2017 School Nurses’ Conference
school nurses: leaders in school health services
AUGUST1 1, 2017
Partnerships
The 2017 School Nurses’ Conference is brought to you by:
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welcome
The school nurse is a health leader in the world of
education. Your role as leader and advocate for the
students on your campus make a positive difference
in improved attendance and enhanced academic
success. You lead in setting priorities, establishing
office procedures, and creating a culture of health.
Thank you for choosing the 2017 School Nurses’
Conference to gain knowledge for the upcoming
school year. I wish you the best as you not only lead,
but lead with heart!
Sherri Wright
Coordinator, Federal Programs
Region 7 Education Service Center
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8:00 AM - 8:30 AM agenda
8:30 AM - 8:40 AM
8:40 AM - 9:20 AM Breakfast
9:30 AM - 10:20 AM
10:30 AM - 11:20 AM Sponsored by MacGill
11:30 AM - 12:20 PM
12:30 PM - 1:20 PM Welcome
1:30 PM - 2:20 PM Jenny Sullivan, RN, DSHS
2:30 PM - 3:30 PM
Immunization Updates
3:30 PM - 4:00 PM
Breakout Sessions 1
LiveBinder Breakout Sessions 2
Working Lunch
Breakout Sessions 3
Breakout Sessions 4
Anita Wheeler, MSN, RN, DSHS
School Nurse Laws and Regulations
CNE Certificate Pickup
DSHS Website
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jenny sullivan
8:40 AM - 9:20 AM
Jenny Sullivan, RN, DSHS
Immunization Updates
Jenny Sullivan is a Registered Nurse who works for the State of
Texas Immunization Program as an Immunization Nurse Consultant.
She has been in her role with the state for over 4 years now and has
experience as a school nurse, camp nurse, and a medical/surgical
staff nurse. She lives in Paris, TX with her husband and 2 daughters.
One of her favorite parts of her job is serving as a resource to the
school nurses in her region.
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7/12/17
jenny sullivan
8:40 AM - 9:20 AM
School Immunization Who Am I?
Requirements and Reporting
My name is Jenny Sullivan. I
School Year 2017-18 am a registered nurse who
works for the Texas
By: Jenny Sullivan, RN Department of State Health
Immunization Nurse Consultant Services in the Communicable
Disease program. Part of my
job is to be a resource to 2
school nurses about
Immunization requirements
and reporting.
7/6/2017
Thank You! Requirements vs.
Recommendations
7/6/2017
• Immunization requirements are mandatory
vaccinations a child must receive in order to
attend school in the State of Texas.
Immunization Requirements are mandated by
the Department of State Health Services
(DSHS).
• Immunization recommendations are not
mandatory. They are for all children,
nationwide, whether they are attending school
or not. Immunization recommendations are
made by the Centers for Disease Control and
Prevention's (CDC) Advisory Committee on
Immunization Practices (ACIP).
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jenny sullivan
8:40 AM - 9:20 AM
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Requirement for Diphtheria/Tetanus Requirement for Diphtheria/Tetanus
Containing vaccines Containing vaccines
• Requirement for DTP/DTaP/Td • Td/Tdap/DT/DTP/DTaP for Children 7 years
or Older
• Upon entry into Kindergarten, a child is
required to have five doses of any • Students 7 years or older are required to
combination DTaP/DTP with one dose on or have at least three doses of any
after their 4th birthday. Students who combination Td/Tdap/DT/DTP/DTaP
received the 4th dose in the calendar vaccine, provided at least one dose was
month of or prior to the 4th birthday are in administered on or after the 4th birthday.
compliance if the 4th dose was
administered prior to August 1, 2004 or • For students in 8th through 12th grade,
they were enrolled in a grade (K-12) prior one dose of Tdap is required if at least 10
to August 1, 2004. years have passed since the last dose of a
tetanus-containing vaccine.
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7/12/17
jenny sullivan
8:40 AM - 9:20 AM
Requirement for the Polio Vaccine Requirement for the MMR
Vaccine
• For grades K-12, a child needs to have 4
doses of Inactivated Polio Vaccine (IPV) to be • 2 doses are required, with the 1st dose
admitted into kindergarten, one of which has received on/after the 1st birthday
to be on or after their 4th birthday.
• Students vaccinated prior to 2009 with 2
• Three doses of IPV are acceptable as long as doses of measles and one dose each of
the third dose was given on or after the 4th rubella and mumps satisfy this requirement
birthday.
• Serologic evidence (Positive titer) of
• Polio Requirement – OPV Versus IPV immunity is acceptable in place of vaccine
• Occasionally, you will come across a student
who has a combination of OPV/IPV doses. If a
student shows 4 doses of any combination of
both OPV and IPV vaccines, then a dose
on/after 4th birthday is not necessary.
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Requirement for the Hepatitis B Vaccine Requirement for the Varicella Vaccine
• 3 doses required for grades PreK-12th. • For K-12th Grade: 2 doses are required.
• The 1st dose of varicella must be received
• You do not have to take the interval doses
were administered at into consideration for on/after the 1st birthday. Receipt of the
state compliance purposes. Simply count dose up to (and including) 4 days before
the doses the birthday will satisfy the school entry
immunization requirement.
• For students age 11-15 years, 2 doses • Serologic evidence (Positive titer) of
meet the requirement if adult hepatitis B immunity is acceptable in place of vaccine
vaccine (Recombivax) was received, but it • Previous illness may be documented with a
must be clearly documented as written statement from a physician, school
Recombivax. nurse or the child’s parent or guardian.
Statement must contain date of illness.
• Serologic evidence (Positive titer) of This written statement will be acceptable in
immunity is acceptable in place of vaccine place of the varicella vaccine doses.
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7/12/17
jenny sullivan
8:40 AM - 9:20 AM
Requirement for the Meningococcal Vaccine
• 7th – 12th grade, 1 dose of quadrivalent Requirement for the Hepatitis A Vaccine
meningococcal conjugate vaccine is required
on or after the student’s 11th birthday. Note: • K-8th Grade: 2 doses are required
If a student received the vaccine at 10 years • The first dose must be received on/after
of age, this will satisfy the requirement.
the 1st birthday
• Students showing proof of meningococcal • Special Note: a child will not be considered
vaccine for the first time (i.e., new 7th grade
students and out-of-state transfer students), delinquent in this series until 18 months
must have an immunization record that clearly have elapsed since receiving the 1st dose
indicates one of the following: MCV4, • Serologic evidence (Positive titer) of
immunity is acceptable in place of vaccine
MenACWY, Menveo, or Menactra. Students
that have previously submitted proof of
meningococcal vaccination may be considered
compliant if the dose of meningococcal vaccine
was administered on or after the 11th
7/6/201b7 irthday.
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What’s New this Year? Medical Exemptions
• Hep A: 2 doses required for K-8th grades If a child has a medical contraindication
• Conscientious Exemption Form has that prevents them from meeting the
vaccine requirements, they must bring a
changed statement from their doctor:
• The statement must be signed by a
physician (M.D.) or Doctor of Osteopathy
(D.O.) licensed to practice in the United
States.
• A medical exemption does not need to be
notarized, the doctor’s signature is enough.
7/6/2017 15 • The one or more vaccines that are 16
7/6/201c7ontraindicated must be spelled out.
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jenny sullivan
8:40 AM - 9:20 AM
Medical Exemptions Conscientious Exemptions
• The doctor can write the statement in their Documenting Conscientious Exemption to Vaccination
own words, they do not have to use a Parents who want a vaccine exemption for reasons of
certain form. The doctor only needs to say conscience must do the following:
that it is their opinion that the required
immunization would be harmful to the • Submit a letter requesting the affidavit form to the
health and well being of the child or a DSHS Immunization Branch. Parents can request up to
family household member. 5 forms at a time. The letter must be submitted by the
US Postal service, a commercial carrier, by fax or online
• This statement is only good for one year, at the DSHS secure FTP site. E- mail requests are not
and must be renewed each year, unless a cce p ta b l e .
the child has a lifelong condition. If the
contraindication is a lifelong condition, the • Complete the affidavit form with all required
doctor must explain that in the statement. i nfo r ma ti o n.
• Sign the affidavit form in front of a notary public.
• Bring the notarized form to the school or child-care
facility. Parents must bring the original notarized
form. Photocopies of the form are not valid. If the
parent loses their affidavit, they must request a new
one.
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Conscientious Exemptions Conscientious Exemptions
• The completed form is not submitted to • Updating Conscientious Exemptions
DSHS.
• The notarized affidavit form for a
• The affidavit form is only valid for two conscientious exemption is a legal
years. document and cannot be modified. If a
parent wants to add another vaccine to the
• For more info go to: list of those they object to, they will have
http://dshs.texas.gov/immunize/school/ex to request, complete, notarize and submit
emptions.aspx another form. The same holds true when
new vaccines are added to the
• You can direct parents who want more requirements. A student may have two
information about completing this form to: exemption forms on file simultaneously.
http://www.dshs.state.tx.us/immunize/sch Both of those affidavit forms are valid.
ool/default.shtm#exclusions.
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jenny sullivan
8:40 AM - 9:20 AM
Conscientious Exemptions Provisional Enrollment
• Outbreaks, Emergencies and Epidemics In-state Transfers:
• If the Commissioner of Health declares an • When a student is transferring from a
outbreak of a vaccine-preventable disease, school within Texas, it is assumed that the
students who have not been vaccinated child had to meet DSHS vaccination
against that disease for reasons of requirements in order to be admitted into
conscience may be excluded from that school. However, it is still required
attending school. that the immunization history proving
compliance be presented within 30 days for
the student to remain enrolled.
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Provisional Enrollment Provisional Enrollment
Out-of-state Transfers Out-of State Exception:
• Students transferring from schools outside Military Dependents
of Texas are NOT allowed provisional
enrollment. Students transferring from • DSHS allows provisional enrollment if the
another state in the U.S., or from another student is a dependent of a family member
country, MUST present a valid on active duty in the military. Military
immunization history that demonstrates dependents are granted an automatic 30
compliance with DSHS vaccination day provisional enrollment to submit an
requirements before they can be enrolled. immunization record.
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jenny sullivan
8:40 AM - 9:20 AM
Provisional Enrollment Annual Report of
Immunization Status
Out-of-State Transfer Exception: • As required by state law, all schools must
Homeless students may also be granted provisional complete this report. This report must be
enrollment. A student is considered homeless as defined submitted online.
by the McKinney-Vento Act which defines a homeless
individual as: • You will report the status of students as of the
last Friday in October. For 2017 that will be
• an individual who lacks a fixed, regular, and adequate October 27th. Any immunizations received by
nighttime residence; and students after that date will not be counted
towards the report. Likewise, if a student
• an individual who has a primary nighttime residence enrolls in your school after that date, he/she
that is--- a supervised publicly or privately operated should not be included on your Annual Report.
shelter designed to provide temporary living
accommodations (including welfare hotels, congregate • This report must be submitted no later than
shelters, and transitional housing for the mentally ill); the second Friday in December. For 2017
that day will be December 8th.
