Vaccine 32 (2014) 4500–4504
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Frequency and erroneous usage of temporary medical exemptions and knowledge of immunization guidelines among some Miami-Dade County Florida providers Alazandria R. Cruze ∗ , Guoyan Zhang, Lakisha Thomas, Jorge Alonso, Lydia Sandoval Florida Department of Health in Miami-Dade County, Epidemiology, Disease Control and Immunization Services, Florida Department of Health in Miami-Dade County, 8600 NW 17th St. Suite 200, Miami, FL 33126, USA
a r t i c l e
i n f o
Article history: Received 22 May 2013 Received in revised form 12 May 2014 Accepted 11 June 2014 Available online 21 June 2014 Keywords: School immunizations Knowledge Practice Temporary medical exemptions School health Pediatricians
a b s t r a c t Objective: We assessed knowledge and practices regarding immunization guidelines and the Florida Certificate of Immunization (DH-680) based on FL-DOH and CDC recommendations, to identify the cause of the increasing number of erroneously issued temporary medical exemptions (TME) among selected health care providers in Miami-Dade County Florida. Methodology: After reviewing immunization certificates from all public schools, a list of physicians who improperly issued 3 or more TMEs, defined as one given to a child who was up to date for their kindergarten and seventh grade requirements, was compiled. The DOH-Miami-Dade developed educational materials and questionnaires, and conducted face-to-face interviews and interventions during site visits to these providers (n = 134). Data was analyzed using SAS 9.2. Results: Of the 104 questionnaires completed, 4 (3.85%) had correct answers to all 10 vaccine knowledge and practice related questions, while 10 (9.62%) had 7 or more incorrect answers. Frequently missed questions included: the required doses of varicella vaccine for seventh grade students entering the 2011–12 school year (86, 82.7%) and the proper scenario for issuing a TME (57, 54.8%). Conclusions: In order to eliminate the improper use of TMEs, long-term efforts are needed to provide immunization-related educational materials and trainings to the medical community regarding vaccinations. These findings also suggest a need for enhanced explanation in multiple languages on the current Florida Immunization Certificate. Due to enhanced surveillance and education, the number of TMEs for kindergarten and seventh grade students was reduced by 12% and 4.9%, respectively, during the 2011 and 2012 school year. © 2014 Elsevier Ltd. All rights reserved.
What’s Known on This Subject Immunization and vaccine practice is well researched and documented for providers nationwide. The evaluation of providers’ knowledge and use of temporary medical exemptions both statewide and nationally is limited. What This Study Adds This study evaluates and reports selected provider knowledge and practices of immunization guidelines and their use of
Abbreviations: ACIP, Advisory Committee on Immunization Practices; CDC, Centers for Disease Control and Prevention; EDC-IS, Epidemiology, Disease Control and Immunization Services; DOH-Miami-Dade, Florida Department of Health in Miami Dade County, DOH-Florida Department of Health; FL-SHOTS, Florida State Health Online Tracking System; MDCPS, Miami Dade County Public School; TME, temporary medical exemption; VPD, vaccine preventable disease. ∗ Corresponding author. Tel.: +1 786 336 1254; fax: +1 305 470 5533. E-mail address: Alazandria [email protected].fl.us (A.R. Cruze). http://dx.doi.org/10.1016/j.vaccine.2014.06.041 0264-410X/© 2014 Elsevier Ltd. All rights reserved.
temporary medical exemptions for kindergarten and seventh grade students.
1. Introduction Widespread use of vaccines has led to a dramatic increase in life expectancy and a significant decline in the incidence of vaccinepreventable diseases (VPDs) [1,2]. Immunizations are one of the most cost effective and beneficial disease prevention measures available [3]. In the United States, rates have dramatically decreased for VPDs such as measles and pertussis [4]. These achievements are attributable to: strong vaccine research and development, implementation of national guidelines for vaccine use, establishment of federal programs that support state and local immunization efforts, increased immunization education among health care providers and parents, decline in barriers to vaccination (including financial), and increase in school immunization laws [5].
A.R. Cruze et al. / Vaccine 32 (2014) 4500–4504
School immunization laws requiring students to be immunized with specific vaccines before entering school have contributed to a 98–100% reduction in the incidence of most VPDs [5]. Documentation of vaccination is required in all states for school entry. In addition, some state laws require immunizations for licensed child care and college entrance [6–8]. All states allow exemptions for medical reasons and currently, 48 states grant religious exemptions and 20 allow philosophical exemptions [9]. In Florida, three types of exemptions are allowed on the Certificate of Immunization DH-680; religious exemptions provided solely by the department of health, medical exemptions, and temporary medical exemptions (TME). TMEs, identified as Part B on the DH-680 [S1] are designed to allow entrance into school (k-12), pre-school and child care, for children in the process of completing required immunizations. To be valid, a TME must have an expiration date that relates to the date the next required immunization is due based on the current school year immunization requirements. A child must return to their health care provider before this date or the exemption is no longer valid and the child must be removed from school until receiving the required immunizations [10]. However, TMEs may be incorrectly issued by some health care providers and school registrars may not be properly trained to identify this type of error. Miami-Dade is the largest county in Florida with a population of 2.5 million, of which 15.4% is White non-Hispanic, 18.9% is Black non-Hispanic and 65.1% is Hispanic. Due to the high volume of immigration, Miami-Dade County has the highest percentage (50.9%) of foreign-born residents among United States counties. In 2009, there was an international net immigration of approximately 42,000 individuals into the county [11]. With such a high number of immigrants, physicians and medical staff are required to create catch-up schedules for children entering school. A catch-up schedule is designed for children and adolescents who have fallen behind on their shots by either missing a dose or starting late. Additionally, catch up schedules help ensure adequate coverage is reached [12]. Children following catch up schedules may be issued a TME to allow entrance into school despite not having met all the school vaccination requirements. There are approximately 350,000 students enrolled in Miami-Dade County Public Schools (MDCPS). MDCPS is the fourth largest school district in the United States with 392 public schools. Approximately, 582 pediatricians and 319 family doctors currently provide care for school-aged children in MiamiDade County [13]. During the past 3 years, MDCPS has experienced an increase in TMEs from 8.4% during the 2007–08 school year to 21.9% in 2010–11 among kindergarten children, and maintained a high percentage (approximately 15%) of TMEs among seventh grade students for the same time period [10]. The Florida Department of Health in Miami-Dade County (DOH-Miami-Dade) launched an investigation to determine if students were properly vaccinated. Few studies focus on the proper use of exemption status guidelines by health-care providers. In addition, there is limited research on the follow-up for children who are not completely immunized, or what the school board’s role is in ensuring children have complete and up-to-date shot records. To our knowledge, this is the first study reporting on selected health care provider’s knowledge regarding TMEs and evaluating their utilization.
2. Methods In September 2011, an investigation was initiated by the DOHMiami-Dade regarding the number of erroneously issued TMEs. The investigation involved several components including multiple interventions, healthcare provider selection for questionnaire dissemination and interviews, survey creation and data analysis.
