Immunization Requirements for
California College Students
Marc Lerner, M.D.
Medical Officer, Orange County Department of Education
With thanks to:
Mary Knudtson, DNSc, NP-UC Santa Cruz Executive Director of Health and Wellness
Gina Fleming, MD, MSPH-UCOP Medical Director of Student Health and Counseling
Mary Ferris, M.D., M.A., M.S.Ed.-Executive Director Student Health Services
Requirements for Vaccination for
College Students
• 38 states require the meningitis vaccine
• 12 states mandate Hepatitis B
• 28 states require measles vaccine
• 23 require the MMR vaccines
• 14 require the Td or Tdap
• 5 require varicella vaccine
ACIP Immunization Recommendations
• Annual influenza immunization
• Catch-up immunizations at 18
– Tdap
– 2 MMR
– 2 Varicella
– Meningococcal conjugate at 16 or older
– HBV x 3
– HPV x 3
– HAV x 2
• High risk recs (PCV 13, PPSV23, Hib, etc.)
CAIR – Current 18-25 YOs
Outbreaks on UC Campuses
• Berkeley
– Measles case(s)
– Mumps
• Davis
– Mumps in international student
– Measles international student
– 4 cases of Active Tuberculosis in 2014-15
– Meningitis Type B single case
• Most campuses
– Active tuberculosis cases (including MDR TB)
• Santa Barbara
– Meningitis (type B) outbreak November 2013
– 4 cases in 2 weeks
• San Diego
– Multiple active TB, including MDR-TB with 1000 exposed
Vaccination Rates for College Students
• Only 8-13% of college students received the flu
vaccine in a recent year
• Reason: Unwarranted Optimism” about their own
health: They do not see the flu “as a personal risk
and tend to overestimate how safe they truly are.”
Barriers to College Student Influenza
Vaccination
Questionnaires were completed by a convenience sample of 383
undergraduate students in January 2014. Findings:
• Only 20.6% of students reported receiving the vaccine within
the last 6 months
• For non-vaccinated college students who did not receive the
vaccine:
– 47.8% believed they would get influenza from the vaccine
– 41.6% believed the vaccination may have dangerous side
effects
– 39.6% believed they were not at risk for contracting
influenza
• The majority of non-vaccinated students did not believe cost
of the vaccine or access to the vaccine were barriers
SM Benjamin; Influenza Res Treat. 2016; 2016: 4248071
Study to increase College Influenza
Vaccinations
Swarthmore College study of 3 scenarios
1. Email sent from another student at the school urging
the recipient to get vaccinated
2. Email with audio of coughing, to “make the cost of
getting sick more salient,” and promotion of vaccination
3. Email offering a $30 incentive
Findings:
• Few students who said they were planning to get vaccinated
actually followed through
• Offering money was the most effective and the most costly
• In the $ incentive group only 43% followed through
Meningococcal Vaccinations at College
• In 1997, the American College Health Association (ACHA
represents about half of colleges) released a statement
recommending:
– College health services should take a more proactive role
in alerting students and their parents about the dangers
of meningococcal disease
– Colleges and universities ensure all students have access
to a vaccination program for those who want to be
vaccinated
• ACHA / CDC surveys were sent to 1,200 ACHA-member
schools
• 691 schools responded
• 57 (8%) reported that pre-exposure meningococcal
vaccination campaigns had been conducted on their campus
• During the 1998--1999 school year, 3%--5% of 148 students
enrolled in a case-control study reported receiving
prophylactic meningococcal vaccination
College / University Immunization
Requirements
• Unlike primary and secondary school
requirements, there are no comprehensive
statewide immunization requirements.
• Most requirements are made at the university
or system level.
• Immunization requirements differ between
colleges and universities.
• Protocols for collection and verification of
records and enforcement also differ.