• an institution that provides a temporary residence for
individuals intended to be institutionalized; or • Failure to submit your annual report by the
due date may result in a school audit.
• a public or private place not designed for, or ordinarily
used as, a regular sleeping accommodation for human
b e i ng s.
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Annual Report of Foreign Record Translation
Immunization Status
• Sometimes you get immunization records
• For a tutorial on how to complete the Annual in a foreign language
Report of Immunization Status, go to
www.artximmunize.com and click on • If you need help translating these records,
“Immunization Data Entry” we can sometimes help.
• If your school has software that computerizes • There are also resources we can send to
your annual report, please do not send the you that may help in translating foreign
computerized printout to DSHS. Instead, use records.
the printout to complete the annual report
online.
• It is very important that you keep a copy of
your annual report for your records.
• If you have questions or concerns about this
report, you may call me at 903-737- 0231. I
am happy to help you complete it if you need
assistance.
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jenny sullivan
8:40 AM - 9:20 AM
Mexican Vaccine ImmTrac2
Records
• ImmTrac has changed to the new
• Always request to see the original copy of the ImmTrac2 system
record
• If you need help with the new system or
• Sometimes there will be dates written in you do not currently have access to
pencil on the record, these penciled in dates ImmTrac2, please contact Amanda Rich.
are when a dose was due, not when it was Amanda Rich
given Regional ImmTrac Coodinator
Ph: 903-533-5350
• If you don’t look at the original copy it can be Email: [email protected]
impossible to tell if all dates are written in ink
• Remember that dates on Mexican vaccine
records are often written: Day-Month-Year.
For example 3-5-12, would be May 3, 2012,
not March 5, 2012.
7/6/2017 29 7/6/2017 30
ImmTrac2 Immtrac for
Troubleshooting Help High School Seniors
• I will be at the DSHS Immunizations Table • IWmhmenTrsatuc dLiefnettismtuerrneg1i8strthye. y are eligible to enroll in the
for the rest of the day with a sign-up sheet • This means that their records will always be kept in ImmTrac
to have a PowerPoint on troubleshooting
ImmTrac2 sent to your email. where they can access them if needed for college/work.
• If they do not sign an adult consent before they turn 19,
• Please come and sign-up at the table if you
want to receive this trouble-shooting slide- their records will be deleted from ImmTrac.
set • tPhleeiarsreeecnorcdosurwaigllebyeokuerpsteinnioIrms mtoTsraigcn. tAhsisacnonImsemnTt rsaoctuhsaetr,
you also have the ability to enter their adult consent into
ImmTrac, or you may also collect the consents and mail
twhheomwtiollAemntaenrdthaeRmichfo,rouyorur.egional ImmTrac Coordinator,
Amanda Rich
DSHS Tyler
2521 W. Front St.
Tyler, TX 75702
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7/12/17
jenny sullivan
8:40 AM - 9:20 AM
Project Vaccination Project Vaccination
A free outreach program by the Texas To be an eligible school for this program you
Department of State Health Services to: must:
• Be in a county with no local health
• Educate high school seniors about
vaccines they need for college and the department.
workforce. • Be willing to send out required paperwork
• Offer free immunizations to Medicaid to students’ families
and uninsured students. • Coordinate with Jenny Sullivan to set up a
• Offer seniors the chance to safely date for us to come to your school
store their immunization records in If you are interested in this program,
the ImmTrac lifetime registry. please see Jenny Sullivan after today’s
presentation and fill out an interest
form.
7/6/2017 33 7/6/2017 34
Thank you
Jenny Sullivan, RN 35
1460 19th St. NW
Paris, TX 75460
Office: 903-737-0231 Cell: 903-
526-9858
Fax: 903-737-0330
7/6/2017 Email: [email protected]
15
Documenting History of Illness: Varicella (Chickenpox)
This form summarizes the “Exceptions to Immunization Requirements (Verification of
Immunity/History of Illness)” incorporated in Title 25 Health Services §97.65 of the
Texas Administrative Code (TAC)
§97.65 of the TAC states, “A written statement from a parent (or legal guardian or managing
conservator), school nurse, or physician attesting to a child's positive history of varicella disease
(chickenpox), or of varicella immunity, is acceptable in lieu of a vaccine record for that disease (see
form at http://www.dshs.state.tx.us/immunize/docs/c-9.pdf).” School nurses may also write this
statement to document cases of chickenpox that they observe. The school shall accurately record
the existence of any statements attesting to previous varicella illness or the results of any serologic
tests supplied as proof of immunity. The original should be returned to the child/student or the
child’s/student’s parent or guardian. If a child or student is unable to submit such a statement or
serologic evidence, varicella vaccine is required.
Documentation of prior varicella illness can be provided by the following methods:
1. A serologic confirmation of varicella immunity (positive varicella IgG result).
2. A written statement from a physician, school nurse, or the child’s/student’s parent or
guardian containing wording such as:
“This is to verify ________________________had varicella disease (chickenpox)
(Name of student)
on or about _________________________and does not need the varicella vaccine.”
(Approximate month/day/year)
Visit our website at: ________________________________________
http://www.immunizetexas.com/
(Signature)
________________________________________
(Relationship to student)
________________________________________
(Date)
Mailing Address:
Texas Department of State Health Services
Immunization Branch
MC-1946
P.O. Box 149347
Austin, Texas 78714-9347
Stock No. C-9 Revised 05/09
16
Documentando la Enfermedad de la Varicela (Chickenpox)
Esta forma resume las “Excepciones a los Requisitos de Inmunización (Verificación de la
inmunidad/ historial de la enfermedad)” incorporadas en los Servicios Médicos §97.65 del
Título 25 del Código Administrativo de Texas (TAC, por sus siglas en inglés).
§97.65 del TAC declara, “Una declaración por escrito de un padre (o guardián legal o manejador
de bienes), enfermera de la escuela, o médico que atestigua a una historia positiva del niño de la
enfermedad de varicela (viruela loca), o de la inmunidad de varicela, es aceptable en vez de un reg-
istro de vacuna para esa enfermedad (ver forma en http://www.dshs.state.tx.us/immunize/docs/c-9.
pdf).” La enfermera de la escuela también puede escribir esta declaración para documentar cual-
quier caso de varicela que haya ocurrido en la escuela. La escuela debe anotar correctamente la
existencia de cualquier documentación atestando a enfermedad previa de varicela o el resultado de
prueba serológica dada como prueba de inmunidad. El documento original se debe devolver al niño
o estudiante o al padre o tutor legal del niño o estudiante. Si el niño o estudiante no puede someter
tal informe o evidencia serológica, la vacuna contra la varicela se requiere.
La enfermedad de la varicela debe ser documentada por medio de los siguientes medios de informe:
1. Prueba serológica que confirma inmunidad contra la varicela (resultado positivo
de la prueba de la varicela IgG).
2. Un informe escrito por el médico, la enfermera de la escuela o el padre o tutor legal
del niño que contiene palabras tales como las siguientes:
“Esto es para verificar _________________________tuvo la enfermedad de la varicela
(Nombre del estudiante)
en o por el día ___________________________y no necesita la vacuna contra la varicela.”
(mes/día/año aproximado)
_____________________________________
(Fecha)
_____________________________________
(Parentesco o relación al estudiante)
Visite nuestro sitio Web en: _____________________________________
http://www.immunizetexas.com/
(Firma)
Dirección de correo:
Texas Department of State Health Services
Immunization Branch
MC-1946
P.O. Box 149347
Austin, Texas 78714-9347
Stock No. C-9 Revised 05/09
17
2017 - 2018 Texas Minimum State Vaccine Requirements for Students Grades K - 12
This chart summarizes the vaccine requirements incorporated in the Texas Administrative Code (TAC), Title 25 Health Services, §§97.61-97.72. This document
is not intended as a substitute for the TAC, which has other provisions and details. The Department of State Health Services (DSHS) is granted authority to set
immunization requirements by the Texas Education Code, Chapter 38.
IMMUNIZATION REQUIREMENTS
A student shall show acceptable evidence of vaccination prior to entry, attendance,
or transfer to a child-care facility or public or private elementary or secondary school in Texas.
Vaccine Required Minimum Number of Doses Required by Grade Level
(Attention to notes
Grades K - 6th Grade 7th Grades 8th - 12th Notes
and footnotes)
Diphtheria/Tetanus/Pertussis1 K 1 2 3 4 5 6 7 8 9 10 11 12
(DTaP/DTP/DT/Td/Tdap)
5 doses or 4 doses 3 dose 3 dose primary For K – 6th grade: 5 doses of diphtheria-tetanus-pertussis vaccine; 1
primary series series and 1 dose must have been received on or after the 4th birthday. However,
Tdap / Td 4 doses meet the requirement if the 4th dose was received on or after
and 1 booster within the 4th birthday. For students aged 7 years and older, 3 doses meet the
Tdap / Td the last 10 years requirement if 1 dose was received on or after the 4th birthday.
booster within For 7th grade: 1 dose of Tdap is required if at least 5 years have
the last 5 years passed since the last dose of tetanus-containing vaccine.
For 8th – 12th grade: 1 dose of Tdap is required when 10 years have
18 passed since the last dose of tetanus-containing vaccine. Td is accept-
able in place of Tdap if a medical contraindication to pertussis exists.
Polio1 4 doses or 3 doses For K – 12th grade: 4 doses of polio; 1 dose must be received on
or after the 4th birthday. However, 3 doses meet the requirement if
the 3rd dose was received on or after the 4th birthday.
Measles, Mumps, and Rubella1, 2 2 doses For K – 12th grade: 2 doses are required, with the 1st dose received
(MMR) on or after the 1st birthday. Students vaccinated prior to 2009
with 2 doses of measles and one dose each of rubella and mumps
satisfy this requirement.
Hepatitis B2 3 doses For students aged 11 – 15 years, 2 doses meet the requirement if
adult hepatitis B vaccine (Recombivax®) was received. Dosage (10
mcg /1.0 mL) and type of vaccine (Recombivax®) must be clearly
documented. If Recombivax® was not the vaccine received, a
3-dose series is required.
Varicella1, 2, 3 2 doses The 1st dose of varicella must be received on or after the 1st birthday.
Meningococcal1 1 dose For K – 12th grade: 2 doses are required.
(MCV4) For 7th – 12th grade, 1 dose of quadrivalent meningococcal
conjugate vaccine is required on or after the student’s 11th birthday.
Note: If a student received the vaccine at 10 years of age, this will
satisfy the requirement.
Hepatitis A1, 2 2 doses The 1st dose of hepatitis A must be received on or after the 1st birthday.
For K – 8th grade: 2 doses are required.
↓ Notes on the back page, please turn over.↓ Rev. 03/2017
19 NOTE: Shaded area indicates that the vaccine is not required for the respective age group.
1 Receipt of the dose up to (and including) 4 days before the birthday will satisfy the school entry immunization requirement.