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2.1. Interventions Interventions by the DOH-Miami-Dade included: reviewing DH-680s from public schools, sending a letter to all health care providers and public school registrars notifying them that the DOH-Miami-Dade was initiating an investigation to identify the cause of the high number of TMEs, contacting the MDCPS school health program and registrars to set up meetings to learn about their immunization databases, creating a simplified immunization guidelines document, creation of a one page document on the “do’s and don’ts” of filling out the DH-680, creating and disseminating a questionnaire that included questions regarding knowledge of immunization requirements and practices of the DH-680, and conducting interviews at clinics to speak about concerns, question and trainings providers have regarding the DH-680, FL-SHOTS or other immunization topics. 2.2. Intervention team The intervention team included 10 members: 8 epidemiologists and 2 computer analysts. Four of the 10 members spoke both English and Spanish. The Epidemiology, Disease Control, and Immunization Services (EDC-IS) intervention team was specifically trained by DOH-Miami-Dade immunization program specialists in the areas of immunization knowledge and practice before beginning the survey process. Responsibilities included conducting site visits, disseminating questionnaires, providing education, distributing educational materials, and conducting interviews. 2.3. Health care provider selection Nurses from the DOH-Miami-Dade immunization and school health programs reviewed DH-680 certificates with TMEs from all public schools in Miami-Dade County. From the review, a list of providers was compiled containing the names and locations of providers incorrectly issuing TMEs for kindergarten and seventh grade students. An improperly issued TME was defined as one that was given when the child was up to date with their vaccinations for their age and grade level. In total, 300 clinics were identified as improperly issuing TMEs, of which clinics with a minimum of 3 improperly issued TMEs (134, 44.7%) were chosen for targeted intervention. After contacting the selected 134 clinics, 51 (38.1%) of the 134 sites agreed to be visited by the intervention team. The 51 clinics were comprised of mainly pediatric practices and varied by size of practice and location within the County. 2.4. Survey creation, content and procedures A self-administered questionnaire was designed that did not require any identifying information. The questionnaire was reviewed and pilot-tested by the DOH-Miami-Dade immunization program staff to ensure clarity of the text and refine wording of vaccine-related questions. The questionnaire included 28 questions with three sections. Part 1 addressed provider/clinic specific questions including general information about the clinic setting, the primary person administering the vaccines, who is responsible for completing the DH-680s either in hard copy or through the Florida State Health Online Tracking System (FL-SHOTS), utilization of reminder/recall methods and sources used for vaccine related updates and information. Part 2 encompassed vaccine specific questions, including knowledge of the required vaccines, vaccination schedules for school-aged children and vaccination requirements for the 2011–12 school year. Part 3 assessed specific situations and practices regarding the DH-680 and Florida SHOTS. The primary individuals responsible for administering immunizations and completing the DH-680 were asked to complete the
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Table 1 Proportion of providers responsible for filling out the DH-680. Providers
Proportion of providers
Medical assistants LPN/RN and medical assistants Physicians or medical assistants Other Medical assistants and other
55.9 15.4 11.5 10.8 5.9
questionnaire. Questionnaires were completed within 20 min during the visit with the team. 2.5. Interviews Interviews were conducted among individuals that completed questionnaires and ranged from 10 to 30 min. Topics included utilization of FL-SHOTS, concerns regarding the DH-680 and immunization guidelines, and use of an immunization reminder/recall system within their practice. 2.6. Data analysis Data was analyzed using frequency and Chi-Square tests to describe the percentage of respondents and to test association among categorical variables. P-values were considered significant when less than 0.05. Data analyses were conducted using SAS version 9.2 (SAS Inc., Cary, NC). 3. Results Questionnaires were given to 104 participants who were defined as the primary person to administer vaccines and/or fill out the immunization certificate at the 51 clinic sites throughout Miami-Dade County. Of the 104 participants, 91 (87.5%) described themselves as working in private practice. Additionally, 86 (82.7%) of the 104 participants focused on pediatric medicine, 10 (9.62%) focused on pediatric/family/internal medicine, 6 (5.76%) in family medicine alone and 2 (1.92%) responded other. Forty-two (40.8%) participants described their practice as having four or more physicians and 87 (83.7%) reported seeing more than 75 children weekly. 3.1. Years experience working with childhood immunizations Among respondents, 41 (39.4%) have been working with childhood immunizations for 11 years or more, 39 (37.5%) reported working in childhood immunizations for 4–10 years and 24 (23.1%) had worked in childhood immunizations for less than 4 years. 3.2. Primary person to administer vaccines and/or fill out the DH-680 Multiple individuals were responsible for completing the DH680 and/or administering vaccines among clinic sites and some individuals may have been captured by more than one category. Medical assistants alone (60, 59.4%) were listed as the primary person to administer vaccines, followed by medical assistants or physicians (14, 13.9%), LPN/RN or medical assistant (13, 12.5%), as well as physician alone (10, 9.9%). Medical assistants (57, 55.9%) alone were primarily responsible for completing the DH-680 either through hard copy or in Florida SHOTS. Other individuals responsible for completing the DH-680 included 16 (15.4%) LPN/RN or medical assistants, 12 (11.5%) physicians or medical assistants, 11 (10.8%) other and 6 (5.9%) medical assistants or other (i.e. clerks) (Table 1).
3.3. Vaccine related knowledge and practice Of the 104 questionnaires collected, 4 (3.85%) participants answered all 10 vaccine knowledge and practice related questions properly, while 10 (9.62%) participants failed to answer more than 3 questions correctly. The most frequently missed questions were regarding the required doses of varicella vaccine for seventh grade students entering the 2011–12 school year (86, 82.7%), the minimum number of doses required for the DTaP series (76, 73.1%) and the proper scenario for issuing a TME (57, 54.8%). Forty-five (43.3%) participants were unclear when to issue a TME for kindergarten students. There was no association found between years of experience working in childhood immunizations and the number of questions answered correctly. The majority of respondents, regardless of years worked (≤6 years or >6 years) answered between 5 and 7 questions correctly (48.3% and 51.7%) (Table 2). Additionally, 96 (91.4%) participants reported routinely screening immunization records at visits other than scheduled childhood immunization appointments, and 12 (11.7%) respondents reported not using any type of reminder recall methods to bring children back for scheduled immunization appointments. However, through interview, half of participants stated they marked Part B TME to have an expiration date on the certificate as a reminder for children to return for their next scheduled appointment. Most of the 104 participants (98, 94.2%) had responded on the questionnaire that they had accessed a copy of the immunization guidelines from the Florida Department of Health (DOH) or local health department. Amendments to DH-680s that included removing erroneously issued TMEs and correctly classifying those children as fully immunized (complete), as well as working with the Bureau of Immunizations to make changes to FL-SHOTS, may have contributed to the reduction in the percentage of MDCPS students in kindergarten with a TME to 9.90% for the 2011–12 school year from 21.9% in 2010–11. The percent of seventh grade students with improperly issued TMEs was reduced as well from 14.8% in 2010–11 to 9.90% for 2011–12. For the 2012–13 school year, the TME rate among kindergarten students and seventh grade students fell to 6.70% from the 2011–12 percentages of 9.90%.
