section of the guidelines cover only those most common (i.e., situations with which school/child care nurses and personnel are more likely to be confronted). HIV and AIDS, chlamydia, genital herpes, genital warts, gonorrhea, hepatitis B, pubic lice (crabs), and syphilis can be spread in this way. The possibility of sexual abuse must be considered when infections occur in prepubescent children and must be reported to appropriate authorities.

Appropriate Antibiotic Use Antibiotics are important drugs that fight infections caused by bacteria. Over recent decades, bacteria have developed resistance to these drugs, partially due to antibiotic misuse and overuse. While antibiotics should be used to treat bacterial infections, they are not effective and should not be used with viral infections like the common cold, most sore throats, and influenza. Antibiotic-resistant infections may be more difficult to treat and may result in more serious illness if not initially treated with appropriate antibiotics. When someone is prescribed antibiotics by a health care provider for a particular illness, it is important to always follow the prescription and take all prescribed doses, even if the person is feeling better.

Disease Prevention: Handwashing Handwashing is one of the best tools for controlling the spread of infections. All children and staff should perform effective handwashing, which will reduce the amount of illness in child care and school settings. Handwashing technique: • Use SOAP and warm RUNNING WATER. • Rub hands vigorously as you wash them. • Wash ALL surfaces including the backs of hands, wrists, between fingers and under fingernails. • Wash for about 20 seconds, if possible. • Rinse hands well. • Dry hands with a paper towel or air dryer. • If using paper towels, turn off the water using a paper towel instead of bare hands. State health regulations for schools require that soap and paper towels or air dryers be available for all bathroom facilities. Schools often have a problem keeping the restrooms stocked with soap and paper towels due to children playing with the items and clogging toilets or making messes. It is suggested that schools try to find solutions to these problems rather than removing soap and paper towels from the restrooms. When to wash hands: • After using the toilet. • After changing diapers (wash both the staff person’s and child’s hands). • After coughing, sneezing, and wiping your nose or someone else’s nose. • Before eating or drinking. • Before serving food to children. • After cleaning. • After petting/handling animals. • After handling or cleaning an animal’s cage or enclosure. • Whenever hands are dirty. • Food handlers should wash hands before preparing and handling food and when hands are soiled. • Children who are unable to wash their own hands should have assistance from staff. Sanitizing hand gels have increased in popularity. Sanitizing hand gels are not effective when hands are visibly dirty. Children should be supervised when using these products and they should only be used on children over the age of three. The rules and regulations governing both schools and child care prohibit the use of hand sanitizer in lieu of handwashing. It is recommended that these products be used in addition to regular handwashing and only used as the main method of handwashing when facilities are not readily available, such as on a field trip.

Disease Prevention: Immunizations CHILDHOOD IMMUNIZATIONS Immunizations help prevent serious illnesses. State health regulations require children attending out-of-home child care and school settings to be up to date on all immunizations or have a valid exemption (either a medical, religious or personal exemption). Required immunizations for school-aged children include: diphtheria, tetanus, whooping cough (pertussis), polio, measles, mumps, rubella, hepatitis B, and chickenpox (varicella). Required immunizations for child care-aged children include those listed above for school-aged children plus Haemophilus influenzae type B (Hib), and pneumococcal disease. Hepatitis A, influenza, and meningococcal disease vaccines are recommended but not required for school attendance. School and child care facilities should have documentation of the immunization status of all children on file. Information on

immunization requirements and forms can be found at the following website: https://www.colorado.gov/pacific/cdphe/school-immunizations ADULT IMMUNIZATIONS It is strongly recommended that child care and school personnel be vaccinated (or have proof of immunity) against pertussis, diphtheria, tetanus, mumps, measles, polio, chickenpox (varicella), and rubella (German measles). It is especially important for women of childbearing age to be immune to rubella as this infection can cause complications for the developing fetus. Pregnant child care and school personnel who work with young children should tell their physicians they work in these settings.

Disease Prevention: Covering Coughs Influenza and other respiratory illnesses can be spread by coughing, sneezing, or unclean hands. To help prevent the spread of these illnesses, children and staff should try to use proper cough etiquette, including: • Cover your mouth and nose with a tissue when you cough or sneeze; • Put used tissues into the trash; • If a tissue is not available, cough or sneeze into your upper sleeve or elbow, instead of the hands; • Wash your hands often using proper technique. Educational materials on cough etiquette for school and child care settings can be found on the CDC website: http://www.cdc.gov/flu/protect/covercough.htm

Disease Prevention: Food Safety Foodborne illness can often be prevented by adhering to the following safe food handling guidelines: • Train all food handling staff on food safety. • Children and staff handling food must wash their hands prior to handling food. A sink dedicated to handwashing must be used; sinks intended for food preparation must not be used for handwashing. • Ready-to-eat foods like salads, sandwiches, and fruit (basically any food that is not going to be cooked prior to consumption) should not be prepared or handled with bare hands; gloves should be used. • Ill children and staff must not handle food, especially if they are ill with gastrointestinal symptoms like vomiting or diarrhea. • Children or staff with skin lesions on exposed areas like the face, hands, and fingers must not handle food unless the wound is covered with a waterproof bandage and gloves are worn for all food handling activities. • Store food at proper temperatures. Potentially hazardous cold foods like eggs, milk, dairy products, meat products, etc., must be stored at 41°F or below. Hot foods must be held at 135°F or above. • Meat and poultry products must be cooked to the proper temperature. Ground beef must be cooked to an internal temperature of 155°F, and poultry must be cooked to 165°F. • The facility must have a calibrated thermometer on hand to check food temperatures. • Thaw foods in an appropriate manner, such as in the refrigerator, under continuously running cold water in a continuously draining sink, or in the microwave immediately before serving or cooking. • Raw meat and poultry must be stored on the bottom shelf of the refrigerator to prevent contamination of other food items. • Thoroughly wash fresh produce in a clean food preparation sink before preparation. This includes fruits with a peel, such as cantaloupe, watermelon, and avocado prior to cutting. • Use an approved sanitizer on all food contact surfaces. Have a test kit on hand to check the sanitizer concentration to ensure it is at proper levels. • Avoid cross-contamination by washing hands, cutting boards, utensils and dishes between different foods. Use separate cutting boards for produce and raw meats/poultry. • All food products must be stored away from medications, first aid supplies, cleaning products and other chemicals. • Do NOT serve unpasteurized milk, cheese, other dairy products, or juice in the facility. • For regulations covering infant feeding (hygienic practices, food storage, handling bottles, and solid food), please reference chapter 8 in the Colorado “Rules and Regulations Governing the Health and Sanitation of Child Care Facilities in the State of Colorado” (available at: https://www.colorado.gov/pacific/cdphe/child-care). For additional information on food safety, please consult with the state or local public health agency.

Disease Prevention: The Facility Environment KEEP AGE GROUPS SEPARATE Separating children by age groups, particularly in child care facilities, helps to prevent spread of infections to other groups of children and staff; ill children who are being sent home should also be separated from other children. MEAL TIMES Children should not share food, plates, or utensils. Tabletops should be cleaned and sanitized before meals and between different groups of children using the tables. For child care facilities, use a separate utensil for each baby. NAP TIMES (for child care facilities) Children should be provided with their own crib (for infants), or cot or mat (for older children). If this is not possible, they should be provided with their own set of mattress covers and linens (linens should be laundered weekly, if possible). CLEANING, SANITIZING, AND DISINFECTING Cleaning, sanitizing, and disinfecting surfaces in school and child care settings will help prevent transmission of infectious diseases. These terms all have different meanings and involve different types and concentrations of chemicals/solutions. • Cleaning removes visible soil and debris, and is done before sanitizing or disinfecting. Cleaning solutions are typically detergent and water. • Sanitizing kills 99.9% of microorganisms on a surface, so it is unlikely that persons having contact with a sanitized surface would be exposed to disease causing organisms. Unscented household chlorine bleach mixed with water is a common sanitizing solution, although other chemicals are available. Generally, a bleach solution made at a concentration of 50 to 200 parts per million is sufficient for sanitizing surfaces and is not toxic to humans. Because several different bleach concentrations are available for purchase, follow the mixing instructions for sanitizing on the specific bottle of bleach used. Bleach solutions may need to be made every couple of days because the concentration declines with time. If a school or child care center is using a sanitizer other than a bleach solution, they should check with their local public health agency to ensure the chemical meets regulatory requirements. Sanitizing solutions should be stored in a labeled container out of reach of children. ◦ In classrooms with young children, toys should be cleaned and sanitized regularly, especially if the toys are soiled or placed in a child’s mouth. Common areas, desks/tables, doorknobs and handles, faucet handles, toilet seats, and drinking fountains are examples of areas that should be kept clean and periodically sanitized. • Disinfecting kills nearly 100% of microorganisms on a surface, so it is very unlikely that persons having contact with a disinfected surface would be exposed to disease causing organisms. Unscented household chlorine bleach mixed with water (at higher concentrations than used for sanitizing solutions) is also commonly used as a disinfectant, although other chemicals are available. Use disinfectant according to the label on the product or EPA registration. A list of approved disinfectants can be found at https://www.colorado.gov/pacific/cdphe/child-care. In an outbreak situation, public health may recommend using an even stronger bleach solution for disinfecting surfaces, depending on the organism causing the outbreak. If a school or child care center is using a disinfectant other than a bleach solution or one that is on the approved disinfectant list, they should check with their local public health agency to ensure the chemical meets regulatory requirements. If a surface is contaminated with a bodily fluid or excretion like blood or vomit or feces (such as on a diaper changing table), a disinfectant must be used to ensure disease causing organisms are destroyed. Soft furnishings and linens can be sanitized or disinfected by washing in hot water in a washing machine and using a laundry sanitizer or disinfectant. For additional information about cleaning, sanitizing, and disinfecting, please see the CDPHE guidelines on this topic at: https://www.colorado.gov/pacific/cdphe/child-care

DIAPER CHANGING Infections that are transmitted by the fecal→oral route can be spread by poor diaper changing procedures. To avoid this, always use the following method for changing diapers: • Check to make sure the supplies you need are ready (i.e., disposable gloves, fresh diapers, clothes, and damp paper towels or pre-moistened towelette wipes). • Ensure that the diapering table is covered with a dry, non-absorbent, easily cleanable material that has been cleaned and disinfected between diaper changes. • Individuals changing diapers must wear a new pair of disposable gloves prior to beginning each child’s diaper change. • Hold the child away from your body when you pick him/her up. When you know a child has soiled his/her diaper with fecal material, only use your hands to carry the child. • Lay the child on the diapering table. • Remove soiled diaper and clothes soiled with urine/feces. ◦ Put soiled cloth diapers in a plastic bag for parents/guardians to take home with the child at the end of the day. Soiled cloth diapers should not be rinsed at the facility. ◦ Soiled disposable diapers should promptly be placed in a covered trash receptacle lined with a trash bag. ◦ Clothing soiled with urine/feces should be placed in a plastic bag for the parents/guardians to take home with the child at the end of the day. Soiled clothing should not be rinsed at the facility. • Clean the child's bottom and any other soiled body area with a damp paper towel or wipe and discard it in a covered trash receptacle lined with a trash bag. • If topical ointments are applied, clean gloves should be placed on hands. Gloves should be removed before handling clean clothing and diapers. • Place a clean diaper on the child (and clean clothes if the clothes the child was wearing became soiled with urine/feces) and dress the child. • Wash the child's hands. The child may then be returned to a clean crib or play area. • Clean and disinfect the diapering area, equipment or supplies touched during diapering, as well as any equipment (like cribs), surfaces, or toys that may have been soiled from the diaper. Use disinfectant according to the label on the product or EPA registration. • Wash your hands. TOILET-TRAINING CHILDREN It is recommended that facilities place soiled clothes in a plastic bag for parents/guardians to take home at the end of the day. Parents should supply a clean change of clothes to the facility ahead of time in case of accidents. After helping children use the toilet, show them how to wash their hands. The use of potty chairs in child care facilities is not permitted. CLEANING UP VOMITING OR FECAL ACCIDENTS If a child has a fecal or vomiting accident somewhere in the school or child care facility, the following procedure should be followed to clean the soiled area to try to prevent widespread contamination: • The person cleaning up the area should use disposable gloves, mask, and gown or coverall to avoid direct contact with fecal material or vomit, and any potentially contaminated surface. Safety glasses can be worn as well. • Get a 2½ to 5 gallon bucket. • Mix a disinfectant solution of one cup regular household, non-scented bleach with one gallon (sixteen cups) of water in the bucket. This will be a 5000 parts per million (ppm) bleach solution. This stronger bleach solution is recommended in order to inactivate norovirus and other viral gastroenteritis agents. This is a concentrated solution so handle with care and ensure the solution is kept out of reach of children. If the contaminated surface will be damaged by a bleach solution, an alternate disinfectant can be used. It is recommended that the disinfectant used be effective against norovirus, since norovirus is a common cause of sudden onset of vomiting and diarrhea. Quaternary ammonia solutions typically are NOT effective at destroying norovirus. A list of disinfectants effective against norovirus can be found at the following US Environmental Protection Agency (EPA) website: http://www2.epa.gov/sites/production/files/2015-10/documents/list_g_norovirus.pdf • Place the disinfectant solution into a spray bottle. • Obtain disposable paper towels or disposable rags, and two trash bags for the cleanup.

• Spray disinfectant solution directly onto the contaminants (vomit or feces), cover with the disposable towels/rags and allow the disinfectant to contact the materials for 10 minutes. • Carefully pick up the contaminants with the towels/rags. Place all soiled towels/rags in a trash bag. • Use the disinfectant solution again to spray the affected surface and wipe down with clean towels/rags. Place all soiled towels/rags in a trash bag. • Apply disinfectant to the cleaned surface again and let stand for 1 more minute while air drying. • Carefully remove the disposable gloves, mask, and gown or coverall and place in the trash bag. If safety glasses are worn, they should be disposed as well, or sprayed with the 5000 ppm bleach solution and allowed to air dry. • Place the trash bag containing the soiled towels/rags and gloves, mask, and gown within another trash bag. Make sure the bags go directly to the dumpster. • Any commonly touched surfaces (like door knobs, hand rails, elevator buttons, faucet handles, etc.) in the vicinity (within a 25-foot radius) of where the vomit or fecal accident occurred should be wiped down with the 5000 ppm bleach solution or appropriate disinfectant. • Be sure to wash hands after cleanup with soap and hot water, rubbing hand together for at least 20 seconds. An alcohol-based hand sanitizer can be applied after handwashing (but hand sanitizers should NOT take the place of proper handwashing with soap and hot water). • Open the room to outside air at least until the odor of the disinfectant has gone away. • Contaminated linens (sheets, blankets, towels, etc.) can be washed in hot water (140°F) with detergent and bleach (if bleach will not damage the material) and dried in a hot dryer (140°F). Contaminated linens should be laundered separately to reduce the potential for spreading contamination. • Steam cleaning carpets and upholstery after cleaning up the vomit or fecal material can be helpful. Special considerations for food contact surfaces (tables, kitchen counters, food preparation areas, etc.) and items that could potentially be placed in persons mouths (kitchen utensils, toys or other surfaces in a child care setting, etc.): • If the 5000 ppm bleach disinfectant solution or other strong disinfecting solution is used on these surfaces or items (or any item that could potentially end up in someone’s mouth), it is important that the surface/item be rinsed off with clean water after disinfection after a one minute contact time. • Any food items or single-service items (drinking straws, takeout containers, paper napkins, paper plates, etc.) that may have been in the vicinity of location where the vomit or fecal accident occurred should be immediately discarded. ANIMALS / PETS AT CHILD CARE AND SCHOOL SETTINGS Animals in the classroom can be beneficial in the education process; however, some animals can present potential health and safety risks to humans, including infectious disease transmission, bites, and allergies. For example, many animals, especially reptiles and live poultry like chicks and ducklings, shed Salmonella bacteria in their feces without being sick, themselves. People can contaminate their hands with feces when they handle the animal, feed the animal, or clean up after the animal (such as cleaning the cage or other enclosure), and disease can spread through the fecal→oral route. Some animals are not appropriate for the classroom, such as: poisonous animals (like poisonous/venomous spiders, snakes, and insects); wild, stray, or aggressive animals; or animals from an unknown source. To minimize the risk of children and staff acquiring an infectious disease from an animal or from being bitten, simple precautions should be taken, as outlined below: General information: • Children (especially those under the age of 5 years) should be supervised carefully when around animals and animal enclosures, especially if children are handling animals. • Reptiles, amphibians and live poultry (e.g., chicks and ducklings) are prohibited in classrooms with children who are kindergarten age or younger. This includes hatching eggs in an incubator. • Inform parents/guardians of animals that are kept onsite or that may be visiting the facility. • Animal cages or enclosures should be kept clean and in good repair. Do not clean animal cages or enclosures in sinks or other areas used to prepare food and drink or used for handwashing. Children under the age of 5 years should not clean enclosures. • Children and staff should always wash their hands with soap and running water after any contact with animals, their cages or enclosures, or their food, and after visiting places with animals such as zoos or farms. • Children should never “kiss” animals or have them in contact with their faces. • Do not allow animals to roam free in the facility.

• Do not allow animals in areas where food and drinks are prepared or consumed. • Staff should clean and disinfect all areas where animals have been present. • Animals kept onsite should receive regular veterinary care, and should be up-to-date on all recommended animal vaccinations. School Settings: • If children assist in cleaning the cage or enclosure, they should be supervised and should wash their hands afterwards. • Live poultry (e.g., chicks and ducklings), reptiles, and amphibians are prohibited from classrooms with children kindergarten age or younger or communal areas that these children use. Because infections from these animals spread via fecal→oral transmission (hand-to-mouth behaviors), having these animals in other classrooms where children engage in frequent hand to mouth behaviors is discouraged. Child Care Settings: • Live poultry (e.g., chicks and ducklings), reptiles and amphibians are prohibited in child care settings where all children are less than 5 years of age. This includes hatching eggs from an incubator. • In facilities that also have kids over age 5, live poultry (e.g., chicks and ducklings), reptiles, and amphibians are prohibited from classrooms with children kindergarten age or younger or communal areas that these children use. This includes hatching eggs from an incubator. Because infections from these animals spread via fecal→oral transmission (hand-to-mouth behaviors), having these animals in other classrooms where children engage in frequent hand-to-mouth behaviors is discouraged. • The following animals are also prohibited in all child care facilities: psittacine birds, ferrets, primates, poisonous fish, poisonous reptiles, poisonous amphibians, aggressive animals and fish, wild-caught animals or any other animal which may pose a hazard to the health of the children. • Children in child care settings should not assist in cleaning cages or enclosures. • Exposure to other farm animals such as goats, sheep or cows is strongly discouraged in child care settings where children less than 5 years of age are present due to the potential risk for disease transmission. • Mobile petting zoos are strongly discouraged from visiting child care settings where children less than 5 years of age are present due to the potential risk for disease transmission. The National Association of State Public Health Veterinarians produces a document titled “Compendium of Measures to Prevent Disease Associated with Animals in Public Settings” (available at: http://nasphv.org/documentsCompendiumAnimals.html). This document provides recommendations for controlling disease and minimizing health risks associated with animal contact in a variety of settings. The CDC also has information about the health risks of a variety of animals at http://www.cdc.gov/healthypets/.

Resources The following resources may be helpful when dealing with infectious disease issues in school and child care settings: American Academy of Pediatrics (AAP): http://www.aap.org/ Bloodborne Pathogens: contact CDPHE at 303-692-2700 Centers for Disease Control and Prevention (CDC): http://www.cdc.gov/ Children’s Hospital Colorado - Denver: http://www.childrenscolorado.org/ ◦ School Health Program: 303-281-2790 Colorado Department of Education (CDE): http://www.cde.state.co.us/index_home.htm ◦ School Nursing and Health Consultant: 303-866-6779 Colorado Department of Public Health and Environment (CDPHE): https://www.colorado.gov/cdphe ◦ Main Phone: 303-692-2000 or 800-866-7689 • Child and Adolescent Health: https://www.colorado.gov/cdphe/categories/services-andinformation/health/personal-and-family-health/children • Communicable Disease Branch: https://www.colorado.gov/pacific/cdphe/categories/services-andinformation/health/diseases-and-conditions ◦ Main Phone: 303-692-2700

• Hepatitis Program: https://www.colorado.gov/pacific/cdphe/hepatitis ◦ Main Phone: 303-692-2700 • Immunization Program: https://www.colorado.gov/pacific/cdphe/categories/services-andinformation/health/prevention-and-wellness/immunization ◦ Main Phone: 303-692-2700 • Sexually Transmitted Infections Branch: https://www.colorado.gov/pacific/cdphe/sti-hivprofessionals ◦ Main Phone: 303-692-2700 • Tuberculosis Program: https://www.colorado.gov/pacific/cdphe/tuberculosis ◦ Main Phone: 303-692-2700 Local public health departments and/or environmental health services: https://www.colorado.gov/pacific/cdphe/find-your-local-public-health-agency Rocky Mountain Poison and Drug Center: http://www.rmpdc.org/ ◦ Main Phone: 800-222-1222 Publications: • “The Red Book,” published by the American Academy of Pediatrics • “Control of Communicable Diseases Manual,” published by the American Public Health Association • “Managing Infectious Diseases in Child Care and Schools,” published by the American Academy of Pediatrics.