2 Serologic evidence of infection or serologic confirmation of immunity to measles, mumps, rubella, hepatitis B, hepatitis A, or varicella is acceptable in place of
vaccine.
3 Previous illness may be documented with a written statement from a physician, school nurse, or the child’s parent or guardian containing wording such as: “This is
to verify that (name of student) had varicella disease (chickenpox) on or about (date) and does not need varicella vaccine.” This written statement will be acceptable
in place of any and all varicella vaccine doses required.
Exemptions
Texas law allows (a) physicians to write medical exemption statements that the vaccine(s) required would be medically harmful or injurious to the health and
well-being of the child or household member, and (b) parents/guardians to choose an exemption from immunization requirements for reasons of conscience,
including a religious belief. The law does not allow parents/guardians to elect an exemption simply because of inconvenience (for example, a record is lost
or incomplete and it is too much trouble to go to a physician or clinic to correct the problem). Schools should maintain an up-to-date list of students with
exemptions, so they may be excluded in times of emergency or epidemic declared by the commissioner of public health.
Instructions for requesting the official exemption affidavit that must be signed by parents/guardians choosing the exemption for reasons of conscience,
including a religious belief, can be found at www.ImmunizeTexas.com under “School & Child-Care.” The original Exemption Affidavit must be completed and
submitted to the school.
For children claiming medical exemptions, a written statement by the physician must be submitted to the school. Unless it is written in the statement that a
lifelong condition exists, the exemption statement is valid for only one year from the date signed by the physician.
Provisional Enrollment
All immunizations should be completed by the first date of attendance. The law requires that students be fully vaccinated against the specified diseases. A
student may be enrolled provisionally if the student has an immunization record that indicates the student has received at least one dose of each specified
age-appropriate vaccine required by this rule. To remain enrolled, the student must complete the required subsequent doses in each vaccine series on schedule
and as rapidly as is medically feasible and provide acceptable evidence of vaccination to the school. A school nurse or school administrator shall review the
immunization status of a provisionally enrolled student every 30 days to ensure continued compliance in completing the required doses of vaccination. If, at
the end of the 30-day period, a student has not received a subsequent dose of vaccine, the student is not in compliance and the school shall exclude the student
from school attendance until the required dose is administered.
Additional guidelines for provisional enrollment of students transferring from one Texas public or private school to another, students who are dependents of
active duty military, students in foster care, and students who are homeless can be found in the TAC, Title 25 Health Services, Sections 97.66 and 97.69.
Documentation
Since many types of personal immunization records are in use, any document will be acceptable provided a physician or public health personnel has validated
it. The month, day, and year that the vaccination was received must be recorded on all school immunization records created or updated after September 1, 1991.
Texas Department of State Health Services • Immunization Unit • MC-1946 • P. O. Box 149347 • Austin, TX 78714-9347 • (800) 252-9152
Stock No. 6-14 Rev. 03/2017
Requisitos mínimos de vacunas en el estado de Texas de 2017 - 2018 para estudiantes de kínder a 12.o grado
Esta gráfica resume los requisitos de vacunación incorporados al Código Administrativo de Texas (TAC), título 25, Servicios de salud, secciones 97.61 a 97.72. Este
documento no tiene como propósito sustituir al TAC, el cual contempla otras disposiciones y detalles. El Código de Educación de Texas, capítulo 38, confiere al
Departamento Estatal de Servicios de Salud (DSHS) la autoridad para establecer los requisitos de inmunización.
REQUISITOS DE INMUNIZACIÓN
Los estudiantes deberán mostrar comprobantes de vacunación aceptables antes de inscribirse,
asistir o ser transferidos a una guardería o una escuela primaria o secundaria pública o privada de Texas.
Vacuna requerida Número mínimo de dosis requeridas por nivel de grado Notas
(Vea las notas y notas De kínder a 6.o grado 7.o grado De 8.o a 12.o grado
K 1 2 3 4 5 6 7 8 9 10 11 12
de pie de página)
Difteria, tétanos, tos ferina1 5 dosis o 4 dosis Una serie Una serie primaria Para los grados kínder a 6.o: 5 dosis de la vacuna contra la difteria, el tétanos
(DTaP, DTP, DT, Td, Tdap) primaria de de 3 dosis y 1 y la tosferina; debe haberse recibido 1 dosis en o después del 4.o cumpleaños.
refuerzo de la Sin embargo, con 4 dosis se cubre el requisito si la 4.a dosis se recibió en o
3 dosis y después del 4.o cumpleaños. Para los estudiantes de 7 años de edad o más, con
1 refuerzo vacuna Tdap / Td 3 dosis cumplen con el requisito si recibieron 1 de las dosis en o después del 4.o
dentro de los cumpleaños.
de la Para el 7.o grado: Se requiere 1 dosis de la vacuna Tdap si han pasado al
vacuna últimos 10 años menos 5 años desde la última dosis de una vacuna que contenga tétanos.
Tdap / Td Para los grados 8.o a 12.o: Se requiere 1 dosis de la vacuna Tdap cuando hayan
dentro de pasado 10 años desde la última dosis de una vacuna que contenga tétanos.
los últimos La vacuna Td es aceptable en lugar de la vacuna Tdap si existe una
5 años
20 contraindicación médica para la vacuna contra la tosferina.
Para los grados kínder a 12.o: 4 dosis de la vacuna contra la polio; debe
Polio1 4 dosis o 3 dosis recibirse 1 dosis en o después del 4.o cumpleaños. Sin embargo, con 3 dosis se
cumple con el requisito si la 3.a dosis se recibió en o después del 4.o cumpleaños.
Para los grados kínder a 12.o: Se requieren 2 dosis de la vacuna, la 1.a de las
Sarampión, paperas y 2 dosis cuales debe recibirse en o después del 1.er cumpleaños. Los estudiantes que
rubeola1, 2 fueron vacunados antes de 2009 con 2 dosis contra el sarampión y una dosis
(MMR) contra la rubeola y una dosis contra las paperas cumplen con este requisito.
Hepatitis B2 3 dosis Para los estudiantes de 11 a 15 años de edad, con 2 dosis cumplen con
el requisito si recibieron la vacuna contra la hepatitis B para adultos
(Recombivax®). Tanto la dosis (10 mcg / 1.0 mL) como el tipo de
vacuna (Recombivax®) deben documentarse claramente. Si la vacuna
recibida no fue Recombivax®, se requiere una serie de 3 dosis.
Varicela1, 2, 3 2 dosis La 1.a dosis de la vacuna contra la varicela debe recibirse en o después
Vacuna antimeningocócica1 1 dosis del 1.er cumpleaños.
(MCV4) Para los grados kínder a 12.o: Se requieren 2 dosis.
Para los grados 7.o a 12.o, se requiere 1 dosis de la vacuna
antimeningocócica tetravalente conjugada en o después del 11.o
cumpleaños del estudiante. Nota: Si un estudiante recibió la vacuna a
los 10 años de edad, esto satisface el requisito.
Hepatitis A1, 2 2 dosis La 1.a dosis de la vacuna contra la hepatitis A debe recibirse en o
después del 1.er cumpleaños.
Para los grados kínder a 8.o: Se requieren 2 dosis.
↓ Notas al reverso, por favor dé la vuelta. ↓ Rev. 03/2017
21 NOTA: Las casillas sombreadas indican que no se requiere la vacuna para el grupo de edad correspondiente.
1 Recibir la dosis hasta (e inclusive) 4 días antes del cumpleaños satisfará el requisito de inmunización para inscribirse en la escuela.
2 Son aceptables en lugar de la vacuna una prueba serológica de infección o la confirmación serológica de inmunidad al sarampión, las paperas, la rubeola, la hepatitis B,
la hepatitis A o la varicela.
3 Si se ha tenido la enfermedad previamente, puede documentarse con una declaración escrita de un médico, un enfermero escolar o uno de los padres o tutor del niño,
la cual diga algo como: “Esto es para comprobar que (nombre del estudiante) tuvo la enfermedad de la varicela (varicella o chickenpox) el (fecha) o alrededor de esa
fecha y no necesita la vacuna contra la varicela”. Dicha declaración escrita será aceptable en lugar de alguna o todas las dosis requeridas de la vacuna contra la varicela.
Exenciones
La ley de Texas autoriza a que (a) los médicos redacten declaraciones de exención médica para una vacuna o vacunas requeridas que podrían ser médicamente dañinas
o perjudiciales para la salud y el bienestar del niño o miembro del hogar, y (b) los padres o tutores opten por una exención de los requisitos de inmunización por
razones de conciencia, incluidas las creencias religiosas. La ley no permite que los padres o tutores opten por una exención simplemente para evitarse inconvenientes
(por ejemplo, cuando un registro se haya perdido o esté incompleto y sea mucha molestia ir con un médico o a una clínica para corregir el problema). Las escuelas
deben mantener una lista actualizada de los estudiantes con exenciones, de forma que se les pueda excluir en casos de emergencias o epidemias declaradas por el
comisionado de salud pública.
Encontrará las instrucciones para solicitar la declaración jurada de exención oficial, la cual debe ser firmada por los padres o tutores que elijan la
exención por razones de conciencia, incluidas las creencias religiosas, en www.ImmunizeTexas.com, en el enlace para “Escuelas y guarderías”. El
original de la declaración jurada de exención debe llenarse y entregarse en la escuela.
En el caso de los niños para quienes se reclamen exenciones médicas, es necesario presentar a la escuela una declaración escrita del médico. A menos que en la
declaración conste por escrito que existe una afección de por vida, la declaración de exención es válida solo por un año a partir de la fecha en que el médico la firmó.
Inscripción provisional
Todas las inmunizaciones deben haberse completado antes del primer día de asistencia. La ley exige que los estudiantes estén completamente vacunados contra las
enfermedades específicas. Un estudiante puede inscribirse de manera provisional si cuenta con un registro de inmunización que indique que el estudiante ha recibido al
menos una dosis de cada vacuna específica apropiada para su edad según lo exige esta regla. Para seguir inscrito, el estudiante debe completar las dosis posteriores requeridas
de cada serie de vacunas a tiempo según el calendario y tan rápidamente como sea médicamente posible, y debe proporcionar a la escuela un comprobante aceptable de
que ha sido vacunado. Un enfermero escolar o administrador escolar revisará cada 30 días el estado de inmunización de los estudiantes inscritos de manera provisional
para garantizar el cumplimiento ininterrumpido de la aplicación de las dosis de vacunas requeridas. Si, al final del periodo de 30 días, un estudiante no ha recibido una dosis
posterior de la vacuna, el estudiante no está cumpliendo con las normas, y la escuela excluirá al estudiante de su asistencia a la escuela hasta que se le administre la dosis
requerida.