4. Discussion Immunization guidelines change frequently as new research findings are published. Changes to state laws or regulations governing school entry vaccination requirements can affect provider knowledge [8]. Health care providers must be familiar with updated recommendations in order to offer the most comprehensive care to their clients. When dealing with under-immunized children, health care providers may have difficulty adhering to complex immunization schedules [14]. The most frequently missed question on the survey was regarding the number of required doses of varicella vaccine for seventh grade students entering the 2011–12 school year. The Advisory Committee on Immunization Practices (ACIP) and CDC made recommendations in 2007 regarding a second dose of varicella vaccine [15], which Florida adopted as incremental approach to ensure all children receive the recommended two doses. Each year in Florida beginning in 2008, an additional grade level requires two doses until school year 2020–21, at which time all students will require two doses [10]. Other states may have adopted this system as well. Many health care providers may have been unclear as to the actual number of required doses for different grade levels. This confusion may have led some providers to improperly issue TMEs. In Florida, for the 2011–12 school year, kindergarten through third grade students required 2 doses of varicella
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Table 2 Vaccine related survey questions and percent of respondents who answered correctly. Question
Percent answered correctly
1. What are the proper age intervals for children receiving the Hepatitis B vaccine? 2. True or false. If the first dose of Hepatitis B vaccine was given to a child more than one year ago, and no subsequent doses were given, you should repeat the first dose. 3. Which combination of vaccines is required for children entering kindergarten? 4. What is the minimum number of doses needed to complete a DTaP series for children? 5. Of the following scenarios, which requires a temporary medical exemption? 6. What is the proper time frame when issuing an expiration date for a temporary medical exemption? 7. Which of the following vaccines may be issued a temporary medical exemption for a child entering kindergarten if a dose is missing? 8. Which of the following childhood vaccine series would qualify a child to have an immunization complete status (part A) for kindergarten? 9. True or false. A temporary medical exemption should be issued for a child entering kindergarten that has all of the required shots but is missing the second dose of MMR? 10. If a child is entering the 7th grade during the 2011–12-school year and has never had the chickenpox, how many doses of varicella are required for the child to be compliant with school vaccines?
84 (80.8%) 73 (70.2%)
vaccine, while grades 4–10 required one [10]. Additionally, during the interview, many health care providers stated that some schools required two doses of varicella for all children, even though a second dose was not necessary for all grade levels. This may also contribute to the unnecessary issuance of TMEs. The complexity of ever changing immunization requirements and schedules may make it increasingly difficult to accurately identify a child’s completion or exemption status. All health care providers, schools and parents must collaborate regarding the current vaccination requirements in order to maintain high coverage among students [16]. Some providers were issuing TMEs for children to return for a fifth dose of DTaP when it was not necessary; for example, when a child received the fourth dose of DTaP on or after their fourth birthday [10]. Despite participants expressing no confusion with the wording of the Part B TME section on the DH-680, over half of providers were unable to clearly identify the proper scenario for issuing a TME. Such a high percentage demonstrates confusion among respondents as to what qualifies a child as “in compliance” and “not in compliance.” Additionally, multiple providers are utilizing the TME as a recall system for children in compliance to return for immunizations not yet needed. Despite provider reminder/recall systems being efficient tools available to help increase childhood immunization rates that are both relatively inexpensive and simple to implement [17], utilizing a TME as a recall system is not efficient and falsely increases the number of under-vaccinated children. Most parents, physicians and schools do not evaluate a child’s DH-680 on a regular basis and therefore TMEs issued as a reminder will not be an efficient method. Additionally, effective reminder/recall systems consist of phone calls, emails, and/or notices disseminated to parents or physician’s office that notify them of upcoming immunizations. Since FL-SHOTS does not contain a reminder/recall feature, the system is unable to send out notices to physicians or parents. A study by Gaudino et al. indicated that self-reports of immunization practices may not accurately reflect actual clinic practices, and suggested the discrepancy may be caused by the desire to mirror best practices [18]. Additionally, physicians may not be fully aware of all office practices taking place in larger clinic settings where nurses and medical assistants are predominately responsible for vaccine administration and completing immunization certificates. The complexity of the vaccine schedule creates a difficult task for the clinician faced with catch-up regimens, particularly when children are delinquent in multiple vaccines. Some physicians may be less familiar with immunization recommendations for older children’s catch-up schedules because of greater divergence from the standard schedule of administration and the complex recommendations [14,19]. Healthcare professionals in Miami-Dade County and throughout the country will continue to face the
92 (88.5%) 28 (26.9%) 47 (45.2%) 68 (65.4%) 59 (56.7%) 98 (94.23%) 66 (63.5%) 18 (17.3%)
challenging task of following a catch-up schedule for those children who recently immigrated to the US as well as for children who have started late for reasons other than immigration such as illness, parental and religious beliefs. Furthermore, a language barrier was identified among health care providers and clinic staff during the survey and interview. This may be due to the fact that 68% of the Miami-Dade County population speaks a language other than English in their homes. 5. Conclusion A TME should be completed only for children not fully immunized for their current school grade, based on the proper spacing of vaccines. The improper issuance of TMEs negatively affects the overall compliance rates when assessing each county’s coverage for school immunizations. The significant reduction in the number of students enrolled in school with TMEs after review of DH-680s, clearly identifies the need for clarification and education among providers regarding immunization requirements, especially regarding guidelines for issuing exemptions. For the 2012–13 school year, Miami-Dade reported TME rates of 6.70% among both kindergarten and seventh grade students, which reflect a further decrease in TME rates from the 2011–12 school year. The rate of erroneous TMEs decreased for two consecutive school years following a multi-faceted intervention by the DOH-Miami-Dade. 5.1. Limitations The findings within this report are subject to five limitations. First, the DOH-Miami-Dade released an alert letter followed by a simplified immunization chart for the 2011–12 school year to local health care providers prior to survey administration. This may have led some survey participants to answer questions in accordance with the regulations in the documents instead of true clinic practices. Second, the survey was only administered in English even in areas where Spanish is the primary language. Translators were used to conduct the survey in instances where the participant did not feel comfortable or was unable to read English. The third limitation encountered was the time frame between contacting the clinic to set up a visit and the date the clinic allowed the intervention team to come administer the survey. This may have allowed participating clinics time to review vaccine schedules and rules regarding issuing TMEs. The fourth limitation identified was respondents were not asked about their profession on the questionnaire. The only question regarding profession was the length of time the individual had spent working with childhood immunizations. Lastly, the fifth limitation was that the 51 participating clinic sites out of the 134 contacted, may have felt more knowledgeable and comfortable in their immunization practices than clinics that did not allow the
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intervention team to administer the survey. The difference among participating clinics and non-participating clinics was not evaluated in this study.
