Texas Health Officials Update Vaccination Schedule for Elementary and
Secondary School Students
By Craig A. Conway, J.D., LL.M.
caconway@central.uh.edu
Introduction
Earlier this year, the Centers for Disease Control and Prevention (CDC), the American
Academy of Pediatrics (AAP), and the American Academy of Family Physicians jointly
released updated recommended immunization schedules for children and adolescents
based upon guidance from the Advisory Committee on Immunization Practices (ACIP).1
The ACIP is made up of 15 experts in fields associated with immunization who have
been selected by the Secretary of the U.S. Department of Health and Human Services to
provide guidance on the control of vaccine-preventable diseases and to develop written
recommendations for the routine administration of vaccines to children and adults.2 The
ACIP is the only entity in the federal government that makes such recommendations.3
The annual recommended immunization schedules issued by the ACIP are used by states
and the federal government to set budget priorities for vaccination programs as well as by
state departments of health to formulate immunization policies for school children; states,
however, are not legally required to adopt the recommended schedules.4
In response to the recommendations proffered by the CDC and ACIP, the Executive
Commissioner on Texas Health and Human Services revised state immunization
requirements for students in public and private elementary and secondary schools.5 This
update to the vaccination schedule comes at a time when an increasing number of parents
are actively voicing objections and concerns about the safety of vaccinations with some
continuing to claim they contribute to debilitating conditions such as autism.6
1
Centers for Dis. Control and Prev., Recommended Immunization Schedules for Persons Aged 0 Through
18 Years – United States, 2009, 57 MORB. AND MORT. WKLY RPT. Nos. 51 & 52, (Jan. 2, 2009), available
at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5751a5.htm (last visited May 18, 2009).
2
See generally Centers for Dis. Control and Prev., Advisory Committee on Immunization Practices (ACIP),
available at http://www.cdc.gov/vaccines/recs/ACIP/default.htm (last visited May 18, 2009).
3
Id.
4
See Ronald Scott, Immunization Law Update, 14 UPDATE ON HEALTH 1 (Jan. 2009).
5
Texas Dep’t of State Health Svcs, Letter to Physicians and School Administrators re: Changes in Texas
Immunization Requirements, (Mar. 6, 2009), available at http://www.dshs.state.tx.us/immunize/school/
SchoolChangesMemo.pdf (last visited May 18, 2009).
6
See generally Jenny McCarthy’s Autism Organization, Generation Rescue, Inc., http://www.
generationrescue.org (last visited May 18, 2009); WMUR, Vaccine Decision Pits Some Parents Against
Doctors, (May 8, 2009), available at http://www.wmur.com/health/19397989/detail.html (last visited May
18, 2009) (New Hampshire has one of the most extensive childhood vaccination schedules in the country).
Vaccination Safety
Government agencies, including the FDA, CDC, and the Department of Health and
Human Services, as well as pediatric and adolescent organizations such as the American
Academy of Pediatrics (AAP), tout vaccines as being safer now than at any other time in
history.7 As some diseases have virtually disappeared in recent decades, in part due to
widespread use of vaccinations, new parents are often concerned as their children receive
between 20 and 30 vaccination injections before the age of two.8 As the AAP explains:
[v]accines contain antigens, which are either live but very weakened
viruses, inactivated viruses, or small parts of bacteria or viruses that
prompt the body to produce protective antibodies without causing the
disease. Even though children receive more vaccines now, the total
number of antigens is less because today’s vaccines are more refined than
older versions. At a very young age, children’s immune systems are
equipped to respond to many antigens at the same time, including those in
vaccines…9
The AAP and other public health authorities assert that “the risks of serious consequences
following vaccination are many hundreds or thousands of times less likely than the risks
associated with the diseases that the vaccines protect against.”10 Most adverse reactions
are not serious—including low-grade fever or soreness at the injection site.11 They
additionally note that, while rare, serious allergic reactions to vaccines include swelling,
itching, weakness, dizziness, and difficulty breathing.12
Many parents are concerned about the allegation that some vaccines, specifically the
MMR vaccine, contribute to a diagnosis of autism in children. Generation Rescue, the
autism organization led by Jenny McCarthy and Jim Carrey, has long voiced a causal link
between vaccines and the incidence of autism. A recent report issued by the organization
concluded that “[t]he United States has the highest number of mandated vaccines of any
country in the world, the highest prevalence of autism in the world, and places 34th for
7
See Am. Acad. of Pediatrics, Facts for Parents About Vaccine Safety, (June 2008), available at http://
www.cispimmunize.org/fam/facts/VaccineSafety_English.doc (last visited May 18, 2009); U.S. Food &
Drug Admin., A Parent’s Guide to Kids’ Vaccines, (July 31, 2007), available at http://www.fda.gov/
consumer/updates/kidsvaccines073107.html (last visited May 18, 2009).
