The New York State Department of Health (NYSDOH) received 19 comments from school nurses and physicians during the comment period. Commenters strongly supported the proposed requirement that students complete the measles, mumps, rubella (MMR), diphtheria, tetanus, and pertussis (DTaP) and polio vaccine series upon kindergarten entry. Additional comments were as follows:

Comment: Amendments to the regulations should not take effect until the Fall of 2016. Schools need more time to update systems and materials and to communicate the new immunization requirements to parents. Many schools have already completed kindergarten registration, and some of those children entering kindergarten have already completed their kindergarten entry physical examinations for the 2015-16 school year. The new immunization requirements should be phased in over a series of years to ease implementation.

Response: The implementation of the proposed revisions to the immunization requirements in the 2015-16 school year is of utmost public health importance. From December 2014 through April 2015, the United States experienced a large, multi-state measles outbreak linked to an amusement park in California. In total, 147 people from seven states were reported to have measles linked to the outbreak; the majority were unvaccinated against measles. Three additional cases of measles have occurred in New York State (NYS), including New York City, since January 2015. Measles continues to circulate in many countries, including Canada, and international travelers continue to bring measles into the United States. Individuals who are not fully vaccinated against measles are at increased risk of contracting measles if they are exposed to it, and measles can spread rapidly among undervaccinated populations. Therefore, it is critically important that the NYSDOH ensure that children attending school in NYS are fully vaccinated with two doses of MMR vaccine prior to kindergarten entry.

Comment: All students who were enrolled during the 2013-14 school year should be deemed in compliance with immunization requirements if they had satisfied the immunization requirements in effect on June 30, 2014. Only new entrants and students in select grades should be required to meet the immunization requirements that took effect in the 2014-15 school year, with a phase-in of requirements for additional grades over a seven-year period.

Response: The 2014-15 varicella and polio requirements already included a seven-year phase-in period. The amendments for the 2015-16 school year would keep the seven-year phase-in of varicella and polio requirements intact.

As a result of changes already adopted in February 2014, existing school immunization regulations require students in all grades to receive age-appropriate doses of DTaP vaccine as established by the Advisory Committee on Immunization Practices (ACIP). Prior to July 1, 2014, students younger than grade six were only required to have three doses of DTaP vaccine. The revisions to regulations adopted in February 2014 required four or five doses, depending on age and vaccine history. Based on these most recent proposed revisions, students in grades six through twelve would still meet the 2014-15 DTaP vaccine requirements with three doses of DTaP vaccine plus a dose of Tdap vaccine – effectively the same requirement in effect on or before June 30, 2014.

Allowing students in grades five or below to be in compliance if they had met immunization requirements in effect on June 30, 2014 would not be in the best interests of public health. Four or five doses of DTaP vaccine, depending on age and vaccine history, are necessary for optimal protection against pertussis infection which continues to circulate widely in the United States. Therefore, it is of critical public health importance to ensure that students in all grades in NYS are fully vaccinated against pertussis.

Comment: School nurses have difficulty implementing a requirement that Tdap be received in grade six at 11 to 12 years of age because many children enter grade six at 10 years of age. Many school nurse hours are spent tracking 10 year old students who had not yet received Tdap upon entering grade six. The minimum age for Tdap vaccine should be decreased to 10 years of age or move the Tdap requirement to grade seven.

Response: Public Health Law § 2164 requires the administration of Tdap in grade six. A statutory change would be necessary to instead require Tdap for grade seven.

Comment: The NYSDOH should notify health care providers of the new school immunization requirements being adopted as a result of this rulemaking as soon as possible.

Response: The NYSDOH recognizes the importance of rapid, timely and complete education of providers on the new school immunization requirements. Health care provider professional associations have already been notified of the proposed amendments to regulations, and the NYSDOH will work through multiple channels to educate health care providers on the new requirements that are being adopted as a result of this rulemaking.

Comment: Health care providers, not schools, should be responsible for monitoring immunization intervals.

Response: PHL § 2164 requires schools to ensure that students comply with applicable immunization requirements. However, health care providers should follow best practices to ensure that vaccines are administered at appropriate ages and intervals. The NYSDOH will continue to work with health care providers to ensure that they are aware of minimum ages and intervals for vaccine doses, to implement systems to prevent administration of vaccine doses prior to minimum ages and intervals, and to encourage use of the New York State Immunization Information System and Citywide Immunization Registry to track vaccine intervals, appropriate schedules, and the validity of doses administered.

Comment: With respect to the amendment allowing a foreign immunization record to be accepted without a health care provider’s signature, some foreign records list a student’s name and date of birth on a separate page from the immunization history. If a parent submits only the immunization history, the school may be unable to verify that the documented immunization history belongs to the student.

Response: A complete official record from a foreign nation would be necessary to be considered an official record. If the parent submits only a portion of a foreign record, it would be deemed incomplete and the rest of the document would need to be produced in order for the record to be considered an official record. The assessment of records must be handled on a case-by-case basis, but if the immunization record given does not include a name and date of birth, the record would be incomplete and not accepted as an official record.

Comment: The requirement for five doses of DTaP vaccine, or four doses if the fourth dose was given at four years of age or older, enables vaccine-hesitant parents to defer the fourth dose of DTaP vaccine until four years of age. Similarly, the requirement for four doses of polio vaccine, or three doses if the third dose was given at four years of age or older, could enable vaccine hesitant parents seeking to defer vaccination. All students should be required to have five doses of DTaP vaccine and four doses of polio vaccine.

Response: The NYSDOH agrees that all children should receive all doses of vaccine at the earliest recommended ages. The regulations, however, are aligned with the current ACIP recommendations for DTaP and polio. The ACIP does not recommend that a fifth dose of DTaP vaccine nor a fourth dose of polio vaccine be administered if the fourth and third doses of DTaP and polio vaccines, respectively, were administered on or after the fourth birthday. The final doses of DTaP and polio vaccine given on or after the fourth birthday boosts the immune system prior to kindergarten entry.