practices and guidelines, assisted in reviewing the manuscript, and approved the final manuscript as submitted. Acknowledgement
5.2. Recommendations Long-term efforts will be needed to address the varying reasons contributing to the misuse of TMEs. The following actions may help significantly reduce improper use of TMEs in Florida: update the simplified guideline of immunization requirements to include English, Spanish and Creole versions and distribute to health care providers and public schools annually; improve the DOH-MiamiDade immunization related educational materials, such as video trainings and webinars on the DOH-Miami-Dade website and provide trainings regarding the DH-680 and immunization requirements for the current school year to providers as well as school nurses and registrars by experienced health department immunization staff; modify and improve FL-SHOTS auto-quality control function to prevent health care provider misuse of TMEs by not allowing physicians or nurses to issue a TME to a child who does not meet the criteria; and to establish a partnership between the DOH-Miami-Dade and MDCPS to collaborate to further increase the rates of appropriately vaccinated children. Identifying all parties that have a vital role in childhood immunizations is an important factor in ensuring an adequate response is made during an investigation or when identifying a breakdown in childhood immunizations. Issues with vaccination rates and coverage are complex and require a collaborative effort from multiple organizations to fix the underlying problems. Funding support No external funding was secured for this study. Financial disclosure The authors have no financial relationship relevant to this article to disclose. Conflict of interest The authors of this study have no conflicts of interest to disclose. Contributors statement Alazandria R. Cruze: Ms. Cruze designed the data collection instruments, coordinated and supervised data collection, conducted extensive literature reviews, drafted the initial manuscript, responsible for reviewing and revising the manuscript, and approved the final manuscript as submitted. Guoyan Zhang: Dr. Zhang carried out data analysis, contributed to the writing of the methods and results, reviewed and revised the manuscript, and approved the final manuscript as submitted. Lakisha Thomas: Ms. Thomas designed the data collection instruments, coordinated and supervised data collection, critically reviewed the manuscript, and approved the final manuscript as submitted. Jorge Alonso: Mr. Alonso reviewed and revised data collection instruments, trained questionnaire staff in immunization practices and guidelines, assisted in reviewing the manuscript, and approved the final manuscript as submitted. Lydia Sandoval: Ms. Sandoval reviewed and revised data collection instruments, trained questionnaire staff in immunization
The following individuals participated in questionnaire administration and intervention: Anthoni Llau, Lizbeth Londono, Stephanie Vento, Nicole Aston, Michelle Joseph, Anne Barrera, and Jennifer Lawrence. Appendix A. Supplementary data Supplementary material related to this article can be found, in the online version, at http://dx.doi.org/10.1016/j.vaccine. 2014.06.041. References [1] Thompson JW, Tyson S, Card-Higginson PC, Jacobs RF, Wheeler G, Simpson P, et al. Impact of addition of philosophical exemptions on childhood immunization rates. Am J Prev Med 2007;32(3):194–201. [2] Hinman AR, Orenstein WA, Schuchat A. Vaccine-preventable diseases, immunizations, and the epidemic intelligence service. Am J Epidemiol 2003;174:S16–22. [3] Pickering LK, Baker CJ, Freed GL, Gall SA, Grogg SE, Poland GA, et al. Immunization programs for infants, children, adolescents, and adults: clinical practice guidelines by the infectious diseases society of America. CID 2009;49:817–40. [4] Burns IT, Zimmerman RK. Immunization barriers and solutions. J Fam Pract 2005;54:S58–62. [5] Salmon DA, Moulton LH, Lesley SB, Chace LM, Klassen A, Talebian P, et al. Knowledge, attitudes, and beliefs of school nurses and personnel and associations with nonmedical immunization exemptions. Pediatrics 2004;113:e552–9. [6] Salmon DA, Omer SB, Moulton LH, Stokely S, deHart P, Lett S, et al. Exemptions to school immunization requirements: the role of school-level requirements, policies, and procedures. Am J Public Health 2005;95:436–40. [7] Rota JS, Salmon DA, Rodewald LE, Chen RT, Hibbs BF, Gangarosa EJ. Processes for obtaining nonmedical exemptions to state immunization laws. Am J Public Health 2001;91:645–8. [8] Fogarty KJ, Massoudi MS, Gallo W, Averhoff FM, Yusuf H, Fishbein D. Vaccine coverage levels after implementation of a middle school vaccination requirement, Florida, 1197–2000. Public Health Rep 2004;119:163–9. [9] National Conference of State Legislature [Internet]. States with religious and philosophical exemptions from school immunization requirements; 2012 [cited 2011 March 11]. Available from: www.ncsl.org/issues-research/ health/school-immunization-exemption-state-laws.aspx [10] Florida Department of Health. Bureau of Immunizations. Tallahassee, FL: Immunization Guidelines; 2008. Available from: http://www.ehcs.org/ schoolguide.pdf [11] Miami-Dade County Department of Planning and Zoning. Population projections: Miami-Dade County, 2006–2030. Figure 5: immigrants to Miami-Dade County-annual average for five years prior to census, 1970 to 2020. Available from: http://www.miamidade.gov/planzone/Library/research/ PopProj2006-2030.pdf [12] US Department of Health and Human Services [Internet]. Atlanta: Centers for Disease Control and Prevention (US); Birth-18 Years & Catch-up Immunization Schedules [updated 2014 May 5; cited 2012 Sept 26]. Available from: http://www.cdc.gov/vaccines/schedules/hcp/child-adolescent.html [13] Medical Quality Assurance Services [Internet]. Florida; Licensure data download [cited 2012 Sept 20]. Available from: https://ww2.doh.state.fl.us/ downloadnet/Licensure.aspx [14] Cohen NJ, Lauderdale DS, Shete PB, Seal JB, Daum RS. Physician knowledge of catch-up regimens and contraindications for childhood immunizations. Pediatrics 2003;111:925–32. [15] Centers for Disease Control and Prevention. Prevention of varicella: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2007;56(No. RR04):1–40. Available from: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5604a1.htm. [16] Lindley MC, Boyer-Chu L, Fishbein DB, Kolasa M, Middleman AB, Wilson T, et al. The role of schools in strengthening delivery of new adolescent vaccinations. Pediatrics 2008;121:S46–54. [17] Humiston SG, Rosenthal SL. Challenges to vaccinating adolescents, vaccine implementation issues. Ped Infect Dis J 2005;24:S134–40. [18] Gaudino JA, deHart MP, Cheadle A, Martin DP, Moore DL, Schwartz SJ, et al. Gaps between knowledge and action among family practice physicians and pediatricians in Washington State, 1998. Arch Ped Adolesc Med 2002;156:978–85. [19] Luman ET, McCauley MM, Stokley S, Chu SY, Pickering LK. Timeliness of childhood immunizations. Pediatrics 2002;110:935–9.