ANIMAL BITES/RABIES WHAT IS AN ANIMAL BITE/RABIES? Animal bites, especially dog and cat bites, occur frequently. Rabies is a fatal viral disease that affects the nervous system of humans and other mammals. The virus is shed in the saliva of infected mammals, and appears in saliva around the time of symptom onset. On average, one or two people die of rabies each year in the United States, usually from a bat bite. As of 2015, the last human case of rabies in Colorado was in 1931. The majority of animal rabies cases in the United States occur in four wild animals species: raccoons, skunks, bats, and foxes. Rabies in domestic animals (like cats and dogs) is infrequent. Rabies in rodents and lagomorphs (hamsters, guinea pigs, squirrels, and rabbits) is extremely rare. In Colorado, the primary reservoir animals for rabies are bats and skunks. SIGNS & SYMPTOMS IN HUMANS The first symptoms of rabies may be very similar to those of the flu including general weakness or discomfort, fever, or headache. There may also be discomfort or a prickling or itching sensation at the site of bite, progressing within days to symptoms of central nervous system dysfunction: anxiety, confusion, agitation, delirium, abnormal behavior, hallucinations, and insomnia. Once a person begins to exhibit signs of the disease, survival is rare. To date, fewer than 10 documented cases of human survival from clinical rabies have been reported and only two have not had a history of pre- or post-exposure prophylaxis. SIGNS & SYMPTOMS IN ANIMALS Rabies virus causes acute encephalitis in all mammals and the outcome is almost always fatal. The first symptoms of rabies may be nonspecific and include lethargy, fever, vomiting, and anorexia. Signs progress within days to central nervous system dysfunction, cranial nerve dysfunction, trouble walking, weakness, paralysis, seizures, difficulty breathing, difficulty swallowing, excessive salivation, abnormal behavior, aggression, and/or self-mutilation. A bat found on the ground maybe unable to fly due to rabies causing weakness or paralysis of the wings. INCUBATION PERIOD Rabies: range of eight days to six years with median of six weeks, but usually 3-8 weeks HOW IS IT SPREAD? Rabies is transmitted through the saliva of infected mammals, primarily through a bite. Though transmission has been rarely documented via other routes such as contamination of mucous membranes (i.e., eyes, nose, mouth), and corneal and organ transplantations. Bat bite wounds may be unnoticeable upon examination of skin, and children may not report contact with bats to an adult. The most likely way a child at a school or child care facility would be exposed to rabies is through unrecognized contact with a bat. PUBLIC HEALTH REPORTING REQUIREMENTS • REPORTING: Report the animal bite incident to the local animal control agency local public health agency, or police department within 24 hours. Any bat found in a room or on the ground in a fenced yard with an unattended child should be tested for rabies. The parents/guardians of a child bitten by an animal or found unattended with a bat must be notified. • A child with an animal bite should receive immediate medical treatment. • Occasionally children are found touching or playing with live or dead bats. If this occurs, the local or state public health agency must be notified immediately and the bat must be submitted to the CDPHE laboratory for rabies testing. CONTROL OF SPREAD • Exclusion of a child involved in an animal bite is NOT necessary. • Children should be instructed not to approach, attempt to pet, or handle strange or wild animals. • Any school or child care facility with a bat colony on the premises should take steps to reduce the chance of contact between the children and bats. Please see https://www.colorado.gov/pacific/cdphe/rabies for more information. • All dogs, cats, and ferrets should be vaccinated against rabies by a veterinarian.

â&#x20AC;˘ A dog, cat, or ferret involved in a human bite must be observed for 10 days following the bite. The local animal control agency or police/sheriff department usually enforces this observation period. If the animal is still alive 10 days after the bite, there is zero chance that rabies virus was in the saliva of the animal at the time of the bite. This time period is not established for domestic-wild hybrids or any wild mammal. TREATMENT Animal bite treatment includes thorough cleaning of the wound and tetanus prophylaxis, if appropriate (see page 79). Occasionally, antibiotics are prescribed to treat bacterial infections. There is no treatment for rabies after symptoms appear. Rabies vaccine can provide immunity when administered after an exposure. The treating health care provider and state or local public health agency will evaluate each bite incident to determine if rabies vaccine is needed. Rabies post-exposure vaccination for humans is a series of four or five rabies vaccinations over 2-4 weeks, and one dose of human rabies immunoglobulin given as soon as possible after the exposure. This series of vaccinations and wound care usually must be initiated in the ER of a hospital or an urgent care setting. In general, public health assumes that skunks, raccoons, foxes, and bats have rabies until proven otherwise. In Colorado, dog and cat bites usually do not require rabies vaccine.

BACTERIAL MENINGITIS WHAT IS BACTERIAL MENINGITIS? Bacterial meningitis is an inflammation of the tissues surrounding the brain and spinal cord and is a medical emergency caused by several types of bacteria (e.g. meningococcal, pneumococcal, and Haemophilus influenzae). A person’s blood may also be infected with the bacteria. Some people may carry these bacteria in their nose and/or throat and have no symptoms of disease. SIGNS • • • •

& SYMPTOMS High fever Severe headache Stiff neck Sleepiness

• • • •

Nausea/vomiting Loss of appetite Being disoriented, irritable or confused Eyes sensitive to light

INCUBATION PERIOD Meningococcal: 1-10 days (usually less than four days) Haemophilus influenzae (H. flu): unknown (probably a few days) Pneumococcal: as short as 1-3 days HOW IS IT SPREAD? Bacteria that cause meningitis can be spread by direct contact with saliva or nose/throat discharges of the infected person. Infected individuals who do not have symptoms can still infect others. HOW LONG CAN A PERSON PASS THE INFECTION TO OTHERS? Cases can be contagious until completing 24 hours of antibiotic treatment. PUBLIC HEALTH REPORTING REQUIREMENTS For meningococcal and H. flu, report the infection to the state or local public health agency within 24 hours of a suspected or confirmed diagnosis. For pneumococcal, report the infection to the state or local public health agency within seven days of diagnosis. CONTROL OF SPREAD • EXCLUDE all infected students and staff until at least 24 hours after treatment with antibiotics. • Suspect cases of meningitis should be referred to a health care provider. • Contact state or local public health agency for assistance if the school or child care facility plans to notify parents/guardians about a case of meningitis in the facility. • Preventative Antibiotics ◦ For meningococcal infections, close contacts (such as household members, boyfriend/girlfriend, and child care classroom contacts) should receive a preventative antibiotic. School classmates, teachers, and personnel do not routinely require a preventative antibiotic, unless they had prolonged exposure beyond the classroom. ◦ For H. flu serotype B (Hib) infections, a preventative antibiotic may be recommended for household and child care contacts in certain situations. Typically, the state or local public health agency will notify household contacts if a preventive antibiotic is needed. • Vaccine is recommended for certain age groups for some causes of bacterial meningitis. Meningococcal vaccine is routinely given to pre-teens and college students. Hib and pneumococcal vaccines are routinely given to children starting at age 2 months. Healthy children 5 years and older do not routinely receive Hib and pneumococcal vaccine. • The Colorado School Immunization Rules require child care/preschool students to have Haemophilus influenza serotype b(Hib) vaccine and pneumococcal vaccine starting at 4 months of age or an exemption of vaccination. TREATMENT

Cases of bacterial meningitis and bloodstream infections often require hospitalization and are treated with antibiotics.

BED BUGS The state health department does not respond to or investigate bed bug infestations as there is no evidence that bed bugs transmit disease. The presence of bed bugs in schools is not reportable. RECOMMENDATIONS We recommend that schools develop a bed bug plan to coordinate their response to the presence of bed bugs in the facility. Plan stakeholders should include at a minimum the school nurse, faculty, administrators and facilities staff. It is important to formulate a response strategy before an infestation is suspected or identified. Schools dealing with bed bugs brought in by a student or staff member should make decisions beforehand about how to handle privacy issues, parent or guardian notifications, student or faculty exclusions from the school, and bed bug treatment/eradication options. The introduction of bed bugs into the school environment is a complex issue and should be planned for appropriately. RESOURCES FOR DEVELOPING A BED BUG RESPONSE PLAN http://www.epa.gov/childcare/bed-bugs-go-school https://www.michigan.gov/documents/emergingdiseases/Bed_bugs_schools_293498_7.pdf http://webdoc.agsci.colostate.edu/ipm/Recommendations%20bed%20bugs2014.pdf PSYCHOSOCIAL & HEALTH EFFECTS OF BED BUG INFESTATIONS IN A STUDENT’S HOME 1. The presence of bed bugs in a student’s home may be a significant stressor to the child. Perceptions of social stigma and physical discomfort caused by bed bug bites can affect a student’s ability to learn and perform in the school environment. 2. People may or may not develop a bite reaction following bed bug bites. For those who develop itching, scratching of bites may lead to secondary infections. 3. School nurses may need to assess students who display persistent scratching for insect bites or the presence of lice. There are no characteristics of bed bug bites that are diagnostic of bed bugs; insect bites, in general, appear similar to one another. A history of exposure and discussion with the student is often required to determine that the source of bites is bed bugs. 4. The facility’s bed bug response plan should identify resources for affected students (and faculty). This may include educational materials, social or environmental health services, or recommendations for the treatment of bed bugs. It is anticipated that recommendations and available resources will differ among school districts.

CAMPYLOBACTER WHAT IS CAMPYLOBACTER? Campylobacter infection causes an intestinal illness referred to as campylobacteriosis. Campylobacteriosis is the most commonly reported bacterial intestinal illness in the United States. Campylobacter bacteria commonly live in poultry and cattle, but can also be found in puppies, kittens, birds and other animals. SIGNS & SYMPTOMS • Diarrhea (sometimes bloody) • Low-grade fever

• Abdominal pain • Malaise

INCUBATION PERIOD 1-10 days (usually 2-5 days) HOW IS IT SPREAD? Campylobacter is spread through the fecal→oral route and can occur when a person drinks contaminated water or unpasteurized milk, eats contaminated food (it is commonly found in raw poultry), or comes into contact with animals that are infected (including pets and farm animals). Transmission can occur from person-toperson through the fecal→oral route, but this is not common. HOW LONG CAN A PERSON PASS THE INFECTION TO OTHERS? Campylobacter can be spread as long as the bacteria are in the stool. A person may be contagious for a few days after symptoms are gone, but is most contagious while having diarrhea. PUBLIC HEALTH REPORTING REQUIREMENTS • Staff who become aware of illness should report the infection to the facility director or the school nurse. The facility should report to the state or local public health agency within seven days of diagnosis. • If other children or staff are ill with diarrhea, refer them to their health care providers and contact public health as soon as possible as this could be an outbreak. CONTROL OF SPREAD • EXCLUDE all infected children and/or caregivers until at least 24 hours after diarrhea has resolved. • CHILD CARE: Ill children should not go to another facility during the period of exclusion. • In rare circumstances, public health may require additional testing before an infected person can return to work, school, or child care. • EXCLUDE affected individuals from food preparation until cleared by the state or local public health agency. • Encourage frequent handwashing, especially after animal contact, after using the toilet, changing diapers and before eating. • Promptly sanitize contaminated surfaces (like diaper changing areas) and other commonly touched surfaces (like toys) and discard food or water if it is thought to be contaminated. See page 16. • Refer to page 15 of this document for information on food safety. TREATMENT Treatment with antibiotics shortens the duration of the illness and prevents relapse when given early in the infection. Antibiotic treatment is typically 5-7 days, and usually eradicates the organism from the stool within two or three days.

CHICKENPOX (VARICELLA) & SHINGLES (HERPES ZOSTER) WHAT IS CHICKENPOX? Chickenpox is a highly contagious viral illness. The virus remains inactive in the person’s nerve cells after chickenpox resolves, and reactivation can occur later in life resulting in shingles. A vaccinated person may get chickenpox as a mild illness with fewer lesions that might not be blister-like. CHICKENPOX SIGNS & SYMPTOMS • Itchy rash (small, flat spots that become blister-like, then scab over) • Rash more on trunk than extremities • Fever

• Crops of lesions appear over several days resulting in rash in various stages • Fatigue

SHINGLES SIGNS & SYMPTOMS Painful rash on one side of the body INCUBATION PERIOD Chickenpox: 10-21 days (usually 14-16 days) HOW IS IT SPREAD? Chickenpox is spread through the air when an infected person coughs and/or sneezes, or by direct contact with the rash of an infected person. Direct contact with a shingles rash (prior to crusting) can cause chickenpox in persons not immune to chickenpox. HOW LONG CAN A PERSON PASS THE INFECTION TO OTHERS? A person is contagious with chickenpox 1-2 days before the rash appears until all the blisters have crusted over (usually five days after rash onset). A person with shingles is contagious until all blisters have crusted over. PUBLIC HEALTH REPORTING REQUIREMENTS Report cases of chickenpox to the state or local public health agency within seven days of a suspected or confirmed diagnosis. The report from the school should include as much information as possible without violating the Family Educational Rights and Privacy Act (FERPA), and the amount of personal information reported may vary by school or school district. Shingles does not need to be reported. CONTROL OF SPREAD • EXCLUDE all students and/or staff with chickenpox until all blisters have formed scabs and crusted. • Persons with shingles may attend school and child care if the rash is covered. • A sample letter to notify parents and additional information are available on the CDPHE varicella website: https://www.colorado.gov/pacific/cdphe/chicken-pox • Properly dispose of articles soiled with nose/throat discharges. • Two doses of varicella vaccine are recommended with the first dose given at age 12-15 months and the second dose given at age 4-6 years. • All child care/preschool students 15 months of age to kindergarten are required to have one varicella vaccine dose unless they have a documented history of varicella or an exemption to vaccination. • As of the 2012-2013 school year, the varicella requirement for students in kindergarten through 12th grade varies by grade level. • Younger elementary students are required to have two varicella vaccine doses and some high school students are not required to have varicella vaccine. Each school year an additional grade level will be added to the requirement until all grades are required to have one dose by 2013 and two doses by 2019. • Varicella vaccine administered within 3-5 days of exposure may prevent the disease.

TREATMENT ASPIRIN SHOULD BE AVOIDED because it increases the risk of Reye's Syndrome, a serious disorder that can lead to coma and death. If a medicine to lower temperature or reduce discomfort is necessary, acetaminophencontaining medicines (like Tylenol) are recommended. An anti-viral medication may be given to persons at increased risk of getting severe disease.

CHLAMYDIA WHAT IS CHLAMYDIA? Chlamydia trachomatis, a bacterium, causes chlamydia infection, which is the most frequent bacterial sexually transmitted infection (STI) in the United States. The majority of infections do not cause symptoms and are detected through screening tests. Symptoms of chlamydia, when present, are similar to those of gonorrhea. These two infections often present as co-infections in the same person and his or her partner(s). SIGNS & SYMPTOMS • Many infected persons do not have symptoms (asymptomatic). • Females may have cervical discharge with swelling, redness and bleeding. Complications can include pelvic inflammatory disease (PID), which can lead to ectopic pregnancy, infertility, and chronic pelvic pain. • Males may have urethritis, characterized by a whitish or clear discharge, and painful or difficult urination. Complications can include epididymitis, infertility, and reactive arthritis (Reiter’s syndrome). INCUBATION PERIOD Usually 1-3 weeks. HOW IS IT SPREAD? Through sexual contact: oral, anal, and vaginal. HOW LONG CAN A PERSON PASS THE INFECTION TO OTHERS? As long as the bacteria are present. PUBLIC HEALTH REPORTING REQUIREMENTS • Chlamydia infections must be reported by laboratory and health care providers to the state or local public health agency within 7 days of a suspected or confirmed diagnosis. • The possibility of sexual abuse must be considered when infections occur in prepubescent children and must be reported to appropriate authorities. CONTROL OF SPREAD • No exclusions or environmental interventions are necessary, since STIs require close intimate physical contact for transmission, virtually always of a sexual nature. • Infected persons should be examined by a health care provider and treated as soon as the diagnosis is confirmed to prevent complications. Treatment of partner(s) is a crucial strategy to prevent reinfection. Infected persons should seek medical care if symptoms persist or recur. Parental consent is not required for minors to be examined and treated. • Infected persons should avoid sexual activity until they and their partner(s) are treated and cured. • Infected persons should abstain from sex or use condoms to prevent future infections. • General education of STI prevention is advocated. • Additional information is available at: http://www.cdc.gov/std/chlamydia/default.htm TREATMENT Treatment is with antibiotics. Concurrent treatment of sex partner(s) with same regimen is essential to prevent re-infection or spread of disease.

CLOSTRIDIUM DIFFICILE WHAT IS CLOSTRIDIUM DIFFICILE? Clostridium difficile (C. difficile) is a bacterial infection that can cause diarrhea. Symptoms can range from mild diarrheal illness to severe colitis and can result in death. C. difficile causes almost half a million illnesses per year. Most of these illnesses occur in adults and in people who have recent exposures to medical care and antibiotics. However, anyone, including children, can become ill from C. difficile under the right circumstances. The burden of C. difficile among pediatric patients appears to be much higher in community settings compared to hospital settings. SIGNS & SYMPTOMS • Watery diarrhea (typically at least three bowel movements per day at least one day or longer) • Fever

• Loss of appetite • Nausea • Abdominal pain and tenderness

INCUBATION PERIOD Variable; symptoms typically develop 3-7 days after the exposure to an antibiotic however symptoms can occur anywhere between 1 day and 10 weeks or more. Some people will experience a recurrent infection which may occur after the initial episode of diarrhea has been treated and resolved. People who experience a relapse of diarrhea or have fever, chills, and or abdominal pain should contact their doctor. HOW IS IT SPREAD? C. difficile is spread through the fecal→oral route and can occur when a person comes into contact with a contaminated surface or it can be spread person-to-person, including via hands of staff in child care facilities and schools. People who are ill with C. difficile can shed the bacteria into the environment, causing surfaces to become contaminated. Improper hand hygiene is a major contributor to the spread of C. difficile. Not everyone who ingests C. difficile bacteria will become ill. There are two types of C. difficile bacteria, toxigenic and non-toxigenic. Only toxigenic C. difficile bacteria can cause symptoms. A person must also have an imbalance in their normal, healthy gut flora, which allows C. difficile to flourish and cause inflammation and damage to the gut. Normal, healthy gut flora can be disturbed for many reasons, but a major cause is previous exposure to antibiotics. HOW LONG CAN A PERSON PASS THE INFECTION TO OTHERS? C. difficile can spread as long as the bacteria are in the stool, but people are most likely to shed the bacteria when they have active diarrhea. The more frequent and uncontrolled the diarrhea is, the more likely they are to shed the bacteria. People who are being treated for C. difficile are less infectious than those who are not on treatment. A person is generally considered contagious until 48 hours after the last episode of diarrhea. However, it is not fully understood how long a person may continue to shed bacteria after diarrhea stops. C. difficile can live on environmental surfaces for several months. PUBLIC HEALTH REPORTING REQUIREMENTS • C. difficile infections are laboratory reportable to the state health department for residents of the Denver metropolitan area (Adams, Arapahoe, Denver, Douglas and Jefferson counties). Single cases outside of these five counties are not reportable. • Hospitalized cases of C. difficile are also reported to the state health department by hospitals statewide. • The school nurse or Child Care Health Consultant should be consulted for specific concerns, or consultation with state or local public health personnel is available. • If other children or staff from the same classroom are ill with diarrhea, refer them to their health care providers and contact public health as soon as possible as this could be an outbreak, and all outbreaks are reportable to the state or local health departments.

CONTROL OF SPREAD EXCLUDE students who have diagnosed Clostridium difficile with active diarrhea until 48 hours after the last diarrheal stool. • In certain cases persons might experience recurring or, ongoing diarrheal illness with C. difficile infection. In these circumstances, the benefits and risks of having the student attend school should be considered. • Factors that should be considered in the decision to allow students with recurring/ongoing diarrheal illness with C. difficile infection include: ◦ if the diarrhea is controlled (the student or child is not having accidents and is able to go to the bathroom when needed or if the student or child is in diapers the diarrhea must be able to be contained in the diaper) ◦ if the student is receiving treatment for the infection • CDPHE and your local public health department are available for consultation as needed. Meticulous hand hygiene for staff and students: Hand washing with soap and water is the most effective method to prevent the spread of C. difficile. • Proper hand hygiene with soap and water is required especially after using the bathroom, after changing a diaper, prior to preparing and eating meals and anytime hands are visibly soiled. • Alcohol based hand sanitizer does not kill C. difficile spores. • Glove use is required if contact with stool could occur and hand hygiene must be performed with soap and water immediately following removal of gloves. Environmental Cleaning • CDC recommends meticulous cleaning following by disinfection using hypochlorite (bleach) based germicides as appropriate. • Surfaces that are contaminated with stool (diaper changing areas and bathrooms) should be: ◦ Cleaned by wetting the surface and removing any dirt and debris ◦ Disinfected by applying ~ an EPA registered disinfectant labeled effective against C. difficile spores (http://www.epa.gov/pesticide-registration/selected-epa-registered-disinfectants) OR ~ Household bleach  CDC recommends a 1:10 dilution of 5.25% - 6.15% household bleach with a contact time of 10 minutes in order to inactive C. difficile spores.  It is important to note that household bleach concentrations have increased in recent years to 8.25%. More concentrated bleach may require different dilutions and different contact times. For example, bleach with an 8.25% concentration requires a 1:9 dilution to be effective against killing C. difficile spores (1 part bleach, 8 parts water) and requires a contact time of 5 minutes. ~ CDC recommends that users read labels carefully to ensure the correct product is applied efficiently because many products are designed for a specific purpose and is to be used in a certain manner. ◦ Gloves must be worn when cleaning areas contaminated with stool, and hand hygiene with soap and water are required immediately after glove removal. Soiled Linen and Clothing • Clothing, towels and blankets that are soiled can be with laundered in hot water with normal detergent and dried on high heat. • Items that are contaminated with high hazard bodily fluids, such as stool, should be laundered separately. TREATMENT Typically patients are prescribed metronidazole, vancomycin or fidoxamicin for an initial episode, depending on disease severity and other factors. Some providers may choose to not treat an episode of C. difficile under certain circumstances. Patients with multiple recurrences may be treated with fecal transplants and surgery can be considered for patients with severe illness.

CYTOMEGALOVIRUS (CMV) WHAT IS CYTOMEGALOVIRUS? Cytomegalovirus (CMV) infection is most common in children under five years of age. Most infections cause no symptoms or mild symptoms such as a low-grade fever. The disease can be more serious in persons with impaired immune systems. The virus is a frequent cause of post-transplant and post-transfusion infections. Most people have been exposed to CMV by the time they are adults and are immune to it. Infants can be infected before they are born. A small percentage of these infants will develop illness, while most will not have symptoms and will be immune to subsequent infections. SIGNS • • •

& SYMPTOMS Sudden onset of bloody diarrhea Abdominal cramps Little or no fever

• Sometimes vomiting and watery (non-bloody) diarrhea is present

INCUBATION PERIOD About 3-12 weeks HOW IS IT SPREAD? CMV is spread by contact with body secretions of infected individuals (in children, primarily saliva and urine). Infection requires close contact with a person excreting the virus. HOW LONG CAN A PERSON PASS THE INFECTION TO OTHERS? People are contagious as long as the virus is in body secretions, which can be months or years. PUBLIC HEALTH REPORTING REQUIREMENTS • Individual cases are not reportable. The school nurse should be consulted for specific concerns, or consultation with the state or local public health agency is available. • Referral to a health care provider is optional unless symptoms are severe. CONTROL OF SPREAD • Exclusion is not necessary. • Women of childbearing age working with young children should pay close attention proper handwashing procedures (especially those who work with developmentally disabled children). • Encourage frequent handwashing and proper hygiene techniques especially after changing diapers. TREATMENT There is no treatment for CMV infection in healthy individuals. However, immunocompromised individuals should consult a health care provider regarding appropriate treatment.