Las normas adicionales para la inscripción provisional de estudiantes transferidos de una escuela pública o privada de Texas a otra, estudiantes que dependen de militares en
servicio activo, estudiantes que viven en hogar de acogida y estudiantes en situación sin hogar, se encuentran en el TAC, título 25, Servicios de salud, secciones 97.66 y 97.69.
Documentación
Dado que se usan muchos tipos de registros de inmunización personales, cualquier documento es aceptable si un médico o el personal de salud pública lo ha validado.
Debe registrarse el mes, día y año en que se recibió la vacuna en todos los registros de inmunización escolares creados o actualizados después del 1 de septiembre de 1991.
Texas Department of State Health Services • Immunization Unit • MC-1946 • P. O. Box 149347 • Austin, TX 78714-9347 • (800) 252-9152
Stock No. 6-14 Rev. 03/2017
2017-2018 Texas Minimum State Vaccine Requirements for Child-Care and Pre-K Facilities
This chart summarizes the vaccine requirements incorporated in the Texas Administrative Code (TAC), Title 25 Health Services, §§97.61-97.72. This chart
is not intended as a substitute for consulting the TAC, which has other provisions and details. The Department of State Health Services (DSHS) is granted
authority to set immunization requirements by the Human Resources Code, Chapter 42.
A child shall show acceptable evidence of vaccination prior to entry, attendance, or transfer to a child-care facility
or public or private elementary or secondary school in Texas.
Age at which child must have Minimum Number of Doses Required of Each Vaccine
vaccines to be in compliance:
DTaP Polio HepB Hib PCV MMR Varicella HepA
0 through 2 months
By 3 months 1 Dose 1 Dose 1 Dose 1 Dose 1 Dose
By 5 months 2 Doses 2 Doses 2 Doses
22 By 7 months 3 Doses 2 Doses 2 Doses 2 Doses 2 Doses
By 16 months 3 Doses 2 Doses 2 Doses
By 19 months 4 Doses 3 Doses 3 Doses 2 Doses1 3 Doses2
By 25 months 4 Doses 3 Doses 3 Doses
By 43 months 4 Doses 3 Doses 3 Doses 3 Doses1 4 Doses2 1 Dose3 1 Dose3
1 Dose3
3 Doses1 4 Doses2 1 Dose3 1 Dose3
1 Dose3
3 Doses1 4 Doses2 1 Dose3 1 Dose3
3 Doses1 4 Doses2 1 Dose3 2 Doses3
1 A complete Hib series is two doses plus a booster dose on or after 12 months of age (three doses total). If a child receives the first dose of Hib vaccine at
12 - 14 months of age, only one additional dose is required (two doses total). Any child who has received a single dose of Hib vaccine on or after 15 - 59
months of age is in compliance with these specified vaccine requirements. Children 60 months of age and older are not required to receive Hib vaccine.
↓ Notes on the back page, please turn over.↓ Rev. 03/2017
23 2 If the PCV series is started when a child is seven months of age or older or the child is delinquent in the series, then all four doses may not be required.
Please reference the information below to assist with compliance:
• For children seven through 11 months of age, two doses are required.
• For children 12 - 23 months of age: if three doses have been received prior to 12 months of age, then an additional dose is required (total of four doses)
on or after 12 months of age. If one or two doses were received prior to 12 months of age, then a total of three doses are required with at least one
dose on or after 12 months of age. If zero doses have been received, then two doses are required with both doses on or after 12 months of age.
• Children 24 months through 59 months meet the requirement if they have at least three doses with one dose on or after 12 months of age, or two
doses with both doses on or after 12 months of age, or one dose on or after 24 months of age. Otherwise, one additional dose is required. Children 60
months of age and older are not required to receive PCV vaccine.
3 For MMR, Varicella, and Hepatitis A vaccines, the first dose must be given on or after the first birthday. Vaccine doses administered within 4 days before the
first birthday will satisfy the requirement.
Information on exclusions from immunization requirements, provisional enrollment, and acceptable documentation of immunizations may be found in
§97.62, §97.66, and §97.68 of the Texas Administrative Code, respectively.
Vaccines:
DTaP: Diphtheria, tetanus, and acellular pertussis (whooping cough); record may show DT or DTP
Polio: IPV - inactivated polio vaccine; OPV – oral polio vaccine
HepB: Hepatitis B vaccine
Hib: Haemophilus influenzae type b vaccine
PCV or PCV13: Pneumococcal conjugate vaccine
MMR: Measles, mumps, and rubella vaccines combined
Varicella: Chickenpox vaccine. May be written VAR on record.
HepA: Hepatitis A vaccine
Texas Department of State Health Services • Immunization Unit • MC-1946 • P. O. Box 149347 • Austin, TX 78714-9347 • (800) 252-9152
Stock No. 6-15 Rev. 03/2017
Requisitos mínimos de vacunas en el estado de Texas de 2017- 2018 para las guarderías y centros de pre-kínder
Esta gráfica resume los requisitos para vacunas incorporados al Código Administrativo de Texas (TAC), título 25, Servicios de salud, secciones 97.61 a
97.72. Esta gráfica no tiene como propósito sustituir las consultas al TAC, el cual contempla otras disposiciones y detalles. El Código de Recursos Humanos,
capítulo 42, confiere al Departamento Estatal de Servicios de Salud (DSHS) la autoridad para establecer los requisitos de inmunización.
Los niños deberán mostrar comprobantes de vacunación aceptables antes de inscribirse,
asistir o ser transferidos a una guardería o una escuela primaria o secundaria pública o privada de Texas
Edad a la que el niño debe recibir las Número mínimo de dosis requeridas de cada vacuna
vacunas para cumplir con los requisitos:
DTaP Polio HepB Hib PCV MMR Varicella HepA
De 0 a 2 meses
Antes de los 3 meses 1 dosis 1 dosis 1 dosis 1 dosis 1 dosis
24 Antes de los 5 meses 2 dosis 2 dosis 2 dosis 2 dosis 2 dosis
Antes de los 7 meses 3 dosis 2 dosis 2 dosis 2 dosis1 3 dosis2
Antes de los 16 meses 3 dosis 2 dosis 2 dosis 3 dosis1 4 dosis2 1 dosis3 1 dosis3
Antes de los 19 meses 4 dosis 3 dosis 3 dosis 3 dosis1 4 dosis2 1 dosis3 1 dosis3
Antes de los 25 meses 4 dosis 3 dosis 3 dosis 3 dosis1 4 dosis2 1 dosis3 1 dosis3 1 dosis3
Antes de los 43 meses 4 dosis 3 dosis 3 dosis 3 dosis1 4 dosis2 1 dosis3 1 dosis3 2 dosis3
1 Una serie completa de la vacuna Hib consta de dos dosis más una dosis de refuerzo a los 12 meses de edad o después (tres dosis en total). Si un niño recibe
la primera dosis de la vacuna Hib entre los 12 y los 14 meses de edad, se requiere solo una dosis adicional (dos dosis en total). Si un niño ha recibido una sola
dosis de la vacuna Hib entre o después de los 15 y los 59 meses de edad, cumple con los requisitos de esta vacuna específica. Los niños de 60 meses de edad
o mayores no requieren recibir la vacuna Hib.
↓ Notas al reverso, por favor dé la vuelta. ↓ Rev. 03/2017
25 2 Si la serie de vacunas PCV se empieza a administrar cuando el niño tiene siete meses de edad o más, o si el niño está atrasado con alguna dosis de la serie,
entonces puede que no sean necesarias las cuatro dosis. Por favor refiérase a la información siguiente para ayudarse a cumplir con los requisitos:
• Para los niños de siete a 11 meses de edad, se requieren dos dosis.
• Para los niños de 12 a 23 meses de edad: si han recibido tres dosis antes de los 12 meses de edad, entonces requieren una dosis adicional (para un total
de cuatro dosis) a los 12 meses de edad o después. Si recibieron una o dos dosis antes de los 12 meses de edad, entonces requieren un total de tres dosis,
y al menos una de las dosis deberán recibirla a los 12 meses de edad o después. Si no han recibido ninguna dosis, entonces requieren dos dosis y ambas
deberán recibirlas a los 12 meses de edad o después.
• Los niños de entre 24 meses y 59 meses de edad cumplen con los requisitos si recibieron al menos tres dosis, y una de las cuales la recibieron a los 12
meses de edad o después; o dos dosis, ambas recibidas a los 12 meses de edad o después; o una dosis recibida a los 24 meses de edad o después. De lo
contrario, es necesaria una dosis adicional. Los niños de 60 meses de edad o mayores no necesitan recibir la vacuna PCV.
3 Para la vacuna MMR y las vacunas contra la varicela y contra la hepatitis A, la primera dosis debe administrarse en o después del primer cumpleaños. Las
dosis de vacunas administradas dentro de los 4 días anteriores al primer cumpleaños satisfacen los requisitos.
La información sobre las exclusiones de los requisitos de inmunización, la inscripción provisional y la documentación aceptable de las inmunizaciones puede
encontrase en las secciones 97.62, 97.66 y 97.68, respectivamente, del Código Administrativo de Texas.
Las vacunas:
DTaP: Difteria, tétanos y tosferina acelular (pertussis); en el registro pueden aparecer como DT o DTP
Polio: IPV - vacuna inactivada contra la poliomielitis (polio); OPV - vacuna oral contra la poliomielitis
HepB: Vacuna contra la hepatitis B
Hib: Vacuna contra Haemophilus influenzae tipo b
PCV o PCV13: Vacuna antineumocócica conjugada
MMR: Vacuna combinada contra el sarampión, las paperas y la rubeola
Varicella: Vacuna contra la varicela. En el registro puede aparecer escrita como VAR.
HepA: Vacuna contra la hepatitis A
Texas Department of State Health Services • Immunization Unit • MC-1946 • P. O. Box 149347 • Austin, TX 78714-9347 • (800) 252-9152
Stock No. 6-15 Rev. 03/2017
Request for Exemption from Immunizations for Reasons of Conscience
Date: In order to expedite your request, please print or type the name
and date of birth for each child. If you are submitting this request
by fax, please provide your telephone number so that we can
contact you if there is a problem with the fax transmission.
Thank You.
I wish to obtain an Exemption from Immunizations for Reasons of Conscience Affidavit Form. Please provide me with an
exemption affidavit form for each of my children listed below (maximum 5 forms per child):
Name of Parent/Legal Guardian:
Mailing address:
Apartment Number:
City/State/Zip:
Telephone Number (Needed for faxed requests)
Signature of Parent or Legal Guardian
Important note: No requests will be filled at the time of hand-delivery.
First Name Middle Name Last Name Birth date Number
(mm/dd/yyyy) of forms
Please mail, fax, or hand deliver your request to:
Mailing Address: Hand Deliver:
Department of State Health Services Department of State Health Services
Immunization Branch (MC 1946)
Immunization Branch (MC 1946)
P.O. Box 149347 1100 West 49th Street
Austin, TX 78756
Austin, TX 78714-9347
Fax (512) 776-7544
Please provide all information requested to expedite your request. Thank you.