Hepatitis B Vaccine Requirements
• California Health and Safety Code, Section
120390-120390.7
• … “the Trustees of the California State University,
and the Regents of the University of California*
shall require the first-time enrollees at those
institutions who are 18 years of age or younger to
provide proof of full immunization against the
hepatitis B virus prior to enrollment”
*Applicable to UC by UC resolution only
Immunization Requirements for the
California State University System
• Applicable for students since fall, 2002
• Allows medical, personal belief and religious
exemptions
• Meningococcal Vaccine
– All incoming freshman residing on campus must
acknowledge being informed and choice on whether
they got the vaccination
• Measles / Rubella / HBV
– Must provide proof during application
– If not fully immunized, may be admitted conditionally,
can’t enroll for next year until done
https://www.calstate.edu/eo/EO-803.pdf
http://leginfo.legislature.ca.gov/faces/codes_displayText.xhtml?lawCode=
HSC&division=105.&title=&part=2.&chapter=1.5.&article
University of California
The University of California opened
its doors in 1869 with just 10 faculty
members and 38 students.
Today, the UC system includes
more than 190,000 faculty and
more than 257,000 students,
with more than 1.6 million
alumni living and working around
the world.
Meningococcal Disease Informing
• Each degree-granting public postsecondary educational institution* that provides
on-campus housing in the state shall do all of the following:
– Provide information on meningococcal disease to each incoming freshman
who has been accepted for admission to the postsecondary educational
institution and who will be residing in on-campus housing, including a
response form with space:
• to indicate that the incoming freshman has received the information
about meningococcal disease and the availability of the vaccine.
• To indicate if he or she has chosen to receive the vaccination, and
• For his or her signature.
– Require incoming freshman to return to the form to the institution with the
above information
• Does not require the postsecondary educational institution to provide the
vaccination to the students
• Each degree-granting private postsecondary educational institution that provides
on-campus housing in the state shall adopt a policy to notify all incoming students
about meningococcal disease and the availability of the vaccination
CA Health and Safety Code, Sec 120395-120399
UC System
• 10 campuses
• 5 medical centers
• 3 national laboratories
• 150 academic disciplines
• 600 graduate degree
programs
• 257,000 students
• 198,300 employees
• 1.6 million living alumni
• 61 Nobel laureates
• 17,000 UC extension
courses
• 430,000 jobs supported
• $46.3 billion contributed
to California economy
• Secures $7 in federal and
private dollars for every
$1 in research funding
provided by the state of
California
UC Student Health
• All registered students are required to have health
insurance as a condition of enrollment
• All campuses have on campus student health centers
• Following an assessment of the cost analyses, market
analysis, campus consolidation requirements,
evaluation/selection of vendors, and claims experience
of campus student health plans, a health insurance
plan was created
– UC SHIP: A self funded, centralized, system wide health
insurance plan for all UC students and their dependents
Student Health
• Student Health Services’ (SHS) mission includes public
health and education of students regarding health
threats and preventive care
• Why create an immunization policy?
• Planning began in early 2014
– Response to infectious disease outbreaks on UC Campuses
over past 10 years, Mumps, Measles, Meningitis, Varicella,
Pertussis, Active TB
– ACA coverage for cost of vaccines
– EMR systems that facilitate immunization data gathering
• Immunization Registry
• System wide use of Point and Click (PNC) EMR by UC
Tipping Point
• School health service directors convened in 2014 and
voted to pursue system wide plan to include vaccine
history AND require immunizations recommended by CDPH
• Decision to link acknowledgement of vaccine
recommendations with registration, but had already missed
deadlines for fall 2014, and therefore efforts began with
communications for Fall 2015
• Identified “Immunization Plan Committee” comprised of 5-
6 SHS Directors and UCOP SHS Medical Director
– Later expanded to include representation from each campus
UC Immunization Policy: Requirements
Notice: All incoming UC students are REQUIRED to obtain the following vaccines and undergo screening
for Tuberculosis.
Required Vaccinations & Screenings
Required Dosage & Screening Information
Vaccine: Measles, Mumps and Rubella (MMR)
Two (2) doses with first dose on or after 1st birthday; OR positive titer
(laboratory evidence of immunity to disease)
Vaccine: Varicella (Chickenpox)
Two (2) doses with first dose on or after 1st birthday; OR positive titer
Vaccine: Tetanus, Diphtheria and Pertussis (Tdap)
One (1) dose after age 7; tetanus booster (Td) every 10 years after initial
Tdap
Vaccine: Meningococcal conjugate (
Serogroups
A,
C, Y, & W
-135)
One (1) dose on or after age 16 for all students who are ages 21 years or
younger
Screening: Tuberculosis (TB)
All incoming students must complete a Tuberculosis risk questionnaire.