8
See Centers for Dis. Control and Prev., Vaccines & Immunizations: Why Immunize?, (July 11, 2003),
available at http://www.cdc.gov/vaccines/vac-gen/why.htm (last visited May 18, 2009); Donald G.
McNeil, Jr., A Multitude of Vaccine Benefits, Yet Controversy Persists, N.Y. TIMES, (Mar. 29, 2008),
available at http://health.nytimes.com/ref/health/healthguide/esn-vaccinations-ess.html (last visited May
18, 2009).
9
Facts for Parents About Vaccine Safety, supra note 7.
10
Immunization Action Coalition, It’s Federal Law! You Must Give Your Patients Current Vaccine
Information Statements, (Dec. 2008), available at http://www.immunize.org/catg.d/p2027.pdf (last visited
May 18, 2009).
11
See Guide to Kids’ Vaccines, supra note 7.
12
Id.
under 5 mortality.”13 It stated that further research is needed to conclusively determine a
lack of causal relationship between vaccines and autism.14 Jim Carrey recently stated:
[i]n this growing crisis, we cannot afford to blindly trumpet the agenda of
the CDC, the American Academy of Pediatrics (AAP) or vaccine makers.
Now more than ever, we must resist the urge to close this book before it's
been written. The anecdotal evidence of millions of parents who've seen
their totally normal kids regress into sickness and mental isolation after a
trip to the pediatrician's office must be seriously considered.15
In February 2009, the London Sunday Times reported that the doctor who first raised
concerns about the safety of the measles, mumps, and rubella (MMR) vaccine “changed
and misreported results in his research, creating the appearance of a possible link with
autism.”16 This news came after years of numerous scientific studies conducted on the
relationship between autism and thimerosal, a mercury-based preservative once used in
several vaccines, including the MMR vaccine.17 The studies concluded there was no
causal connection between the presence of thimerosal in vaccines and the incidence of
autism in children.18
Thimerosal was removed from childhood vaccines in 2001, and the AAP states that
autism rates have actually increased—thus suggesting that the presence of thimerosal is
13
Generation Rescue, Inc., Autism and Vaccines Around the World: Vaccine Schedules, Autism Rates, and
Under 5 Mortality, (Apr. 2009), available at http://www.generationrescue.org/documents/SPECIAL%20
REPORT%20AUTISM%202.pdf (last visited May 18, 2009).
14
Id.
15
Jim Carrey, The Judgment on Vaccines Is In???, THE HUFFINGTON POST, (Apr. 22, 2009), available at
http:// www.huffingtonpost.com/jim-carrey/the-judgment-on-vaccines_b_189777.html (last visited May 18,
2009).
16
Brian Deer, MMR Doctor Andrew Wakefield Fixed Data on Autism, THE SUNDAY TIMES, (Feb. 8, 2009),
available at http://www.timesonline.co.uk/tol/life_and_style/health/article5683671.ece (last visited May
18, 2009).
17
Facts for Parents About Vaccine Safety, supra note 7.