Texas Department of State Health Services Stock No. EF11-13140
Immunization Branch Rev. 08/11
26
Texas Department of State Health Services, Immunization Branch
Provisional Enrollment for Students (Non-Higher Education; Non-Veterinary Students)
Students with an Immunization Record
The immunization record The immunization record indicates The immunization record
indicates that the student that the student has received at least indicates that the student is
has all required vaccine one dose of each specified age- delinquent with a vaccine, or a
doses. appropriate vaccine required, and is dose in a vaccine series.
on schedule to receive subsequent
27 doses as rapidly as medically
feasible. Student must not be
overdue for next dose in series to be
considered provisional.
Enroll The student must provide proof
that he/she has received the
The student may be enrolled provisionally. A
school nurse or school administrator shall required vaccine; otherwise, the
review the immunization status of a student is not in compliance, and
provisionally enrolled student every 30 days to the school shall exclude the
ensure continued compliance in completing student from school attendance
the required doses of vaccine(s).
until the required dose is
administered.
1
Source: Title 25 Health Services, 97.66 and 97.69 of the Texas Administrative Code. If you have any questions, please contact the Texas
Department of State Health Services, Immunization Branch at: (800) 252-9152.
Stock No. E11-13255 Rev. 04/07/2011
Texas Department of State Health Services, Immunization Branch
Provisional Enrollment for Students (Non-Higher Education; Non-Veterinary Students)
Students without an Immunization Record
A student has never attended A student is transferring A student is homeless. A student is a dependent of a
school before, or is transferring from another school (within person who is on active duty
from out of state. Texas). with the Armed Forces of the
United States.
The student cannot be enrolled until The student shall be admitted temporarily 28
an immunization record is provided. for 30 days if acceptable evidence of
Once received, if the immunization record vaccination is not available. The school
shall promptly refer the student to the
indicates that the student has received at appropriate public health programs to
least one dose of each specified age- obtain the required vaccines.
appropriate vaccine required and is on
schedule to receive subsequent doses as
rapidly as medically feasible, the student
may be enrolled provisionally.
The student may be enrolled The student can be enrolled
provisionally for 30 days while provisionally for no more than 30 days
awaiting the transfer of the if transferring from one school to
immunization record. another and waiting on the transfer of
the immunization record.
2
Source: Title 25 Health Services, 97.66 and 97.69 of the Texas Administrative Code. If you have any questions, please contact the Texas
Department of State Health Services, Immunization Branch at: (800) 252-9152.
Stock No. E11-13255 Rev. 04/07/2011
Frequently Asked Questions
Vaccine Exemption for Reasons of Conscience
Q. How do I obtain a vaccine exemption for reasons of conscience for my
child?
A. Parents or guardians need to request a vaccine exemption affidavit form in
writing or via a secure online request. Each child’s name and date of birth must
be included in the request. Written requests must be submitted through the U.S.
Postal Service, commercial carrier, fax, or online:
Mailing Address: Hand Deliver:
Department of State Health Services Department of State Health Services
Immunization Branch (MC 1946) Immunization Branch
P.O. Box 149347 1100 West 49th Street
Austin, TX 78714-9347 Austin, TX 78756
Fax (512) 776-7544
Secure online request form for exemption affidavit:
https://webds.dshs.state.tx.us/immco
Phone and email requests cannot be accepted.
Households requesting an affidavit for more than one child should submit only
one request form. The request should include the name and date of birth of each
child living within that household who needs affidavit forms. This will ensure you
receive the forms in a timely manner.
Q. What information will be listed on the vaccine exemption affidavit form I
receive?
A. Information on the form will include the child’s name and date of birth; a list of
required vaccines for which exemptions may be requested; a statement for the
requesting parent or guardian to indicate their relationship to the child; and an
acknowledgement that the parent or guardian has read the attached information
entitled The Benefits and Risks of Vaccinations. Parents or guardians will then
have to sign the form in front of a notary public.
Q. How many vaccine exemption affidavit forms can a parent or guardian
request at one time?
A. Parents or guardians can request up to five vaccine exemption affidavit forms per
child.
Texas Department of State Health Services Page 1 of 3 Stock No. E11-13159
Immunization Branch Revised 07/2012
29
Q. What should parents or guardians do with the vaccine exemption affidavit
form?
A. After the original vaccine exemption affidavit form is signed and notarized, it must
be submitted to the child’s school.
Q. For how long is each child’s individual exemption affidavit valid?
A. Each individual vaccine exemption affidavit is good for two years from the date
notarized.
Q. What happens if the parent or school loses the original vaccine exemption
affidavit?
A. Photocopies of the vaccine exemption affidavit form are not valid. If parents or
schools lose the exemption affidavit, the parent or guardian needs to request
another vaccine exemption affidavit in writing following the same procedures
used to obtain the first form.
Q. What if my child changes schools?
A. The vaccine exemption affidavit is part of the child’s school records and should
be sent to the new school with other school records.
Q. What will happen to the information collected on each child?
A. Requests submitted to DSHS will be returned to parents or guardians along with
the vaccine exemption affidavit forms. DSHS will track and report on the number
of affidavit requests and zip code. No other information will be maintained.
Q. Does a child have a 90-day provisional enrollment in school while awaiting
the vaccine exemption form?
A. No. Admission to a school is not allowed until records are produced showing that
(1) the child has been immunized in accordance with the rules; (2) the child has
an exemption affidavit from immunization requirements on file with the school in
accordance with the rules; or (3) the child is entitled to provisional enrollment.
Q. What is required for school enrollment if I want my child exempted from
some vaccines but not all of them?
A. Two different immunization documents will be needed: 1) an official notarized
DSHS vaccine exemption affidavit for those vaccines the parent or guardian has
chosen for reasons of conscience to have their child exempt from; and 2) a valid
immunization record indicating the month, date, and year each vaccine for which
the child is not exempt was administered, with appropriate validation by a
physician or public health clinic.
Texas Department of State Health Services Page 2 of 3 Stock No. E11-13159
Immunization Branch Revised 07/2012
30
Q. If a child currently has a religious exemption for vaccinations on file with
the school do they need to obtain a new vaccine exemption for reasons of
conscience affidavit?
A. No. Students who had religious exemptions filed at the school prior to
September 1, 2003 do not need a new vaccine exemption affidavit form. The
religious exemption on file remains valid.
Q. What if there is a vaccine-preventable disease—such as measles—
outbreak at a school?
A. Each parent or guardian who signs a vaccine exemption affidavit form also is
acknowledging they understand that their child may be excluded from school
attendance in times of emergency or epidemic declared by the Texas
Commissioner of Health.
Q. Does this new vaccine exemption option mean that my vaccinated child
may be attending school with other children who are not fully vaccinated?
A. Yes.
Q. Can an expectant parent request a vaccination exemption affidavit form for
an unborn child?
A. No. Because the child’s name and date of birth is required when the vaccine
exemption affidavit form is requested, expectant parents must wait until after the
child is born to request the vaccine exemption affidavit form.
Q. Are there other reasons a child may be exempted from vaccination
requirements?
A. A child may be exempted from one or more vaccinations for medical reasons.
The parent or guardian must provide the school with a certificate signed by a
physician (M.D. or D.O.), registered and licensed to practice medicine in the
United States, which states that, in the physician’s opinion, the immunization
required would be injurious to the child’s health and well-being or to any of the
child’s family or household members. Unless a lifelong condition is specified,
that certificate is valid for one year from the date signed by the physician and
must be renewed every year for the exclusion to remain in effect.
Texas Department of State Health Services Page 3 of 3 Stock No. E11-13159
Immunization Branch Revised 07/2012
31
breakout sessions 1
9:30 AM - 10:20 AM
Auditorium The Health Department’s Role with Reportable
Diseases in Schools
Dr. Amanda Kubala & Dr. Jason Geslois, Northeast Texas Public Health District
This presentation will give an overview of the most common infectious diseases school nurses are required
to report to the health department. It will also discuss control measures school nurses can implement with
additional resources including letters to parents and FAQs for staff and administrators.
Room 3207 School Nurse Guide To Pharmaceutical Care Best Practices
Dr. Takova Wallace, Assistant Clinical Professor, UT Tyler
This presentation will discuss the regulations regarding medication storage, administration, and safety.
Room 3211 Shatter The Silence - Best Practices During Abuse Investigations for
Children and Schools (9:30 AM - 11:20 AM)
Christie Glenn-Moore, Forensic Interviewer/Intake Coordinator, Katelyn Holland, R.N., SANE Nurse, CHRISTUS
Trinity Mother Frances Health System , Kelsey Drennan, Investigator, Child Protective Services, Debra Stiles,
Detective for Longview Police Department
Crimes committed against children must be handled very differently from crimes involving adult victims.
This workshop is presented by professional investigators and caseworkers who will dispel 10 common myths
associated with reporting, investigating, and prosecuting child abuse cases.
Room 3213 School Nursing 101: Laws and Statutes that Govern School
Health & Responsibilities
Martha Baker, BSN, MS, RN, Independent Consultant
In this session you will learn the roles of the R.N., L.V.N., and Health Aide in the school setting, identify the
components of school health and distinguish the nurse’s role and responsibility, and develop 3 ways to
implement new goals.
32
breakout sessions 2
10:30 AM - 11:20 AM
Auditorium Sports Concussions
Dr. James Rapp, Director of Sports Medicine at CHRISTUS Trinity Mother Frances Health System
Session Description.
Room 3207 School Nurse Guide to Pharmaceutical Care: Best Practices
Dr. Takova Wallace, Assistant Clinical Professor, UT Tyler
This presentation will discuss the regulations regarding medication storage, administration and safety.
Room 3213 Building Stronger Schools & Communities by Identifying
SHAC Roles & Networking
Martha Baker, BSN, MS, RN, Independent Consultant
This session will define SHAC, review the purpose of SHAC, discuss membership, and learn about the
benefits of the SHAC program.
working lunch
11:30 AM - 12:20 PM
Auditorium Youth Mental Health First Aid Overview
Kristi Roberts, CBSE Coordinator, TX AHEC East Northeast Region
An introduction to the certification course. Youth Mental Health First Aid USA is an 8 hour public
education program which introduces participants to the unique risk factors and warning signs of mental
health problems in adolescents, builds understanding of the importance of early intervention, and teaches
individuals how to help an adolescent in crisis or experiencing a mental health challenge. Mental Health
First Aid uses role-playing and simulations to demonstrate how to assess a mental health crisis; select
interventions and provide initial help; and connect young people to professional, peer, social, and self-help
care.
33
breakout sessions 3
12:30 PM - 1:20 PM
Auditorium Child Mental Health and the School Nurse
Dr. Ray Scardina, Assistant Professor, UTHSC-Tyler
This session will provide you with improved familiarity with common child mental health problems and
interventions.