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Vaccine journal homepage: www.elsevier.com/locate/vaccine
Frequency and erroneous usage of temporary medical exemptions and knowledge of immunization guidelines among some Miami-Dade County Florida providers Alazandria R. Cruze ∗ , Guoyan Zhang, Lakisha Thomas, Jorge Alonso, Lydia Sandoval Florida Department of Health in Miami-Dade County, Epidemiology, Disease Control and Immunization Services, Florida Department of Health in Miami-Dade County, 8600 NW 17th St. Suite 200, Miami, FL 33126, USA
a r t i c l e
i n f o
Article history: Received 22 May 2013 Received in revised form 12 May 2014 Accepted 11 June 2014 Available online 21 June 2014 Keywords: School immunizations Knowledge Practice Temporary medical exemptions School health Pediatricians
a b s t r a c t Objective: We assessed knowledge and practices regarding immunization guidelines and the Florida Certificate of Immunization (DH-680) based on FL-DOH and CDC recommendations, to identify the cause of the increasing number of erroneously issued temporary medical exemptions (TME) among selected health care providers in Miami-Dade County Florida. Methodology: After reviewing immunization certificates from all public schools, a list of physicians who improperly issued 3 or more TMEs, defined as one given to a child who was up to date for their kindergarten and seventh grade requirements, was compiled. The DOH-Miami-Dade developed educational materials and questionnaires, and conducted face-to-face interviews and interventions during site visits to these providers (n = 134). Data was analyzed using SAS 9.2. Results: Of the 104 questionnaires completed, 4 (3.85%) had correct answers to all 10 vaccine knowledge and practice related questions, while 10 (9.62%) had 7 or more incorrect answers. Frequently missed questions included: the required doses of varicella vaccine for seventh grade students entering the 2011–12 school year (86, 82.7%) and the proper scenario for issuing a TME (57, 54.8%). Conclusions: In order to eliminate the improper use of TMEs, long-term efforts are needed to provide immunization-related educational materials and trainings to the medical community regarding vaccinations. These findings also suggest a need for enhanced explanation in multiple languages on the current Florida Immunization Certificate. Due to enhanced surveillance and education, the number of TMEs for kindergarten and seventh grade students was reduced by 12% and 4.9%, respectively, during the 2011 and 2012 school year. © 2014 Elsevier Ltd. All rights reserved.
What’s Known on This Subject Immunization and vaccine practice is well researched and documented for providers nationwide. The evaluation of providers’ knowledge and use of temporary medical exemptions both statewide and nationally is limited. What This Study Adds This study evaluates and reports selected provider knowledge and practices of immunization guidelines and their use of
Abbreviations: ACIP, Advisory Committee on Immunization Practices; CDC, Centers for Disease Control and Prevention; EDC-IS, Epidemiology, Disease Control and Immunization Services; DOH-Miami-Dade, Florida Department of Health in Miami Dade County, DOH-Florida Department of Health; FL-SHOTS, Florida State Health Online Tracking System; MDCPS, Miami Dade County Public School; TME, temporary medical exemption; VPD, vaccine preventable disease. ∗ Corresponding author. Tel.: +1 786 336 1254; fax: +1 305 470 5533. E-mail address: Alazandria [email protected].fl.us (A.R. Cruze). http://dx.doi.org/10.1016/j.vaccine.2014.06.041 0264-410X/© 2014 Elsevier Ltd. All rights reserved.
temporary medical exemptions for kindergarten and seventh grade students.
1. Introduction Widespread use of vaccines has led to a dramatic increase in life expectancy and a significant decline in the incidence of vaccinepreventable diseases (VPDs) [1,2]. Immunizations are one of the most cost effective and beneficial disease prevention measures available [3]. In the United States, rates have dramatically decreased for VPDs such as measles and pertussis [4]. These achievements are attributable to: strong vaccine research and development, implementation of national guidelines for vaccine use, establishment of federal programs that support state and local immunization efforts, increased immunization education among health care providers and parents, decline in barriers to vaccination (including financial), and increase in school immunization laws [5].
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School immunization laws requiring students to be immunized with specific vaccines before entering school have contributed to a 98–100% reduction in the incidence of most VPDs [5]. Documentation of vaccination is required in all states for school entry. In addition, some state laws require immunizations for licensed child care and college entrance [6–8]. All states allow exemptions for medical reasons and currently, 48 states grant religious exemptions and 20 allow philosophical exemptions [9]. In Florida, three types of exemptions are allowed on the Certificate of Immunization DH-680; religious exemptions provided solely by the department of health, medical exemptions, and temporary medical exemptions (TME). TMEs, identified as Part B on the DH-680 [S1] are designed to allow entrance into school (k-12), pre-school and child care, for children in the process of completing required immunizations. To be valid, a TME must have an expiration date that relates to the date the next required immunization is due based on the current school year immunization requirements. A child must return to their health care provider before this date or the exemption is no longer valid and the child must be removed from school until receiving the required immunizations [10]. However, TMEs may be incorrectly issued by some health care providers and school registrars may not be properly trained to identify this type of error. Miami-Dade is the largest county in Florida with a population of 2.5 million, of which 15.4% is White non-Hispanic, 18.9% is Black non-Hispanic and 65.1% is Hispanic. Due to the high volume of immigration, Miami-Dade County has the highest percentage (50.9%) of foreign-born residents among United States counties. In 2009, there was an international net immigration of approximately 42,000 individuals into the county [11]. With such a high number of immigrants, physicians and medical staff are required to create catch-up schedules for children entering school. A catch-up schedule is designed for children and adolescents who have fallen behind on their shots by either missing a dose or starting late. Additionally, catch up schedules help ensure adequate coverage is reached [12]. Children following catch up schedules may be issued a TME to allow entrance into school despite not having met all the school vaccination requirements. There are approximately 350,000 students enrolled in Miami-Dade County Public Schools (MDCPS). MDCPS is the fourth largest school district in the United States with 392 public schools. Approximately, 582 pediatricians and 319 family doctors currently provide care for school-aged children in MiamiDade County [13]. During the past 3 years, MDCPS has experienced an increase in TMEs from 8.4% during the 2007–08 school year to 21.9% in 2010–11 among kindergarten children, and maintained a high percentage (approximately 15%) of TMEs among seventh grade students for the same time period [10]. The Florida Department of Health in Miami-Dade County (DOH-Miami-Dade) launched an investigation to determine if students were properly vaccinated. Few studies focus on the proper use of exemption status guidelines by health-care providers. In addition, there is limited research on the follow-up for children who are not completely immunized, or what the school board’s role is in ensuring children have complete and up-to-date shot records. To our knowledge, this is the first study reporting on selected health care provider’s knowledge regarding TMEs and evaluating their utilization.
2. Methods In September 2011, an investigation was initiated by the DOHMiami-Dade regarding the number of erroneously issued TMEs. The investigation involved several components including multiple interventions, healthcare provider selection for questionnaire dissemination and interviews, survey creation and data analysis.