COMMON COLD WHAT IS THE COMMON COLD? Many different viruses cause the common cold. The common cold is an upper respiratory illness characterized by runny or stuffy nose, sneezing, coughing, watery eyes, mild sore throat, chills, and fatigue lasting 2-7 days. Fever is uncommon in children over three years of age and is rare in adults. Children and adults are more susceptible to colds in the fall and winter. SIGNS • • •

& SYMPTOMS Runny or stuffy nose Sneezing Coughing

• Chills • Sore throat • Fatigue

INCUBATION PERIOD About 1-3 days (usually 48 hours) HOW IS IT SPREAD? The common cold is spread through contact with droplets (produced by coughing and sneezing) and infectious discharges from an infected person. Contact with hands, tissues, and other articles contaminated with nose/throat discharges of ill people can spread the virus. HOW LONG CAN A PERSON PASS THE INFECTION TO OTHERS? People are contagious from about one day before the symptoms appear until five days after the first signs of illness. PUBLIC HEALTH REPORTING REQUIREMENTS • REPORTING: Individual cases are not reportable. The school nurse should be consulted for specific concerns, or consultation with the state or local public health agency is available. • If the child develops more severe symptoms or experiences ongoing symptoms, he/she should be referred to a health care provider to be checked for secondary complications (such as bronchitis, sinus infections, middle ear infections, and laryngitis). CONTROL OF SPREAD • Exclusion is not necessary, unless the child is displaying severe symptoms like fever accompanied by behavior change, or difficulty breathing. • Encourage frequent handwashing and proper hygiene techniques. • Teach children to cover their mouth when coughing and sneezing. • Properly dispose of articles soiled with nose/throat discharges, such as tissues. TREATMENT There is no specific treatment for the common cold. Check with the child’s doctor before giving symptom relieving medications like cough suppressants and decongestants. ASPIRIN SHOULD BE AVOIDED because it increases the risk of Reye's Syndrome, a serious disorder that can lead to coma and death. Antibiotics should not be used for viral infections such as the common cold.

CROUP WHAT IS CROUP? Croup refers to the swelling around the vocal chords and other parts of the upper and middle airway that causes a harsh repetitive cough similar to a seal barking. This type of infection is typically caused by a group of viruses called human parainfluenza viruses (HPIVs). Less often, respiratory syncytial virus (RSV) or other respiratory viruses can cause croup. More cases of croup are typically seen in the fall. SIGNS • • •

& SYMPTOMS Sharp, barking cough (usually at night) Labored or noisy breathing Fever

• Exacerbates symptoms of chronic lung disease • Pneumonia • Bronchitis

INCUBATION PERIOD Ranges from 2-7 days HOW IS IT SPREAD? Parainfluenza viruses and other respiratory viruses are spread from person to person primarily by respiratory droplets created by coughing or sneezing. Transmission may also occur through contact with contaminated surfaces, hands, used tissues, or other articles soiled by nose and throat secretions. HOW LONG CAN A PERSON PASS THE INFECTION TO OTHERS? The infection is passed for up to one week before onset of symptoms to 1-3 weeks after symptoms. PUBLIC HEALTH REPORTING REQUIREMENTS Report the infection to the facility director or school nurse. If this becomes a group outbreak (three or more ill at one time) report the outbreak to the local or state health department within 24 hours of diagnosis. CONTROL OF SPREAD • Exclusion is not necessary, but it is recommended that children experiencing acute respiratory symptoms stay home until they feel better. • Ill people should avoid direct and indirect exposure to non-infected individuals. • Disinfection of eating and drinking utensils and commonly touched surfaces. See page 16. • Promptly dispose of tissues soiled with nose and throat secretions. • Teach children to cover their nose and mouth when they cough or sneeze. • Emphasize frequent and thorough hand washing especially after coughing or sneezing. • Please consult with local or state public health if help is needed with implementation of control measures. TREATMENT There is no antibiotic treatment for a viral infection. Most infections are self-limited and require no treatment. Oral and nebulized steroids are sometime used in severe cases.

CRYPTOSPORIDIUM WHAT IS CRYPTOSPORIDIUM?

Cryptosporidium is a parasite that causes an intestinal illness referred to as cryptosporidiosis. In children, symptoms often begin with loss of appetite and vomiting. Some people can be infected without showing any symptoms. The infection can be more severe in people with weakened immune systems. Healthy children usually get better on their own. The illness usually lasts an average of 10 days, but can last up to 20 days or longer. SIGNS • • •

& SYMPTOMS Watery, non-bloody diarrhea Abdominal cramps Little or no fever

• Sometimes vomiting • General Malaise

INCUBATION PERIOD:

1-12 days (usually seven days) HOW IS IT SPREAD?

Cryptosporidium is spread by fecal→oral transmission and occurs by ingesting the parasite from the stool of infected people or animals. People can be exposed to this parasite when they swim in or drink contaminated water, eat contaminated food, or visit a petting zoo where animals are infected. The parasite can survive outside the body for 2-6 months in moist surroundings. HOW LONG CAN A PERSON PASS THE INFECTION TO OTHERS?

People are contagious as long as they have the parasite in their intestine, and are most contagious while they have diarrhea. The parasite may be present in the stool for several weeks after symptoms subside. PUBLIC HEALTH REPORTING REQUIREMENTS • Staff who become aware should report the infection to the facility director or school nurse. The facility should report to state or local public health agency within seven days of diagnosis. • If other children or staff are ill with diarrhea, refer them to their health care providers and contact public health as soon as possible as this could be an outbreak. CONTROL OF SPREAD • EXCLUDE all infected children and/or caregivers until 24 hours after diarrhea has resolved. ◦ CHILD CARE: Ill children should not go to another facility during the period of exclusion. • EXCLUDE affected individuals from food preparation until cleared by the state or local public health agency • Affected individuals should not swim in pools or other recreational water until 2 weeks after their diarrhea has resolved. • Encourage frequent handwashing and proper hygiene techniques • Chlorine sanitizers (such as bleach) do not kill this organism. A non-chlorine sanitizer should be used to sanitize contaminated articles (such as a 5% ammonia solution or 3% hydrogen peroxide solution for ten minutes). Heat (140°F for two minutes) will also destroy the organism. Do not mix bleach and ammonia products. • Untreated water (such as water from lakes, ponds, springs, rivers, and streams) should not be used as drinking water unless it is boiled for at least one minute or adequately filtered. Chemical disinfectants such as chlorine and iodine are not effective at killing Cryptosporidium. TREATMENT Most people with healthy immune systems will recover without treatment. People with suppressed immune systems should contact their health care provider. Ill persons should be given plenty of fluids to prevent dehydration.

E. COLI O157 & OTHER SHIGA TOXIN-PRODUCING BACTERIA WHAT IS E. COLI? Escherichia coli (serotype O157) and other Shiga toxin-producing bacteria can cause illness ranging from mild intestinal symptoms to severe kidney complications. In most cases, the illness is mild and lasts 1-3 days. These types of bacteria are carried in many animals, including cattle, sheep, goats, deer, and elk. SIGNS & SYMPTOMS • Diarrhea, which can be bloody • Abdominal cramps

• Little or no fever • Sometimes vomiting

INCUBATION PERIOD Ranges from 1-10 days (usually 3-4 days) HOW IS IT SPREAD? E. coli infection is spread through eating contaminated food (e.g., undercooked ground beef, unpasteurized juice or milk, or contaminated produce), drinking or swimming in contaminated water, or having contact with animals or their feces, as at a petting zoo or farm. E. coli is highly contagious and can spread person-to-person through the fecal → oral route, especially in child care centers. HOW LONG CAN A PERSON PASS THE INFECTION TO OTHERS? As long as the bacteria is in the stool, typically 1-4 weeks, even after symptoms have resolved. PUBLIC HEALTH REPORTING REQUIREMENTS • Report the infection to the facility director or the school nurse and the local or state health department within seven days of diagnosis. • If other children or staff are ill with diarrhea, refer them to their health care providers and contact public health as soon as possible as this could be an outbreak. CONTROL OF SPREAD • Please consult with local or state public health on implementation of control measures. • EXCLUDE all infected children and/or caregivers until diarrhea has resolved, AND ◦ CHILD CARE: Children with E. coli O157 must be excluded until they have two consecutive negative stool samples collected 24 hours apart. Ill children should not go to another facility during the period of exclusion. Exclusion requirements for children with non-O157 E. coli will be determined by public health. ◦ Most STAFF in CHILD CARE should be excluded until they have two negative stool samples collected 24 hours apart. Consult with public health about the necessity of follow-up testing. ◦ SCHOOLS: Children who wear diapers or have developmental delays resulting in fecal incontinence or hygiene concerns should be excluded until they have two consecutive negative stool samples collected 24 hours apart. ◦ STAFF in SCHOOLS who handle food should be excluded until they have two negative stool samples collected 24 hours apart. • If other children or staff are ill with diarrhea, refer them to their health care providers and contact public health as soon as possible as this could be an outbreak. • EXCLUDE affected individuals from food preparation until cleared by the state or local public health agency. • Encourage frequent handwashing, especially after animal contact, after using the toilet, changing diapers and before eating. • Promptly sanitize contaminated surfaces (like diaper changing areas) and other commonly touched surfaces (like toys) and discard food or water if it is thought to be contaminated. See page 16. • Refer to page 15 of this document for information on food safety.

TREATMENT For mild illness, antibiotics have not been shown to shorten the duration of symptoms and may increase complications in some people. Severe complications such as HUS require hospitalization.

FIFTH DISEASE WHAT IS FIFTH DISEASE? Fifth disease is a common and mild childhood illness caused by a virus called parvovirus B19. Some people have this infection without symptoms. Infection leads to long-term immunity. Over 50% of adults are immune to fifth disease. For women who have never been infected, there is a small risk of miscarriage if they become infected while they are pregnant. Infection is not a proven cause of birth defects or mental retardation. Persons with a compromised immune system may have a more serious illness. SIGNS & SYMPTOMS • Rash (“slapped cheek” rash on face and lacy rash on the rest of the body) • Rash may go away and return over time • Low-grade fever

• Cold symptoms before rash • Tired/malaise • Joint pain and swelling in older children and adults

INCUBATION PERIOD 4-14 days; sometimes as long as 21 days HOW IS IT SPREAD? Fifth disease is spread from person-to-person through contact with nose/throat discharges. It can be spread by sneezing and coughing or direct contact with contaminated utensils and drinking glasses. HOW LONG CAN A PERSON PASS THE INFECTION TO OTHERS? The virus is spread during the early part of the illness, before the rash appears. Once the rash appears a person is unlikely to be contagious. PUBLIC HEALTH REPORTING REQUIREMENTS • Individual cases are not reportable. • Inform parents/guardians of outbreaks since the disease is highly contagious. CONTROL OF SPREAD • Exclusion is not necessary for a healthy person since the person is no longer contagious by the time the disease is recognizable. • Routine exclusion of pregnant caregivers when fifth disease is occurring is not recommended. However, pregnant staff members may choose to avoid exposure during an outbreak. • A pregnant woman exposed to fifth disease is advised to contact a health care provider regarding counseling and antibody testing. • Encourage frequent handwashing, especially after contact with any item soiled with nose/throat discharges. • Encourage students to cover their mouths and noses when sneezing or coughing. • Dispose of tissues soiled with nose/throat secretions. • Please consult with local or state public health about control measures. TREATMENT There is no specific treatment. Most infections are mild enough that they do not require medicine.

GENITAL HERPES (HERPES SIMPLEX VIRUS (HSV)) WHAT IS GENITAL HERPES (HSV)? Genital herpes are caused by the herpes simplex virus (HSV). There are two types of HSV (type one and type two); both can cause genital herpes, although type two is a more common cause. Genital herpes may be recurrent and has no cure. The first occurrence typically lasts about 12 days. Subsequent, usually milder, occurrences typically last about 4 days. The interval between clinical episodes is called the latent period. Viral shedding occurs intermittently during latency and sexual transmission of HSV may occur at these times. SIGNS & SYMPTOMS • Single or multiple fluid-filled sores appear anywhere on the genitalia. • Sores spontaneously rupture to form shallow ulcers that can be very painful. The ulcers resolve spontaneously with minimal scarring. • Central nervous system involvement, development of sores at other sites, and fungal infections are possible (but rare) complications. INCUBATION PERIOD Usually 2-12 days HOW IS IT SPREAD? Genital herpes is transmitted through sexual contact: oral, anal, and vaginal. HOW LONG CAN A PERSON PASS THE INFECTION TO OTHERS? Once a person is infected with HSV, he/she can shed it intermittently for years and possibly lifelong. PUBLIC HEALTH REPORTING REQUIREMENTS • Cases of genital herpes are NOT reportable to public health. • The possibility of sexual abuse must be considered when infections occur in prepubescent children and must be reported to appropriate authorities. CONTROL OF SPREAD • No exclusions or environmental interventions are necessary, since STIs require close intimate physical contact for transmission, virtually always of a sexual nature. • Infected persons should be examined by a health care provider. Infected persons should seek medical care if symptoms persist or recur. Parental consent is not required for minors to be examined and treated. • Sexual activity should be avoided if a person has signs and symptoms. • Patients should abstain from sex or use condoms to prevent future infections. • General education of STI prevention is advocated. • Additional information is available at: http://www.cdc.gov/std/herpes/default.htm TREATMENT The antiviral drug acyclovir can reduce shedding of the virus, diminish pain and accelerate healing time. However, the virus may be shed intermittently for years and possibly lifelong.

GENITAL WARTS (HUMAN PAPILLOMAVIRUS (HPV)) WHAT ARE GENITAL WARTS (HPV)? Genital warts are caused by the human papillomavirus (HPV), and are the most common sexually transmitted infection (STI). There are more than 40 types of HPV. A diagnosis may be made based on the typical clinical presentation; however many people infected with HPV do not have noticeable symptoms and do not know they are infected. Some types of HPV are associated with cervical dysplasia (abnormal cell growth) and cancer; however these types of HPV do not cause genital warts. SIGNS & SYMPTOMS • Single or multiple soft, fleshy, painless growths/bumps anywhere on or around the genitalia. They can be small or large, raised or flat. • HPV may also infect the mouth and throat, although this is rare. • Generally symptoms are minor or not present at all. INCUBATION PERIOD Variable HOW IS IT SPREAD? Genital warts are transmitted through sexual contact: oral, anal, and vaginal. HOW LONG CAN A PERSON PASS THE INFECTION TO OTHERS? Once a person is infected, they may spread the infection to others throughout life. PUBLIC HEALTH REPORTING REQUIREMENTS • Cases of genital warts or HPV infections are NOT reportable to public health. • The possibility of sexual abuse must be considered when infections occur in prepubescent children and must be reported to appropriate authorities. CONTROL OF SPREAD • No exclusions or environmental interventions are necessary, since STIs require close intimate physical contact for transmission, virtually always of a sexual nature. • Infected persons should be examined by a health care provider and should seek medical care if symptoms persist or recur. Parental consent is not required for minors to be examined and treated. • Sexual activity should be avoided if a person has signs and symptoms. • Patients should abstain from sex or use condoms to prevent future infections. • There is a vaccine available for the most common types of HPV. The vaccine is given in three doses; it is important to get all three doses to get the best protection. The vaccine is most effective when given before a person’s first sexual contact. Females can receive either Cervarix or Gardasil vaccines. Males can receive Gardasil. • Additional information is available at: http://www.cdc.gov/std/HPV/STDFact-HPV.htm TREATMENT There is no treatment for HPV, but visible genital warts can be physically removed by a health care provider. Wart removal does not eradicate HPV; however, it will decrease the amount of virus available for transmission. Removal regimens include cryotherapy, electrodessication, electrocautery or other topical treatments.

GIARDIA WHAT IS GIARDIA? Giardia is a parasite (Giardia lamblia) that causes an intestinal infection in people and animals referred to as giardiasis. Symptoms sometimes start and stop so it can take several weeks before an ill person seeks medical care and is diagnosed. Many people infected with Giardia have no symptoms. SIGNS • • •

& SYMPTOMS Diarrhea Foul-smelling stools Abdominal cramping

• Excess gas or bloating • Nausea • Fatigue

INCUBATION PERIOD 1-3 weeks, commonly 7-10 days HOW IS IT SPREAD? Giardia is spread by the fecal→oral route and may result from drinking contaminated water or eating contaminated food. Transmission from person to person does occur, but is not often reported. HOW LONG CAN A PERSON PASS THE INFECTION TO OTHERS? As long as the organism is present in the stool, sometimes up to months. People with diarrhea are more likely to spread the infection than asymptomatic carriers. PUBLIC HEALTH REPORTING REQUIREMENTS • Staff who become aware should report the infection to the facility director or school nurse. The facility should report to the local or state health department within 7 days of diagnosis. • If other children or staff are ill with diarrhea, refer them to their health care providers and contact public health as soon as possible as this could be an outbreak. CONTROL OF SPREAD • EXCLUDE all infected children and/or caregivers until 24 hours after diarrhea has resolved. • CHILD CARE: Ill children should not go to another facility during period of exclusion. • EXCLUDE affected individuals from food preparation until cleared by the state or local public health agency. • Encourage frequent handwashing, especially after animal contact, after using the toilet, changing diapers, and before eating. • Promptly sanitize contaminated surfaces and discard food or water if it is thought to be contaminated. See page 16. • Untreated water (such as from lakes, ponds, springs, rivers, and streams) should not be used as drinking water unless it is boiled for at least one minute, adequately filtered, or adequately treated with chemical disinfectants like chlorine or iodine. TREATMENT Treatment of ill children with appropriate antibiotic/anti-parasitic medication usually makes them noninfectious within a few days. Testing and treatment of students with no symptoms is not usually necessary.

GONORRHEA WHAT IS GONORRHEA? Neisseria gonorrhoeae, a bacterium, causes gonorrhea infection (sometimes referred to as gonococcal infections). The majority of infections do not cause symptoms and are detected through screening tests. Symptoms of gonorrhea, when present, are similar to those of chlamydia. These two are often seen together as co-infections in the same person and his or her partner(s). SIGNS & SYMPTOMS • Many infected persons do not have symptoms (asymptomatic). • Females may have abnormal vaginal discharge, abnormal menses, or have painful or difficult urination. Ten percent to 20% of infected females develop pelvic inflammatory disease (PID), which can lead to ectopic pregnancy, infertility, and chronic pelvic pain. • Males may have painful or difficult urination, increased frequency of urination, and urethral discharge. Males are at risk for epididymitis. • Anorectal and pharyngeal (throat) infections occur and a person may or may not have symptoms. INCUBATION PERIOD Usually 1-14 days. HOW IS IT SPREAD? Through sexual contact: oral, anal, and vaginal. HOW LONG CAN A PERSON PASS THE INFECTION TO OTHERS? As long as the bacteria are present. PUBLIC HEALTH REPORTING REQUIREMENTS • Gonorrhea infections must be reported to the state or local public health agency within seven days of a suspected or confirmed diagnosis. • The possibility of sexual abuse must be considered when infections occur in prepubescent children and must be reported to appropriate authorities. CONTROL OF SPREAD • No exclusions or environmental interventions are necessary, since STIs require close intimate physical contact for transmission, virtually always of a sexual nature. • Infected persons should be examined by a health care provider and treated as soon as the diagnosis is confirmed to prevent complications. Treatment of partner(s) is a crucial strategy to prevent reinfection. Infected persons should seek medical care if symptoms persist or recur. Parental consent is not required for minors to be examined and treated. • Infected persons should avoid sexual activity until they and their partner(s) are treated and cured. • Infected persons should abstain from sex or use condoms to prevent future infections. • Additional information is available at: http://www.cdc.gov/std/gonorrhea/default.htm TREATMENT Treatment is with antibiotics. Concurrent treatment of sex partner(s) with same regimen is essential to prevent re-infection or spread of disease. Because of the high incidence of gonorrhea and chlamydia coinfection, treatment of gonorrhea should include treatment for chlamydia.

HAND, FOOT & MOUTH DISEASE (HFMD) WHAT IS HAND, FOOT & MOUTH DISEASE? Hand, foot and mouth disease (HFMD) is a common and mild childhood illness caused by specific strains of enterovirus or coxsackievirus. Since several different types of viruses can cause HFMD, people can develop the disease more than once if exposed to a different virus type. HFMD is most common in children under 5 years of age, but can sometimes occur in adults. It is frequently seen in the summer and fall. SIGNS & SYMPTOMS • Fever • Poor appetite

• Sore throat • Small blistering sores*

* The sores appear in the mouth, on the palms of the hands, buttocks, and on the soles of the feet. The sores fade without treatment in 710 days.

INCUBATION PERIOD Usually 3-6 days HOW IS IT SPREAD? Infection is spread from person-to-person through direct contact with nose/throat discharges or stool of infected persons. HOW LONG CAN A PERSON PASS THE INFECTION TO OTHERS? An infected person is most contagious during the first week of the illness. However, the virus can be present in the body for weeks after the symptoms have gone away. PUBLIC HEALTH REPORTING REQUIREMENTS • Individual cases are not reportable. The school nurse should be consulted for specific concerns, or consultation with the state or local public health agency is available. • Suspected outbreaks should be reported to the state or local public health agency. CONTROL OF SPREAD • Exclusion is not necessary unless the student has mouth sores and is drooling uncontrollably. • Referral to a health care provider may be necessary to ensure that the child does not have a more serious disease (such as measles). • Encourage students to cover their mouths and noses when sneezing or coughing. • Encourage frequent and thorough handwashing, especially after using the toilet, and contact with any item soiled with nose/throat discharges. • Promptly disinfect contaminated surfaces (like diaper changing areas) and other commonly touched surfaces (like toys). See page 16. • Please consult with local or state public health with implementation of control measures. TREATMENT There is no specific treatment. Over-the-counter medications can provide some degree of relief from fever or aches and pains associated with the sores.

HEAD LICE (PEDICULOSIS) WHAT IS PEDICULOSIS (HEAD LICE INFESTATION)? Head lice are tiny insects about the size of a sesame seed that live on the skin of the scalp and on the hair. They feed on blood and lay eggs that they attach to the hair shaft. Eggs hatch in about a week, and the young lice feed and molt three times before molting again to an adult. Adult lice will live about a month. Lice are common among children in all socioeconomic groups and are not a health hazard or a sign of uncleanliness. SIGNS & SYMPTOMS • Presence of lice or attached eggs on the scalp or on the hair • Itching behind the ears and at the back of the neck. Scratching may lead to secondary infections. INCUBATION PERIOD There is no incubation period. An infestation begins with the transfer of a louse or several lice to a new human host. Rarely, a shed hair with an attached nit can hatch and start an infestation. Shed hairs may be present on clothing or bedding. HOW IS IT SPREAD? Head lice are spread by direct contact with the head of an infested person, or by contact with items used by an infested person such as combs, brushes and hats. Lice walk, they cannot hop or fly. HOW LONG CAN A PERSON PASS THE INFECTION TO OTHERS? A person can transfer lice to others as long as they are infested with live lice. Even when no live lice are present, there may be nits close to the scalp that have not hatched. Once these eggs hatch, live lice are once again present and can be transferred. PUBLIC HEALTH REPORTING REQUIREMENTS Individual cases are not reportable. The school nurse/facility director should be consulted for specific concerns. Consultation with the state or local public health agency is also available. CONTROL OF SPREAD • Exclude a child or children with an active infestation. ◦ Child care centers: exclude until after a pediculocide treatment has been applied. ◦ Schools: from the end of the school day until after the first pediculocide treatment. • Students likely to have had direct head-to-head contact with an infested student should be checked for lice and treated if live lice are found. • Parents of infested students should be instructed about in-home control measures and should check other household members for lice. • Checking entire classrooms or schools has not been shown to be effective at controlling spread. • No-nit policies are not recommended because they have not been shown to be effective at controlling head lice infestations, and such policies may keep children out of the program needlessly. TREATMENT • Over-the-counter and prescription treatments are available. Parents should consult with their pediatrician if they have any questions about which treatment to use. • Follow treatment instructions closely. Nits can survive treatment, so a second treatment is needed 7-10 days after the first treatment to kill lice that have hatched from those eggs. • Flammable or toxic substances such as gasoline or kerosene should never be used. • Use a nit comb to remove nits from the hair. ENVIRONMENTAL CONTROL MEASURES • Carpet and furniture can be vacuumed or gently ironed (not sprayed with insecticide). • Combs and brushes should be soaked in a disinfectant or lice-killing solution for at least 10 minutes. • Launder clothing and bedding in hot water (130o F) and dry them on the high heat setting for at least 40 minutes, OR dry clean them. This should be done for items in the facility and at the home. • Items that cannot be cleaned should be placed in a plastic bag for 2 weeks.

