STATE BOARD OF HEALTH

[Filed October 22, 2019, 2:54 p.m., effective multiple dates]

Effective Date of Rule: Thirty-one days after filing; and August 1, 2020.

Other Findings Required by Other Provisions of Law as Precondition to Adoption or Effectiveness of Rule: WAC 246-105-040 and 246-105-055 will become effective thirty-one days after filing; and WAC 246-105-020, 246-105-050, 246-105-060, 246-105-070, 246-105-080, and 246-105-090 will become effective August 1, 2020.

Purpose: Chapter 246-105 WAC, Immunization of child care and school children against certain vaccine-preventable diseases, the state board of health has adopted rules regarding documentation of immunization status, the process for students who are in conditional status, updating the reference to the national immunization standards set by the advisory committee on immunization practices, and improving clarity and usability of the rule.

Citation of Rules Affected by this Order: New WAC 246-105-055; and amending WAC 246-105-020, 246-105-040, 246-105-050, 246-105-060, 246-105-070, 246-105-080, and 246-105-090.

Statutory Authority for Adoption: RCW 28A.210.140.

Other Authority: RCW 28A.210.080, 28A.210.100.

Adopted under notice filed as WSR 19-14-102 on July 2, 2019.

Changes Other than Editing from Proposed to Adopted Version: The board struck "full" from the definition of conditional status to clarify that a child in this status must provide proof of immunization status consistent with the requirements of the rule instead of proof of "full" immunization. If a child has proof of full immunization then they are not in conditional status. Next, the board revised the definition of "school nurse" based on comments from the office of superintendent of public instruction and the professional educator standards board (PESB) to align with the certification and qualification requirements for "school nurses" established by PESB. Clarifications were made in the definitions and throughout the rule to indicate that a parent, not the child, must provide proof of immunization status or an exemption. The board added the word "both" in subsection (1) of WAC 246-105-050 to reflect that parents may submit a certificate of immunization status (CIS), certificate of exemption (COE), or both because there may be circumstances where a parent chooses to immunize their child with some of the required vaccines and exempt them from others. In this case, submitting both a CIS and COE would be appropriate. Finally, the board added language in WAC 246-105-050 and following sections regarding federal statutes that allow students experiencing homelessness and foster youth clarifying that these children must be immediately enrolled even if they are lacking documentation of immunization status.

A final cost-benefit analysis is available by contacting Alexandra Montano, P.O. Box 47990, Olympia, WA 98504-7990, phone 360-236-4106, fax 360-236-4088, TTY 360-833-6388 or 711, email alexandra.montano@sboh.wa.gov.

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 1, Amended 0, Repealed 0.

Number of Sections Adopted at the Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's own Initiative: New 0, Amended 7, Repealed 0.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 4, Repealed 0.

Number of Sections Adopted using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 1, Amended 7, Repealed 0.

Date Adopted: August 14, 2019.

AMENDATORY SECTION(Amending WSR 14-06-037, filed 2/25/14, effective 3/28/14)

WAC 246-105-020Definitions.

((For the purposes of this chapter, the words and phrases in this section have the following meanings))The definitions in this section apply throughout this chapter unless the context clearly indicates otherwise:

(1) "Certificate of exemption (COE)" means a form for the purpose of documenting an exemption to the school or child care immunization requirements that is((:

(a)))approved by the department and consistent with the requirements of WAC 246-105-050(((2); or

(b) An immunization form produced by the state immunization information system))(4).

(2) "Certificate of immunization status (CIS)" means a form for the purpose of documenting a person's immunization status that is((:

(a)))approved by the department and consistent with the requirements of WAC 246-105-050(((1); or

(b) An immunization form produced by the state immunization information system))(2).

(3) "Chief administrator" means:

(a) The person with the authority and responsibility for supervising the immediate operation of a school or child care center; or

(b) A person designated in writing by the statutory or corporate board of directors of the school district or school; or

(c) If (a) and (b) of this subsection do not apply, a person or persons with the authority and responsibility for supervising the general operation of the school district or school.

(4) "Child" means any person regardless of age admitted to:

(a) Any public school district; or

(b) Any private school or private institution subject to approval by the state board of education or described in RCW 28A.305.130 and 28A.195.010 through 28A.195.060; or

(5) "Child care center" means any facility or center licensed by the department of ((early learning))children, youth, and families under chapter ((43.215))43.216 RCW that regularly provides ((care for a group of thirteen or more children one month of age through twelve years of age))early childhood education and early learning services for a group of children for periods of less than twenty-four hours per day.