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2.1. Interventions Interventions by the DOH-Miami-Dade included: reviewing DH-680s from public schools, sending a letter to all health care providers and public school registrars notifying them that the DOH-Miami-Dade was initiating an investigation to identify the cause of the high number of TMEs, contacting the MDCPS school health program and registrars to set up meetings to learn about their immunization databases, creating a simplified immunization guidelines document, creation of a one page document on the “do’s and don’ts” of filling out the DH-680, creating and disseminating a questionnaire that included questions regarding knowledge of immunization requirements and practices of the DH-680, and conducting interviews at clinics to speak about concerns, question and trainings providers have regarding the DH-680, FL-SHOTS or other immunization topics. 2.2. Intervention team The intervention team included 10 members: 8 epidemiologists and 2 computer analysts. Four of the 10 members spoke both English and Spanish. The Epidemiology, Disease Control, and Immunization Services (EDC-IS) intervention team was specifically trained by DOH-Miami-Dade immunization program specialists in the areas of immunization knowledge and practice before beginning the survey process. Responsibilities included conducting site visits, disseminating questionnaires, providing education, distributing educational materials, and conducting interviews. 2.3. Health care provider selection Nurses from the DOH-Miami-Dade immunization and school health programs reviewed DH-680 certificates with TMEs from all public schools in Miami-Dade County. From the review, a list of providers was compiled containing the names and locations of providers incorrectly issuing TMEs for kindergarten and seventh grade students. An improperly issued TME was defined as one that was given when the child was up to date with their vaccinations for their age and grade level. In total, 300 clinics were identified as improperly issuing TMEs, of which clinics with a minimum of 3 improperly issued TMEs (134, 44.7%) were chosen for targeted intervention. After contacting the selected 134 clinics, 51 (38.1%) of the 134 sites agreed to be visited by the intervention team. The 51 clinics were comprised of mainly pediatric practices and varied by size of practice and location within the County. 2.4. Survey creation, content and procedures A self-administered questionnaire was designed that did not require any identifying information. The questionnaire was reviewed and pilot-tested by the DOH-Miami-Dade immunization program staff to ensure clarity of the text and refine wording of vaccine-related questions. The questionnaire included 28 questions with three sections. Part 1 addressed provider/clinic specific questions including general information about the clinic setting, the primary person administering the vaccines, who is responsible for completing the DH-680s either in hard copy or through the Florida State Health Online Tracking System (FL-SHOTS), utilization of reminder/recall methods and sources used for vaccine related updates and information. Part 2 encompassed vaccine specific questions, including knowledge of the required vaccines, vaccination schedules for school-aged children and vaccination requirements for the 2011–12 school year. Part 3 assessed specific situations and practices regarding the DH-680 and Florida SHOTS. The primary individuals responsible for administering immunizations and completing the DH-680 were asked to complete the
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Table 1 Proportion of providers responsible for filling out the DH-680. Providers
Proportion of providers
Medical assistants LPN/RN and medical assistants Physicians or medical assistants Other Medical assistants and other
55.9 15.4 11.5 10.8 5.9
questionnaire. Questionnaires were completed within 20 min during the visit with the team. 2.5. Interviews Interviews were conducted among individuals that completed questionnaires and ranged from 10 to 30 min. Topics included utilization of FL-SHOTS, concerns regarding the DH-680 and immunization guidelines, and use of an immunization reminder/recall system within their practice. 2.6. Data analysis Data was analyzed using frequency and Chi-Square tests to describe the percentage of respondents and to test association among categorical variables. P-values were considered significant when less than 0.05. Data analyses were conducted using SAS version 9.2 (SAS Inc., Cary, NC). 3. Results Questionnaires were given to 104 participants who were defined as the primary person to administer vaccines and/or fill out the immunization certificate at the 51 clinic sites throughout Miami-Dade County. Of the 104 participants, 91 (87.5%) described themselves as working in private practice. Additionally, 86 (82.7%) of the 104 participants focused on pediatric medicine, 10 (9.62%) focused on pediatric/family/internal medicine, 6 (5.76%) in family medicine alone and 2 (1.92%) responded other. Forty-two (40.8%) participants described their practice as having four or more physicians and 87 (83.7%) reported seeing more than 75 children weekly. 3.1. Years experience working with childhood immunizations Among respondents, 41 (39.4%) have been working with childhood immunizations for 11 years or more, 39 (37.5%) reported working in childhood immunizations for 4–10 years and 24 (23.1%) had worked in childhood immunizations for less than 4 years. 3.2. Primary person to administer vaccines and/or fill out the DH-680 Multiple individuals were responsible for completing the DH680 and/or administering vaccines among clinic sites and some individuals may have been captured by more than one category. Medical assistants alone (60, 59.4%) were listed as the primary person to administer vaccines, followed by medical assistants or physicians (14, 13.9%), LPN/RN or medical assistant (13, 12.5%), as well as physician alone (10, 9.9%). Medical assistants (57, 55.9%) alone were primarily responsible for completing the DH-680 either through hard copy or in Florida SHOTS. Other individuals responsible for completing the DH-680 included 16 (15.4%) LPN/RN or medical assistants, 12 (11.5%) physicians or medical assistants, 11 (10.8%) other and 6 (5.9%) medical assistants or other (i.e. clerks) (Table 1).
3.3. Vaccine related knowledge and practice Of the 104 questionnaires collected, 4 (3.85%) participants answered all 10 vaccine knowledge and practice related questions properly, while 10 (9.62%) participants failed to answer more than 3 questions correctly. The most frequently missed questions were regarding the required doses of varicella vaccine for seventh grade students entering the 2011–12 school year (86, 82.7%), the minimum number of doses required for the DTaP series (76, 73.1%) and the proper scenario for issuing a TME (57, 54.8%). Forty-five (43.3%) participants were unclear when to issue a TME for kindergarten students. There was no association found between years of experience working in childhood immunizations and the number of questions answered correctly. The majority of respondents, regardless of years worked (≤6 years or >6 years) answered between 5 and 7 questions correctly (48.3% and 51.7%) (Table 2). Additionally, 96 (91.4%) participants reported routinely screening immunization records at visits other than scheduled childhood immunization appointments, and 12 (11.7%) respondents reported not using any type of reminder recall methods to bring children back for scheduled immunization appointments. However, through interview, half of participants stated they marked Part B TME to have an expiration date on the certificate as a reminder for children to return for their next scheduled appointment. Most of the 104 participants (98, 94.2%) had responded on the questionnaire that they had accessed a copy of the immunization guidelines from the Florida Department of Health (DOH) or local health department. Amendments to DH-680s that included removing erroneously issued TMEs and correctly classifying those children as fully immunized (complete), as well as working with the Bureau of Immunizations to make changes to FL-SHOTS, may have contributed to the reduction in the percentage of MDCPS students in kindergarten with a TME to 9.90% for the 2011–12 school year from 21.9% in 2010–11. The percent of seventh grade students with improperly issued TMEs was reduced as well from 14.8% in 2010–11 to 9.90% for 2011–12. For the 2012–13 school year, the TME rate among kindergarten students and seventh grade students fell to 6.70% from the 2011–12 percentages of 9.90%.