Room 3207 Narcotics Awareness and Current Trends
Sergeant Humphreys & Detective Rockett, Gregg County Organized Drug Unit
This session will provide you with information on the current drug trends and increase your awareness of narcotics.
Room 3211 Shatter The Silence - Best Practices During Abuse Investigations for
Children and Schools (12:30 PM - 2:20 PM)
Christie Glenn-Moore, Forensic Interviewer/Intake Coordinator, Katelyn Holland, R.N., SANE Nurse, CHRISTUS
Trinity Mother Frances Health System, Kelsey Drennan, Investigator, Child Protective Services, Debra Stiles,
Detective for Longview Police Department
Crimes committed against children must be handled very differently from crimes involving adult victims. This
workshop is presented by professional investigators and caseworkers who will dispel 10 common myths associated
with reporting, investigating, and prosecuting child abuse cases.
Room 3212 Nurse-Family Partnership®: Transforming the Lives of First-Time
Moms and Their Babies
Laura Young, Nursing Supervisor at UT Health
Nurse-Family Partnership®, an evidence-based Maternal-Child community healthcare program, empowers
first-time, low-income, mothers to become confident parents and strong women by partnering them with nurse
home visitors. This trusted relationship instills a level of confidence in the first-time moms that will help them
guide them and their children to successful futures. The program introduces vulnerable first-time parents to caring
nurses who deliver the support first-time moms (and dads, if available!) need to have a healthy pregnancy, become
knowledgeable and responsible parents, and provide their babies with the best possible start in life.
The relationship between mother and nurse provides the foundation for strong families, and lives are forever
changed – for the better.
Room 3213 Building Stronger Schools & Communities by Identifying SHAC
Roles & Networking
Martha Baker, BSN, MS, RN, Independent Consultant
This session will define SHAC, review the purpose of SHAC, discuss membership, and learn about the benefits of
the SHAC program.
34
breakout sessions 4
1:30 PM - 2:20 PM
Auditorium New DSHS Resources for the New School Year
Anita Wheeler, MSN, RN, DSHS
This session will provide an overview of the following new publications/resources:
DSHS-School Nurse Notes, DSHS Medication Guide, DSHS Guide to School Health Services Web Portal,
DSHS/BON-Frequently Asked Questions, Awards for Excellence in Texas School Health
Room 3207 Narcotics Awareness and Current Trends
Sergeant Humphreys & Detective Rockett, Gregg County Organized Drug Unit
This session will provide you with information on the current drug trends and increase your awareness of
narcotics.
Room 3212 Nurse-Family Partnership®: Transforming the Lives of
First-Time Moms and Their Babies
Laura Young, Nursing Supervisor at UT Health
Nurse-Family Partnership®, an evidence-based Maternal-Child community healthcare program, empowers
first-time, low-income, mothers to become confident parents and strong women by partnering them with nurse
home visitors. This trusted relationship instills a level of confidence in the first-time moms that will help them
guide them and their children to successful futures. The program introduces vulnerable first-time parents to
caring nurses who deliver the support first-time moms (and dads, if available!) need to have a healthy pregnancy,
become knowledgeable and responsible parents, and provide their babies with the best possible start in life.
The relationship between mother and nurse provides the foundation for strong families, and lives are forever
changed – for the better.
35
anita wheeler
2:30 PM - 3:30 PM
2017 Awards for Excellence in Texas School Health
Applications for the 2017 Awards for Excellence Program are currently available. Now is
the time to apply for one of the categories of awards!
✭ Reaching for Excellence Grant - Money to Begin a New Program, $1,200 each (four available)
✭ Discovery Award - Recognition of a Current School Health Program, $1,500 each (three available)
✭ Vanguard Award - Recognition of a Previous Discovery Award winner, $1,000 (one available)
✭Award of Achievement (bonus award)* - Recognition of a Current Middle School Health
Program, $1,000 each (three available) (*Automatically entered for this award if an applicant’s program
focuses on reducing obesity in adolescents.)
Additional Awards for Excellence prizes include the following:
« An engraved plaque.
« A travel expense-paid trip to the Award Ceremony for one with banquet meal for two.
« Also provided will be a take-home booklet of the winning program abstracts published in an official
Texas Department of State Health Services (DSHS) publication as well as on the DSHS School Health
Program website.
• Applications Deadline: August 31, 2017 • Winners Noti ed: October 2017
wards for is sponsored by the School Health Program of the Department of State Health Services and is funded
by the exas Institute and the exas Foundation. For more information on the awards program, visit
the wards for in exas School website at www.dshs.texas.gov/schoolhealth/awards.shtm. Contact the
School Health Program at [email protected] or by phone at (512) 776-7279.
36
85th Legislative Session
School Health and Public Education
2017 Related Legislation Tracking
This document contains school health related legislation taken directly from the official
Texas Legislature On-Line (TLO) Web site: www.capitol.state.tx.us/Home.aspx. The
bills listed have been signed by the Texas House and Senate and have made it through
the legislative process.
NOTE: A brief descriptive caption of each bill has been provided. Captions provide only
the most basic information about a bill. It is always best to read the entire bill to
understand all relative items. To check the current status of a bill, click on the bill link.
How to Use this Document
• Bill Links Column:
o The bill number provides access to a complete history of the bill by going to
the main bill page. Specific information can be obtained from this page
including any fiscal notes attached to the bill, and any revisions that have
been made to the bill.
• Bill Information Column:
o Each bill summary is included directly from the TLO Web site. As previously
noted, the summary does not always include specific details on the bill. It is
advised that you read the entire bill to gain more information about the bill.
• Tracking Columns:
o The tracking columns are there to assist you in tracking the bill. Each bill
must be heard in both the House and the Senate. For more information on
how a bill becomes law, check out the TLO Web site at the following link:
http://www.tlc.state.tx.us/gtli/legproc/process.html.
Bill Senate Bills Passed Voted Passed Voted
Number Out of on by Out of on by
Senate Senate House House
Committee Committee
SB 179 Relating to student harassment, bullying, X X XX
cyberbullying, injury to or death of a
minor; creating a criminal offense.
Signed by the Governor
Texas Department of State Health Services, DSHS, Last Updated on June 22, 2017
37
Bill Senate Bills Passed Voted Passed Voted
Number Out of on by Out of on by
Senate Senate House House
Committee Committee
Relating to a notification requirement if a
public school, including an open-enrollment
charter school, does not have a nurse,
SB 196 school counselor, or librarian assigned to X X X X
the school during all instructional hours.
https://gov.texas.gov/news/post/governor-
abbott-vetoes-sb-196
Vetoed by the Governor
Relating to recommendations regarding
SB 489 instruction in public schools to prevent the X X X X
use of e-cigarettes.
Signed by the Governor
SB 490 Relating to information regarding the X X XX
number of school counselors in public
schools.
Signed by the Governor
Relating to the use of epinephrine auto-
injectors on private school campuses and
SB 579 at or in transit to or from off-campus X X XX
school events.
(Companion to HB 1583)
Signed by the Governor
Relating to three-point seat belts on buses
SB 693 that transport school children. X X XX
Signed by the Governor
Relating to a report regarding certain
SB 1873 health and safety information prepared by X X X X
the Texas Education Agency.
Signed by the Governor
Relating to the development of a program
and training for public schools on the
prevention of sexual abuse and sex
SB 2039 trafficking and participation by the human X X X X
trafficking prevention task force in that
development.
Signed by the Governor
Texas Department of State Health Services, DSHS, Last Updated on June 22, 2017
38
Bill House Bills Passed Passed Passed Passed
Number Out of Out of Out of Out of
HB 1076 Relating to the mandatory House House Senate Senate
spinal screening of public and Committee Committee
HB 1583 private school students. X X
X X
HB 3024 Signed by the Governor SB 579 X
X passed in X
HB 3157 Relating to the use of place of X
HB 3296 epinephrine auto-injectors on X X X
private school campuses and at this bill
or in transit to or from off- X X
campus school events. X
X
Companion to SB 579 X
Relating to the removal of a X
public school student from an
interscholastic athletic activity
on the basis of a suspected
concussion.
Signed by the Governor
Relating to requirements for
screenings in public or private
schools to detect vision disorders
of students.
Signed by the Governor
Relating to persons required to
establish nursing peer review
committees.
Signed by the Governor
External links to other sites appearing here are intended to be informational and do not
represent an endorsement by the Texas Department of State Health Services (DSHS). These
sites may also not be accessible to people with disabilities. External email links are provided to
you as a courtesy. Please be advised that you are not emailing the DSHS and DSHS policies do
not apply should you choose to correspond. For information about any of the information listed,
contact the sponsoring organization directly. For comments or questions about this publication,
contact the school health program at (512) 776-7279 or [email protected].
Copyright free. Permission granted to forward or make copies as needed.
Texas Department of State Health Services, DSHS, Last Updated on June 22, 2017
39
School Nurse Notes | February 2017
Adrenal Insufficiency and the Use of Solu-Cortef®
To address the needs of school nurses, the Texas Department of State Health Services
(DSHS)–School Health Program has developed this repository of information. With each
issue of School Nurse Notes, DSHS brings you the latest research, evidence-based practices,
and resources in school nursing related to a topic of interest. If you have any questions or
comments about this publication, please contact Anita Wheeler, School Nurse Consultant, at
(512) 776-2909 or at [email protected].
Background
The Medication
Solu-Cortef® is the product name for hydrocortisone sodium succinate, of
the corticosteroids drug class. 1, 2 The medication comes as powder and must
be mixed with liquid to be administered via the IV or IM route or with Act-O-
Vial®. 1, 2 Solu-Cortef® is approved for pediatric anti-inflammatory or
immunosuppressive uses. 1 It works by replacing steroids in people whose
natural level of corticosteroids is low. 2 Solu-Cortef® is indicated for
endocrine disorders such as primary or secondary adrenocortical
insufficiency; acute adrenocortical insufficiency; preoperatively and in the
event of serious trauma or illness, in patients with known adrenal
insufficiency or when adrenocortical reserve is doubtful; and congenital
adrenal hyperplasia. 1
The Condition
Adrenal insufficiency can be caused by hormonal imbalances that originate in
the adrenal glands (one sits atop each kidney), pituitary gland, or
hypothalamus. Primary adrenal insufficiency, also called Addison’s
disease, refers to conditions in which the adrenal glands are damaged and
not producing sufficient levels of cortisol. Most cases of Addison’s disease
are caused by autoimmune disorders. 3 Secondary adrenal insufficiency
refers, most commonly, to conditions in which hormone imbalances of the
pituitary gland impact cortisol production in the adrenal glands. Secondary
adrenal insufficiency is much more common than Addison’s disease. 3
Regardless of the type of adrenal insufficiency or its cause, life-
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40
threatening adrenal crisis may result if the adrenal insufficient
patient is not given a Solu-Cortef® injection during times of
physiological stress, such as illness or a severe injury. Sudden, severe
worsening of adrenal insufficiency symptoms is called adrenal crisis. 3
Research
The following articles have been compiled from a review of the scientific
literature. For assistance in obtaining an article, please contact the DSHS
Library at [email protected] and mention inclusion of the requested
article in the School Nurse Notes. The articles are presented on a continuum,
ranging from those that address adrenal insufficiency and adrenal crisis in
general to those that relate to specific forms of the condition, such as
Addison’s disease or Congenital Adrenal Hyperplasia (CAH). Following each
citation is a portion of the article’s abstract.