PREVENTION OF HEAD LICE INFESTATIONS • Teach children not to share personal items like hats, combs, brushes, scarves or coats. • Hang coats separately. Do not hang or pile them on top of each other. • Student’s clothing and personal items should be stored separately (different hooks, cubby holes, etc.).

HEPATITIS A WHAT IS HEPATITIS A? Hepatitis A is a viral infection that causes inflammation of the liver. The severity of illness ranges from mild, lasting 1-2 weeks, to severe, lasting several months. Older children and adults are more likely to have symptoms, while young children may have mild symptoms or no symptoms at all. A blood test for hepatitis A antibodies (IgM) is needed to diagnose this infection. Animals do not carry or spread this virus. SIGNS • • •

& SYMPTOMS Yellow skin and eyes (jaundice) Abdominal cramps Diarrhea

• Dark urine • Pale stools • Low-grade fever

INCUBATION PERIOD 2-6 weeks, usually four weeks HOW IS IT SPREAD? The disease is spread through the fecal→oral route (through consumption of contaminated food and water or through person-to-person transmission) and can be spread by people who do not have symptoms. HOW LONG CAN A PERSON PASS THE INFECTION TO OTHERS? A person is most contagious in the two weeks before symptoms begin, and remains contagious for a week after jaundice begins. PUBLIC HEALTH REPORTING REQUIREMENTS • Report the infection to the local or state health department within 24 hours of a suspected or confirmed diagnosis. • Notify local or state public health department if the Hepatitis A case prepares food for others or attends or works in a child care facility. CONTROL OF SPREAD • Please consult immediately with local or state public health for implementation of control measures. • EXCLUDE all infected children and/or staff until 1 week after the onset of jaundice. ◦ CHILD CARE: Ill children should not go to another facility during the period of exclusion. • EXCLUDE affected individuals from food preparation until cleared by the state or local public health agency. • Unvaccinated people who are exposed to someone with hepatitis A (through close contact or eating food prepared by the ill person) can be given vaccine or immune globulin (IG) in the 2 weeks after exposure in order to prevent illness or lessen the severity of symptoms. • The local public health agency will evaluate whether anyone should receive IG or hepatitis A vaccine. Parents/ guardians, siblings, or close playmates may need IG/vaccine. ◦ SCHOOLS: In most instances, teachers and classmates are not at risk of becoming infected. ◦ CHILD CARE: Consult with public health as soon as possible to determine risks of transmission and persons who may require IG/vaccine. • Encourage frequent handwashing, especially after using the toilet, changing diapers and before eating. • Promptly sanitize contaminated surfaces (like diaper changing areas) and other commonly touched surfaces (like toys) and discard food or water if it is thought to be contaminated. See page 16. TREATMENT There is no specific treatment for hepatitis A after symptoms have developed. Vaccination for hepatitis A is effective in preventing the disease and is recommended for all children at age one.

HEPATITIS B WHAT IS HEPATITIS B? Hepatitis B is a viral infection. Like hepatitis A and C, hepatitis B causes inflammation of the liver, and infected children are unlikely to have symptoms. Only a blood test can identify hepatitis B infection and distinguish hepatitis A, B, and C infections from one another. Hepatitis B virus can cause lifelong infection, cirrhosis (scarring) of the liver, liver cancer, liver failure, and death. There is a safe and effective vaccine to prevent Hepatitis B infections. SIGNS • • • • •

& SYMPTOMS Nausea Loss of appetite Abdominal pain Vomiting Joint pain

• Dark urine • Jaundice (yellowing of the skin and whites of eyes) • Fatigue

INCUBATION PERIOD 45-160 days (average 120 days) HOW IS IT SPREAD? Hepatitis B is transmitted by direct inoculation of infective blood or body fluids into fresh cuts, wounds, or mucous membranes, or by intimate sexual contact. It can also be spread by sharing nonsterilized needles or syringes, or from a pregnant mother to her infant at birth. Hepatitis B is not spread through casual activities such as hugging, kissing, or by sharing eating utensils. It is uncommon in school/child care facilities. HOW LONG CAN A PERSON PASS THE INFECTION TO OTHERS? Persons are contagious as long as the virus is in the blood. This can be several weeks before the onset of symptoms, throughout the clinical course of the illness, and in some cases, into a carrier state that may last for many years. PUBLIC HEALTH REPORTING REQUIREMENTS Report the infection to the facility director or school nurse and the local or state health department within 7 days of diagnosis. CONTROL OF SPREAD • Exclusion is not necessary. The Colorado School Immunization Rules requires children in child care and schools to be vaccinated against Hepatitis B or have an appropriate exemption. • Prevent scratching, biting, or combative behavior. • Vaccination is recommended for residents and staff of facilities for developmentally disabled persons and for anyone seeking protection from hepatitis B infection. • Surfaces contaminated with blood should be cleaned and sanitized while wearing medical exam quality gloves, then sanitized with a bleach-based or other appropriate sanitizer. See page 16. • Dispose of soiled items in plastic bags. • Encourage proper handwashing techniques. • Please consult with local or state public health with implementation of control measures. TREATMENT There is no specific treatment for acute Hepatitis B infection. There are treatment options for cases with chronic hepatitis B.

HEPATITIS C WHAT IS HEPATITIS C? Hepatitis C describes an inflammation of the liver caused by the hepatitis C virus. For every one hundred people infected with the hepatitis C virus, 75-85 people will develop a chronic infection. Chronic infections can lead to serious liver problems, including liver damage, cirrhosis (scarring), liver failure, or liver cancer. Many adults and most children with a hepatitis C infection do not have symptoms. SIGNS & SYMPTOMS An estimated 3.2 million people in the United States have chronic hepatitis C. Most are unaware of their infection, because they have never experienced symptoms. Symptoms may include: • • • • • •

• • • •

Nausea Loss of appetite Fatigue Abdominal pain Vomiting Joint pain

Dark urine Fever Gray-colored bowel movements Jaundice (yellowing of the skin and whites of eyes)

INCUBATION PERIOD 14-180 days (average: 45 days) HOW IS IT SPREAD? Hepatitis C is transmitted when blood from a person infected with the hepatitis C virus enters the body of someone who is not infected. This can occur by sharing personal items with infected blood such as razors, nail clippers, toothbrushes or glucose monitors. It can also be spread by sharing non-sterilized needles or syringes. Having a sexually transmitted disease or sex with multiple partners also increases the risk of acquiring the hepatitis C virus from an infected partner. If a pregnant woman is infected with the hepatitis C virus, there is a 5% chance that the newborn child will also become infected with the hepatitis C virus. Hepatitis C virus is not spread through casual contact in a typical school/child care setting. HOW LONG CAN A PERSON PASS THE INFECTION TO OTHERS? Cases are contagious one or more weeks before onset of symptoms and as long as the virus is present in the blood. A person can be contagious for life. PUBLIC HEALTH REPORTING REQUIREMENTS Report the infection to the facility director or school nurse and the local or state health department within 7 days of diagnosis. CONTROL OF SPREAD • Exclusion is not necessary • Prevent scratching, biting, or combative behavior. • Surfaces contaminated with blood should be cleaned and sanitized while wearing medical exam quality gloves, then sanitized with a bleach-based or other appropriate sanitizer. See page 16. • Dispose of soiled items in plastic bags. • No vaccine is available. Immune globulin (IG) is not useful in preventing Hepatitis C. • Please consult with local or state public health with implementation of control measures. TREATMENT There are treatments available for people with chronic Hepatitis C.

HERPES (COLD SORES, FEVER BLISTERS) WHAT IS HERPES? Herpes is a common infection that causes fluid-filled sores on the face or lips caused by the Herpes simplex virus (HSV) types 1 and 2. Type 1 usually causes cold sores/fever blisters and type 2 usually causes genital herpes (see page 40). Sometimes herpes infections are referred to as cold sores or fever blisters, although herpes is not related to having a cold or a fever. The sores can be painful, and usually heal within several days. After the initial outbreak, the virus is usually dormant in the skin or in the nerves until something triggers another eruption. In some people, overexposure to sunlight, fever, physical or emotional stress, hormonal changes, or certain foods and drugs seem to reactivate the virus. In rare cases, the herpes virus can infect the brain and other parts of the nervous system. This complication is usually seen only in immunocompromised individuals. SIGNS & SYMPTOMS • Painful fluid-filled blisters on the face or lips • Tingling, itching or burning of th eskin before the blisters appear INCUBATION PERIOD 2-12 days HOW IS IT SPREAD? Herpes is spread by direct contact through kissing and contact with open sores. Less commonly, it can be spread through articles contaminated by the fluid from the blisters or saliva. HOW LONG CAN A PERSON PASS THE INFECTION TO OTHERS? Cases are contagious until the sores heal. PUBLIC HEALTH REPORTING REQUIREMENTS Individual cases are not reportable. The school nurse should be consulted for specific concerns, or consultation with the state or local public health agency is available. CONTROL OF SPREAD • Exclusion is not necessary unless the student has open sores and is drooling uncontrollably. • A person with sores should wash their hands often and avoid touching their eyes after touching the sore. • Disinfect objects or toys that have come into contact with saliva. See page 16. • Do not share food or drinks. • Please consult with local or state public health with implementation of control measures. TREATMENT There is no cure for herpes. Over-the-counter medications can help reduce the irritation while the sores heal. The antiviral drug acyclovir has been shown to reduce shedding of the virus, diminish pain, and accelerate healing time. The virus may be shed intermittently for years and possibly lifelong.

HIV AND AIDS WHAT IS HIV AND AIDS? The human immunodeficiency virus (HIV) causes HIV infection and Acquired Immune Deficiency Syndrome (AIDS). There are two types of HIV: HIV-1 and HIV-2. HIV attacks certain cells of the immune system and typically leads to an increased susceptibility to disease. AIDS is the most severe manifestation of HIV infection. There has not been a cure for HIV infection identified. SIGNS & SYMPTOMS Many people with HIV infection feel and appear completely healthy. People with HIV-related illness may have generalized lymphadenopathy (swollen lymph nodes all over their body), weight loss, chronic fever, chronic diarrhea, and/or fatigue, which may progress to AIDS or other illnesses due to the weakened immune system. INCUBATION PERIOD Variable. The time from HIV infection to the development of detectable antibodies is generally 1-3 months. The time from HIV infection to diagnosis of AIDS can be less than one year to more than 15 years. Infants who acquire HIV infection before or during birth from infected mothers typically develop symptoms between 12 and 18 months, although some remain symptom-free for more than five years. HOW IS IT SPREAD? HIV is present in the blood and some body fluids (semen, vaginal secretions, breast milk), and infection is spread by sexual contact, sharing injectable drug needles and syringes, transfusion of infected blood or blood products (which rarely occurs due to blood screening), transplantation of infected tissues or organs (also very rare), and from mother to child before or during birth, or through infected breast milk. All HIV infected persons can spread the disease by these routes. HIV is not spread by casual social contact in the workplace, school, or child care setting. Sharing food, eating utensils, dishes, or toilet facilities does not spread the disease, nor is it spread through touching or insect bites. HOW LONG CAN A PERSON PASS THE INFECTION TO OTHERS? All HIV infected persons can spread the virus throughout their lifetime. PUBLIC HEALTH REPORTING REQUIREMENTS • HIV/AIDS must be reported by laboratory and health care providers to the state or local public health agency within seven days of a suspected or confirmed diagnosis. • The identity of persons with HIV or AIDS should be known only to the people providing direct care to the infected person. The penalties for a breach of confidentiality are severe. CONTROL OF SPREAD • Students with HIV or AIDS should be able to attend child care and school without special restrictions. Contact the CDPHE STI/HIV Section at 303-692-2700 for further guidance on this issue. • Persons cleaning surfaces contaminated with blood should wear latex gloves, and the surface should be cleaned with soap and water, followed by disinfection with a bleach solution (1 cup bleach in 1 gallon of water). See page 16. • School health education should stress that having unprotected sex and sharing drug paraphernalia increase the risk of HIV infection. TREATMENT Effective antiretroviral treatment is available.

IMPETIGO WHAT IS IMPETIGO? Impetigo is a skin infection caused by streptococcal and staphylococcal bacteria. It can occur in people of any age, but is more common in children. Impetigo can affect skin anywhere on the body, although it most often occurs on the face. SIGNS • • •

& SYMPTOMS Area of itchy skin where tiny blisters develop Blisters will eventually burst to reveal areas of red skin that may weep fluid Most commonly found on the arms, legs and face

INCUBATION PERIOD 7-10 days for Streptococcal; variable for Staphylococcal HOW IS IT SPREAD? Infections may be spread by direct contact with infected skin. Less commonly, it can be spread through direct contact with articles (such as clothing, bedding, towels, etc.) that have come in with the rash. HOW LONG CAN A PERSON PASS THE INFECTION TO OTHERS? Treated persons are no longer contagious after 24 hours of antibiotic therapy. Untreated persons are contagious as long as there is discharge from affected areas. PUBLIC HEALTH REPORTING REQUIREMENTS • Report the infection to the facility director or school nurse. • Individual cases of impetigo are not reportable to public health. • Suspected outbreaks of all types (including impetigo) are reportable to state or local public health. CONTROL OF SPREAD • EXCLUDE infected students until 24 hours after beginning antibiotics. ◦ CHILD CARE: Children should be excluded until 24 hours after antibiotic treatment has begun. ◦ SCHOOLS: Children should be excluded until 24 hours after antibiotic treatment has begun. • Discourage scratching or touching the sores and scabs. • Keep the sores covered with a bandage. • Encourage frequent handwashing, and wash hands after touching anything that could be contaminated with fluid from the sores. • Sharing of towels, clothing and other personal items should be discouraged. • Cleanliness and prompt attention to minor wounds will help prevent impetigo. • Wash contaminated clothes, linens and towels. • Please consult with local or state public health with implementation of control measures. TREATMENT Oral or topical antibiotics may be prescribed to treat impetigo. Antibiotics will decrease spread of disease and the risk of secondary infections, and speed healing.

INFLUENZA WHAT IS INFLUENZA? Influenza (flu) is a very contagious viral illness caused by the influenza virus and should not be confused with “stomach flu” (viral gastroenteritis). Influenza causes community-wide outbreaks every winter, usually from November through March. In general, healthy children tolerate influenza well and suffer only a few days of discomfort. Persons most at risk for complications from influenza are infants, the elderly, and those with certain chronic underlying medical conditions (including, but not limited to, asthma, cystic fibrosis, diabetes, and neurological conditions). SIGNS • • •

& SYMPTOMS Fever (typically sudden onset) Headache Muscle aches

• Dry cough • Sore throat • Nausea and vomiting may occur

INCUBATION PERIOD 1-4 days (usually two days) HOW IS IT SPREAD? The influenza virus is spread from person to person primarily by respiratory droplets created by coughing or sneezing. Transmission may also occur through contact with contaminated surfaces, hands, used tissues, or other articles soiled by nose and throat secretions. HOW LONG CAN A PERSON PASS THE INFECTION TO OTHERS? Infected persons are contagious from 24 hours before to 5-7 days after the onset of symptoms. Children may be contagious for longer than seven days. PUBLIC HEALTH REPORTING REQUIREMENTS Non-hospitalized cases of influenza do not need to be reported. Influenza-associated hospitalizations are reportable to the state or local public health agency within seven days of diagnosis. Additionally, an influenzaassociated death in a child under the age of 18 years (with or without hospitalization) must be reported to the state or local public health agency within seven days. Outbreaks of influenza can cause large increases in absenteeism rather suddenly; schools should report significant increases in school absenteeism resulting from influenza-like illness to the state or local public health agency. Consultation with the state or local public health agency is available in these situations. CONTROL OF SPREAD • EXCLUDE children/students/staff with flu-like symptoms from child care/school/work until at least 24 hours after they no longer have a fever or signs of a fever (chills, feeling very warm, flushed appearance, or sweating) without the use of fever-reducing medicine. • Ill children/students/staff should be separated from others until they can be picked up/go home. • Teach children to: ◦ Cover their nose and mouth with a tissue when they cough or sneeze, and to throw away the tissue after they use it; ◦ Avoid touching their eyes, nose, or mouth; ◦ Wash their hands frequently with soap and water, especially after they cough or sneeze; an alcoholbased hand rub can be used if soap and water are not nearby. • The flu vaccine is available each year and recommendations for who should receive the vaccine are revised annually. It is recommended that everyone 6 months of age and older receive the vaccine each year, especially persons at higher risk for flu-related complications as noted above. . . People who live with or care for those at high risk should also receive the vaccine. ◦ School closure is not indicated to control spread; however, some schools may decide to close based on local considerations, such as high student and staff absenteeism. ◦ Please consult with local or state public health with implementation of control measures/school closures.

TREATMENT In certain circumstances, a health care provider may prescribe antiviral medications. These medications may reduce symptoms and duration of illness by one or two days. Acetaminophen-containing medicines (such as Tylenol) can be used to lower temperature or reduce discomfort. ASPIRIN SHOULD BE AVOIDED because it increases the risk of Reye's Syndrome, a rare but serious illness than can lead to confusion, seizures, or coma. Antibiotics should not be used for viral infections such as influenza.

MEASLES WHAT IS MEASLES? Measles is a highly viral contagious illness that is currently very rare in this country. Measles can result in serious complications, such as ear infections, pneumonia, seizures, brain damage and death. SIGNS & SYMPTOMS • Rash (red, raised and flat spots) that begins on face, along hairline and behind ears & becomes generalized over 3 days. • Fever, usually 101o F or higher • Cough

• Koplik’s spots (tiny white spots with bluishwhite centers found inside the mouth • Runny nose • Red, watery eyes • Rash begins on face and spreads

INCUBATION PERIOD 7-21 days (usually 10-12 days) HOW IS IT SPREAD? Measles is a highly contagious disease spread by direct contact with nose/throat discharges of an infected person, or, less commonly, through the airborne route. The virus may remain infectious in the air and on surfaces for up to two hours. A person is contagious from four days before rash onset through the first five days of rash. HOW LONG CAN A PERSON PASS THE INFECTION TO OTHERS? Measles is contagious from four days before the rash begins through the first five days or rash. PUBLIC HEALTH REPORTING REQUIREMENTS Report the infection to the state or local public health agency within 24 hours of a suspected or confirmed diagnosis. CONTROL OF SPREAD • EXCLUDE a case until after the fifth day of rash. Case should be isolated at home during these 5 days. ◦ CHILD CARE & SCHOOLS: If a measles exposure occurs within a school, all susceptible children and staff refusing measles-containing vaccine or lacking proof of immunity to measles will be excluded from school until the outbreak is over (i.e. until 21 days after the onset of rash in the last reported case). Discuss school exclusion with the state or local public health agency. • Review student’s vaccination records for two measles immunizations and staff’s vaccination records for measles immunity status. Measles vaccine administered within 72 hours of exposure may prevent disease. • Recommend measles vaccine for persons without measles immunity. • Suspect cases with diarrhea should be referred to a health care provider. • Do not transfer children to other facilities. • Measles virus vaccine, in combination with mumps and rubella (MMR) and sometimes varicella vaccine (MMRV), is routinely given at 12-15 months of age with a second dose recommended at age 4-6 years. • The Colorado School Immunization Rules requires students in K through 12 to have two measles immunizations and child care/preschool students 15 months of age to Kindergarten to have one dose of rubella vaccine unless the student has an exemption to immunization. • Please consult with local or state public health with implementation of control measures. TREATMENT There is no specific treatment for measles, but there is a highly effective vaccine to prevent infection.

MOLLUSCUM CONTAGIOSUM WHAT IS MOLLUSCUM CONTAGIOSUM? Molluscum contagiosum is caused by a pox virus and causes a mild skin disease similar to warts. It is characterized by small, pearly, flesh-colored bumps with a tiny, hard, central depression that may be itchy. Molluscum infections occur worldwide but are more common in warm, humid climates and where living conditions are crowded. SIGNS • • • •

& SYMPTOMS 2-20 discrete papules Lesions on adults are usually found on the lower abdomen, pubis, and inner thigh Lesions on children are usually on the trunk, face and arms Occasionally the lesions may apear linearly due to patient scratching

INCUBATION PERIOD Ranges from 2-7 weeks and may take as long as six months. HOW IS IT SPREAD? The virus is spread from person to person through direct and indirect physical contact. Direct contact may be either through play, rough housing, touching, or sexual contact. Indirect contact is when the lesions (virus) come in contact with towels, toys, or clothing and another person uses those items prior to cleaning. HOW LONG CAN A PERSON PASS THE INFECTION TO OTHERS? It is not known how long a person is infectious; however, it is presumed to be as long as the lesions are present. PUBLIC HEALTH REPORTING REQUIREMENTS • Report the infection to the facility director or school nurse. • Report to the local or state health department only if two or more cases are identified within 7 days of diagnosis of the first case as this may be an outbreak. CONTROL OF SPREAD • Exclusion is not necessary for child care or school. • Encourage frequent and proper hand washing. • Scratching the bumps should be avoided as that can spread the virus to another site or allow bacteria to enter. • Make sure all lesions are covered by clothing. If lesions are not covered by clothing, make sure to cover with a water tight bandage. • If a child with growths in the underwear/diaper area needs assistance going to the restroom or needs a diaper change, then the lesions in this area needs covering too if possible. • All infected individuals should not participate in contact sports as long as the lesions are present. • Activities that use shared gear should be avoided unless the lesions can be covered. • Swimming should also be avoided unless the lesions can be covered with a water tight bandage. • Do not share items such as hair brushes, unwashed cloths, soap, and towels. • If the lesions are in the pubic area avoid sexual contact until seen by your health care provider. • Please consult with local or state public health for help with implementation of control measures. TREATMENT There is generally no treatment required as the lesions usually go away on their own within six months, however this may take up to four years. When a therapy is recommended by a health care provider, the physical destruction of the lesions should be done in a physician’s office. Do not follow any treatment methods that are not directly recommended by a physician.