(6) "Child care health consultant" means a licensed registered nurse meeting the qualifications established in WAC 110-300-0275 or their designee.

(7) "Conditional" means a type of temporary immunization status where a child is not fully immunized against one or more of the vaccine-preventable diseases required by this chapter ((for full immunization)). A child in this status is allowed to attend a school or child care center ((provided))only if the ((child makes satisfactory progress toward full immunization))parent provides proof of immunization consistent with the schedule established in WAC 246-105-060 (2)(a).

(((7)))(8) "Department" means the Washington state department of health.

(((8)))(9) "Exempt" or "exemption" means a type of immunization status where a child has not been fully immunized against one or more of the vaccine-preventable diseases required by this chapter ((for full immunization)) due to medical, religious, philosophical or personal reasons. A child in this status is allowed to attend a school or child care center only by providing the required COE form.

(((9)))(10) "Full immunization" or "fully immunized" means an immunization status where a child has ((provided)) proof of acquired immunity or has been vaccinated with immunizing agents against each of the vaccine-preventable diseases listed in WAC 246-105-030 according to the national immunization guidelines described in WAC 246-105-040.

(((10)))(11) "Health care practitioner" means a physician licensed under chapter 18.71 or 18.57 RCW, a naturopath licensed under chapter 18.36A RCW, a physician assistant licensed under chapter 18.71A or 18.57A RCW, or an advanced registered nurse practitioner licensed under chapter 18.79 RCW.

(((11)))(12) "Health care provider" means a person licensed, certified or registered in a profession listed in RCW 18.130.040(2), if administering vaccinations is within the profession's scope of practice.

(((12)))(13) "Immunizing agent" means any vaccine or other immunologic drug licensed and approved by the United States Food and Drug Administration (FDA), or meeting World Health Organization (WHO) requirements, for immunization of persons against vaccine-preventable diseases.

(((13)))(14) "Local health officer" means the individual appointed under chapter 70.05 RCW as the health officer for the local health department, or appointed under chapter 70.08 RCW as the director of public health of a combined city-county or combined county health district.

(((14)))(15) "Medically verified immunization record" means a valid record that is:

(a) An electronic or written medical health record from a health care provider or facility at which the provider practices; or

(b) A document from a secure, web-based application that records and tracks immunization dates such as an immunization registry.

(16) "National immunization guidelines" means guidelines that are:

(a) Approved by the Advisory Committee on Immunization Practices (ACIP); and

(b) Published in the Morbidity and Mortality Weekly Report (MMWR); and

(((15)))(17) "Out of compliance" means a type of immunization status where a child:

(a) Is not fully immunized for their age and grade against any of the vaccine-preventable diseases listed in WAC 246-105-030 according to the national immunization guidelines described in WAC 246-105-040; and

(b) Is not in conditional status for the missing required immunization; and

(18) "Parent" means, for the purposes of signature requirements in this rule:

(a) The mother, father, legal guardian, or any adult in loco parentis of a child less than eighteen years of age; or

(b) A person who is eighteen years of age or older and signing for themselves; or

(((16)))(19) "Religious membership" means membership in a religious body or church whose teachings or beliefs preclude a health care practitioner from providing medical treatment to the child.

(((17) "Satisfactory progress" for purposes of conditional status or an expired temporary medical exemption means the start or continuance towards full immunization status through the receipt of missing immunizations in a manner consistent with the national immunization guidelines described in WAC 246-105-040 and within the following time frames:

(a) Any missing immunizations must be received within thirty days after the first day of attendance or after a temporary medical exemption is no longer valid, unless receipt within such time is inconsistent with the guidelines.

(b) When the immunizations are part of a series with recommended intervals between doses, each additional missing immunization must be received no later than thirty days past the recommended date of administration of the next dose as established by the guidelines.

(18)))(20) "School" means a facility, site, or campus for programs of education as defined in RCW 28A.210.070 to include preschool and kindergarten through grade twelve.

(21) "School nurse" means person credentialed under chapter 18.79 RCW, meeting the qualifications for a school nurse established under chapter 181-79A WAC, or their designee.

(22) "Washington state immunization information system (WAIIS)" means a statewide, secure, web-based lifetime immunization registry that tracks medically verified immunization records for people of all ages in Washington state.

(23) "WAIIS school module" means a feature of the WAIIS that allows users to track and manage medically verified student and school-level immunization information.

AMENDATORY SECTION(Amending WSR 17-16-124, filed 7/31/17, effective 8/31/17)

WAC 246-105-040Requirements based on national immunization guidelines.