1. Moloney S, Murphy N, Collin J. An overview of the nursing issues
involved in caring for a child with adrenal insufficiency. Nurs Child
Young People. 2015;27(7):28-36.
Adrenal insufficiency is an endocrine condition defined as the inadequate
production or action of glucocorticoids . . . . While rare in childhood, it carries
the risk of adrenal crisis in the event of a child becoming unwell as a result of
inter-current illness, injury or surgery. Children’s nurses must be vigilant in
caring for a child with adrenal insufficiency and have a clear understanding
and awareness of the principles of emergency management at home and in
hospital.
2. Bornstein, SR. Predisposing Factors for Adrenal Insufficiency. N Engl J
Med. 2009;360:2328-2339.
Adrenal insufficiency—the clinical manifestation of deficient production or
action of glucocorticoids—is a life-threatening disorder that may result from
either primary adrenal failure or secondary adrenal disease due to
impairment of the hypothalamic-pituitary axis. This article focuses on
providing the practicing clinician with new insights into predisposing factors
for adrenal insufficiency. . . . The cardinal clinical symptoms of adrenocortical
insufficiency, as first described by Thomas Addison in 1855, include
weakness, fatigue, anorexia, and abdominal pain, with orthostatic
hypotension, salt craving, and characteristic hyperpigmentation of the skin
occurring with primary adrenal failure.
3. Elder CJ, Dimitri P. Hydrocortisone for adrenal insufficiency. Arch Dis
Child Educ Pract Ed. 2015;100:272-276.
Thomas Addison first described Addison’s disease in 1855 in patients who
had adrenal tuberculosis, highlighting the importance of the adrenal cortex to
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41
survive. In 1952, a decade after the medical landmark discovery of cortisone
as a treatment for inflammatory conditions, the first case of adrenal crisis
and death in a patient on glucocorticoid therapy undergoing surgery was
described . . . . A knowledge of how to treat adrenal insufficiency during
times of (patho) physiological stress is paramount to prevent complications
and death.
4. Shulman DI, Palmert MR, Kemp SF. Adrenal insufficiency: Still a cause of
morbidity and death in childhood. Pediatrics. 2007;119(2):e484-e494.
If unrecognized adrenal insufficiency may present with life-threatening
cardiovascular collapse. Adrenal crisis continues to occur in children with
known primary or secondary adrenal insufficiency during intercurrent illness
because of failure to increase glucocorticoid dosage. . . . Suggestions for
prevention of adrenal crisis in patients at risk are provided for health care
professionals and families.
5. Puar TH, Stikkelbroeck NM, Smans LC, et al. Adrenal crisis: Still a deadly
event in the 21st century. Am J Med. 2016;129:339.e1-339.e9.
Gastrointestinal illness is the most common precipitant for an adrenal crisis.
Although most patients are educated about “sick day rules,” patients, and
physicians too, are often reluctant to increase their glucocorticoid doses or
switch to parenteral injections, and thereby fail to avert the rapid
deterioration of the patients’ condition. . . . There is generally a paucity of
studies on adrenal crisis. Hence, we will review the current literature, while
also focusing on the incidence, presentation, treatment, prevention
strategies, and latest recommendations in terms of steroid dosing in stress
situations.
6. Bornstein SR, Allolio B, Arlt W, et al. Diagnosis and treatment of primary
adrenal insufficiency: An endocrine society clinical practice guideline.
J Clin Endocrinol Metab. 2016;101(2):364-389.
This clinical practice guideline addresses the diagnosis and treatment of
primary adrenal insufficiency. . . . We recommend diagnostic tests for the
exclusion of primary adrenal insufficiency in all patients with indicative
clinical symptoms or signs. In particular, we suggest a low diagnostic (and
therapeutic) threshold in acutely ill patients, as well as in patients with
predisposing factors. . . . We recommend a short corticotropin test (250 µg)
as the “gold standard” diagnostic tool to establish the diagnosis. . . .
Diagnosis of the underlying cause should include a validated assay of
antibodies against 21-hydroxylase. . . . In children, hydrocortisone (~8mg/
m2/d) is recommended. (See Resources and Tools section for PDF.)
7. Moloney S, Dowling M. Early intervention and management of adrenal
insufficiency in children. Nurse Child Young People. 2012;24(7):25-28.
The endocrine disorder adrenal insufficiency includes inadequate production
of the steroid hormone cortisol. This results in poor physiological responses
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42
to illness, trauma or other stressors and risk of adrenal crisis. Management is
based on administration of hydrocortisone. . . . A steroid therapy card for
adrenal insufficiency containing personal information on a patient’s condition
was developed for use by families and their specialist centres.
8. Malikova J, Flück CE. Novel insight into etiology, diagnosis, and
management of primal adrenal insufficiency. Horm Res Paediatr.
2014;82:142-157.
Primary adrenal insufficiency (PAI) is a rare condition in childhood which is
either inherited (mostly) or acquired. . . . The most common form in children
is 21-hydroxylase deficiency, which belongs to the steroid biosynthetic
defects causing PAI. . . . Other forms of PAI include metabolic disorders,
autoimmune disorders and adrenal dysgenesis, e.g. the IMAGe syndrome, for
which the underlying genetic defect has been recently identified. Newer work
has also expanded the genetic causes underlying isolated, familial
glucocorticoid deficiency (FGD).
9. Perry R, Kecha O, Paquette J, et al. Primary adrenal insufficiency in
children: Twenty years experience at the Sainte-Justine Hospital,
Montreal. J Clin Endocrinol Metab. 2005;90:3243-3250.
Primary adrenal insufficiency (PAI) in the pediatric population (0-18 yr.) is
most commonly attributed to congenital adrenal hyperplasia (CAH), which
occurs in about 1 in 15,000 births, followed by Addison’s disease, with an
assumed autoimmune etiology. . . . All patients with a diagnosis of PAI
followed by the Endocrinology Service at our institution between September
1981 and September 2001 were studied. One hundred three patients (48
boys) were identified, primarily by the Endocrinology Clinic case registry.
CAH was the most frequent etiology (71.8 percent. However, non-CAH
etiologies accounted for 28.2 percent, of which 55 percent were non-
autoimmune in etiology.
10. Michels A, Michels N. Addison disease: Early detection and treatment
principles. Am Fam Physician. 2014;89(7):563-568.
Primary adrenal insufficiency, or Addison disease, has many causes, the most
common of which is autoimmune adrenalitis. Autoimmune adrenalitis results
from destruction of the adrenal cortex . . . . The clinical manifestations before
an adrenal crisis are subtle and can include hyperpigmentation, fatigue,
anorexia, orthostasis, nausea, muscle and joint pain, and salt craving. . . .
During times of stress (e.g., illness, invasive surgical procedures), stress-
dose glucocorticoids are required because destruction of the adrenal glands
prevents an adequate physiologic response.
11. Øksnes M, Ross R, Løvås K. Optimal glucocorticoid replacement in
adrenal insufficiency. Best Pract Res Clin Endocrinol Metab. 2015;29:3-15.
Adrenal insufficiency (glucocorticoid deficiency) comprises a group of rare
diseases, including primary adrenal insufficiency, secondary adrenal
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43
insufficiency and congenital adrenal hyperplasia. . . . Over the past decade,
systematic cohort and registry studies have described reduced health-related
quality of life, an unfavourable metabolic profile and increased mortality in
patients with adrenal insufficiency, which may relate to unphysiological
glucocorticoid replacement. . . . Here, evidence for the inadequacy of
conventional glucocorticoid therapy and recent developments in treatment
are reviewed, with an emphasis on primary adrenal insufficiency.
12. Webb EA, Krone N. Current and novel approaches to children and
young people with congenital adrenal hyperplasia and adrenal
insufficiency. Best Pract Res Clin Endocrinol Metab. 2015;29:449-468.
Congenital adrenal hyperplasia (CAH) represents a group of autosomal
recessive conditions . . . . CAH is the most common cause of adrenal
insufficiency (AI) in the pediatric population. The majority of the other forms
of primary and secondary adrenal insufficiency are rare conditions. Following
the introduction of life-saving glucocorticoid replacement 60 years ago,
steroid hormone replacement regimes have been refined leading to
significant reductions in glucocorticoid doses over the last 2 decades. . . .
However, despite optimization of existing glucocorticoid replacement
regimens fail to mimic the physiologic circadian rhythm of glucocorticoid
secretion, current efforts therefore focus on optimizing replacement
strategies. In addition, in recent years novel experimental therapies have
been developed which target adrenal sex steroid synthesis in patients with
CAH (congenital adrenal hyperplasia) aiming to reduce co-morbidities
associated with sex steroid excess.
13. Merke DP, Poppas DP. Management of adolescents with congenital
adrenal hyperplasia. Lancet Diabetes Endocrinol. 2013;1(4):341-352.
The management of congenital adrenal hyperplasia (CAH) involves
suppression of adrenal androgen production, in addition to treatment of
adrenal insufficiency. Management of adolescents with CAH is especially
challenging because changes in the hormonal milieu during puberty can lead
to inadequate suppression of adrenal androgens, psychosocial issues often
affect adherence to medical therapy, and sexual function plays a major part
in adolescence and young adulthood. . . . Extensive patient education is key
during transition from pediatric care to adult care and should include
education of females with classic CAH regarding their genital anatomy and
surgical history. . . . Education of health-care providers on how to
successfully transition patients is greatly needed.
14. Zöllner EW, Lombard CJ, Galal U, et al. Hypothalamic-pituitary-adrenal
axis suppression in asthmatic school children. Pediatrics.
2012;130(6):e1512-e1519.
Hypothalamic-pituitary-adrenal axis suppression (HPAS) when treating
children with corticosteroids is thought to be rare. Our objective was to
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44
determine the prevalence of and predictive factors for various degrees of
HPAS. Clinical feature of HPAS, doses, adherence, asthma score, and lung
functions were recorded in 143 asthmatic children. . . . Two-thirds of children
on corticosteroids may have hypothalamic-pituitary-adrenal axis dysfunction.
In one-third, central function had recovered but adrenal suppression
persisted. Predictive factors for HPAS are nasal steroid (NS) use, BMI, and
adherence to inhaled corticosteroid (ICS) and NS.
15. de Lind van Wijngaarden RF, Otten, BJ, Festen DA, et al. High prevalence
of central adrenal insufficiency in patients with Prader-Willi
syndrome. J Clin Endocrinol Metab. 2008;93(5):1649-1654.