MONONUCLEOSIS WHAT IS MONONUCLEOSIS? Mononucleosis is caused by the Epstein-Barr virus and is characterized by swollen lymph glands, sore throat, and fever lasting from 1-4 weeks. Enlargement of the spleen can occur as well. Some infected children do not have symptoms or develop very mild symptoms, but 35-50% of adolescents or young adults develop infectious mononucleosis. The disease is most common in high school and college-aged children. SIGNS & SYMPTOMS • Swollen lymph glands • Fever

• Sore throat • Fatigue

INCUBATION PERIOD Usually 4-6 weeks HOW IS IT SPREAD? Mononucleosis is spread person-to-person through saliva. HOW LONG CAN A PERSON PASS THE INFECTION TO OTHERS? Individuals with mononucleosis can excrete the virus for a period of weeks or months after initial infection. The virus can be present over the infected person’s lifetime in throat or blood cells. Most people who have had a previous infection are not susceptible to a second infection. PUBLIC HEALTH REPORTING REQUIREMENTS Individual cases are not reportable. The school nurse or child care health consultant should be contacted for specific concerns, or consultation with the local or state health department is available. CONTROL OF SPREAD • Exclusion is not necessary. • Suspect cases with severe tonsil and throat swelling should be referred to a health care provider. • Dispose of tissues soiled with throat secretions. • Encourage frequent handwashing. • Promptly sanitize contaminated articles soiled by throat secretions. See page 16. • Avoid kissing that involves the transfer of saliva directly or indirectly through objects. • Please consult with local or state public health with implementation of control measures. TREATMENT There is no specific treatment for mononucleosis other than treating the symptoms. Over-the-counter medications can provide some relief from fever or sore throat. A health care provider may prescribe steroids to control severe swelling of the tonsil and throat.

METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS (MRSA) & STAPHYLOCOCCUS AUREUS WHAT IS METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS (MRSA) AND STAPHYLOCOCCUS AUREUS? Staphylococcus aureus (often referred to as “staph”) is a type of bacteria commonly found on the skin or in the nose of healthy people (referred to as colonization). Staph is a common cause of skin infections, but it can also cause serious infections like surgical wound infections, bloodstream infections, and pneumonia, most frequently among patients in healthcare settings. Some staph bacteria are resistant to certain classes of antibiotics. These resistant bacteria are called methicillin-resistant Staphylococcus aureus, or MRSA. Historically, MRSA infections occurred in hospitalized patients, but now these infections are also common in the community. People who have MRSA infections acquired in the community typically have infections of the skin. SIGNS & SYMPTOMS • Signs and symptoms will vary by the type of infection. • In child care and school settings, most staph and MRSA infections are skin or soft tissue infections that may appear as pustules or boils which are often red, swollen, painful, and/or have pus or other drainage. Often, MRSA skin and soft tissue infections may look like spider or insect bites. Pictures of MRSA skin and soft tissue infections can be found at the CDC website: http://www.cdc.gov/mrsa/community/photos/index.html INCUBATION PERIOD: Variable; depends on the type and severity of infection. HOW IS IT SPREAD? MRSA and other staph bacteria are usually spread from one person to another by direct skin-to-skin contact or contact with a contaminated item (such as towels or bandages) used by someone with MRSA or staph on their skin. Persons who have draining skin infections are more likely to spread MRSA and staph. HOW LONG CAN A PERSON PASS THE INFECTION TO OTHERS? As long as the bacteria are present. PUBLIC HEALTH REPORTING REQUIREMENTS • Report the infection to the facility director or school nurse. • Only MRSA cultured from normally sterile sites (such as blood or CSF) in residents of the Denver metropolitan area are reportable to public health within 7 days of diagnosis. Individual cases of MRSA skin or soft tissues infections are not reportable to public health. • Suspected outbreaks of all types (including staph and MRSA) are reportable to state or local public health. Outbreaks have been documented in school sports teams, such as football and wrestling teams. CONTROL OF SPREAD CDPHE has developed thorough recommendations for placement and exclusion of children with MRSA in school and child care settings. These recommendations, titled “Recommendations for Management of Children with MRSA in School and Child Care Settings” can be found on the CDPHE website: https://www.colorado.gov/pacific/cdphe/infectious-disease-guidelines-schools-and-childcare-settings TREATMENT Treatment for staph and MRSA will vary by the type and location of infection. Persons infected with staph or MRSA should seek care from a healthcare professional so proper treatment can occur.

MUMPS WHAT IS MUMPS? Mumps is caused by a virus and is more severe in adults. Mumps typically starts with a few days of fever, headache, muscle aches, tiredness, and loss of appetite, and is followed by swelling of salivary glands. The most common complication in adolescent and adult males is swollen testicles; however, mumps very rarely leads to sterility. Other complications may include meningitis (inflammation of the tissue surrounding the brain and spinal cord), inflammation of the ovaries, and deafness. Approximately one-third of individuals infected with mumps do not develop symptoms, but are contagious. Immunity from mumps is life-long. SIGNS & SYMPTOMS • Usually parotid gland swelling (located in cheek area at the back angle of the jaw) • Swelling of one or more salivary glands on one or both sides of the face

• Fever (usually low-grade) • Headache • Muscle aches

INCUBATION PERIOD: Ranges from 12-25 days (usually 16-18 days) HOW IS IT SPREAD? Transmission is by nose/throat discharges and direct contact with saliva from an infected individual. Infected individuals who do not have symptoms can still infect others. HOW LONG CAN A PERSON PASS THE INFECTION TO OTHERS? A case is contagious from two days before to five days after swelling onset. PUBLIC HEALTH REPORTING REQUIREMENTS Report the infection to the facility director or school nurse and the local or state health department within seven days of diagnosis. CONTROL OF SPREAD • EXCLUDE all infected students and/or staff until 5 days after swelling onset. • Discuss possible exclusion of children and staff without proof of mumps immunity with the state or local public health agency. • Do not transfer children in or out of the facility. • Review students’ vaccination records and staff’s immunity status. • Recommend mumps vaccination for children and staff without mumps immunization or positive immunity lab results. Post-exposure vaccination may not protect against the disease but may provide protection against future exposure. • Mumps virus vaccine is routinely given at 12-15 months of age in combination with measles and rubella (MMR) vaccine and sometimes varicella vaccine (MMRV) with a second dose recommended at age 4-6 years. The Colorado School Immunization Rules requires children in grades K through 12 to have two mumps immunizations and child care/preschool students 15 months of age to kindergarten to have one dose of rubella vaccine, unless the student has an exemption to immunization. TREATMENT There is no specific treatment for mumps.

NOROVIRUS and OTHER VIRAL GASTROENTERITIS WHAT IS VIRAL GASTROENTERITIS? Often referred to as “stomach flu” (a misnomer, as it is not caused by the influenza virus) these viruses include rotavirus, adenovirus, calicivirus, astrovirus, and norovirus. Viral gastroenteritis is seen more often in the winter months. Illness usually lasts 1-2 days, but can be longer. SIGNS • • •

& SYMPTOMS Low-grade fever Abdominal cramps Diarrhea

• Vomiting • Nausea • Headache

INCUBATION PERIOD Varies depending on the specific virus, but often 1-2 days. HOW IS IT SPREAD? Viral gastroenteritis is highly contagious and is spread mainly through the fecal→oral route, either by consumption of fecally contaminated food or water, or by direct person-to-person spread. It may also be spread by inhaling virus particles that have been released into the air when an infected person vomits. HOW LONG CAN A PERSON PASS THE INFECTION TO OTHERS? During the illness and for several days after symptoms have resolved. PUBLIC HEALTH REPORTING REQUIREMENTS • Single cases of illness do not need to be reported to public health. • Clusters of illness (such as two or more people ill with similar symptoms closely grouped in terms of time and place) should be reported to the state or local public health agency immediately as this could be an outbreak. CONTROL OF SPREAD • EXCLUDE all infected children and/or staff until diarrhea and vomiting have resolved for at least 48 hours. • Affected individuals should not prepare food for others for at least 48 hours after resolution of symptoms. • Encourage frequent handwashing, especially after using the toilet, changing diapers and before eating. • Immediately clear the room or area after a public display of vomiting. • Persons cleaning up vomit are encouraged to wear a simple face mask. • Promptly sanitize contaminated surfaces (like diaper changing areas) and other commonly touched surfaces (like toys) and discard food or water if it is thought to be contaminated. See page 16. • Persons with severe or prolonged diarrhea (lasting longer than 2-3 days) or who have a high fever or bloody diarrhea should be referred to a health care provider. • Noroviruses are resistant to many commonly used disinfectants. If norovirus is suspected, it is important to use a 5000 part per million (ppm) bleach solution (one cup bleach in one gallon water) or a disinfectant approved by the EPA with specific claims for activity against norovirus. A list of EPAregistered disinfectants effective against norovirus is available at: http://www2.epa.gov/sites/production/files/2015-10/documents/list_g_norovirus.pdf. TREATMENT There is no specific treatment for viral gastroenteritis. Fluids are important to prevent dehydration. No immunization is available.

PERTUSSIS (WHOOPING COUGH) WHAT IS WHOOPING COUTH (PERTUSSIS)? Whooping cough, also known as pertussis, is caused by the bacteria Bordatella pertussis. A vaccine exists for this disease. Pertussis may be severe in infants and young children, especially those who have not had three doses of vaccine, resulting in hospitalizations, pneumonia, neurologic problems, and death. The cough may last as long as 3 months. Pertussis may not be as severe in adults and fully immunized children. SIGNS • • •

& SYMPTOMS Begins with cold-like symptoms including mild cough and low-grade or no fever Cough becomes more severe, causing coughing spells or fits. Coughing spells may be followed by vomiting, difficulty catching breath, face turning blue, and/or highpitched whoop • Appears well between coughing spells

INCUBATION PERIOD Ranges from 4-21 days (usually 7-10 days) HOW IS IT SPREAD? Transmission is by direct contact with nose/throat discharges of an infected person. HOW LONG CAN A PERSON PASS THE INFECTION TO OTHERS? A person is most contagious in the early stages of the disease. Individuals are virtually noncontagious after the third week of coughing, or after five days of appropriate antibiotic treatment. PUBLIC HEALTH REPORTING REQUIREMENTS Report the infection to the local or state health department within 24 hours of diagnosis. CONTROL OF SPREAD • EXCLUDE individuals with pertussis until they have completed five days of appropriate antibiotic treatment or until three weeks after the onset of cough or until the cough has stopped, whichever period is shorter. ◦ If close contacts to a person with pertussis have pertussis symptoms, they should be excluded from child care or school until meeting the criteria listed above. • Household or other close contacts (regardless of immunization status) should be referred to a health care provider to receive appropriate antibiotics to prevent infection or reduce symptoms. • An antibiotic to prevent infection is frequently recommended for child care/preschool classroom contacts and rarely recommended for school classroom contacts. • Consult with the child care center or school nurse, or state or local public health agency, about notifying parents/guardians of exposed classmates. • Pertussis vaccine is routinely given in combination with diphtheria and tetanus vaccine (DTap and Tdap) starting at age 2 months. • Children should receive five doses of pertussis vaccine by 4-6 years of age. • A pertussis booster (Tdap) is recommended for children >10 years of age and adults • Review pertussis immunization records and recommend DTaP or Tdap vaccine for under-immunized students and staff. Vaccine administration after exposure will not prevent infection; however, it may provide protection against future exposure. • The Colorado School Immunization Rules require all students older than 3 months of age to have pertussis immunizations or an exemption to immunization. • The number of required pertussis doses varies by the age of the student. • Additional information is available at: https://www.colorado.gov/pacific/cdphe/pertussis-whoopingcough TREATMENT Appropriate antibiotic treatment shortens the period of contagiousness, but does not reduce symptoms except when given during the incubation period or in the early stages of the disease.

PINK EYE (CONJUNCTIVITIS) WHAT IS PINK EYE (CONJUNCTIVITIS)? Pink eye can be caused by a variety of bacterial, viral, and fungal pathogens, as well as allergies (such as pollen, mold, or cosmetics), contact lens use, indoor or outdoor air pollution (such as smoke or dust), and chemical irritation (such as after swimming, or exposure to chemical fumes). Pink eye is common in children and adults, and it can be difficult to determine the exact cause. SIGNS • • •

& SYMPTOMS Excess amount of blood in the whites of the eye and eyelid, giving the eye a pink or red appearance Eye itchiness, irritation, swelling, watery, light sensitivity, and/or burning Bacterial or viral: One or both eyes can be affected. There is usually a discharge (thicker, whitishyellowish in bacterial infections) from the eye. Respiratory infection symptoms or swollen lymph nodes near the front of the ear may be present. Bacterial pink eye symptoms can last a couple of days to three weeks, but generally symptoms improve in 2-5 days without treatment. Viral pink eye symptoms can last from 1-3 weeks or more. • Allergies: Usually both eyes are affected. Symptoms like itchy nose, sneezing, or scratchy throat may be present, and symptoms may be seasonal. Typically symptoms clear once the allergen is removed. • Chemical irritation: One or both eyes can be affected.

INCUBATION PERIOD Bacterial: 24-72 hours Viral: usually 1-12 days Allergies or chemical irritation: variable HOW IS IT SPREAD? Bacterial and viral: Can be easily spread by direct contact with discharge from the eye of an infected person or by direct contact with objects contaminated with eye discharge. Contaminated fingers, clothing, towels, shared eye makeup applicators, etc. may spread the infection. Allergies or chemical irritation: Not contagious. HOW LONG CAN A PERSON PASS THE INFECTION TO OTHERS? Bacterial: Infected persons are contagious as long as they have symptoms or until antibiotic eye drops or ointment are started. Viral: Some types are contagious as long as a person has symptoms (which can be variable). PUBLIC HEALTH REPORTING REQUIREMENTS • Individual cases are not reportable. • Suspected outbreaks of all types (including pink eye) are reportable to state or local public health. CONTROL OF SPREAD • Children do NOT need to be excluded for pink eye unless the child meets other exclusion criteria, such as fever or behavioral change. Consult a health professional for diagnosis and possible treatment. • Encourage frequent handwashing. • Avoid touching or rubbing eyes and avoid sharing personal items. • Ensure good cleaning and sanitizing practices are being followed. See page 16. TREATMENT Bacterial: A health care provider may prescribe antibiotic eye drops or topical ointment. Antibiotic treatment will generally speed recovery and reduce spread to others. Viral: There is usually no treatment. Allergies: May be treated with allergy medications. Chemical irritation: Symptoms generally resolves once the irritant is removed.

PINWORM WHAT ARE PINWORMS? Enterobius vermicularis is a small thin white roundworm (nematode) that lives in the large intestine. While an infected person sleeps, female pinworms leave the intestine through the anus and deposit their eggs on the surrounding skin. SIGNS • • •

& SYMPTOMS Itching and irritation around the anal or vaginal area There is the potential for a secondary infection of scratched sites Noticeable worms seen in the perianal region 2-3 hours after child goes to sleep

INCUBATION PERIOD 1-2 months (or longer) from the ingestion of an egg until the adult females are noticeable in the perianal region HOW IS IT SPREAD? Pinworm infections are spread through direct transfer of eggs through the fecal→oral route, or indirectly through clothing, bedding, food, or other articles contaminated with the parasite eggs. A dust borne infection is possible in heavily contaminated areas. HOW LONG CAN A PERSON PASS THE INFECTION TO OTHERS? A person is infectious as long as eggs are present on the perianal skin. Eggs remain infective in an indoor environment for about 2-3 weeks. PUBLIC HEALTH REPORTING REQUIREMENTS • Report the infection to the facility director or school nurse. • If more than one child is ill, refer them to a physician and contact public health as this may be an outbreak. CONTROL OF SPREAD • Exclusion of an infected child or staff member is not necessary unless proper precautions to control the spread cannot be followed. • EXCLUDE infected individuals from food preparation until cleared by physician. • Educate children and staff on good personal hygiene, particularly the need for hand washing before eating and food preparation. • Keep fingernails as short as possible. • Make sure those infected with pinworms, as well as household contacts and caregivers, are receiving proper treatment. • Daily bathing in the morning with showers or stand up baths is recommended over sit-down bathing in a bathtub. Co-bathing children should be avoided. • Frequent changing of underclothing, night clothes, towels and bedding. • Launder clothing, towels and bedding in hot water daily for several days post treatment. • Clean home/daycare/classroom daily for several days post treatment. • Please consult with local or state public health for help with implementation of control measures. TREATMENT There are appropriate anti-worm medications that will be prescribed by a physician, which are taken two weeks apart. Control is difficult in child care centers and schools due to high reinfection rates. In such situations, mass and simultaneous treatments, repeated in two weeks, may be effective.

PUBIC LICE (CRABS) WHAT ARE PUBIC LICE (Phthirus pubis)? Pubic lice, which resemble crabs through a magnifying glass, are an infestation of the louse Phthirus pubis. Adult pubic lice are about 1.5 to 2 millimeters in length, are tan to grayish-white in color and are typically found attached to hair in the pubic area. Occasionally pubic lice may be found on coarse hair elsewhere on the body such as the eyebrows, chest, or armpits. Pubic lice feed on human blood and have a life cycle similar to head lice. They are most commonly spread through sexual contact, though transfer of live lice through contact with the clothing or bedding of an infested person is possible. SIGNS & SYMPTOMS • Itching in the pubic/genital region. • Adult lice or lice eggs may be visible on pubic hair. INCUBATION PERIOD There is no incubation period. An infestation begins with the transfer of a louse or several lice to a new human host. HOW IS IT SPREAD? Pubic lice are most commonly transmitted through sexual contact. Rarely a shed hair with an attached nit can hatch and start an infestation. Live lice or shed hairs may be present on clothing or bedding that has been used by an infested person. HOW LONG CAN A PERSON PASS THE INFECTION TO OTHERS? As long as nymphs (immature lice) or adult lice are present. PUBLIC HEALTH REPORTING REQUIREMENTS Cases of pubic lice are not reportable to public health. (The possibility of sexual abuse must be considered when infestations occur in prepubescent children. These occurences must be reported to the appropriate authority.)

CONTROL OF SPREAD • Persons with pubic lice should be examined by a healthcare provider and be treated for lice. • They should also be evaluated for other sexually transmitted infections. • Sexual contacts should be likewise evaluated and treated. • Parental consent is not required for minors to be examined and treated. • Persons with pubic lice, or who have signs or symptoms of pubic lice, should avoid sexual activity until after treatment. • General education on STI prevention should be provided to infested people. TREATMENT • Over-the-counter and prescription treatments are available. Infested people should consult with a healthcare provider if they have any questions about which treatment to use. • Follow treatment instructions closely. Nits can survive treatment, so depending on the medication a second treatment may be needed to kill lice that have hatched from those eggs. • If pubic lice are present on the eyebrows or eyelashes special care must be taken. Follow the product directions for applying treatments, or consult with a healthcare provider for guidance on product use. • Use a nit comb or fingernails to remove nits from the hair. ENVIRONMENTAL CONTROL MEASURES • Launder clothing and bedding of infested persons in hot water (130o F) and dry them on the high heat setting for at least 40 minutes. • Alternately items may be dry cleaned. • Items that cannot be cleaned can be placed in a plastic bag for 2 weeks.

RASHES A rash involves a change in the color and/or texture of skin, and can have many different causes. It can be a symptom of a contagious or non-contagious disease. Contact dermatitis (an inflammation of the skin caused by direct contact with an irritating substance) can occur following an exposure to dyes and chemicals found in clothing, chemicals found in elastic and rubber products, cosmetics, poison ivy, and poison oak. This type of rash usually occurs where the irritating agent touches the skin. Eczema (a chronic hypersensitivity reaction in the skin) can cause a scaly and itchy rash. Medications, foods, or insect bites that cause allergic reactions can also cause a rash. The table below outlines eleven different illnesses that can cause rashes.

ILLNESS Chickenpox - viral (Varicella)

Fifth Disease - viral (Erythema Infectiosum, Human Parvovirus)

Hand-Foot-Mouth viral (Entero- and Coxsackieviruses, Viral Exanthem) Impetigo – bacterial

APPEARANCE

Blister-like rash that scabs over.

Red cheeks (“slapped cheek”). Red, lace-like rash on body.

DISTRIBUTION More abundant on trunk than extremities Begins on cheeks, spreads to trunk and extremities

ITCHING Yes

COMMENTS/EXCLUSION Highly contagious.

Immunization is available. Exclude until blisters scab over. Slight, if any

No exclusion necessary for healthy persons. Exposed pregnant women should contact their health care provider.

May fade and then reappear. Small blister-like sores.

Palms, soles of feet, mouth and buttocks

No exclusion necessary unless the child has mouth sores and is drooling uncontrollably.

Small blisters that burst to reveal red skin.

Usually the face, arms, or legs but can occur anywhere

Yes

Exclude until 24 hours after appropriate antibiotic treatment.

Measles - viral

Red, raised and flat spots.

(Rubeola,

Rash turns white on pressure.

Begins on face along hairline, spreads to trunk and extremities

Slight, if any

Small red bump or ring that spreads outward.

A single area of skin

Yes

Exclude from the end of the day until after the first treatment.

Small, discrete pinkish-red spots.

Begins on face, chest and abdomen, spreads to entire body

Most common in children 6 to 24 months of age.

Begins on face, spreads to neck, trunk & extremities

Begins on neck and groin,

(Streptococcal and Staphylococcal bacteria)

Hard Measles) Ringworm – fungal (Tinea) Roseola - viral (Exanthem subitum, Sixth Disease)

Almond shaped flat spots appear on trunk and neck.

Rubella - viral

Small pink spots.

(German Measles)

May become confluent but remains pink.

Scarlet Fever bacterial

Small red bumps. Rash turns white on

Highly contagious. Immunization is available. Exclude for 5 days after rash onset.

No exclusion necessary unless child has a fever along with the rash. Immunization is available. Exclude for 7 days after rash onset. Strep throat symptoms are present.

ILLNESS (Group A streptococci)

APPEARANCE pressure.

Pigmented areas in skin creases. Shingles - viral (Herpes Zoster)

Smallpox - viral

Blister-like rash that scabs over.

DISTRIBUTION spreads to rest of body

ITCHING

A single area of skin

Sometimes

Exclude until 24 hours after appropriate antibiotic treatment.

Painful in affected area. Deep-seated, hard, round, fluid-filled blisters.

COMMENTS/EXCLUSION

Reactivation of the chickenpox virus. No exclusion necessary if blisters are covered.

Entire body

Highly contagious. Notify public health immediately.