The department shall develop and distribute implementation guidelines for schools and child care centers that are consistent with the national immunization guidelines described in this section and the requirements in WAC 246-105-090.

(1) Unless otherwise stated in this section, a child must be vaccinated against, or provide documentation of immunity against, each vaccine-preventable disease listed in WAC 246-105-030 at ages and intervals according to the national immunization guidelines in the "Advisory Committee on Immunization Practices (ACIP) Recommended Immunization Schedule for Children and Adolescents Aged 18 Years or Younger—United States, ((2017))2019"; as published in the Morbidity and Mortality Weekly Report (MMWR) ((2017;66(5):134-135))2019; 68(5):112-114.

(2) As part of the implementation guidelines, the department shall align the ages and intervals specified in the national immunization guidelines and this chapter with a corresponding grade level.

(3) In addition to the ages and intervals required by subsections (1) and (2) of this section, the following vaccine administration guidelines shall apply.

(a) Schools shall accept proof of immunization status by grade level as required by subsection (2) of this section.

(b) Schools and child care centers may accept one of the following as proof of a child's immunization status against varicella:

(((a)))(i) Documentation on the CIS form that the child received age appropriate varicella vaccine; or

(((b)))(ii) Diagnosis or verification of a history of varicella disease by a health care provider acting within ((his or her))their scope of practice; or

(((c)))(iii) Diagnosis or verification of a history of herpes zoster by a health care provider acting within ((his or her))their scope of practice; or

(((d)))(iv) Serologic proof of immunity against varicella; or

(((e)))(v) Documentation by the parent that a child has a history of varicella. This type of proof will be accepted only for certain grade levels described in the department's implementation guidelines according to WAC 246-105-090(2).

AMENDATORY SECTION(Amending WSR 14-06-037, filed 2/25/14, effective 3/28/14)

WAC 246-105-050Required documentation of immunization status.

(1)(a) Before a child may attend a school or child care center, a parent must provide proof of immunization status using ((the following documentation:

(a) A department-approved CIS form signed by the parent. The CIS form must include:

(i)))either a CIS or a COE form, or both. Information provided on these forms is to be used by a school nurse, child care health consultant, or the chief administrator to determine the immunization status of a child as: Fully immunized, out of compliance, conditional, or exempt.

(b) Any child identified as experiencing homelessness under the McKinney-Vento Homeless Assistance Act 42 U.S.C. 11431 et seq., or in foster care under 20 U.S.C. 6311(g)(1)(E) lacking documentation of immunization status on or before the first day of attendance must be immediately enrolled and allowed to fully participate in all school activities.

(2) The CIS form must be either produced from the WAIIS or a department-approved hardcopy CIS form. A hardcopy CIS form not produced from the WAIIS must include completion of the following fields:

(a) Name of child;

(((ii)))(b) Birth date;

(((iii)))(c) Type of vaccine(s) administered;

(((iv)))(d) Month, day, and year of each dose of vaccine received;

(((v)))(e) A section to indicate whether a COE form accompanies the CIS form;

(((vi)))(f) If applicable, a statement signed and dated by a parent acknowledging the requirements for their child's attendance under conditional status, which includes progress towards full immunization consistent with the schedule established in WAC 246-105-060 (2)(a);

(g) A section to document serologic proof of immunity signed by a health care provider acting within ((his or her))their scope of practice ((and including a copy of a lab report)); and

(((vii) Parent signature and date.

(b) If applicable,))(h) A statement signed and dated by a health care provider stating that the information on the CIS is accurate; or

(i) A statement signed and dated by a school nurse, child care health consultant, or the chief administrator stating that they have confirmed the accuracy of the CIS by review of the child's medically verified immunization record, and have attached the medically verified record to the CIS. For the verification to be valid the immunization record must contain:

(i) Name of child;

(ii) Birth date;

(iii) Type(s) of vaccines administered;

(iv) Month, day, and year of each vaccine administration or if applicable serologic proof of immunity verified by a health care provider acting within their scope of practice; and

(v) The name and signature of the health care provider responsible for administering or reviewing each immunization; or

(vi) A unique stamp, logo, or other information identifying the health care provider or facility at which the provider practices.

(3) Alternately, in lieu of a CIS, a school or child care center using the WAIIS school module may accept verification by school staff that the child is fully immunized as recorded in the WAIIS.