18
See M.E. Pichichero, A. Gentile, N. Giglio, et al., Mercury levels in newborns and infants after receipt of
thimerosal-containing vaccines, 121(2) PEDIATRICS e208-14 (2008) (finding relatively low blood mercury
levels in all age groups); R. Schechter and J.K. Grether, Continuing increases in autism reported to
California’s Developmental Services System: Mercury in retrograde, 65(1) ARCH. GEN. PSYCH. 19-24
(2008) (data showed no decrease in rates of autism as exposure to thimerosal was reduced or eliminated);
W.W. Thompson, C. Price, and B. Goodson, et al., Early thimerosal exposure and neuropsychological
outcomes at 7 to 10 years, 357(13) NEW ENG. J. MED. 1281-92 (2007) (data suggests no causal connection
between increasing exposure to mercury in thimerosal early in life and subsequent neuropsychological
issues at 7 to 10 years of age); S.K. Parker, B. Schwartz, J. Todd, and L.K. Pickering, ThimerosalContaining Vaccines and Autistic Spectrum Disorder: A Critical Review of Published Original Data, 114
PEDIATRICS 793-804 (2004) (data demonstrated no association between thimerosal-containing vaccines and
autism); J. Heron, J. Golding, et al., Thimerosal Exposure in Infants and Developmental Disorders: A
Prospective Cohort Study in the United Kingdom Does Not Support a Causal Association, 114 PEDIATRICS
577-83 (2004) (study shows no evidence of any harmful effect of thimerosal-containing vaccines on
neurologic or psychological outcomes); P. Stehr-Green, P. Tull, M. Stellfeld, et al., Autism and thimerosalcontaining vaccines: Lack of consistent evidence, 25(2) AM. J. OF PREV. MED. 101-106 (2003) (study adds
to evidence that thimerosal-containing vaccines do not cause autism or similar disorders).
not linked to autism.19 The Institute of Medicine concluded that “the evidence favors
rejection of a causal relationship between thimerosal-containing vaccines and autism.”20
Additionally, a recent report from a CDC-funded study in Italy additionally concluded
that thimerosal “once used in many vaccines doesn’t hurt children, offering more
reassurance to parents.”21
Vaccines are continuously reviewed and monitored by government agencies. The Center
for Biologics Evaluation and Research (CBER) is an arm of the FDA that regulates
vaccines in the United States.22 It works with other agencies to study and monitor
vaccine safety and effectiveness. Additionally, Federal law requires that Vaccine
Information Statements (VISs) produced by the CDC be handed out to recipients
whenever vaccinations are given.23
Texas Vaccination Schedule for Students
On March 6, 2009, the Texas Department of State Health Services (DSHS) issued a letter
to physicians and school administrators informing them of changes to required
immunizations for students.24 Currently, there is no required immunization against
human papillomavirus.25 Below is a summary of the changes made to the vaccination
schedule for the Texas 2009-2010 school year:
Hepatitis A Vaccine: Beginning August 1, 2009, all students entering kindergarten,
statewide, will be required to have 2 doses of Hepatitis A vaccine.26 Hepatitis A is an
easily transmittable liver disease caused by the virus producing “flu-like” illness,
jaundice, stomach pains, and diarrhea.27 The vaccine has been administered worldwide
and is known to have only mild side effects including soreness at the injection site, loss
of appetite, and/or tiredness.28
19
Facts for Parents About Vaccine Safety, supra note 7.
See Centers for Dis. Control and Prev., Mercury and Vaccines (Thimerosal), http://www.cdc.gov/vaccine
safety/concerns/thimerosal.htm (last visited May 20, 2009); Inst. of Med., Immunization Safety Review:
Vaccines and Autism, (May 17, 2004), available at http://www.iom.edu/CMS/3793/4705/20155.aspx (last
visited May 21, 2009).
21
Carla K. Johnson, Assoc. Press, Study Adds to Evidence of Vaccine Safety, ABC NEWS, (Jan. 26, 2009),
available at http://abcnews.go.com/Health/AutismNews/wireStory?id=6729335 (last visited May 18,
2009).
22
See Guide to Kids’ Vaccines, supra note 7.
23
See generally Centers for Dis. Control and Prev., Vaccine Information Statements, http://www.cdc.gov/
vaccines/pubs/vis/default.htm (last visited May 19, 2009).
24
See Letter to Physicians and School Administrators re: Changes in Texas Immunization Requirements,
supra note 5.
25
TEX. EDUC. CODE ANN. § 38.001(b-1) (Vernon 2007).
26
See Letter to Physicians and School Administrators re: Changes in Texas Immunization Requirements,
supra note 5.