RINGWORM AND OTHER FUNGAL SKIN INFECTIONS (TINEA, DERMATOPHYTES) WHAT IS RINGWORM AND OTHER FUNGAL SKIN INFECTIONS? Some fungi, called dermatophytes, can cause skin, hair, and nail infections. Examples of fungal skin infections include ringworm (also known as tinea – it is not caused by a worm) and athlete’s foot (also known as tinea pedis). These types of infections are very common and can affect anyone. Persons with weakened immune systems and persons involved in contact sports (such as wrestling) may be affected more often. These infections typically have no long-term health consequences and can be effectively treated. SIGNS & SYMPTOMS • Fungal infections can affect skin on almost any area of the body, including the scalp. Moist areas of skin (such as skin folds) can be affected more often. • Affected areas can be itchy and become infected if scratching is excessive. • Ringworm begins as a small red bump or ring that spreads outwards. Affected areas have a red, scaly outer ring with a clear central area, or may appear wet and crusty. • If the scalp is affected, a bald patch of scaly skin may appear. INCUBATION PERIOD Between 4-14 days HOW IS IT SPREAD? Fungal infections, including ringworm, are spread by direct contact with the rash on an affected human or animal, or by direct contact with a contaminated object/surface (such as clothing, towels, and bedding). Animals like dogs, cats, cows, goats, pigs, and horses can have ringworm and can transmit it to people. HOW LONG CAN A PERSON PASS THE INFECTION TO OTHERS? As long as the rash is present on the skin. PUBLIC HEALTH REPORTING REQUIREMENTS • Individual cases are not reportable. • Suspected outbreaks of all types (including fungal infections/ringworm) are reportable to state or local public health. CONTROL OF SPREAD • Ringworm: EXCLUDE children and staff with ringworm from the end of the child care/school day until treatment has started. • Other fungal infections: Consult with public health about exclusion. • Ensure all infected persons and pets are treated. • Avoid sharing personal items. • Encourage good hygiene and handwashing. • See page 16 for sanitizing and disinfecting guidelines. TREATMENT Fungal infections, including ringworm, can be treated with antifungal medicine that can be taken in tablet or liquid form by mouth, or as a topical cream applied directly to the affected area. The particular medication used and duration of treatment is based on the location of the infection. Some treatments require a prescription by a health care provider, and some topical creams can be purchased over-the-counter.

ROSEOLA (SIXTH DISEASE) WHAT IS ROSEOLA (SIXTH DISEASE)? Roseola is a rash illness caused by a virus, either human herpesvirus 6 or 7. Some people have a mild illness without a rash. Roseola occurs mainly in children between the ages of 6 and 24 months. Most children have had roseola before 4 years of age. Sometimes it is referred to as Sixth Disease, or exanthem subitum. SIGNS • • • •

& SYMPTOMS High fever (often > 103oF) lasting 3-7 days Seizures may occur with the high fever Rash appears after the fever ends Rash, if present, lasts hours to several days ◦ Rash is typically pinkish-red spots that are not itchy ◦ Rash usually begins on face, the trunk, and then spreads to the neck, arms, legs and back ◦ Rash is typically flat with some raised spots

INCUBATION PERIOD Probably 5-15 days (average of 9-10 days) HOW IS IT SPREAD? Person-to-person, probably from infected nose and throat discharges. The virus exists in the nose and throat discharges of persons with symptoms and without symptoms, who have had roseola in the past. After having roseola, the virus remains inactive in the person’s body and may be reactivated later without causing symptoms. HOW LONG CAN A PERSON PASS THE INFECTION TO OTHERS? Probably as long as the virus is present in a person’s nose and throat discharges. The virus has been found intermittently in nose and throat discharges of healthy persons who had roseola in the past, so persons infected at some point in their life can potentially transmit to others. It appears that roseola is not very contagious. PUBLIC HEALTH REPORTING REQUIREMENTS Roseola does not need to be reported to public health, unless an outbreak is occurring. Outbreaks are uncommon. CONTROL OF SPREAD • Exclusion is not necessary unless child has a fever along with the rash. • Any child with a fever and rash should seek medical care to ensure that he/she does not have a more serious illness. • Children should be taught to cover his/her mouth when sneezing or coughing, and then washing hands after doing so. • Dispose of tissues soiled with nose and/or throat discharges. • Children and staff should practice proper and frequent handwashing. TREATMENT There is no treatment for roseola, and it typically goes away on its own.

ROTAVIRUS WHAT IS ROTAVIRUS? Rotavirus is a virus that causes gastrointestinal illness. Infants and young children are most often affected, and the illness can be severe in these populations. Older children and adults can also become infected, but illness generally is not as severe as in younger children. Symptoms generally last 3-8 days. There are two rotavirus vaccines licensed for use in the US (RotaTeq and Rotarix), which have been shown to be safe and effective at preventing severe illness. Vaccinated and unvaccinated persons may develop rotavirus infection more than once because there are many different types of rotavirus. Usually a person’s first infection with rotavirus causes the most severe symptoms. Rotavirus infection can occur any time of the year, but is more likely to occur in the winter and spring months. SIGNS • • •

& SYMPTOMS Watery, non-bloody diarrhea (can be severe) Abdominal pain/cramps Loss of appetite

• Vomiting • Fever • Dehydration

INCUBATION PERIOD: Ranges from 1-3 days HOW IS IT SPREAD? Persons ill with rotavirus shed the virus in their feces (stool). The virus is easily spread (especially among young children) by the fecal→oral route, meaning that the virus is shed by infected persons in their feces and then enters susceptible persons mouths (by contaminated hands, toys, surfaces, food, water, etc.) to cause infection. HOW LONG CAN A PERSON PASS THE INFECTION TO OTHERS? As long as the virus is in the feces, which can occur before symptoms appear and up to 21 days after a person becomes ill. PUBLIC HEALTH REPORTING REQUIREMENTS • Report the infection to the facility director or school nurse. • Individual cases of rotavirus are not reportable to public health. • Suspected outbreaks of all types (including rotavirus and other diarrheal illness) are reportable to state or local public health. CONTROL OF SPREAD • EXCLUDE all infected children and staff, including food preparation staff, until diarrhea has resolved. • Do not transfer ill children to other facilities. • Encourage frequent hand washing, especially after using the toilet, changing diapers, before eating, and before food preparation. • Promptly sanitize contaminated surfaces (like diaper changing areas) and other commonly touched surfaces (like toys), and discard food or water if it is thought to be contaminated. See page 16. • Encourage routine rotavirus vaccination in infants. • Consult with local or state public health for help with implementation of control measures. TREATMENT There is no treatment for this infection; since it is caused by a virus, antibiotics will not help. Infected persons should drink plenty of fluids to prevent dehydration. Oral rehydration fluids (like Pedialyte and similar fluids) should be used if possible.

RSV (RESPIRATORY SYNCYTIAL VIRUS) WHAT IS RSV (RESPIRATORY SYNCYTIAL VIRUS)? RSV causes respiratory tract illness in people of all ages. Symptoms can last for 8-15 days. Symptoms can be severe in infants, young children, older adults, and immunocompromised persons and hospitalization may be required. Premature infants, children under 2 years of age with chronic lung or heart conditions, and children with weakened immune systems are at particularly high risk for developing severe infections. RSV is more common in the late fall, winter, and early spring. Almost all children will be infected with RSV by their second birthday. SIGNS & SYMPTOMS • Similar to the common cold – runny/stuffy nose, sneezing, coughing • Fever • Decreased appetite • Sometimes wheezing

• Pneumonia and/or bronchiolitis (inflammation of the small airways in the lungs) can occur in infants and young children • Infants may only have symptoms of irritability, decreased activity, and breathing difficulties

INCUBATION PERIOD Ranges from 2-8 days (usually 4-6 days) HOW IS IT SPREAD? RSV is spread by inhaling or having contact (typically through the mouth, nose, or eyes) with virus-containing droplets produced by an infected person who is coughing and sneezing. Virus-containing droplets do not stay in the air for very long, but can settle on surfaces that are touched by others. Contact with hands, tissues, and other articles contaminated with nose/throat discharges of ill people can spread the virus. HOW LONG CAN A PERSON PASS THE INFECTION TO OTHERS? Infected persons are usually contagious for 3-8 days. Some infants and persons with weakened immune systems can be contagious for as long as four weeks. PUBLIC HEALTH REPORTING REQUIREMENTS • Individual cases are not reportable. • Suspected outbreaks of all types (including RSV) are reportable to state or local public health. • Consultation with the state or local public health agency is available. CONTROL OF SPREAD • Exclusion is not necessary, but it is recommended that children experiencing acute respiratory symptoms stay home until they feel better. • Encourage frequent handwashing. • Encourage children to cover coughs and sneezes. • Clean potentially contaminated surfaces, like doorknobs, tables, hand rails, etc. See page 16. • Avoid sharing cups and eating utensils. • Persons with respiratory symptoms should not interact with children at high-risk for severe disease. TREATMENT There is no specific treatment for RSV, and it usually resolves on its own. Antibiotics should not be used for viral infections, such as RSV. Aspirin should be avoided because it increases the risk of Reye’s Syndrome, a serious disorder that can lead to coma and death.

RUBELLA (GERMAN MEASLES) WHAT IS RUBELLA (GERMAN MEASLES)? Rubella is caused by the rubella virus. In children, rubella is a fairly mild illness. However, rubella infection during the first trimester of pregnancy can cause fetal death, premature delivery, and serious birth defects known as congenital rubella syndrome. A vaccine exists for Rubella. SIGNS & SYMPTOMS • Generalized rash: Pink isolated spots which appear first on the face, then spread rapidly to the trunk, upper arms, and upper legs. Over about two days the rash fades from the face and trunk and spreads to the forearms, hands, and feet. The rash is usually gone within three days. • Swollen glands, usually at the base of the skull and behind the ears • Mild or no fever • 20-50% of infected individuals will not have symptoms INCUBATION PERIOD Ranges from 12-23 days (usually 14 days) HOW IS IT SPREAD? Rubella is spread by contact with nose/throat discharges of infected persons through coughing and sneezing. HOW LONG CAN A PERSON PASS THE INFECTION TO OTHERS? Cases are contagious from seven days before to 5-7 days after the rash onset. Infected individuals who do not have symptoms can still infect others. PUBLIC HEALTH REPORTING REQUIREMENTS Report the infection to the local or state health department within 24 hours of diagnosis. CONTROL OF SPREAD • EXCLUDE all infected children and/or staff until seven days after the rash onset. ◦ Discuss with the state or local public health agency possible exclusion of children/students and staff without prior proof of rubella immunity. • Suspect rubella cases should be referred to a health care provider. Laboratory testing is needed to confirm the diagnosis, because the rubella rash looks similar to other rashes. • Determine if any exposed contacts are pregnant, and provide names of pregnant contacts to the state or local public health agency. [See Regulation 5 (regarding investigations) of the Rules and Regulations Pertaining to Epidemic and Communicable Disease Control]. Exposed pregnant women, especially those in the first trimester, should contact their healthcare provider to find out if they are immune to rubella. • Review students’ rubella immunization records and staff’s rubella immunity status. Only one dose of rubella vaccine given on or after the first birthday is needed for proof of immunity. • Recommend rubella vaccine for persons without rubella immunity. Vaccine given after exposure will not prevent infection; however, it may provide protection against future exposure. • A live rubella virus vaccine is routinely given at 12-15 months of age in combination with measles and mumps vaccine (MMR vaccine) and sometimes varicella vaccine (MMRV). A second MMR is recommended at age 4-6 years. • The Colorado School Immunization Rules requires students in grades K through 12 are required to have two doses of rubella vaccine and child care/preschool students 15 months of age to kindergarten to have one dose of rubella vaccine unless the student has an exemption to immunization. • Pregnant women should not receive a rubella vaccination due to the possible risk to the developing child. TREATMENT There is no specific treatment for rubella.

SALMONELLA WHAT IS SALMONELLA? Salmonella infection can cause an intestinal illness referred to as salmonellosis. Salmonella bacteria live in a very wide range of animals including reptiles, amphibians, chicks, ducks, rodents and cattle. SIGNS & SYMPTOMS • Diarrhea (sometimes bloody) • Abdominal cramps

• Vomiting • Fever

INCUBATION PERIOD: 6-72 hours (usually 12-36 hours), but could be up to seven days HOW IS IT SPREAD? Salmonella is spread by the fecal→oral route through eating contaminated food, drinking contaminated water, or putting contaminated objects in the mouth. Salmonella is also spread from person-to-person and from animals to people (especially reptiles and chicks). A wide variety of foods have been associated with infection include undercooked meat/poultry or eggs, unpasteurized milk, and produce. HOW LONG CAN A PERSON PASS THE INFECTION TO OTHERS? Salmonella can be spread as long as the bacteria are in the stool. People who are having diarrhea are more likely to spread the illness than those whose symptoms have resolved. People may continue to shed Salmonella bacteria in their stools for many weeks after their illness has gone away. PUBLIC HEALTH REPORTING REQUIREMENTS • Staff who become aware of illness should report the infection to the facility director or school nurse. The facility should report to the local or state health department within seven days of diagnosis. • If other children or staff are ill with diarrhea, refer them to their health care providers and contact public health as soon as possible as this could be an outbreak. CONTROL OF SPREAD • EXCLUDE all infected children and/or staff until until at least 24 hours after diarrhea has resolved. ◦ CHILD CARE: Ill children should not go to another facility during the period of exclusion. ◦ In rare circumstances, public health may require additional testing before an infected person can return to work, school, or child care. • EXCLUDE affected individuals from food preparation until cleared by the state or local public health agency. • Encourage frequent handwashing, especially after animal contact, after using the toilet, changing diapers and before eating. • Promptly sanitize contaminated surfaces (like diaper changing areas) and other commonly touched surfaces (like toys) and discard food or water if it is thought to be contaminated. See page 16. • Refer to page 15 of this document for information on food safety. TREATMENT Ill people are usually not given antibiotics for mild Salmonella infections because antibiotics do not shorten the duration of illness and may prolong shedding of the bacteria in the stool.

SCABIES WHAT IS SCABIES? Scabies is a condition caused by Sarcoptes scabiei var. hominis, a microscopic mite that infests the top skin layer of humans. Scabies is not a result of poor personal hygiene, but is contracted through skin to skin contact with someone who is infested. People with scabies usually have only 10 or 12 mites on their body. Scabies should only be diagnosed by a healthcare provider; mis-diagnoses by lay people are common. SIGNS • • •

& SYMPTOMS Initial symptoms consist of small itchy bumps, blisters, or pus-filled bumps that break when scratched Intense itching may occur, particularly at night or after a bath Commonly affected areas include the hands and feet, especially the webbing between digits, the inner wrists and armpits • Other areas of the body may also be affected • Tiny, raised, crooked, grayish-white or skin-colored burrows may be seen in the skin

INCUBATION PERIOD The incubation period is the time from the mite’s penetration and entry into the top skin layer until the time the infested person develops symptoms. People who have never had scabies before may not develop symptom until 2-6 weeks after they are infested. For people who have had scabies before, the incubation period is much shorter, and can be as little as 1-4 days. HOW IS IT SPREAD? Scabies is transmitted by direct, prolonged, physical contact (skin-to-skin) with an infested person or through contact with infested clothing or bedding. An infested person can spread the scabies mite before he/she shows signs and symptoms. Mites cannot reproduce or survive without a human host, so objects like toys and desks are not important in the spread of scabies. HOW LONG CAN A PERSON PASS THE INFECTION TO OTHERS? Infested individuals can spread the mites until the mites and eggs are destroyed by treatment. PUBLIC HEALTH REPORTING REQUIREMENTS Individual cases are not reportable. The school nurse/facility director should be consulted for specific concerns, or consultation with the state or local public health agency is available. CONTROL OF SPREAD • Refer suspect infested people to a health care provider for diagnosis and treatment. • Exclude infested students and staff until after a treatment has been applied. • Close contacts of an infested person should be monitored for symptoms, or may be treated prophylactically. • The type and duration of contact will determine whether prophylaxis is needed. Sexual contacts are at high risk for scabies. TREATMENT • Treatments for scabies are only available with a prescription. Suspect infested people should consult their health care provider for a diagnosis and prescription. • Itching is due to a reaction to the mite, its eggs, and its feces in the skin. Itching may increase and even continue for several weeks following a successful treatment as the mites die. • Mites can be resistant to treatment. A health care provider should be consulted if symptoms persist for more than three weeks after treatment.

ENVIRONMENTAL CONTROL MEASURES • Scabies mites cannot live for longer than two or three days off a human, thus mites in the environment will die in a few days if there is no host to feed on. • Clothing and bedding used by an infested person should be laundered using hot water and the high heat setting on the dryer. • Items from an infested person that cannot be laundered can be placed in a plastic bag for 4 days. • Carpet and furniture can be vacuumed. Do not use pesticides.

SEXUALLY TRANSMITTED INFECTIONS (STIs) WHAT ARE SEXUALLY TRANSMITTED INFECTIONS (STIs)? Over sixteen infectious diseases are recognized as being STIs. The STIs described in this section of the guidelines cover only those most common (i.e., situations with which school/child care nurses and personnel are more likely to be confronted). Teens, especially females, have very high reported rates of STIs for several reasons: • Many STIs do not cause symptoms, sexual partners do not know that they are infected and can spread the disease; • Social stigma attached to STIs may cause embarrassment and result in hesitance to be examined for fear that others will “find out” about the infection; • Lack of knowledge about STIs and how they are transmitted. SIGNS & SYMPTOMS Varies depending on the disease. See the disease-specific chapters in these guidelines. INCUBATION PERIOD Varies depending on the disease. See the disease-specific chapters in these guidelines. HOW IS IT SPREAD? STIs are transmitted through various forms of sexual contact: oral, anal, and vaginal. People with an STI are generally contagious until they receive treatment, although some STIs are potentially communicable for life (like HIV, genital herpes, and genital warts). HOW LONG CAN A PERSON PASS THE INFECTION TO OTHERS? Varies depending on the disease. See the disease-specific chapters in these guidelines. PUBLIC HEALTH REPORTING REQUIREMENTS • Chlamydia, gonorrhea and Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome (HIV/AIDS) must be reported to the state or local public health agency within seven days of diagnosis. • Syphilis must be reported with 24 hours of a suspected or confirmed diagnosis. • The possibility of sexual abuse must be considered when infections occur in prepubescent children and must be reported to appropriate authorities. CONTROL OF SPREAD • No exclusions or environmental interventions are necessary, since STIs require close intimate physical contact for transmission, virtually always of a sexual nature. • Infected persons should be examined by a health care provider and treated (if treatment is available) as soon as the diagnosis is confirmed to prevent complications. Treatment of partner(s) is a crucial strategy to prevent re-infection. Infected persons should seek medical care if symptoms persist or recur. Parental consent is not required for minors to be examined and treated. • Infected persons should avoid sexual activity until they and their partner(s) are treated (if treatment is available) and cured. • Infected persons should abstain from sex or use condoms to prevent future infections. • General education of STI prevention is advocated. • A vaccine exists for the most common types of Human Papillomavirus (HPV) (the virus that causes genital warts); there are currently no other vaccines for STIs. • Additional information is available at: https://www.colorado.gov/pacific/cdphe/sti-hiv TREATMENT Infected persons should be taught how to take prescribed medications correctly. For additional treatment information, see the 2010 Sexually Transmitted Diseases Treatment Guidelines, published by the CDC: http://www.cdc.gov/std/tg2015/

SHIGELLA WHAT IS SHIGELLA? Shigella infection causes an intestinal illness referred to as shigellosis. Most infections resolve in 2-3 days. Sometime people can be infected and not show any symptoms. Animals do not carry or spread this type of bacteria. SIGNS & SYMPTOMS • Diarrhea (sometimes with blood or mucus) • Abdominal cramps

• Fever • Vomiting

INCUBATION PERIOD: 1-7 days (usually 1-3 days) HOW IS IT SPREAD? Shigella is highly contagious and spreads easily from person-to-person, especially in child care facilities. Shigella is spread by the fecal→oral route through direct contact with infected people, by coming into contact with contaminated surfaces, or by eating food contaminated by infected persons. HOW LONG CAN A PERSON PASS THE INFECTION TO OTHERS? People are contagious as long as the organism is present in the stool, which can be weeks. People with diarrhea are more likely to spread it than those who are infected but do not have symptoms. PUBLIC HEALTH REPORTING REQUIREMENTS • Staff who become aware of illness should report the infection to the facility director or school nurse. The facility should report to the local or state health department within seven days of diagnosis. • If other children or staff are ill with diarrhea, refer them to their health care providers and contact public health as soon as possible as this could be an outbreak. CONTROL OF SPREAD • Please consult with local or state public health with implementation of control measures. • EXCLUDE all infected children and/or staff until at least 24 hours after diarrhea has resolved, AND ◦ CHILD CARE: Children should be excluded until they have been treated with an effective antibiotic for three days OR they have two consecutive negative stool samples collected 24 hours apart. Ill children should not go to another facility during the period of exclusion. ◦ Most STAFF in CHILD CARE should be excluded until they have two negative stool samples collected 24 hours apart. Consult with public health about the necessity of follow-up testing. ◦ SCHOOLS: Children who wear diapers or have developmental delays resulting in fecal incontinence or hygiene concerns should be excluded until they have two consecutive negative stool samples collected 24 hours apart OR the child has been treated with an effective antibiotic for three days. ◦ STAFF in SCHOOLS who handle food should be excluded until they have two negative stool samples collected 24 hours apart. • EXCLUDE affected individuals from food preparation until cleared by the state or local public health agency. • Encourage frequent handwashing, after using the toilet, changing diapers and before eating. • Promptly sanitize contaminated surfaces (like diaper changing areas) and other commonly touched surfaces (like toys) and discard food or water if it is thought to be contaminated. See page 16. TREATMENT Antibiotics can be used to treat infections, but some antibiotics will not eliminate these bacteria. Antibiotic treatment is recommended for cases with severe disease or underlying immunosuppressive conditions. Some Shigella bacteria have become resistant to certain antibiotics. Laboratory tests can determine which antibiotics are effective for a specific Shigella case.

STREPTOCOCCAL SORE THROAT (STREP THROAT) WHAT IS STREPTOCOCCAL SORE THROAT (STREP THROAT)? Streptococcal sore throat, also referred to as strep throat, is caused by the bacteria Streptococcus pyogenes (also known as Group A streptococcus). Not all sore throats are caused by streptococcal bacteria. Persons ill with a sore throat should see a health care provider to determine the cause. Strep throat is usually diagnosed by a rapid strep test or a throat culture. SIGNS & SYMPTOMS • Sore throat – throat appears red and there may be white pus on the tonsils • Fever • Enlarged lymph nodes in the neck • Runny nose (toddlers may only have a runny nose and/or fever) • Sometimes headache, stomach pain, nausea, and/or vomiting • Some persons may develop a skin rash called a scarlatiniform rash

• Complications of strep throat can include: ◦ Rheumatic fever, an inflammatory disease that can involve the heart, joints, skin, and brain. The risk of rheumatic fever is reduced by promptly treating strep throat with the appropriate antibiotics. ◦ Acute glomerulonephritis, a disease of the kidneys. ◦ Toxic shock syndrome.