4. Discussion Immunization guidelines change frequently as new research findings are published. Changes to state laws or regulations governing school entry vaccination requirements can affect provider knowledge [8]. Health care providers must be familiar with updated recommendations in order to offer the most comprehensive care to their clients. When dealing with under-immunized children, health care providers may have difficulty adhering to complex immunization schedules [14]. The most frequently missed question on the survey was regarding the number of required doses of varicella vaccine for seventh grade students entering the 2011–12 school year. The Advisory Committee on Immunization Practices (ACIP) and CDC made recommendations in 2007 regarding a second dose of varicella vaccine [15], which Florida adopted as incremental approach to ensure all children receive the recommended two doses. Each year in Florida beginning in 2008, an additional grade level requires two doses until school year 2020–21, at which time all students will require two doses [10]. Other states may have adopted this system as well. Many health care providers may have been unclear as to the actual number of required doses for different grade levels. This confusion may have led some providers to improperly issue TMEs. In Florida, for the 2011–12 school year, kindergarten through third grade students required 2 doses of varicella
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Table 2 Vaccine related survey questions and percent of respondents who answered correctly. Question
Percent answered correctly
1. What are the proper age intervals for children receiving the Hepatitis B vaccine? 2. True or false. If the first dose of Hepatitis B vaccine was given to a child more than one year ago, and no subsequent doses were given, you should repeat the first dose. 3. Which combination of vaccines is required for children entering kindergarten? 4. What is the minimum number of doses needed to complete a DTaP series for children? 5. Of the following scenarios, which requires a temporary medical exemption? 6. What is the proper time frame when issuing an expiration date for a temporary medical exemption? 7. Which of the following vaccines may be issued a temporary medical exemption for a child entering kindergarten if a dose is missing? 8. Which of the following childhood vaccine series would qualify a child to have an immunization complete status (part A) for kindergarten? 9. True or false. A temporary medical exemption should be issued for a child entering kindergarten that has all of the required shots but is missing the second dose of MMR? 10. If a child is entering the 7th grade during the 2011–12-school year and has never had the chickenpox, how many doses of varicella are required for the child to be compliant with school vaccines?
84 (80.8%) 73 (70.2%)
vaccine, while grades 4–10 required one [10]. Additionally, during the interview, many health care providers stated that some schools required two doses of varicella for all children, even though a second dose was not necessary for all grade levels. This may also contribute to the unnecessary issuance of TMEs. The complexity of ever changing immunization requirements and schedules may make it increasingly difficult to accurately identify a child’s completion or exemption status. All health care providers, schools and parents must collaborate regarding the current vaccination requirements in order to maintain high coverage among students [16]. Some providers were issuing TMEs for children to return for a fifth dose of DTaP when it was not necessary; for example, when a child received the fourth dose of DTaP on or after their fourth birthday [10]. Despite participants expressing no confusion with the wording of the Part B TME section on the DH-680, over half of providers were unable to clearly identify the proper scenario for issuing a TME. Such a high percentage demonstrates confusion among respondents as to what qualifies a child as “in compliance” and “not in compliance.” Additionally, multiple providers are utilizing the TME as a recall system for children in compliance to return for immunizations not yet needed. Despite provider reminder/recall systems being efficient tools available to help increase childhood immunization rates that are both relatively inexpensive and simple to implement [17], utilizing a TME as a recall system is not efficient and falsely increases the number of under-vaccinated children. Most parents, physicians and schools do not evaluate a child’s DH-680 on a regular basis and therefore TMEs issued as a reminder will not be an efficient method. Additionally, effective reminder/recall systems consist of phone calls, emails, and/or notices disseminated to parents or physician’s office that notify them of upcoming immunizations. Since FL-SHOTS does not contain a reminder/recall feature, the system is unable to send out notices to physicians or parents. A study by Gaudino et al. indicated that self-reports of immunization practices may not accurately reflect actual clinic practices, and suggested the discrepancy may be caused by the desire to mirror best practices [18]. Additionally, physicians may not be fully aware of all office practices taking place in larger clinic settings where nurses and medical assistants are predominately responsible for vaccine administration and completing immunization certificates. The complexity of the vaccine schedule creates a difficult task for the clinician faced with catch-up regimens, particularly when children are delinquent in multiple vaccines. Some physicians may be less familiar with immunization recommendations for older children’s catch-up schedules because of greater divergence from the standard schedule of administration and the complex recommendations [14,19]. Healthcare professionals in Miami-Dade County and throughout the country will continue to face the
92 (88.5%) 28 (26.9%) 47 (45.2%) 68 (65.4%) 59 (56.7%) 98 (94.23%) 66 (63.5%) 18 (17.3%)
challenging task of following a catch-up schedule for those children who recently immigrated to the US as well as for children who have started late for reasons other than immigration such as illness, parental and religious beliefs. Furthermore, a language barrier was identified among health care providers and clinic staff during the survey and interview. This may be due to the fact that 68% of the Miami-Dade County population speaks a language other than English in their homes. 5. Conclusion A TME should be completed only for children not fully immunized for their current school grade, based on the proper spacing of vaccines. The improper issuance of TMEs negatively affects the overall compliance rates when assessing each county’s coverage for school immunizations. The significant reduction in the number of students enrolled in school with TMEs after review of DH-680s, clearly identifies the need for clarification and education among providers regarding immunization requirements, especially regarding guidelines for issuing exemptions. For the 2012–13 school year, Miami-Dade reported TME rates of 6.70% among both kindergarten and seventh grade students, which reflect a further decrease in TME rates from the 2011–12 school year. The rate of erroneous TMEs decreased for two consecutive school years following a multi-faceted intervention by the DOH-Miami-Dade. 5.1. Limitations The findings within this report are subject to five limitations. First, the DOH-Miami-Dade released an alert letter followed by a simplified immunization chart for the 2011–12 school year to local health care providers prior to survey administration. This may have led some survey participants to answer questions in accordance with the regulations in the documents instead of true clinic practices. Second, the survey was only administered in English even in areas where Spanish is the primary language. Translators were used to conduct the survey in instances where the participant did not feel comfortable or was unable to read English. The third limitation encountered was the time frame between contacting the clinic to set up a visit and the date the clinic allowed the intervention team to come administer the survey. This may have allowed participating clinics time to review vaccine schedules and rules regarding issuing TMEs. The fourth limitation identified was respondents were not asked about their profession on the questionnaire. The only question regarding profession was the length of time the individual had spent working with childhood immunizations. Lastly, the fifth limitation was that the 51 participating clinic sites out of the 134 contacted, may have felt more knowledgeable and comfortable in their immunization practices than clinics that did not allow the
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intervention team to administer the survey. The difference among participating clinics and non-participating clinics was not evaluated in this study.