27
See Guide to Kids’ Vaccines, supra note 7.
28
Id.
20
Measles, Mumps, Rubella (MMR) Vaccine: Beginning August 1, 2009, all students
entering kindergarten will be required to have 2 doses of the MMR vaccine.29 Measles is
a respiratory infection causing skin rash and flu-like symptoms.30 Serious complications
can lead to ear infection, pneumonia, seizures and brain damage.31 Mumps causes fever,
headache, swollen glands and in some cases, deafness and meningitis.32 Rubella, also
referred to as the German Measles, is an infection of the skin and lymph nodes sometimes
causing arthritis.33 Pregnant women should not receive the MMR vaccine as there is a
risk of serious consequences to the fetus.34 Common side effects of this vaccine include
fever, soreness at the injection site, and a mild rash.35
Varicella (Chickenpox) Vaccine: Beginning August 1, 2009, all students entering
kindergarten and 7th grade will be required to have 2 doses of this vaccine.36 However, a
written statement from a parent, guardian, school nurse, or physician attesting that a child
has been exposed to, or has a positive history of chickenpox, or otherwise is immune, is
acceptable in lieu of immunization.37 Chicken pox is caused by the varicella-zoster virus,
causing itchy blisters and fever.38 More serious complications can include skin infection,
swelling of the brain, and pneumonia.39
Tetanus, Diphtheria, and acellular pertussis-containing vaccine (Tdap): Beginning
August 1, 2009, all students entering the 7th grade will be required to have one dose of
Tdap vaccine. Students in the 7th grade will be required to have a booster dose of Tdap
only if it has been 5 years since their last dose of a tetanus-containing vaccine. Students
in grades 8-12 are required to have a booster dose of Tdap if it has been 10 years since
their previous dose of a tetanus-containing vaccine. Td is acceptable in lieu of Tdap if a
contradiction to pertussis exists.40 The Tdap vaccine protects children against bacterial
infections resulting in lockjaw and whooping cough.41 The Tdap vaccine, Boostrix, is
licensed for use in children, ages 10 to 18 years.42 Adacel is licensed for individuals,
ages 11 to 64.43 Common side effects include mild fever, pain at the injection site,
headache, and fatigue.44
29
See Letter to Physicians and School Administrators re: Changes in Texas Immunization Requirements,
supra note 5.
30
See Guide to Kids’ Vaccines, supra note 7.
31
Id.
32
Id.
33
Id.
34
See Centers for Dis. Control and Prev., Guidelines for Vaccinating Pregnant Women, http://www.cdc.
gov/vaccines/pubs/preg-guide.htm (last visited May 20, 2009).
35
See Guide to Kids’ Vaccines, supra note 7.
36
See Letter to Physicians and School Administrators re: Changes in Texas Immunization Requirements,
supra note 5.
37
Id.
38
See Guide to Kids’ Vaccines, supra note 7.
39
Id.
40
See Letter to Physicians and School Administrators re: Changes in Texas Immunization Requirements,
supra note 5.
41
See Guide to Kids’ Vaccines, supra note 7.
42
Id.
43
Id.
44
Id.
Meningococcal Vaccine: Beginning August 1, 2009, all students entering the 7th grade
will be required to have one dose of this vaccine.45 In October 2007, FDA approved
expanding the age of children eligible to receive this vaccine to those 2 to 10 years.46
Meningococcal disease is the leading cause of bacterial meningitis47 in children 2-18
years old in the United States and is contracted by contact with an infected person, i.e.,
kissing, sharing food/drink, etc.48 Common side effects include soreness at the injection
site, headache, and fatigue.49
A phase-in schedule accompanies the vaccination schedule for the specific school year
and grade(s) for each vaccine requirement. The phase-in schedule may be found on the
Texas
DSHS
website
at
the
following
web
address:
http://www.dshs.state.tx.us/immunize/school/SchoolRules_Phase-InSschedule.pdf.