INCUBATION PERIOD 2-5 days HOW IS IT SPREAD? Strep throat is usually transmitted through contact with droplets and respiratory secretions from an infected person, such as through coughing and sneezing. HOW LONG CAN A PERSON PASS THE INFECTION TO OTHERS? Persons are no longer contagious within 24 hours of appropriate antimicrobial therapy. Communicability of persons who are not treated gradually diminishes over a period of weeks. PUBLIC HEALTH REPORTING REQUIREMENTS • Report the infection to the facility director or school nurse. • Individual cases of strep throat infections, scarlet fever, and rheumatic fever are not reportable to public health. • Suspected outbreaks of all types (including strep throat) are reportable to state or local public health. CONTROL OF SPREAD • EXCLUDE symptomatic children and staff in child care centers and schools with strep throat until 24 hours after beginning antibiotic treatment. • A student or staff member without symptoms, regardless of a positive test result, does not need to be excluded. • Family members and household contacts of an ill person do not need to be routinely tested unless they are symptomatic, or contacts are at increased risk of developing sequelae from strep infection, or the child has rheumatic fever or acute glomerulonephritis. • Follow-up testing of symptomatic persons with a positive strep test is not routinely recommended. If symptoms persist after antibiotic therapy, a health care provider should be consulted. • Encourage frequent handwashing. TREATMENT Typically antibiotics (usually penicillin or amoxicillin) are prescribed to treat strep throat. Treatment instructions should be followed closely in order to prevent complications such as rheumatic fever.

SYPHILIS WHAT IS SYPHILIS? Syphilis is caused by Treponema pallidum, a bacterium. Syphilis can affect the entire body, and has three stages: primary, secondary, and late. Symptoms vary and can be indistinguishable from other diseases, and often people with syphilis do not have noticeable symptoms for years. SIGNS & SYMPTOMS • Primary stage: One or more small, round, hard, painless sores (called chancres) appear at the site of exposure, usually around the penis, mouth, vagina, and/or anus. Chancres generally resolve after 3-6 weeks without treatment. • Secondary stage: If not treated, a non-itchy, reddish, rough rash develops on the palms of the hands and on the bottoms of the feet. A rash with a different appearance may occur on other parts of the body. Sometimes the rash is faint and not noticed. Second-stage symptoms can also include fever, swollen lymph glands, sore throat, patchy hair loss, headaches, weight loss, muscle aches, and tiredness. Even without treatment, the symptoms of secondary syphilis usually resolve. • Late stage: A person with untreated syphilis can experience a period of many years without any symptoms following the primary and secondary stages. Signs and symptoms of the late stage of syphilis include difficulty coordinating muscle movements, paralysis, numbness, gradual blindness, and dementia. The damage may be serious enough to cause death. INCUBATION PERIOD Ten days to three months (usually three weeks). HOW IS IT SPREAD? Direct exposure to a chancre through sexual contact: oral, anal, and vaginal. HOW LONG CAN A PERSON PASS THE INFECTION TO OTHERS? Persons with a chancre(s) who is in the primary or secondary stage can spread syphilis. PUBLIC HEALTH REPORTING REQUIREMENTS • Syphilis infections must be reported by laboratories and health care providers to the state or local public health agency within 24 hours of a suspected or confirmed diagnosis. • The possibility of sexual abuse must be considered when infections occur in prepubescent children and must be reported to appropriate authorities. CONTROL OF SPREAD • No exclusions or environmental interventions are necessary, since STIs require close intimate physical contact for transmission, virtually always of a sexual nature. • Infected persons should be examined by a health care provider and treated as soon as the diagnosis is confirmed to prevent complications. Treatment of the partner(s) is a crucial strategy to prevent reinfection. Infected persons should seek medical care if symptoms persist or recur. Parental consent is not required for minors to be examined and treated. • Infected persons should avoid sexual activity until they and their partner(s) are treated and cured. • Patients should abstain from sex or use condoms to prevent future infections. • General education of STI prevention is advocated. • Additional information is available at: http://www.cdc.gov/std/syphilis/default.htm TREATMENT Treatment is with antibiotics. Syphilis is easy to cure in its early stages. Late stage syphilis complications require more extensive antibiotic treatment.

TETANUS WHAT IS TETANUS? Tetanus is caused by Clostridium tetani, which is a spore-forming bacteria found in soil and in human and animal feces. The spores enter the body through breaks in the skin, often wounds, and grow under low oxygen conditions. The bacteria excrete a potent toxin (poison) that affects the central nervous system. Tetanus can be fatal. There are very few cases of tetanus in the United States due to the use of tetanus vaccine. SIGNS • • • •

& SYMPTOMS The jaw and neck are usually involved first, causing lockjaw, stiff neck, and difficulty swallowing Painful, severe muscular contractions (spasms) Generalized tonic seizure-like activity Eventually the entire body is affected (usually in a descending pattern)

INCUBATION PERIOD Ranges from two days to several months (usually 8-14 days) HOW IS IT SPREAD? Persons can acquire tetanus when spores enter the body through breaks in the skin (wounds). HOW LONG CAN A PERSON PASS THE INFECTION TO OTHERS? Tetanus is not contagious person-to-person. PUBLIC HEALTH REPORTING REQUIREMENTS Report the infection to the facility director or school nurse and the local or state health department within 7 days of diagnosis. CONTROL OF SPREAD • Exclusion is not necessary because tetanus is not spread person-to-person. • Tetanus can be prevented with vaccination. • Tetanus toxoid is part of DTaP, DT, Tdap, and Td vaccines. • Tetanus vaccine is routinely given starting at 2 months of age. • The Colorado School Immunization Rules require students to have tetanus vaccine starting at 4 months of age or an exemption to vaccination. • Tetanus vaccine and/or tetanus immune globulin (TIG) may be recommended after an injury in certain situations depending on the type of wound and the person’s tetanus vaccination status. • Instances where tetanus vaccine and/or TIG may be needed include animal bites, cuts, burns, puncture wounds, and wounds contaminated with soil, feces, or saliva. • Consultation with the state or local public health agency is available or the injured person may be referred to their health care provider. • The following link may help child care and school nurses determine whether tetanus prophylaxis (tetanus shot or TIG) is needed after an injury. See Table 1. Guide to tetanus prophylaxis in routine wound management under the “Vaccination” section of the “Tetanus” chapter of the Centers for Disease Control’s “Manual for the Surveillance of Vaccine Preventable Diseases”: http://www.cdc.gov/vaccines/pubs/surv-manual/chpt16-tetanus.html TREATMENT All wounds should be cleaned. Tetanus immune globulin (TIG) is recommended for persons with tetanus. Antibiotic prophylaxis against tetanus is not useful.

TUBERCULOSIS (TB) WHAT IS TUBERCULOSIS (TB)? Tuberculosis (TB) is a disease caused by Mycobacterium tuberculosis. The bacteria usually attack the lungs, but can attack any part of the body such as the kidney, joints/bones, spine, and brain. If not treated properly, it can be fatal. HOW IS IT SPREAD? TB is spread through the air from one person to another. When a person with active TB disease of the lungs or throat coughs, sneezes, speaks, or sings, the bacteria enters the air. People nearby may breathe in the bacteria and become infected. TB is NOT spread by shaking hands, sharing items (like food, drinks, toothbrushes), touching objects, or kissing. Not everyone infected with TB bacteria becomes sick. Two TB-related conditions exist • Latent TB Infection: TB bacteria can live in your body without making you sick. This is called latent TB infection (LTBI). In most people who breathe in TB bacteria and become infected, the body is able to fight the bacteria to stop it from growing. People with latent TB infection do not feel sick and do not have any symptoms. • Active TB Disease: TB bacteria become active if the immune system cannot stop it from growing. When TB bacteria are active (multiplying in your body), this is called TB disease. TB disease will make you sick. People with TB disease may spread the bacteria to people they spend time with every day. A Person with Latent TB Infection: Has no symptoms

A Person with Active TB Disease: Has symptoms that may include:

Does not feel sick

• a bad cough that lasts 3 weeks or longer • pain in the chest • coughing up blood or sputum Usually feels sick

Cannot spread TB bacteria to others

May spread TB bacteria to others

Usually has a skin test or blood test result indicating TB infection

Has a normal chest x-ray and a negative sputum smear

May have an abnormal chest x-ray, or positive sputum smear or culture

Needs treatment for latent TB infection to prevent active TB disease

Needs treatment to treat active TB disease

• weakness or fatigue • weight loss and/or no appetite • chills and/or fever • sweating at night

PUBLIC HEALTH REPORTING REQUIREMENTS • Report the active TB cases to the facility director or school nurse and the local or state health department within 24 hours of diagnosis. • Report positive TB skin tests to the facility director or school nurse and the local or state health department within seven days of diagnosis. CONTROL OF SPREAD • EXCLUDE active TB cases from child care or school until they are receiving treatment and are cleared by a health care provider or a public health official. Children/students and staff who do not have symptoms should not be excluded from child care or school solely based on a positive skin or blood test. • Referral to a health care provider is mandatory for suspected or confirmed case of TB. Recent skin or blood test converters should have a chest x-ray and consult a health care provider or public health agency to determine if treatment is indicated. • Skin or blood testing of all exposed children and staff may be necessary in some instances.

• No immunization is recommended in the United States. • Consultation with the state or local public health agency is encouraged for situations that may arise in child care or school settings. The CDPHE Tuberculosis Program can be reached at 303-692-2638. • Additional information can be found on the CDPHE TB Program website https://www.colorado.gov/pacific/cdphe/tuberculosis, or CDC’s TB website: http://www.cdc.gov/tb/.

VIRAL MENINGITIS (ASEPTIC MENINGITIS) WHAT IS VIRAL MENINGITIS? Viral meningitis is a relatively common illness but rarely is serious. Meningitis is infection of the tissue that covers the brain and spinal cord. Viral meningitis is usually caused by a group of viruses called enteroviruses. Other causes of viral meningitis include: measles, chickenpox, mumps, herpes virus, and West Nile virus. Increases in cases of viral meningitis occur regularly in the summer and fall and are not cause for alarm. Symptoms of viral meningitis are similar to bacterial meningitis, which can be very severe. Persons suspected of having meningitis should be seen by a health care provider to rule out bacterial meningitis. SIGNS • • • •

& SYMPTOMS Fever Severe headache Stiff neck Trouble waking up

• Sensitivity to light • Confusion • Nausea/vomiting

INCUBATION PERIOD Dependent on the virus involved (i.e., incubation for enterovirus is 3-7 days). HOW IS IT SPREAD? How the infection spreads varies among the viruses that cause viral meningitis. Viral meningitis is most often spread through direct contact with nose/throat discharges or the stool of an infected person. HOW LONG CAN A PERSON PASS THE INFECTION TO OTHERS? Contagiousness varies among the viruses that cause viral meningitis. It is usually spread during the time the infected person has symptoms of illness. PUBLIC HEALTH REPORTING REQUIREMENTS Aseptic meningitis is no longer a reportable condition in Colorado. CONTROL OF SPREAD • Exclusion is usually not necessary. However, meningitis caused by certain viruses, such as chickenpox, mumps, or measles would require exclusion. • Suspect cases with diarrhea should be referred to a health care provider. • Encourage frequent and thorough hand washing. • Encourage covering of mouth and nose when coughing or sneezing. • Promptly disinfect contaminated surfaces (like eating/drinking utensils) and other commonly touched surfaces (like toys) and doorknobs soiled by secretions. See page 16. • Please consult with local or state public health about control measures. TREATMENT No specific treatment is available. Health care providers often recommend rest, plenty of fluids, and over-thecounter medications to relieve fever and headaches.

INFECTIOUS DISEASE IN CHILD CARE AND SCHOOL SETTINGS | SUMMARY CHART REPORT TO PUBLIC HEALTH*

DISEASE Agent

INCUBATION PERIOD

TRANSMISSION

Animal Bites/Rabies

Rabies: 8 days-6 years

Saliva of an infected animal

As long as symptoms are present

YES

Fecal-oral spread, contaminated food/water animals

While diarrhea is present; can spread for a few days after symptoms are gone

YES

Droplet/infectious discharges, skin contact

1-2 days before the rash appears until all the blisters have crusted over (usually days after onset)

YES (7 days)

YES until all blisters have formed scabs and crusted over

Sexual transmission

Until treated

YES

None

Rabies virus

(usually 3-8 weeks) Campylobacter

1-10 days

Campylobacter bacteria

(usually 2-5 days)

Chickenpox (Varicella)

10-21 days

Varicella-zoster virus

(usually 14-16 days)

Chlamydia

1-3 weeks

CONTAGIOUS PERIOD

Chlamydia trachomatis bacteria CMV

(24 hours for animal bites)

(7 days)

EXCLUSION None for animal bites

YES until 24 hours after diarrhea resolves

(7 days) 3-12 weeks

Body secretions (primarily saliva and urine)

As long as the virus is present in body secretions (months or years)

None

Common Cold

1-3 days (usually 48 hours)

1 day before symptom onset until 5 days after

None

A variety of viruses

Droplet/infectious discharges

None unless symptoms are severe

Croup

2-7 days

Droplet/infectious discharges

1 week before symptom onset to 1-3 weeks after symptoms

None

None unless symptoms severe

Cryptosporidium

1-12 days (usually 7 days)

While diarrhea is present; can spread for several weeks after symptoms are gone

YES

Cryptosporidium parvum parasite

Fecal-oral spread, contaminated food/water animals

YES until 24 hours after diarrhea resolves; avoid swimming for 2 weeks after diarrhea

E. coli O157:H7 and other Shiga ToxinProducing E. coli (STEC)

1-10 days

Fecal-oral spread, contaminated food/water, animal

While diarrhea is present; can spread for 1-3 weeks after symptoms are gone

YES

Droplet/infectious discharges

1 week before rash appears

None

Cytomegalovirus

(usually 3-4 days)

Escherichia coli bacteria

Fifth Disease Human parvovirus B19

4-21 days

(7 days)

YES until diarrhea resolves (negative stool testing may be required prior to return) None

TRANSMISSION

CONTAGIOUS PERIOD

REPORT TO PUBLIC HEALTH*

EXCLUSION

Sexual transmission

Potentially lifelong

None

Variable

Sexual transmission

Potentially lifelong

None

Giardia

1-3 weeks (usually 7-10 days)

While diarrhea is present; can spread for months after symptoms are gone

YES

Giardia lamblia parasite

Fecal-oral spread, contaminated food/water

YES until 24 hours after diarrhea resolves

Gonorrhea

1-14 days

Sexual transmission

Until treated

YES

DISEASE Agent

INCUBATION PERIOD

Genital Herpes

2-12 days

Herpes simplex virus Genital Warts Human papillomavirus

Neisseria gonorrhea bacteria Hand, Food, and Mouth Disease

(7 days)

None

(7 days) 3-6 days

Droplet/infectious discharges, fecal-oral spread

During the first week of illness for respiratory droplets; virus can be present in stool 4-6 weeks

None

None-unless the child has mouth sores and is drooling uncontrollably

Nits hatch in 10-14 days, adults live 3-4 weeks

Direct contact with an infested person/object

As long as live lice are present

None

YES from end of school day until after first treatment

Hepatitis A

2-6 weeks (usually 4 weeks)

Most contagious 2 weeks before symptom onset and slightly contagious 1 week after jaundice onset

YES

Hepatitis A virus

Fecal-oral spread, contaminated food/water

(24 hours)

YES until 1 week after symptom onset or jaundice

Hepatitis B

2-6 months

None

(usually 2-3 months)

Several weeks before symptom onset and throughout the illness, some people carry virus for life

YES

Hepatitis B virus

Infective blood or body fluids, sexual transmission

Hepatitis C

2 weeks â&#x20AC;&#x201C; 6 months

Infective blood

YES

Hepatitis C virus

(usually 6-7 weeks)

1 or more weeks before symptom onset and as long as the virus is present in the blood which can be lifelong

Strains of enteroviruses

Head Lice (Pediculosis) Pediculus humanus, the head louse

(7 days)

None

REPORT TO PUBLIC HEALTH*

DISEASE Agent

INCUBATION PERIOD

TRANSMISSION

Herpes (Cold Sores, Fever Blisters)

2-12 days

Direct contact

As long as the sores are present

None

None unless the child has open sores and is drooling uncontrollably

Variable

Infective blood & some body fluids

Lifelong

YES

None

7-10 days for Streptococcal; Variable for Staphylococcal

Direct contact

Until treatment with antibiotics for at least 24 hours or lesions are no longer present

None

Yes-until 24 hours after antibiotic treatment

Influenza

1-4 days (usually 2 days)

From slightly before symptom onset to about day 3 of illness

YES

Influenza virus

Droplet/infectious discharges

Yes-until at least 24 hours after they no longer have fever or signs of a fever

Measles (Rubeola)

7-21 days

Airborne/droplet/

YES

Measles virus

(usually 10-12 days)

Infectious discharges

4 days before rash onset to 5 days after

Meningitis (Bacterial)

Depends on the agent

Droplet/infectious discharges

Until completing 24 hours of antibiotic treatment

YES

CONTAGIOUS PERIOD

Herpes simplex virus HIV and AIDS Human immunodeficiency virus Impetigo Streptococcal or staphylococcal bacteria

Bacteria such as Neisseria meningitides (meningococcal) Haemophilus influenzae (H. flu), Streptococcus pneumoniae (pneumococcal) Meningitis (Viral)

EXCLUSION

(7 days)

(usually 1-10 days)

(hospitalized cases or deaths in children <18 years â&#x20AC;&#x201C;7 days)

(24 hours)

(24 hours for meningococcal and H. flu)

Yes-until 5 days after rash onset Yes- until 24 hours after treatment

(7 days for pneumococcal)

Depends on agents

Droplet/infectious discharges, fecal-oral spread

Depends on agent

None

Molluscum

2-7 weeks

Direct/indirect contact

As long as lesions are present

None

Mononucleosis

4-6 weeks

Saliva

Up to a year after the initial infection

None

Variable

Skin contact or contaminated items

See CDPHE guidelines (link located in chapter)

YES

See CDPHE guidelines (link located in chapter)

Several different viruses

Epstein-Barr virus MRSA Methicillin-resistant Staphylococcus aureus

(from sterile sites in Denver area residents) (7 days)

Mumps

12-25 days

Mumps virus

(usually 16-18 days)

Droplet/infectious discharges, saliva

2 days before swelling onset to 5 days after

YES (7 days)

Yes-until 5 days after swelling onset

DISEASE Agent

INCUBATION PERIOD

Norovirus & Viral Gastroenteritis

Varies by virus (usually 1-2 days)

Various viruses, such as norovirus

TRANSMISSION

REPORT TO PUBLIC HEALTH*

EXCLUSION

Fecal-oral spread, contaminated food/water

While diarrhea or vomiting is present and several days after symptoms are gone

None

Yes-until 48 hours after diarrhea and/or vomiting resolves.

Bacterial: as long as symptoms are present or until treatment has been started

None

No, unless the child meets other exclusion criteria such as fever or behavioral change.

Pink Eye (Conjunctivitis)

Bacterial: 24-72 hours

Bacterial and viral: infectious discharges

Various bacteria and viruses, allergies, chemical irritation

Viral: 1-12 days

Allergies and chemicals: not contagious

Allergies: variable

CONTAGIOUS PERIOD

Viral: as long as symptoms are present

Chemicals: variable

Pinworm

1-2 months

Fecal-oral, indirect contact

As long as eggs are present

None

None, unless proper control measures cannot be followed

Pubic Lice (Crabs)

Average life cycle is 15 days

Sexual transmission

As long as lice are present

None

4-14 days

Skin contact/direct contact

As long as rash is present on skin

None

Yes-from end of school day until after first treatment

5-15 days

Droplet/infectious discharges

As long as virus is present in nose/threat secretions

None

None, unless fever is present with rash

Phthirus pubis, the pubic louse Ringworm (Tinea) Several fungi species Roseola (Sixth Disease)

(usually 9-10 days)

Rotavirus

1-3 days

Fecal-oral spread

As long as virus is in feces; from before symptom onset to 21 days after

None

Yes-until diarrhea has resolved

RSV

2-8 days (usually 4-6 days)

3-8 days after symptom onset

None

Respiratory Syncytial Virus

Droplet/infectious discharges

None-unless symptoms are severe

Rubella (German Measles)

12-23 days

Droplet/infectious discharges

7 days before rash onset to 5-7 days after

YES

Yes-until 7 days after rash onset

Fecal-oral spread, contaminated food/water, animals

While diarrhea is present; can spread for a variable period of time after symptoms are gone

YES

(usually 14 days)

Rubella virus Salmonella Salmonella bacteria

6-72 hours, but up to 7 days (usually 12-36 hours)

(24 hours)

(7 days)

Yes-until diarrhea has resolved

REPORT TO PUBLIC HEALTH*

DISEASE Agent

INCUBATION PERIOD

Scabies

2-6 weeks if never infected, 1-4 days if infected before

Skin contact/direct contact

Until the mites and eggs are destroyed, usually st nd after 1 or 2 treatment

None

Yes-from end of school day until after first treatment

Shigella

1-7 days (usually 1-3 days)

While diarrhea is present; can spread for weeks after symptoms are gone

YES

Shigella bacteria

Fecal-oral spread, contaminated food/water

Yes-until diarrhea resolves (negative stool testing may be required prior to return)

Shingles (Herpes Zoster)

10-21 days

Skin contact

Until all the blisters have crusted over

None

None-as long as the blisters are covered

Sarcoptes scabei, a mite

TRANSMISSION

(usually 14-16 days)

Varicella â&#x20AC;&#x201C;zoster virus

CONTAGIOUS PERIOD

(7 days)

EXCLUSION

Staph Infection

Variable

Skin contact or contaminated items

As long as the bacteria are present

None

See CDPHE guidelines (link located in chapter)

Strep Throat

2-5 days

Droplet/infectious discharges

Until treated with antibiotics for 24 hours, or 10-21 days for untreated cases

None

Yes-until 24 hours after antibiotic treatment

Syphilis

10 days-3 months

Sexual transmission

Until treated

YES

None

Treponema pallidum

(usually 3 weeks)

Streptococcus pyogenes bacteria

(24 hours)

Bacteria Tetanus Clostridium tetani bacteria Tuberculosis

2 days-several months

Through breaks in the skin

Not contagious

YES

Airborne

As long as symptoms are present or until on treatment

YES

Until after the third week of coughing, or until after 5 days of treatment

YES

None

(7 days)

(usually 8-14 days) 2-12 weeks

Mycobacterium tuberculosis mycobacterium Whooping Cough

4-21 days

(Pertussis)

(usually 7-10 days)

Droplet/infectious discharges

Bordetella pertussis bacteria

*Outbreaks of any disease are reportable to public health within 24 hours.

(24 hours)

Yes- (active cases) until on treatment and cleared by a health care provider Yes-until 5 days after treatment or until 3 weeks after cough onset.