Incoming students, who are at higher risk* for TB infection as indicated by
answering “yes” to any of the screening questions, should undergo either
skin or blood testing for TB infection within 1 year of UC entry.
*Higher risk includes travel to or living in South & Central America, Africa,
Asia, Eastern Europe, and the Middle East; prior positive TB test; or
exposure to someone with active TB disease.
UC Immunization Policy:
Recommendations
UC STRONGLY RECOMMMENDS THESE GROUPS OF STUDENTS OBTAIN THE FOLLOWING VACCINATIONS
:
Recommended
Vaccinations
Recommended
Groups
Hepatitis
A vaccine (Hep A)
All
students regardless of age
Hepatitis
B vaccine (Hep B)
All
students regardless of age
Human
papillomavirus vaccine (HPV)
For
women and men through age 26 years
Influenza
vaccine (Flu)
Annually
; All students regardless of age
Meningococcal
B (Meningitis B)
Students
ages 16 – 23 who elect vaccination after discussion with
their
healthcare
provider
Meningococcal
conjugate (Meningitis)
Students
up to age 23
Pneumococcal
vaccine
For
students with certain medical conditions (e.g., severe
asthma,
diabetes,
chronic liver or kidney disease)
Poliovirus
vaccine (Polio)
Regardless
of age, if the series was not completed as a child
Vaccines
for international travel
Based
on destination
UC Immunization Policy 3-Year Plan
Phase 1 - Fall 2015:
All campuses provided information to incoming
students on immunization and TB screening
recommendations
Students concurrently provided a required
acknowledgement of recommendations receipt on the
admissions checklist
Campuses implemented non-mandatory, student self-
entry of vaccine information via the secure electronic
medical record portal
Phase 2 - Fall 2016:
All campuses implement student self-entry of vaccine
and TB screening information via the secure electronic
medical record portal
Portal will:
– Include a link from admissions checklist
– State the requirement of completion prior to
initial registration. Requirement to be “soft,”
without a mandatory registration hold
placement during phase 2
Immunization Policy 3-Year Plan
Phase 3 - Fall 2017:
All campuses to complete implementation of required
student self-entry for vaccine and TB screening
information.
– Submissions via the secure Electronic medical record
portal must be verifiable
– Failure to comply will result in a registration hold
Immunization Policy 3-Year Plan
Efforts to Date
• All campuses have linked notices regarding immunization
requirement to admission and registration communications
• All campuses have updates on their website
• Media picked up story when first launched
• Meetings with UC and campus stakeholders, including:
– UCOP: UC President and Regents, Executive Vice President UC Health,
Office of General Council, Risk Services, Legislative Affairs
– Campuses: Chancellors, Vice Chancellors of Student Affairs, Registrars,
Graduate Deans, International Student Deans, English Language
Program Administrators, and Information Technology.
– Students: UCSHIP EOB, Campus SHACs, Participants on Exemption
Policy Work Group
• Presidential Policy—rationale to support efforts
Exemption Requests
• A task force was convened to determine the
policy and process for exemption requests,
denials and appeals.
• UC SHS Executive and Medical Directors
support waivers for medical exemptions only.
• UC Immunization Policy reviewed for formal
approval via UC Presidential Policy.
Creating an Immunization Exemption
Policy
• Convened Group Meeting
– Reviewed exemption options:
• Personal Belief: student can chose not to have vaccine for any
reason
• Religious: students’ religious beliefs do not allow for vaccination
• Medical Only: students with medical conditions that place them
at risk for adverse events/serious side effects OR those who have
had a previous adverse reaction to vaccination
– CDC and product manufacturers define conditions and risks for
vaccination
– CDC also has list of common misperceptions of contraindication to
vaccination
– Brainstorm pros and cons of each option
– Assess and summarize work group’s leaning regarding
allowable exemptions
University of California Immunization
Exemption Policy
• Medical Exemptions to Vaccination
– UC allows for exemptions to immunization requirements based on a
medical condition that is a contraindication to vaccination for the
following vaccines: MMR (measles, mumps, and rubella), Varicella
(chickenpox), pertussis (whooping cough), or meningitis (for certain
groups of students).