practices and guidelines, assisted in reviewing the manuscript, and approved the final manuscript as submitted. Acknowledgement
5.2. Recommendations Long-term efforts will be needed to address the varying reasons contributing to the misuse of TMEs. The following actions may help significantly reduce improper use of TMEs in Florida: update the simplified guideline of immunization requirements to include English, Spanish and Creole versions and distribute to health care providers and public schools annually; improve the DOH-MiamiDade immunization related educational materials, such as video trainings and webinars on the DOH-Miami-Dade website and provide trainings regarding the DH-680 and immunization requirements for the current school year to providers as well as school nurses and registrars by experienced health department immunization staff; modify and improve FL-SHOTS auto-quality control function to prevent health care provider misuse of TMEs by not allowing physicians or nurses to issue a TME to a child who does not meet the criteria; and to establish a partnership between the DOH-Miami-Dade and MDCPS to collaborate to further increase the rates of appropriately vaccinated children. Identifying all parties that have a vital role in childhood immunizations is an important factor in ensuring an adequate response is made during an investigation or when identifying a breakdown in childhood immunizations. Issues with vaccination rates and coverage are complex and require a collaborative effort from multiple organizations to fix the underlying problems. Funding support No external funding was secured for this study. Financial disclosure The authors have no financial relationship relevant to this article to disclose. Conflict of interest The authors of this study have no conflicts of interest to disclose. Contributors statement Alazandria R. Cruze: Ms. Cruze designed the data collection instruments, coordinated and supervised data collection, conducted extensive literature reviews, drafted the initial manuscript, responsible for reviewing and revising the manuscript, and approved the final manuscript as submitted. Guoyan Zhang: Dr. Zhang carried out data analysis, contributed to the writing of the methods and results, reviewed and revised the manuscript, and approved the final manuscript as submitted. Lakisha Thomas: Ms. Thomas designed the data collection instruments, coordinated and supervised data collection, critically reviewed the manuscript, and approved the final manuscript as submitted. Jorge Alonso: Mr. Alonso reviewed and revised data collection instruments, trained questionnaire staff in immunization practices and guidelines, assisted in reviewing the manuscript, and approved the final manuscript as submitted. Lydia Sandoval: Ms. Sandoval reviewed and revised data collection instruments, trained questionnaire staff in immunization
The following individuals participated in questionnaire administration and intervention: Anthoni Llau, Lizbeth Londono, Stephanie Vento, Nicole Aston, Michelle Joseph, Anne Barrera, and Jennifer Lawrence. Appendix A. Supplementary data Supplementary material related to this article can be found, in the online version, at http://dx.doi.org/10.1016/j.vaccine. 2014.06.041. References [1] Thompson JW, Tyson S, Card-Higginson PC, Jacobs RF, Wheeler G, Simpson P, et al. Impact of addition of philosophical exemptions on childhood immunization rates. Am J Prev Med 2007;32(3):194–201. [2] Hinman AR, Orenstein WA, Schuchat A. Vaccine-preventable diseases, immunizations, and the epidemic intelligence service. Am J Epidemiol 2003;174:S16–22. [3] Pickering LK, Baker CJ, Freed GL, Gall SA, Grogg SE, Poland GA, et al. Immunization programs for infants, children, adolescents, and adults: clinical practice guidelines by the infectious diseases society of America. CID 2009;49:817–40. [4] Burns IT, Zimmerman RK. Immunization barriers and solutions. J Fam Pract 2005;54:S58–62. [5] Salmon DA, Moulton LH, Lesley SB, Chace LM, Klassen A, Talebian P, et al. Knowledge, attitudes, and beliefs of school nurses and personnel and associations with nonmedical immunization exemptions. Pediatrics 2004;113:e552–9. [6] Salmon DA, Omer SB, Moulton LH, Stokely S, deHart P, Lett S, et al. Exemptions to school immunization requirements: the role of school-level requirements, policies, and procedures. Am J Public Health 2005;95:436–40. [7] Rota JS, Salmon DA, Rodewald LE, Chen RT, Hibbs BF, Gangarosa EJ. Processes for obtaining nonmedical exemptions to state immunization laws. Am J Public Health 2001;91:645–8. [8] Fogarty KJ, Massoudi MS, Gallo W, Averhoff FM, Yusuf H, Fishbein D. Vaccine coverage levels after implementation of a middle school vaccination requirement, Florida, 1197–2000. Public Health Rep 2004;119:163–9. [9] National Conference of State Legislature [Internet]. States with religious and philosophical exemptions from school immunization requirements; 2012 [cited 2011 March 11]. Available from: www.ncsl.org/issues-research/ health/school-immunization-exemption-state-laws.aspx [10] Florida Department of Health. Bureau of Immunizations. Tallahassee, FL: Immunization Guidelines; 2008. Available from: http://www.ehcs.org/ schoolguide.pdf [11] Miami-Dade County Department of Planning and Zoning. Population projections: Miami-Dade County, 2006–2030. Figure 5: immigrants to Miami-Dade County-annual average for five years prior to census, 1970 to 2020. Available from: http://www.miamidade.gov/planzone/Library/research/ PopProj2006-2030.pdf [12] US Department of Health and Human Services [Internet]. Atlanta: Centers for Disease Control and Prevention (US); Birth-18 Years & Catch-up Immunization Schedules [updated 2014 May 5; cited 2012 Sept 26]. Available from: http://www.cdc.gov/vaccines/schedules/hcp/child-adolescent.html [13] Medical Quality Assurance Services [Internet]. Florida; Licensure data download [cited 2012 Sept 20]. Available from: https://ww2.doh.state.fl.us/ downloadnet/Licensure.aspx [14] Cohen NJ, Lauderdale DS, Shete PB, Seal JB, Daum RS. Physician knowledge of catch-up regimens and contraindications for childhood immunizations. Pediatrics 2003;111:925–32. [15] Centers for Disease Control and Prevention. Prevention of varicella: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2007;56(No. RR04):1–40. Available from: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5604a1.htm. [16] Lindley MC, Boyer-Chu L, Fishbein DB, Kolasa M, Middleman AB, Wilson T, et al. The role of schools in strengthening delivery of new adolescent vaccinations. Pediatrics 2008;121:S46–54. [17] Humiston SG, Rosenthal SL. Challenges to vaccinating adolescents, vaccine implementation issues. Ped Infect Dis J 2005;24:S134–40. [18] Gaudino JA, deHart MP, Cheadle A, Martin DP, Moore DL, Schwartz SJ, et al. Gaps between knowledge and action among family practice physicians and pediatricians in Washington State, 1998. Arch Ped Adolesc Med 2002;156:978–85. [19] Luman ET, McCauley MM, Stokley S, Chu SY, Pickering LK. Timeliness of childhood immunizations. Pediatrics 2002;110:935–9.