Section Six: Immunization Course for Childcare Providers ď&#x201A;ˇ

Child Care Immunization Manual/Course: Guidance for Childcare and Preschool Providers in Colorado (Version 2015-2016)

For more information, please visit: https://www.colorado.gov/pacific/cdphe/school-immunizations https://www.colorado.gov/pacific/sites/default/files/Imm_Child-Care-Immunization-Course-Instructions.pdf https://www.colorado.gov/pacific/sites/default/files/Imm_Child-Care-Immunization-Course.pdf

2015-2016 School Year

Child Care Immunization Manual and Course Guidance for Child Care and Preschool Providers in Colorado

â&#x20AC;&#x153;The decision to immunize your child is a critical one, because vaccines are the single most effective protection against diseases that continue to threaten our children.â&#x20AC;? - Don Cook, M.D., Former President, American Academy of Pediatrics

Dear Child Care Provider in the 2015-16 School Year The Child Care Immunization Manual and Course: Guidance for Child Care and Preschool Providers in Colorado was developed to help you learn more about immunizations and the immunization requirements for children in a child care or preschool setting in Colorado. Children’s immunizations are a licensing requirement through the Department of Human Services and a well vaccinated student population will help keep your kids healthy and safe. You can earn 2.5 contact hours toward your child care licensing requirement. A new test is developed annually, so you may take the test every year for credit. The Manual and Course will be updated annually so please keep an updated version for current immunization guidance. This 2015-16 School Year version will expire on June 30, 2016. The 2016-17 School Year version will be available on July 1, 2016 and will reflect the new reporting and parent exemption processes. Please download the Manual and Course as you will need it to refer to when answering the test questions electronically on Co.Train. Instructions to access the test are on the last page of the manual. It is also important to download supportive documents, especially “The Child Care Immunization Chart for the 2015-16 School Year.” This chart will help you answer many of the questions in the test. After successfully completing the test on Co.Train, you will be able to print your Certificate of Completion for 2.5 credit hours. Thank you for all you do to care for Colorado’s children. Jamie D’Amico, RN, MSN, CNS Coordinator, Schools and Community 303-692-2957 jamie.damico@state.co.us www.coloradoimmunizations.com

Contents Why are Childhood Immunizations Necessary?................................................................. 4 Colorado Immunization Law ...................................................................................... 5 “In Compliance” with School Immunization Law ........................................................... 5 Parent Letter .................................................................................................... 6 Certificate of Immunization (CI) .............................................................................. 6 Incomplete Immunizations and the 14-Day Rule (In Process) ............................................. 7 Tickler System for Keeping Track of Children’s Immunizations ....................................... 7 Exemptions from Receiving Immunizations.................................................................. 8 Step by Step Process for Collecting Immunizations in Your Child Care .................................... 9 Colorado Immunization Information Systems (CIIS) ......................................................... 10 Required Immunizations ........................................................................................ 11 Immunization Schedule for Pre-Kindergarten Settings ..................................................... 12 Additional Recommended Vaccines ........................................................................... 12 Child Care Staff (Adult) Immunizations ....................................................................... 13 Colorado Website for Schools, Child Cares and Preschools ................................................ 13 Talking to Parents about Vaccine Safety ..................................................................... 14 House Bill 1288 - New requirement for child cares and preschools ……………………………………………14 Supporting Child Cares and Preschools in Keeping Children Healthy..................................... 15 Immunization Course for Childcare Providers in Colorado Signup Procedure ........................... 15 Creating an Account with CO.Train......................................................................... 15 Registering for the Course ................................................................................... 15 Navigating the On-Line Course .............................................................................. 16

Why are Childhood Immunizations Necessary? Children need immunizations (also called vaccinations or “shots”) to protect them against serious diseases. When children do not receive immunizations there is always the possibility of becoming infected by diseases that can cause rashes, fevers, coughing, choking, brain damage, heart problems, paralysis, deafness, and liver disease. Because of their close contact, children in child care settings can easily spread diseases to one another. •

Preschoolers who are behind on their shots need to be vaccinated to “catch up” and be protected.

•

Many parents think that children only need shots when they are ready to enter kindergarten. This is not true. Children need to be vaccinated when they are babies and need most of their shots before the age of two.

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Parents should check with their health care provider or clinic to make sure their child is up-todate on their shots.

“Immunizations - a true medical success story. Without question, immunizations protect our children from dangerous infections that can cause long-term disease, disability, even death.” Don Cook, M.D., Former President, American Academy Pediatrics

Colorado Immunization Law The Colorado Board of Health requires that children attending schools (including child care facilities & preschools) have specific vaccinations. The Colorado School Entry Immunization Law requires that schools shall have on file an official Certificate of Immunization for every student enrolled. A parent will typically provide you with an immunization record from a doctor’s office or clinic. If the parent does not provide the immunizations on an official Certificate of Immunization, it is required that you transcribe that clinic record onto a Certificate of Immunization. These rules regarding immunizations are developed to protect the public’s health and are a guide for schools. As part of the law, in order for a child to attend a school or child care, they must: • •

Have a Certificate of Immunization with vaccines recorded on file with the child care Or A signed exemption form on file with the child care

(No immunization record? No school attendance!) •

If a child has an “incomplete” immunization record or needs to update the record, the school will give the parents “direct personal notification.” The parent will then have 14 days to get the required shots for their child or to make a plan to get that shot as soon as possible.

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Each school must have on file an approved Certificate of Immunization for every student and a copy of that form can be downloaded from the Immunization Website.

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The Colorado Department of Public Health and Environment (CDPHE) – the State Health Department may look at and check the immunization records kept by private childcares licensed by the Department of Human Services. Licensed childcares and preschools are inspected to insure the health and safety of children in your facility and the inspectors may look at immunization records during those inspections.

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If a child does not receive the required shot(s) or did not follow up on the plan to get the shot(s) after the parent received the 14 day “direct personal notification,” that child will not be allowed to attend your child care according to the school immunization law.

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If other children at the school have a vaccine-preventable disease, all un-immunized or underimmunized children may be told to stay home from school.

The best tool for your immunization tool box is the Child Care Immunization Chart 2015-16 SY. This chart is located on our website, www.coloradoimmunizations.com, under the School Immunization section.

“In Compliance” with School Immunization Law To be in compliance with the Colorado Immunization Law ONE of the follow must occur: 1. Children are up-to-date on all their required immunizations 5|

OR 2. Children have an appropriate signed exemption in the their file OR 3. Children are “in process” for getting up-to-date on immunizations

Parent Letter A parent letter describing required and recommended vaccines is required to be sent to parents of children in your facility yearly and is located on our website, www.coloradoimmunizations.com, under the School Immunization section.

Certificate of Immunization (CI) Each child in the school must have an official Certificate of Immunization on file showing the child’s immunizations. The format of a Certificate of Immunization is approved by the CDPHE. You can find the Certificate of Immunization by going to our website, www.coloradoimmunizations.com, under the School Immunization section. An official Certificate of Immunization may come in several forms, such as: • 8 ½ by 11-inch paper version (From our website) • Immunization Administration Record Sheet or Card (from clinics) • Any “alternative” Certificate of Immunization approved by the CDPHE A copy of a Certificate of Immunization is acceptable – including faxed copies. The type of vaccine and the date (month, day, year) the vaccine was given must be recorded on the Certificate of Immunization. If a child comes to your childcare facility with an immunization record that is not on an official Certificate of Immunization form, it is the responsibility of the childcare staff to carefully copy the information onto the official form. The Certificate of Immunization is an ongoing document. In other words, do not use a new Certificate of Immunization each year even if there is a new vaccine requirement. Continue to use the child’s original Certificate of Immunization and write any new required vaccine in the “other” line if you need to. This lessens the problem of making errors when copying immunizations to the CI. The Certificate of Immunization includes several “optional” signature lines based on age and grade. This allows you to check a box and provide a signature to indicate that a child is up to date at a specific age. It also allows for better record keeping and tracking of children’s immunization status. Remember that when any new Certificates of Immunization are available, it is not necessary to recopy onto the new Certificates. It is not a requirement to have a physician or RN signature on the Certificate of Immunization. The Certificate of Immunization is NOT to be completed by a parent.

Incomplete Immunizations and the 14-Day Rule (In Process) If a child is in your facility and is due for a shot, you can notify the parent using the “Notice of Required Immunizations:” located on our website, www.coloradoimmunizations.com, under the School Immunization section. If a child comes to the childcare facility with an incomplete immunization record or falls behind on the required immunization schedule, notify the parent by “direct personal notification” (by telephone, e-mail, in person or in writing). The parent has 14 days to make sure the child receives the required shot(s) and/or has a plan to get the shot(s). Then there must be a written plan for the child to receive any remaining required shots. You can use the “Notice of In-Process” on our website, www.coloradoimmunizations.com, under the School Immunization section. It would be ideal if parents would provide any new vaccine records so remind them to do so. You can develop a “tickler system” for keeping track of a child’s immunizations, as described in the next section.

Tickler System for Keeping Track of Children’s Immunizations This system requires a card file with index cards, a box to hold them, and a set of monthly index card dividers (January – December). For a child needing future immunizations, enter his or her name on an index card and list all doses that will be needed. Using the Child Care Immunization Chart, determine when the next dose is due and note the deadline date on the upper right-hand corner of the follow-up card. Use the “Child Care Immunization Chart” on our website, www.coloradoimmunizations.com, under the School Immunization section. • File each follow-up card by the month the immunization record is due. • At the beginning of each month, call, email, or send a letter or email to the parents to let them know that shots are due and inform them of the due date. Be sure to document on the index card the date the notice was sent. • Enter immunization dates on the Certificate of Immunization when the doctor or clinic record is given to you by the parent. • Repeat the steps above if additional immunizations will be needed in the future until all immunization requirements are met. • It is required by law to exclude children whose parents do not provide proof of up- to-date immunization records after the “exclusion” date you provided. • When no more immunizations are needed, remove the card from the file box. This process can also be set up for tracking electronically if you prefer not to use a box.

Exemptions from Receiving Immunizations A student may have an exemption from receiving the required shots for the following reasons: •

Medical - the child is unable to receive vaccination due to a medical/health issue; must be signed by a health care provider (In a disease outbreak, unimmunized children may be excluded).

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Religious - has a religious belief, including teachings opposed to immunizations; must be signed by parent or guardian (In a disease outbreak, unimmunized children may be excluded).

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Personal - has a personal belief against immunizations; must be signed by parent or guardian (In a disease outbreak, unimmunized children may be excluded).

A note about Personal Exemptions: Personal exemptions are to be signed by parents only if they have a personal or philosophical belief against vaccines or choose not to vaccinate according to the accepted immunization schedule. The personal exemption is NOT to be used for “convenience” as this is a misuse of the exemption process. The exemption form is found on the second page of the Certificate of Immunization and is located on our website, www.coloradoimmunizations.com, under the School Immunization section.

Step by Step Process for Collecting Immunizations in Your Child Care 1. Collecting immunization records is required by the School Immunization Law and is one of your responsibilities as a licensed facility through the Department of Human Services. 2. Collect the child’s immunization record at registration. If the parent has a true personal or religious belief against immunization, they are to sign the exemption form on page 2 of the Certificate of Immunization. Medical exemptions will be signed by a health care provider and presented to you by the parent. 3. Having a parent sign an exemption because they don’t have their immunization record is a misuse of the exemption process. 4. Once you receive the immunization record, copy those immunizations onto the Certificate of Immunization. Determine if the child is up-to-date using the Child Care Immunization Chart. 5. If the child becomes due for an immunization while at your facility contact the parent to inform them that they have 14 days to have their child immunized or to provide a written plan to become immunized. If the parent can get the immunization immediately, you can also send them a “Notice of Required Immunization” which the parent can give to their health care provider. 6. If a child at your facility has to catch up on immunizations, inform the parent they have 14 days to either get the required vaccine(s) or provide a written plan to get the vaccines. You can use the “Notice of In-Process” as written documentation. 7. Track the required vaccines by using the Tickler Box mentioned above or track vaccines using an electronic system specifically designed for that purpose. Do this on a monthly basis in order to stay on top of this task. It may be very involved initially but it becomes much easier once you’ve got the system organized. Ask your Child Care Health Consultant for support.

Colorado Immunization Information Systems (CIIS) Need help with your immunization records? We got you covered! Keeping track of shot records has never been easier! Participate in the Colorado Immunization Information System (CIIS) and you can gain information on your student’s immunizations in your licensed child care center or family home. CIIS is a confidential web program that collects information on immunizations. This program is run through the Colorado Department of Public Health and Environment. It allows child care providers to see immunizations records for children at their facility. CIIS can simplify your record-keeping by: • • • •

Providing free and secure 24/7 access to immunization records online Allowing you to check records and exemptions Allowing you to see if children are missing required immunizations or have incomplete immunization records. Print off the required “Certificate of Immunization” (CI) from the system (this decreases your efforts to transcribe many, if not all, of the child’s immunizations onto the CI

For more information on how your child care facility can join CIIS, Please contact Megan Berry at megan.berry@state.co.us or 303-692-2736

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Required Immunizations Vaccine

DTap

IPV

Hib

MMR

Vaccine Description DTaP is a combination of Diphtheria, Tetanus, and acellular pertussis. A child should have 4 DTaP shots by 19 months of age. A child will have a fifth DTaP shot between the ages of four and six years to prepare for kindergarten entry unless the fourth DTaP shot was given at four years of age. The vaccine is only licensed for kids through 6 years of age so when children turn 7 years they are not to receive this vaccine. IPV is inactivated polio vaccine and is given as a shot, replacing the oral vaccine (OPV) in the U.S. By 5 months of age, a child should have at least two polio vaccinations. A child will have a 4th polio shot between the ages of four and six years to prepare for kindergarten. If the 3rd polio shot was given at four years of age and was given at least 6 month after the last dose the requirement is met and no further polio vaccinations are needed. Hib vaccine protects against the bacteria called Haemophilus influenzae type b. The schedule for Hib depends on when the child first starts getting the vaccine. If a child is five years old, the vaccine is no longer required. If the child has their first Hib vaccine at or after 15 months of age, the requirement is only one dose. If the first dose of vaccine is given between the ages of 12 to 14 months, two doses are required. If the child is given their first dose before the age of 12 months, three doses are required and another dose after 12 months of age. Hib is commonly given as “combined” vaccines and the schedule may vary slightly. MMR is a vaccine that protects against Measles, Mumps, and Rubella (“German Measles”) viruses. The child must be no younger than 4 days before 12 months of age before receiving his or her first MMR shot. If MMR was given more than 4 days before the 1st birthday, it cannot be accepted and is an invalid dose. The invalid dose must be repeated in order for the child care to be in compliance. The second MMR shot is typically given between four and six years of age, however can be given 4 weeks after the first dose.

Hep B

Hep B is the Hepatitis B vaccine that protects against the liver disease caused by the Hepatitis B virus. Three HBV shots are to be given by the time the child turns 19 months of age. The first dose of this vaccine is typically given at birth (birth dose) and the 3rd dose is not to be given until the child turns 24 weeks of age.

PCV13

PCV13 is the vaccine that protects against pneumococcal disease caused by bacteria. One to four shots are given depending on how old the child was when he/she received the first shot (See “Child Care Immunization Chart 2015-16 School Year).

Varicella

Varicella vaccine protects against chickenpox, a common childhood disease. Unless the child has had the chickenpox disease, they will need one dose of varicella vaccine no sooner than 4 days before the first birthday and a 2nd dose before the child turns 7 yrs of age. If a child had a case of chickenpox, it must be documented by a health care provider or screened by the nurse. This documentation is considered a reliable history of disease and the child will not need a vaccination as he/she is considered immune. (MMRV is measles, mumps, rubella and varicella vaccine)

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Immunization Schedule for Pre-Kindergarten Settings Vaccine

Number of Doses and Age Vaccine Must Be Received By

DTap

• • • •

1st Dose received by 3 months of age 2nd Dose received by 5 months of age 3rd Dose received by 7 months of age 4th Dose received by 19 months of age

IPV

• • •

1st Dose received by 3 months of age 2nd Dose received by 5 months of age 3rd Dose received by 19 months of age

Hib

MMR

If the vaccine series is started before 12 months of age: • 3 doses, 4 - 8 weeks apart and 1 additional dose after 12 months of age If the series is started between 12-14 months of age: • 2 doses, each 8 weeks apart If the series is started at 15 months of age or older: • 1 dose No doses are required when child turns 5 years of age. • 1st Dose received by 16 months of age 1 dose can be given no sooner than 4 days before the 1st birthday. st

• • •

Hep B

PCV13

Varicella

1st Dose received by 1 month of age 2nd Dose received by 3 months of age 3rd Dose received by 19 months of age

If the vaccine series is started between 2-6 months of age: • 3 doses, 4 - 8 weeks apart and 1 additional dose after 12-15 months of age at least 8 weeks after last dose If the series is started between 7-11 months of age: • 2 doses, each 8 weeks apart and 1 additional dose after 12-15 months of age If the series is started between 12-23 months of age: • 2 doses, each 8 weeks apart One dose meets the requirement for those 24 months – 4 years of age. No doses are required when child turns 5 years of age. • 1st Dose received by 16 months of age unless the child has had the disease 1 dose can be given no sooner than 4 days before the 1st birthday. st

Additional Recommended Vaccines Other vaccines that are not ‘required’ but are ‘recommended’ for some ages include: •

RotaTeq protects against a diarrheal illness caused by Rotavirus

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•

Hep A which protects against the liver disease Hepatitis A

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Influenza which protects against the flu

Child Care Staff (Adult) Immunizations It is so important that child care staff is appropriately immunized to protect themselves, their families and the infants and children they care for in the child care setting. The Department of Human Services (DHS), the licensing agency for Colorado child cares, state in the Rules Regulating Child Care Centers “staff must be current for all immunizations routinely recommended for adults by their Health Care Provider.” CDC recommends several adult immunizations: Vaccine Chickenpox (varicella)

Vaccine Description 2 doses of the series for those who have not had chicken pox disease

Hepatitis B

3 dose series for staff who perform tasks that involve exposure to blood or body fluids

Hepatitis A

Frequently recommended for child care workers (2 dose series)

Influenza (flu)

All child care personnel should receive an annual vaccination against flu.

Measles, Mumps and Rubella (MMR)

2 doses protect against disease. Staff born in 1957 or later who don’t have a lab verified blood test proving immunity to the diseases, should receive 2 doses of MMR, 4 weeks apart.

Tetanus, Diphtheria and Pertussis (Tdap)

A one-time dose of Tdap should be administered as soon as possible to all child care personnel who have not received Tdap previously. (Colorado had a pertussis epidemic in 2012 and infants and young children were the most vulnerable individuals).

Pneumococcal

1 dose is generally recommended for persons 65 years of age and older. Also recommended for adults 19 years of age diagnosed with asthma or for adults who are smokers.

Some insurance companies cover immunizations, so obtaining those vaccines will be an important part of maintaining your health and the health of the children you care for. An additional resource for lower cost vaccines is your local public health department.

Colorado Website for Schools, Child Cares and Preschools The Colorado Immunization Section provides a “School Immunizations” page for your use. This page includes required parent letters, charts for reading immunization schedules, forms, the Child Care Immunization Course and other important documents to support your efforts to make sure that you are in compliance with the School Immunization Laws: www.coloradoimmunizations.com and then click on “School Immunizations.” 13 |

Talking to Parents about Vaccine Safety Because of the many misleading and distorted news reports, parents have become increasingly fearful or hesitant about having their child immunized. Parents also want to protect their child from vaccinepreventable diseases and sometimes need direction about what is the best thing to do for their child’s health. The Colorado Children’s Immunization Coalition, in collaboration with the Colorado Department of Public Health and Environment, created a wonderful parent immunization website that provides lots of factual information about vaccines and how they protect against disease. It would be great if you, as a child care provider, viewed this site and recommended it to parents. It provides honest, factual information about vaccinations and vaccine safety and will help you guide parents in making good choices about their child’s health. Encourage them to talk to their doctor or clinic about vaccinating their child. The website is geared specifically towards parents, and will answer many questions: • • • • •

Immunize for Good Voices for Vaccines Vaccinate Your Baby Vaccine Education Center from the Children’s Hospital of Philadelphia Colorado Department of Public Health and Environment Immunization Education Module

House Bill 1288 (HB-1288) Colorado Legislators passed HB-1288 in May of 2014. Part of this bill requires child cares, preschools and schools to give their immunization and exemption rates to anyone upon request. Because of this new requirement, it is more important than ever to make sure you’ve collected all of your required immunizations and that exemptions (for parents who are opposed to vaccines) are signed and filed in the child’s chart. By keeping up-to-date on your record keeping, it is hoped that your immunization rates show that the children in your facility are being protected against vaccine preventable diseases. “Child Care and School Immunization Rate Guide” is the tool created to help you calculate your rates: Go to www.coloradoimmunizations.com and click on School Immunizations. Follow the directions on the guide and you will come up with the rates for up-to-date immunizations and medical and non-medical exemptions. 1 Count the doses of immunizations from the Certificate of Immunization and record them on the worksheet. 2. Count medical, religious and personal exemptions and record them on the worksheet. 3. Count the students who are in-process and record those numbers on the worksheet. 14 |

Supporting Child Cares and Preschools in Keeping Children Healthy The Immunization Branch at the Colorado Department of Public Health and Environment (CDPHE) provides assistance in many areas of child, adolescent, and adult immunizations. For details about Colorado’s School Immunization requirements, contact: Jamie D’Amico RN, MSN, CNS at 303-692-2957 or jamie.damico@state.co.us For immunization materials and other resources, be sure to log on to the immunization website and go to the “School Immunization” link at www.coloradoimmunizations.com

Immunization Course for Childcare Providers in Colorado Signup Procedure Creating an Account with CO.Train 1. To sign up for the Immunization Course for Childcare Providers course, logon to the website: www.co.train.org. 2. You must first create an account by clicking on “Create Account” under Member Login on the left side of the page under the Home tab. 3. Review the CO.Train polices and check the box agreeing to the policies. Click the Next button. 4. Fill out the information page to create your login name and password. Each field must be filled out beside the optional fields on the right side of the screen. a. Under the Organization name and Department/ Division fields, enter the word none. Click the Next button. b. Select the region of your work place under the drop down menu after referring to the region map. Then, select the county under the county drop down menu. Click the Next button. c. Answer the question pertaining to the Medical Reserves corps by selecting “yes” or “no.” Click the Next button. d. Answer the question pertaining to additional CDC Training by selecting the “no” option. Click the Next button. e. Select your professional role, Childcare Provider. Click the Next button. f. Select your work setting. Click the Next button. g. Enter your demographic information. Click the Next button. h. Your account has been created. Click the Continue button.

Registering for the Course 15 |

1. Once you are logged into your account, click on the Search at the top left‐hand side of the screen. 2. Click on the Search option. 3. Enter Immunization Course for Childcare Providers and select the “Course Title” option. Click the Search button. 4. Select the Immunization Course for Childcare Providers; it should be the only option. 5. The next screen will give you the course information and description. The course ID should be 1025057. 6. Click on the Registration tab. Under the “Select Credit Type” drop down menu, select Contact Hours. Click the Launch button and begin the course.

Navigating the On-Line Course 1. To move from page to page, click on the arrow keys at the top of the page. 2. The Home button brings you back to the first page. 3. Clicking on a link brings up a separate window for viewing purposes. Exit out of the link window to return to the course. Technical support: 303-692-3020

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