The annual death rate of Prader-Willi syndrome (PWS) patients is very high
(3 percent). Many of these deaths are sudden and unexplained. Because
most deaths occur during moderate infections and PWS patients suffer from
various hypothalamic insufficiencies, we investigated whether PWS patients
suffer from central adrenal insufficiency (CAI) during stressful conditions.
Overnight single-dose metyrapone tests were performed. . . . Morning
salivary cortisol levels and diurnal profiles were normal in all children,
suggesting that CAI becomes apparent only during stressful conditions.
Strikingly, 60 percent of our PWS patients had CAI.
16. Corrias A, Grugni G, Crino A, et al. Assessment of central adrenal
insufficiency in children and adolescents with Prader-Willi syndrome.
Clin Endocrinol. 2012;76:843-850.
A recent study evidenced by metyrapone test a central adrenal insufficiency
(CAI) in 60 percent of Prader-Willi syndrome (PWS) children. . . . We
extended the research by Low-Dose Tetracosactrin Stimulation Test (LDTST)
in pediatric patients with PWS. . . . Responses were correlated with the
patients’ clinical and molecular characteristics to assess genotype-phenotype
correlation. . . . Our results support the hypothesis that, albeit rare, CAI may
be part of the PWS in childhood.
Resources and Tools
Adrenal Insufficiency: A Condition with Many Causes
ü National Institute of Diabetes and Digestive and Kidney Diseases
(NIDDK): Adrenal Insufficiency and Addison’s Disease Fact Sheet 3
• Basic drawing of Hypothalamic-Pituitary-Adrenal Axis
• Broad summary under “Points to Remember”
ü National Adrenal Diseases Foundation (NADF) Website (Includes the
following resources.)
• Potentially Life-Preserving Information Packet for Adrenal
Insufficient Patients (downloadable from home page)
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45
• Articles Tab
Ø Hydration “Salt Wasters” And Dehydration
• Tools for Life Tab (numerous PDFs; 4 research articles)
Ø Adrenal Crisis Alert Poster
• Links & Resources Tab
Ø Kids Pen-Pal Network
ü Endocrine Society website: Membership primarily includes doctors,
scientists, researchers, and educators.
Primary Adrenal Insufficiency: Adrenal Glands Damaged
ü National Adrenal Diseases Foundation (NADF) Website (Includes the
following resources.)
• Potentially Life-Preserving Information Packet for Adrenal
Insufficient Patients (including Addison’s disease)
• Diagnosis and Treatment of Primary Adrenal Insufficiency: An
Endocrine Society Clinical Practice Guideline (#6 in Research
section)
• Adrenal Diseases Tab
Ø Addison’s Disease: The Facts You Need To Know
(downloadable fact sheet)
Secondary Adrenal Insufficiency: Commonly Pituitary Gland Failure
ü National Adrenal Diseases Foundation (NADF) Website (Includes the
following resources.)
• Adrenal Diseases Tab
Ø Secondary Adrenal Insufficiency: The Facts You Need To
Know (downloadable fact sheet)
Ø Congenital Adrenal Hyperplasia (CAH): The Facts You Need
To Know (downloadable fact sheet)
• Potentially Life-Preserving Information Packet for Congenital
Adrenal Hyperplasia (CAH) Patients
ü Texas Department of State Health Services (DSHS): Congenital
Adrenal Hyperplasia, A Handbook for Parents
ü CARES Foundation—Supporting the Congenital Adrenal Hyperplasia
(CAH) community: Website
• Glossary of Terms Related to CAH
• How to Talk About Your Child’s CAH
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46
Medication
ü MedlinePlus: Hydrocortisone Injection 2
ü Nevada (Clark County): Administration of Solu-Cortef® Policy &
Procedure (The following links are included within.)
• Pediatric Endocrinology Nursing Society (PENS): Cortisol
Dependent School Instructions / Solu-Cortef® Injection
Handout/ Adrenocorticoid Medication instructions
• University of Texas, MD Anderson Cancer Center: Act-O-Vial®
Instructions (search in Patient Education)
• Plano Independent School District Adrenal Crisis Action Plan
(2013)
ü Oregon Department of Education: Medication Administration in Oregon
Schools—A Manual for School Personnel
References
For assistance in obtaining any resources, please contact the DSHS Library
at [email protected] and mention inclusion of the requested resource
in the School Nurse Notes.
1. Hydrocortisone Sodium Succinate Injection. Facts and Comparisons
[database online]. Hudson, OH: Wolters Kluwer Clinical Drug
Information. Updated November 2016. Accessed December 9, 2016.
2. U.S. National Library of Medicine. Hydrocortisone Injection:
https://medlineplus.gov/druginfo/meds/a682871.html. Updated May 15,
2016. Accessed December 9, 2016.
3. National Institute of Diabetes and Digestive and Kidney Diseases
(NIDDK). Adrenal insufficiency and Addison’s disease:
https://www.niddk.nih.gov/health-information/health-
topics/endocrine/adrenal-insufficiency-addisons-disease/Pages/fact-
sheet.aspx. Updated May 2014. Accessed December 12, 2016.
External links to other sites appearing here are intended to be informational and do not represent
an endorsement by the DSHS. These sites may also not be accessible to people with disabilities.
External email links are provided to you as a courtesy. Please be advised that you are not
emailing the DSHS and DSHS policies do not apply should you choose to correspond. For
information about any of the initiatives listed, contact the sponsoring organization directly.
Copyright free. Permission granted to forward or make copies in its entirety as needed.
Page 8|8
47
School Nurse Notes | December 2016
Use of Intranasal Midazolam for Seizures
To address the needs of school nurses, the Texas Department of State Health Services
(DSHS) – School Health Program has developed this repository of information. With each
issue of School Nurse Notes, DSHS brings you the latest research, evidence-based practices,
and resources in school nursing related to a topic of interest. If you have any questions or
comments about this publication, please contact Anita Wheeler, School Nurse Consultant, at
(512) 776-2909 or at [email protected].
Background
There has been an increase in the number of children who come to school
with physician’s orders to administer intranasal midazolam for the
emergency treatment of seizures. While the medication has been utilized as
an off-label medication for this purpose, the school nurse is bound by the
Nurse Practice Act to promote the safety of the student, as well as to know
the rationale and effects of medications and be able to administer them
correctly.
In order to assist the school nurse in promoting safety and gaining the
information necessary to utilize nursing judgment in determining if it is safe
to administer this medication in the school setting, the following information
may be helpful.
The Medication
Midazolam (MID aye zoe lam) is classified as a benzodiazepine drug. 1 It is
supplied as a solution for injection or as a syrup for oral use. It is used as a
sedative/anesthesia in preoperative settings and known as Versed. However,
midazolam is also prescribed for off-label use in the treatment of status
epilepticus (SE) and may be supplied via the intranasal route. 2, 3
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Why the Medication May be Prescribed
• A prolonged seizure is harder to stop than a brief seizure. 4 The
majority of seizures remit spontaneously. Status Epilepticus (SE) is
defined as a tonic-clonic (convulsive) seizure that lasts for more than
five minutes; a prolonged non-convulsive seizure; or multiple seizures
that occur without recovery to baseline between events. 5
• The longer the seizure, the longer the recovery period for patients.
• Rescue medications can prevent seizure progression to SE,
transportation to an emergency department, and the associated costs
of escalated treatment. 4
• Seizure emergencies, such as SE or changes in typical seizure clusters
or frequency, are rare but can be life threatening. 7
Research
The following articles have been compiled from a review of the scientific
literature. For assistance in obtaining an article, please contact the DSHS
Library at [email protected] and mention inclusion of the requested
article in the School Nurse Notes. The articles are presented on a continuum,
ranging from those providing basic seizure information to those specifically
addressing the use of intranasal midazolam for SE. Following each citation is
a portion of the article’s abstract.
1. Terry D, Patel AD, Cohen DM, Scherzer D, Kline J. Barriers to seizure
management in schools: perceptions of school nurses. J Child Neurol.
2016:1-5.
Eighty-three school nurses completed an electronic survey. . . . School
nurses are comfortable managing seizures in a school setting. However, a
specific seizure plan for each child and education on intranasal midazolam
and vagus nerve stimulator magnet use are needed.
2. Wolfe TR, Braude DA. Intranasal medication delivery for children: A
brief review and update. Pediatrics. 2010;126:532-537.
Intranasal medication delivery offers an alternative method of drug delivery
that is often as fast in onset as intravenous medication, usually painless,
inexpensive, easy to deliver, and effective in a variety of pediatric medical
conditions. This article briefly reviews the most common uses for intranasal
medication delivery in pediatrics: pain control, anxiolysis, and seizure
control.
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3. Grover EH, Nazzal Y, Hirsch LJ. Treatment of convulsive status
epilepticus. Curr Treat Options Neurol. 2016;18:11.
Convulsive status epilepticus (CSE) is a medical emergency with an
associated high mortality and morbidity. . . . Current guidelines recommend
the use of benzodiazepines (BNZ) as first-line treatment in CSE. . . . Regular
use of home rescue medications such as nasal/buccal midazolam by patients
and caregivers for prolonged seizures and seizure clusters may prevent SE,
prevent emergency room visits, improve quality of life, and lower health care
costs.
4. Dumeier HK, Neininger MP, Bernhard MK, et al. Knowledge and attitudes
of school teachers, preschool teachers and students in teacher
training about epilepsy and emergency management of seizures. Arch
Dis Child. 2015;100:851-855.
Results: 1,243 questionnaires were completed by 302 school teachers, 883
preschool teachers, 56 students and 2 unclassified participants. . . . Only 214
(17 percent) of respondents felt sufficiently prepared for an emergency. . . .
only 186 respondents (15 percent) stated they would be willing to administer
a prescribed rescue medication under any circumstances.
5. Abend NS, Loddenkemper T. Pediatric status epilepticus management.
Curr Opin Pediatr. 2014;26(6):668-674.
This review discusses management of status epilepticus (SE) in children
involving both anticonvulsant medications and overall management
approaches. . . . An example management pathway is provided. . . . SE is a
common neurologic emergency in children and requires rapid intervention.
Having a predetermined SE management pathway can expedite
management.
6. Arzimanoglou A, Lagae L, Cross JH, et al. The administration of rescue
medication to children with prolonged acute convulsive seizures in a
non-hospital setting: an exploratory survey of healthcare
professionals’ perspectives. Eur J Pediatr. 2014;173:773-779.
We present the findings from an exploratory telephone survey of 128
healthcare professionals (HCPs) (85 pediatric neurologists and neurologists,
28 community pediatricians, and 15 epilepsy nurses) from 6 EU countries,
conducted as part of the PERFECT™ initiative. . . . Results of this HCP survey
have identified several gaps that need to be addressed: clearer guidance that
spans all settings of care, greater dissemination of such guidelines across the
chain of care, more open communication and better links between HCPs and
schools, and systematic training of all relevant caregivers on the appropriate
management of prolonged convulsive seizures.
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2017 School Nurse Conference booklet
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