Texas Law
Pursuant to Texas law, the Executive Commissioner of Texas Health and Human
Services Commission or the Department of State Health Services “may modify or delete
any of the immunizations” required for any student entering any elementary or secondary
school.50 The vaccine requirements apply to all children and students, “entering,
attending, enrolling in, and/or transferring to child-care facilities or public or private
primary or secondary schools or institutions of higher education.”51 Although a child is
required to show evidence of vaccination prior to entry, attendance, or transfer to a childcare facility or public or private elementary or secondary school,52 provisional admittance
will be allowed if a parent is able to show that the child has begun the required
immunizations and continues to receive them as rapidly as is medically feasible.53
Acceptable evidence of vaccination includes: (1) documentation from a health care
provider that includes the signature or stamp of the physician or his/her designee, or
public health personnel; (2) an official immunization record generated from a state or
local health authority; or (3) a record received from school officials including a record
from another state.54
45
See Letter to Physicians and School Administrators re: Changes in Texas Immunization Requirements,
supra note 5.
46
See Guide to Kids’ Vaccines, supra note 7.
47
Meningitis is an infection of fluid surrounding the brain and spinal cord.
48
See Guide to Kids’ Vaccines, supra note 7; see also The Children’s Hosp. of Phila., Vaccine Education
Center: A Look at Each Vaccine: Meningococcus Vaccine, available at http://www.chop.edu/consumer/jsp/
division/generic.jsp?id=75734 (last visited May 19, 2009).
49
Id.
50
TEX. EDUC. CODE ANN. § 38.001(b) (Vernon 2007).
51
TEX. ADMIN. CODE ANN. § 97.61(a) (Vernon 2008).
52
TEX. ADMIN. CODE ANN. § 97.63(2) (Vernon 2008).
53
TEX. EDUC. CODE ANN. § 38.001(e) (Vernon 2007); see also TEX. ADMIN. CODE ANN. § 97.66 (Vernon
2008).
54
TEX. ADMIN. CODE ANN. § 97.68 (Vernon 2008).
Exceptions to Immunization
Immunization of children in Texas schools is not required if a parent or guardian submits
an affidavit on a form provided by DSHS,55 signed by a physician, stating that
immunization “poses a significant risk to the health and well-being” of the child or any
member of the child’s family; alternatively, a parent or guardian may submit an affidavit
declining immunization for reasons of conscience, including religious belief.56 It is
important to note that if a student lacks the required immunizations, the child may be
excluded from school in times of emergency or epidemic declared by the commissioner
of public health.57
The form provided by DSHS contains a statement that the parent or guardian understands
the risks and benefits of immunizations as well as the risks of not being vaccinated. The
law requires DSHS to advise the legislature annually of the number of forms sent out, but
specifically prohibits DSHS from maintaining a record of the names of individuals who
request an affidavit form.58 The number of conscientious exemptions has increased every
year since such exemptions were allowed in 2003.59
Conclusion
As a parent, I often struggle with the idea of injecting my three-year-old with anything,
let alone live or inactivated forms of disease-causing bacteria. Further, the number of
shots it takes to become fully immunized is great. The CDC states that if enough parents
do not vaccinate their children, over time, once deadly diseases could potentially stage a
comeback.60 Thus not following immunization schedules could mean risking a child’s
exposure to potentially life-threatening diseases.
The choice for parents therefore
appears to be one of two different paths: vaccinate or not. It is a decision each parent
should weigh.
Health Law Perspectives (May 2009), available at:
http://www.law.uh.edu/healthlaw/perspectives/homepage.asp
55
TEX. HEALTH & SAFETY CODE ANN. § 161.0041 (Vernon 2008).
TEX. EDUC. CODE ANN. § 38.001(c)(1) (Vernon 2007); see also TEX. ADMIN. CODE ANN. § 97.62
(Vernon 2008).
57
TEX. EDUC. CODE ANN. § 38.001(f) (Vernon 2007).
58
See Scott, supra note 4; TEX. HEALTH & SAFETY CODE ANN. § 161.004(e).
59
Tex. Dep’t of State Health Svcs, Reducing Vaccine Preventable Disease in Texas: Strategies to Increase
Vaccine Coverage Levels, at p. 4, (Dec. 2008), available at http://www.dshs.state.tx.us/immunize/docs/
2008Report.pdf (last visited May 19, 2009).
60
Vaccines & Immunizations: Why Immunize?, supra note 8.
56