(4) A parent who seeks an exemption to the immunization requirement must provide a department-approved COE form signed by a parent. A COE form must include:

(((i)))(a) Name of child;

(((ii)))(b) Birth date;

(((iii) A place))(c) A field to indicate whether the parent is claiming a medical, religious, personal, or philosophical exemption. Philosophical and personal objections may not be used to exempt a child from measles, mumps, and rubella vaccine as described in WAC 246-105-055. This field must include:

(((A)))(i) A statement ((signed and dated by a health care practitioner))from a health care practitioner that includes the practitioner's printed name, signature, and date of signature stating that ((he or she has))they have provided the parent information about the benefits and risks of immunization to the child as a condition of obtaining a medical, religious, personal, or philosophical exemption;

(((B)))(ii) The requirement in (((b)(iii)(A)))(4)(c)(i) of this subsection does not apply to a parent who demonstrates a religious membership under subsection (((b)(iii)(F)))(4)(c)(vi) of this subsection;

(((C) A place))(iii) A field to indicate any permanent or temporary medical exemption, and if temporary, the exemption expiration date for one or more vaccines which must be signed and dated by a health care practitioner;

(((D) A place))(iv) A field to indicate any personal or philosophical exemption for one or more vaccines, except for the measles, mumps, and rubella vaccine as described in WAC 246-105-055;

(((E) A place))(v) A field to indicate any religious exemption for one or more vaccines; and

(((F) A place))(vi) A field to demonstrate religious membership. This must include a statement signed and dated by the parent ((identifying the name of the church or religious body,)) affirming membership in ((it, and affirming that the religious beliefs or))a church or religious body where the teachings of the church or religious body preclude a health care practitioner from providing medical treatment to the child;

(((iv)))(d) Notice to parents that if an outbreak of vaccine-preventable disease for which the child is exempted occurs, the child may be excluded from the school or child care center for the duration of the outbreak; and

(((v)))(e) Parent signature and date.

(((2)))(5) Parents who must include a signed statement from a health care practitioner under subsection (((1)(b)(iii)))(4)(c)(i) of this section may submit:

(a) A photocopy of the signed COE in place of the original; or

(b) Along with the COE form, a letter from the health care practitioner in ((place))lieu of the signed statement under subsection (((1)(b)(iii)))(4)(c)(i) of this section. The letter must:

(i) Indicate that the health care practitioner has provided the parent information about the benefits and risks of immunization to the child;

(ii) Reference the child's name; and

(iii) Be signed and dated by the health care practitioner.

(((3)))(6) If immunizations are deferred on a temporary basis for medical reasons under subsection (((1)(b)(iii)(C)))(4)(c)(iii) of this section, the child must ((make satisfactory progress toward))provide proof of full immunization consistent with the schedule established in WAC 246-105-060 (2)(a) once the medical exemption has expired.

WAC 246-105-055Philosophical and personal exemption for measles, mumps, and rubella vaccine prohibited.

A philosophical or personal exemption may not be used to exempt a child from the measles, mumps, and rubella immunization requirement.

AMENDATORY SECTION(Amending WSR 14-06-037, filed 2/25/14, effective 3/28/14)

WAC 246-105-060Duties of schools and child care centers.

(1) Schools and child care centers shall require((:

(a)))on or before the first day of attendance either a CIS or COE form ((conforming to))that documents a child's immunization status as required by WAC 246-105-050 (((1))):

(a) For new enrollees registering for admission into preschool and kindergarten through grade twelve or a child care center as a requirement of admission((. Information on the CIS is used to determine if a child is fully immunized, conditional or exempt.

(b) For enrollees attending under conditional status or an expired temporary medical exemption, documentation of satisfactory progress toward full immunization.

(c) For enrollees claiming exempt status, a signed COE form indicating a medical, religious, philosophical, or personal exemption conforming to WAC 246-105-050 (1)(b)(iii) or, if applicable, WAC 246-105-050(2).

(2)));

(b) Annually for continued enrollment in a child care center; and

(c) Any child identified as experiencing homelessness under the McKinney-Vento Homeless Assistance Act 42 U.S.C. 11431 et seq., or in foster care under 20 U.S.C. 6311(g)(1)(E) lacking documentation of immunization status on or before the first day of attendance must be immediately enrolled and allowed to fully participate in all school activities.

(2) A school nurse, child care health consultant, or chief administrator shall use information from the CIS or COE form to determine the immunization status of a child as: Fully immunized, out of compliance, conditional, or exempt.