– A list of established contraindications to vaccination can be found on
the Centers for Disease Control and Prevention (CDC) website for
Guide to Contraindications
• Medical exemptions must be documented on the UC Medical
Exemption Request Form, indicating the specific vaccine for which
the exemption is requested, and whether the exemption should be
permanent or temporary
– If temporary, the expected duration of the medical condition must be
included.
– All forms must be signed by a licensed medical provider (MDs, DOs,
NPs, PAs)
UC Immunization Exemption Denials
• The UC Immunization Exemption Policy Committee (IPEC)
established
• Includes 10 representatives;
– Physicians (including at least one ID specialist), students, and other
faculty with expertise in fields such as medical ethics, law, public
health, religion, and international student services
• Students requesting an appeal must submit a written request
to their campus student health center to initiate the appeal
• Students whose requests for medical exemption to the
immunization requirement have been denied, will be able to
enroll in classes and register for the upcoming academic term
(quarter, semester, or session) while their request is being
reviewed
UC EHR Immunization Module
• All campuses have purchased and have set up the module
• Immunization Plan Committee and SHS IT staff working
together
– Established criteria for system wide reporting on compliance
• PNC Immunization program has challenges; all data must be
entered in one sitting; does not yet save and allow students to
return to complete
• Requires complex compliance set up for reporting and
coordinating holds
• No interface with Statewide Immunization Registry
• Campuses collecting student self-entered data
Critical Elements & Involved Stakeholders
• End user ease-of-use
• Integration with existing electronic
health records
• Interfaces with Admissions and
Registrar data
• Administrative tracking and
compliance monitoring
• Verification if required
• Clinician display for later medical
care utilization
• New students and
parents IT staff
• IT and campus
officials
• Admin staff
• Clinical and Admin
staff Clinicians
It starts with the Admissions Process
Linked to your Student Health website…
Confidential entry into your electronic medical
records system…
YouTube Video to demonstrate how to find the
right screen…
Finally the actual self-entry of dates (with a
Worksheet?)…
Ability to Enter Disease Dates
Limited displays for alternative options, but can
UPLOAD documents
TB SCREENING FORM
Self-entered immunization dates appear within
medical record…
Uploaded Immunization record is stored in
Scanned Documents…
Immunization Compliance
Reporting…
Options for creating reports and batch
email messages…
Verification in Batches
UC Immunization Communication Plan
• Outreach to Students/Parents
– Create a webpage as entry point from the student dashboard to
explain different requirements and how to meet them.
– Present new immunization requirements to all incoming
students and parents via new student orientation sessions
– Highlight new immunization requirement on New Student
Checklist
– Integrate into all new incoming student communications
– Repeat emails to incoming students re: admission health
requirements
– Mail to local address, secure message, new student orientation
packets, and potential campus message.
– Post on website for new students (both UG and Grad)
– Article in parent newsletter
Communication Plan
• Develop FAQs regarding the required TB
screening/immunizations, and
implementation of the plan
• Convene Immunization Work Group with
stakeholders from campus SHS to address
issues and ensure campuses “on the same
page” in implementation plans
• Inform senior leadership of progress
throughout the process
• Coordinate with University Communications
to create talking points, and identify
spokespersons to provide interviews and
answer questions from press
Future UC Immunization Needs
• Standardization of immunization records
• Mobile portals for ease of entry
• Verification solutions
• Seamless electronic integration with outside
immunization registries
Summary
• Outbreaks of vaccine preventable diseases are
occurring on California college campuses
• Immunization requirements are made at the
university or system level
• The University of California system has
established a three year transition plan to
implement an immunization requirement for
all students