(a) For enrollees attending under conditional status or an enrollee with an expired temporary medical exemption, except those identified under subsection (1)(c) of this section, the following schedule for documenting proof of full immunization applies:

(i) Any doses the child is eligible to receive based on the requirements established in WAC 246-105-040 must be administered on or before the first day of attendance. Any additional missing immunizations must be received within thirty calendar days after the first day of attendance or after a temporary medical exemption is no longer valid, unless receipt within such time is inconsistent with the national immunization guidelines; or

(ii) When the immunizations are part of a series with recommended intervals between doses, each additional missing immunization must be received no later than thirty calendar days past the recommended date of administration of the next dose as established by the national immunization guidelines.

(b) Failure to document proof of full immunization consistent with the schedule established in (a) of this subsection shall result in exclusion of a child from a school or a child care center as described in WAC 246-105-080.

(3) In maintaining child immunization records, schools and child care centers shall:

(a) Keep all department-approved forms described in WAC 246-105-050 for each enrolled child attending their school or child care ((center)).

(b) Keep ((a))or be able to produce within twenty-four hours a current list of children ((currently with medical, religious, philosophical, or personal exemptions))who are not fully immunized. This list must be transmitted to the local health department upon request.

(c) Return the applicable department-approved CIS or ((applicable)) COE or a legible copy of such documents to the parent if the child is withdrawn from a school or child care center or transferred from the school. A school or child care center may not withhold from the parent a child's department-approved CIS or COE for any reasons, including nonpayment of school or child care center fees.

(d) Provide access to immunization records to agents of the state or local health department of each child enrolled.

(((3)))(4) In maintaining child immunization records, the chief administrator shall:

(a) Retain records for at least three years on a child who is excluded from school under this chapter. The record must include the child's name, address, and date of exclusion.

(b) Submit an immunization status report under ((chapter 28A.210 RCW either electronically on the internet or on a form provided))RCW 28A.210.110 in a manner approved by the department. The report must be submitted to the department by November 1 of each year. If a school opens after October 1, the report is due thirty calendar days from the first day of school.

AMENDATORY SECTION(Amending WSR 14-06-037, filed 2/25/14, effective 3/28/14)

WAC 246-105-070Duties of health care providers or organizations.

A health care provider administering immunizations, or the organizations he or she works for, either public or private, shall furnish each person immunized, or ((his or her))their parent, with a ((written))medically verified immunization record ((of immunization)) containing information required by this chapter.

AMENDATORY SECTION(Amending WSR 09-02-003, filed 12/26/08, effective 1/26/09)

WAC 246-105-080Criteria for excluding children from schools or child care centers.

For any child excluded under subsection (1), (2), or (3) of this section, schools must use procedures consistent with chapters 180-38 and 392-380 WAC. A school or child care center shall exclude a child if one or more of the following applies:

(1) Parent(s) fail to provide ((a completed CIS form))documentation of immunization status as required in WAC 246-105-050 on or before the child's first day of attendance.

(2) A child attending under conditional status fails to make ((satisfactory)) progress toward full immunization as required in WAC 246-105-060 (2)(a).

(3) A child has been admitted under a temporary medical exemption and the particular vaccine for which the exemption was granted is no longer contraindicated and the child fails to make ((satisfactory)) progress toward full immunization as required in WAC 246-105-060 (2)(a).

(4) A local health officer excludes a child from school or a child care center under chapter 246-110 WAC during an outbreak of a vaccine-preventable disease if the child has not been fully immunized against that disease due to:

(a) Conditional status;

(b) Out of compliance status;

(((c)))(d) Religious exemption;

(((d)))(e) Philosophical exemption; or

(((e)))(f) Personal exemption.

AMENDATORY SECTION(Amending WSR 09-02-003, filed 12/26/08, effective 1/26/09)

WAC 246-105-090Implementation.

(1) The department shall develop and distribute implementation guidelines for schools and child care centers that:

(a) ((Interpret immunization requirements by grade level consistent with the ages specified in the national immunization guidelines and this chapter))Meet the requirement of WAC 246-105-040(2); and

(b) Reflect national immunization guidelines for children who did not receive required immunizations prior to entry into kindergarten or first grade, and for whom a full series of immunizations is not recommended.

(2) The department may develop school implementation guidelines that waive or modify immunization requirements when a phasing-in period is warranted for a new immunization mandate, when there is limited availability of a required immunizing agent, or when new information about the safety or efficacy of an immunizing agent prompts a reevaluation of an existing vaccination requirement. Any waiver or modification must:

(a) Reflect the best available medical research as indicated by the ACIP or the state health officer recommendation;

(b) Identify a specific vaccine-preventable disease or immunizing agent;

(d) Be limited in duration; and

(e) Be approved by the board.